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Antihistamines

Drug - Antihistamines

February 2017 

Therapeutic area - Respiratory

Antihistamines

Preferred products Nonpreferred products

loratadine  (Rx or OTC* )

  • tablet
  • chewable tablet
  • syrup
  • orally disintegrating tablet (ODT)

cetirizine (Rx or OTC*)

  • tablet
  • chewable tablet
  • syrup

Allegra (fexofenadine) (Rx Brand)

  • tablets
  • suspension
  • orally disintegrating tablet (ODT)

Claritin (Rx Brand)
Clarinex - all formulations
desloratadine - all formulations
levocetirizine – all formulations
Xyzal (levocetirizine) - all formulation

*Not all loratadine OTC or cetirizine OTC are covered.  Please consult the NDC lookup website for specific NDC coverage information

Allegra OTC and fexofenadine OTC are excluded from coverage, and PA’s cannot be given. 

Antihistamine/decongestant combinations

Preferred products Nonpreferred products

loratadine/pseudoephedrine
12 or 24 hour preparation (generic or OTC*)Or 
cetirizine/pseudoephedrine (generic or OTC*)

Allegra-D 12 Hour (Rx Brand)
Allegra-D 24 Hour (Rx Brand)
fexofenadine/pseudoephedrine (Rx generic)
Claritin D 12 or 24 Hour (Rx Brand)
Clarinex D 12 Hour or 24 Hour (Rx Brand)

*Not all loratadine/pseudoephedrine OTC or cetirizine/pseudoephedrine OTC are covered.  Please consult the NDC lookup website for specific NDC coverage information

Allegra-D OTC,fexofenadine/pseudoephedrine OTC and Zyrtec-D OTC are excluded from coverage, and PA’s cannot be given. 

Criteria for any nonpreferred antihistamine

Patient must have failed by ineffectiveness or intolerance all three generically available antihistamines after at least 2 weeks of use before payment for a non-preferred antihistamine will be authorized.

Criteria for any nonpreferred antihistamine-decongestant combination

Trial of loratadine/pseudoephedrine, either 12 or 24 hour preparation, after at least 2 weeks of use -AND- a trial of cetirizine/pseudoephedrine after at least 2 weeks of use.

Patient must have failed preferred antihistamine/decongestant products by ineffectiveness or intolerance before payment will be authorized for a non-preferred antihistamine/decongestant.

Questions?

MHCP Provider Call Center 651-431-2700 or 800-366-5411

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