Brand/Generic Name

Dosage/Strength

Status

Restrictions

Notes

Relative Cost

AccuHist PDX brompheniramine-pseudoeph-DM 1-12.5-3 mg/mL Drops; 0.8-9-3 mg/mL Drops; 1-2.5-2.5 mg/mL Drops   $$ AccuHist PDX chlorpheniramine-phenyleph-DM 1-12.5-3 mg/mL Drops; 0.8-9-3 mg/mL Drops; 1-2.5-2.5 mg/mL Drops   $$ AccuHist PDX chlorpheniramine-pseudoeph-DM 1-12.5-3 mg/mL Drops; 0.8-9-3 mg/mL Drops; 1-2.5-2.5 mg/mL Drops   $$ AccuHist PDX brompheniramin-phenyleph-DM-GG 2-5-5-50 mg/5 mL Syrup   $$ Accuhist PDX Drops Pseudoeph-Bromphen-DM Liquid   $$ Alavert D-12 Allergy-Sinus loratadine-pseudoephedrine 5-120 mg tablet extended release 12 hr     $$ Alavert D-12 Allergy-Sinus loratadine-pseudoephedrine tablet extended release 12 hr     $$ Allegra-D 12 Hour fexofenadine-pseudoephedrine 60-120 mg tablet extended release 12 hr     $ Allegra-D 24 Hour fexofenadine-pseudoephedrine 180-240 mg tablet extended release 24 hr     $ Allegra-D Allergy & Congestion fexofenadine-pseudoephedrine 180-240 mg tablet extended release 24 hr     $ Allegra-D Allergy & Congestion fexofenadine-pseudoephedrine 60-120 mg tablet extended release 12 hr     $ Ambenyl Bromodiphenhydramine-Codeine   $$$ Bromfed brompheniramine-pseudoephedrin 12-120 mg capsule, extended release   $$$ Bromfed brompheniramine-phenylephrine 12-15 mg capsule,extended release 12 hr   $$$ Bromfed brompheniramine-pseudoephedrin 4-60 mg tablet   $$$ Bromfed DM brompheniramine-pseudoeph-DM 2-30-10 mg/5 mL Syrup   $ Bromfed PD brompheniramine-pseudoephedrin 6-60 mg capsule, extended release   $$$ Bromfed PD brompheniramine-phenylephrine 6-7.5 mg capsule,extended release 12 hr   $$$ Cheracol/Codeine codeine-guaifenesin 10-100 mg/5 mL Liquid   $ Clarinex-D 12 HOUR desloratadine-pseudoephedrine 2.5-120 mg tablet, ER multiphase 12 hr   Not Applicable Clarinex-D 24 HOUR desloratadine-pseudoephedrine 5-240 mg tablet, ER multiphase 24 hr   Not Applicable Claritin-D 12 Hour loratadine-pseudoephedrine 5-120 mg tablet extended release 12 hr   $$ Claritin-D 24 Hour loratadine-pseudoephedrine 10-240 mg tablet extended release 24 hr   $$ Deconamine SR chlorpheniramine-pseudoephed 8-120 mg capsule,extended release 12 hr   $$ Dihistine DH Pseudoeph-Chlorphen-Codeine Liquid mg/5ml   Not Applicable Dura-Tap PD Chlorpheniramine-Pseudoeph Cap CR - 22007mg   $$$ Dura-Vent/DA Chlorphen-Phenyleph-Methscop   $$$ DURAFLU pseudoeph-DM-GG-acetaminophen 60-20-200-500 mg tablet   $$ Endal Phenylephrine-Guaifenesin Tab CR mg   $ Entex LA Phenylephrine-Guaifenesin Tablet SR 12 HR mg   $$$$ Entex PSE pseudoephedrine-guaifenesin 120-400 mg capsule,extended release 12 hr   $$$$ Entex PSE pseudoephedrine-guaifenesin 50-525 mg tablet extended release 12 hr; 120-600 mg tablet extended release 12 hr   $$$$ Extendryl chlorphen-phenyleph-methscop 2-10-1.25 mg tablet, chewable   $$$ Extendryl dexchlorpheniram-PE-methscopol 2-10-1.25 mg/5 mL Solution; 1-10-1.25 mg/5 mL Solution   $$$ Extendryl chlorphen-phenyleph-methscop 2-10-1.25 mg/5 mL Solution; 1-10-1.25 mg/5 mL Solution   $$$ Fenesin DM dextromethorphan-guaifenesin 30-600 mg tablet extended release 12 hr   $$ Histex HC Pseudoeph-Carbinox-Hydrocod Liquid mg/5ml   Not Applicable Histussin D pseudoephedrine-hydrocodone 60-5 mg/5 mL Solution   $$ Histussin HC dexbromphenirmn-PE-hydrocodone 1-5-2.5 mg/5 mL Liquid   $$ Histussin HC chlorphen-phenyleph-hydrocodon 2-5-2.5 mg/5 mL Syrup   $$ Hycotuss Expectorant hydrocodone-guaifenesin 5-100 mg/5 mL Syrup   $$ Liquibid-D phenylephrine-guaifenesin 40-600 mg tablet extended release 12 hr   $$ Lufyllin-GG dyphylline-guaifenesin 200-200 mg tablet   $$ Nalex-A chlorphen-phenyltoloxamine-pe 2.5-7.5-5 mg/5 mL Liquid   Not Applicable Nalex-A chlorphen-phenyltoloxamine-pe 4-40-20 mg tablet extended release   Not Applicable Nalex-A 12 Chlorphen Tan-Pyril Tan-PE Tan Suspension   Not Applicable Novahistine DH chlorphen-pseudoephed-codeine 2-30-10 mg/5 mL Liquid; 2-5-7.25 mg/5 mL Liquid; 2-4-6.5 mg/5 mL Liquid   $$ Novahistine DH cpm-phenyleph-dihydrocodeine 2-30-10 mg/5 mL Liquid; 2-5-7.25 mg/5 mL Liquid; 2-4-6.5 mg/5 mL Liquid   $$ PhenaVent phenylephrine-guaifenesin 15-400 mg capsule,extended release 12 hr   Not Applicable PhenaVent D phenylephrine-guaifenesin 40-1,200 mg tablet extended release 12 hr   $$$ PhenaVent LA phenylephrine-guaifenesin 30-400 mg capsule, ER multiphase 12 hr   $$$ PhenaVent PED phenylephrine-guaifenesin 7.5-200 mg capsule, ER multiphase 12 hr   $$$ Phenergan VC promethazine-phenylephrine 6.25-5 mg/5 mL Syrup   $$ Phenergan VC-Codeine phenyleph-promethazine-cod 5-6.25-10 mg/5 mL Syrup   $ Phenergan VC/Codeine phenyleph-promethazine-cod 5-6.25-10 mg/5 mL Syrup   $ Phenergan-Codeine promethazine-codeine 6.25-10 mg/5 mL Syrup   $ Phenergan/Codeine promethazine-codeine 6.25-10 mg/5 mL Syrup   $ phenyleph-promethazine-cod phenyleph-promethazine-cod 5-6.25-10 mg/5 mL Syrup   $ promethazine-DM promethazine-DM 6.25-15 mg/5 mL Syrup   $ Pseudoeph-Triprolidine-Cod Pseudoeph-Triprolidine-Cod   $$ Rescon-MX chlorphen-phenyleph-methscop