Drug - Antihistamines
February 2017
Therapeutic area - Respiratory
| Preferred products | Nonpreferred products |
|
loratadine (Rx or OTC* )
cetirizine (Rx or OTC*)
|
Allegra (fexofenadine) (Rx Brand)
Claritin (Rx Brand)
|
*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.
| Preferred products | Nonpreferred products |
|
loratadine/pseudoephedrine
|
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.
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.
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.
MHCP Provider Call Center 651-431-2700 or 800-366-5411
