Brand/Generic Name

Dosage/Strength

Status

Restrictions

Notes

Relative Cost

Alavert loratadine 10 mg tablet     $$ Alavert loratadine 10 mg tablet,disintegrating     $$ Alavert Children's Allergy loratadine 5 mg/5 mL Solution     $$ Allegra fexofenadine 180 mg tablet; 180 mg tablet     $$$ Allegra fexofenadine 30 mg/5 mL Suspension; 30 mg/5 mL Suspension     $$$ Allegra Allergy fexofenadine 180 mg tablet; 60 mg tablet     $ Allegra Allergy fexofenadine tablet     $ Allegra ODT fexofenadine 30 mg tablet,disintegrating     Not Applicable Allegra ODT fexofenadine tablet,disintegrating     Not Applicable Astelin azelastine 137 mcg Aerosol, Spray     $$ Astepro azelastine Spray, Non-Aerosol     Not Applicable Children's Allegra Allergy fexofenadine 30 mg tablet,disintegrating     $ Children's Allegra Allergy fexofenadine 30 mg/5 mL Suspension     $ Children's Allegra Allergy fexofenadine Suspension     $ Children's Allegra Allergy fexofenadine tablet     $ Children's Zyrtec Allergy cetirizine 1 mg/mL Solution   $$ Clarinex desloratadine 2.5 mg tablet,disintegrating   Not Applicable Clarinex desloratadine 2.5 mg/5 mL (0.5 mg/mL) Syrup   Not Applicable Clarinex desloratadine 5 mg tablet   Not Applicable Clarinex desloratadine 5 mg tablet,disintegrating   Not Applicable Claritin loratadine 5 mg/5 mL Solution     $$ Claritin RediTabs loratadine 10 mg tablet,disintegrating; 5 mg tablet,disintegrating     $$ Histex CT carbinoxamine maleate tablet extended release 12 hr     Not Applicable Histex IE carbinoxamine maleate capsule, ER multiphase 12 hr     Not Applicable Histex PD carbinoxamine maleate Liquid     Not Applicable Patanase olopatadine Spray, Non-Aerosol     Not Applicable PBZ-SR Tripelennamine HCl     $$$ Periactin cyproheptadine 2 mg/5 mL Syrup     $$ Periactin cyproheptadine 4 mg tablet     $$ Phenergan promethazine 12.5 mg tablet; 50 mg tablet; 25 mg tablet     $$$$ Phenergan promethazine 50 mg/mL Solution; 25 mg/mL Solution     $$$$ Phenergan promethazine 6.25 mg/5 mL Syrup     $$$$ Polaramine dexchlorpheniramine maleate 2 mg/5 mL Syrup     $$ Polaramine dexchlorpheniramine maleate 6 mg tablet extended release     $$ Semprex-D acrivastine-pseudoephedrine 8-60 mg capsule     Not Applicable Tavist clemastine tablet     $$$ Xyzal levocetirizine 2.5 mg/5 mL Solution   Not Applicable Xyzal levocetirizine 5 mg tablet   Not Applicable Zyrtec cetirizine 1 mg/mL Solution     Not Applicable Zyrtec cetirizine 10 mg capsule     Not Applicable Zyrtec cetirizine 10 mg tablet,disintegrating     Not Applicable Zyrtec cetirizine 5 mg tablet, chewable; 10 mg tablet, chewable     Not Applicable Zyrtec cetirizine 5 mg tablet; 10 mg tablet     Not Applicable ZyrTEC-D Allergy & Congestion Cetirizine-Pseudoephedrine   $$

Key for Product(s) Listed Above

Formulary Prior Authorization (PA may not be required for some benefit plans) Non-Formulary (Third tier coverage applies for selected plans) Not Reimbursed Quantity Limit Not available through mail order as 90-day supply* Step Therapy Generic Available. Brand name medication may be covered at a higher member cost or may not be covered for certain plans. Notes $Relative cost compared to others in category Specialty distribution for selected plans (Fourth or fifth tier coverage applied for selected plans)

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