Respiratory Agents
Cough and Cold Preparations

Brand/Generic Name Dosage/Strength Status Restrictions Notes Relative Cost
Allegra-D 12 Hour generic.gif (400 bytes)
Fexofenadine-Pseudoephedrine		   approved.gif (510 bytes)

ql.gif

$$$
Allegra-D 24 Hour
Fexofenadine-Pseudoephedrine		   approved.gif (510 bytes)

ql.gif

$$$
Ambenyl generic.gif (400 bytes)
Bromodiphenhydramine-Codeine		   approved.gif (510 bytes)  

$$$
Bromfed generic.gif (400 bytes)
Brompheniramine-Pseudoeph		   approved.gif (510 bytes)  

$$$
Bromfed DM generic.gif (400 bytes)
Pseudoeph-Bromphen-DM		   approved.gif (510 bytes)  

$
Bromfed PD generic.gif (400 bytes)
Brompheniramine-Pseudoeph		   approved.gif (510 bytes)  

$$$
Cheracol/Codeine generic.gif (400 bytes)
Guaifenesin-Codeine		   approved.gif (510 bytes)  

$
Clarinex-D 12 Hour
Desloratadine-Pseudoephedrine		   nonform.gif (625 bytes)

ql.gif st.gif

Not Applicable
Clarinex-D 24 Hour
Desloratadine-Pseudoephedrine		 Table SR 24 HR   nonform.gif (625 bytes)

ql.gif st.gif

Not Applicable
Claritin-D 12 Hour generic.gif (400 bytes)
Loratadine-Pseudoephedrine		   approved.gif (510 bytes)

ql.gif

NOTES_restrict.gif (377 bytes)

$$
Claritin-D 24 Hour generic.gif (400 bytes)
Loratadine-Pseudoephedrine		   approved.gif (510 bytes)

ql.gif

NOTES_restrict.gif (377 bytes)

$$
Deconamine SR generic.gif (400 bytes)
Chlorpheniramine-Pseudoeph		 Cap CR - 8-120 mg   approved.gif (510 bytes)  

$$
Dihistine DH generic.gif (400 bytes)
Pseudoeph-Chlorphen-Codeine		 Liquid - 30-2-10 mg/5ml   approved.gif (510 bytes)  

Not Applicable
Dura-Tap PD generic.gif (400 bytes)
Chlorpheniramine-Pseudoeph		 Cap CR - 4-60 mg   approved.gif (510 bytes)  

$$$
Dura-Vent/DA generic.gif (400 bytes)
Chlorphen-Phenyleph-Methscop		   approved.gif (510 bytes)  

$$$
Endal
Phenylephrine-Guaifenesin		 Tab CR - 20-300 mg   approved.gif (510 bytes)  

$
Entex LA
Phenylephrine-Guaifenesin		 Tablet SR 12 HR - 30-600 mg   approved.gif (510 bytes)  

$$$$
Entex PSE generic.gif (400 bytes)
Pseudoephedrine-Guaifenesin		   approved.gif (510 bytes)  

$$$$
Extendryl generic.gif (400 bytes)
Chlorphen-Phenyleph-Methscop		   approved.gif (510 bytes)  

$$$
Fenesin DM generic.gif (400 bytes)
Dextromethorphan-Guaifenesin		   approved.gif (510 bytes)  

$$
Histex HC
Pseudoeph-Carbinox-Hydrocod		 Liquid - 30-2-5 mg/5ml   nonform.gif (625 bytes)  

Not Applicable
Histussin D generic.gif (400 bytes)
Pseudoeph-Hydrocodone		   approved.gif (510 bytes)  

$$
Histussin HC generic.gif (400 bytes)
Phenyleph-Chlorphen-Hydrocod		   approved.gif (510 bytes)  

$$
Hycotuss Expectorant
Hydrocodone-Guaifenesin		   approved.gif (510 bytes)  

$$
Liquibid-D
Phenylephrine-Guaifenesin		 Tablet SR 12 HR - 40-600 mg   approved.gif (510 bytes)  

$$
Nalex-A
Chlorphen-Phenyltolox-PE		 Tab - 4-40-20 mg   approved.gif (510 bytes)  

Not Applicable
Nalex-A 12 generic.gif (400 bytes)
Chlorphen Tan-Pyril Tan-PE Tan		 Suspension   nonform.gif (625 bytes)  

Not Applicable
Novahistine DH
Pseudoeph-Chlorphen-Codeine		   approved.gif (510 bytes)  

$$
PhenaVent
Phenylephrine-Guaifenesin		 Capsule SR 12 HR   nonform.gif (625 bytes)  

Not Applicable
PhenaVent D generic.gif (400 bytes)
Phenylephrine-Guaifenesin		 Tablet SR 12 HR   approved.gif (510 bytes)  

$$$
PhenaVent LA generic.gif (400 bytes)
Phenylephrine-Guaifenesin		 Capsule SR 12 HR   approved.gif (510 bytes)  

$$$
PhenaVent PED generic.gif (400 bytes)
Phenylephrine-Guaifenesin		 Capsule SR 12 HR   approved.gif (510 bytes)  

$$$
Phenergan VC generic.gif (400 bytes)
Promethazine-Phenylephrine		   approved.gif (510 bytes)  

$$
Phenergan VC/Codeine generic.gif (400 bytes)
Phenyleph-Promethazine-Cod		   approved.gif (510 bytes)  

$
Phenergan/Codeine generic.gif (400 bytes)
Promethazine-Codeine		   approved.gif (510 bytes)  

$
Phenyleph-Promethazine-Cod generic.gif (400 bytes)
Phenyleph-Promethazine-Cod		   approved.gif (510 bytes)  

$
Promethazine-Codeine generic.gif (400 bytes)
Promethazine-Codeine		   approved.gif (510 bytes)  

$
Promethazine-DM generic.gif (400 bytes)
Promethazine-DM		   approved.gif (510 bytes)  

$
Promethazine-Phenylephrine generic.gif (400 bytes)
Promethazine-Phenylephrine		   approved.gif (510 bytes)  

$$
Pseudoeph-Triprolidine-Cod generic.gif (400 bytes)
Pseudoeph-Triprolidine-Cod		   approved.gif (510 bytes)  

$$
Robitussin A-C generic.gif (400 bytes)
Guaifenesin-Codeine		   approved.gif (510 bytes)  

$
Robitussin DAC generic.gif (400 bytes)
Pseudoephedrine-Codeine-GG		   approved.gif (510 bytes)  

$$
Rondec
Brompheniramine-Pseudoeph		 Chew Tab - 4-60 mg   approved.gif (510 bytes)  

$$$
Rondec-DM
Pseudoeph-Carbinox-DM		   approved.gif (510 bytes)  

$$
Ryna-C generic.gif (400 bytes)
Pseudoeph-Chlorphen-Codeine		 Liquid - 30-2-10mg/5ml  approved.gif (510 bytes)  

Not Applicable
Rynatan generic.gif (400 bytes)
Chlorphen-Pyril-Phenyleph		   approved.gif (510 bytes)  

$$$
Rynatuss
PE-Ephed-CPM-Carbetapentane		 Tab   approved.gif (510 bytes)  

$$$
Rynatuss Pediatric
PE-Ephed-CPM-Carbetapentane		 Suspension   nonform.gif (625 bytes)  

Not Applicable
Tetra Tannate Pediatric generic.gif (400 bytes)
PE-Ephed-CPM-Carbetapentane		 Suspension   nonform.gif (625 bytes)  

Not Applicable
Tri-Vent HC generic.gif (400 bytes)
Pseudoeph-Carbinox-Hydrocod		 Liquid - 30-2-5 mg/5ml   nonform.gif (625 bytes)  

Not Applicable
Trinalin Repetabs
Azatadine-Pseudoephedrine		   approved.gif (510 bytes)  

$
TussiCaps
Hydrocod Polst-Chlorphen Polst		 Capsule SR 12 HR   nonform.gif (625 bytes)

ql.gif

Not Applicable
Tussionex Pennkinetic ER
Chlorpheniramine-Hydrocodone		   nonform.gif (625 bytes)

ql.gif

NOTES_restrict.gif (377 bytes)

Not Applicable
Zephrex LA generic.gif (400 bytes)
Pseudoephedrine-Guaifenesin		   approved.gif (510 bytes)  

$$

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
Notes $Relative cost compared to others in category Specialty distribution for selected plans

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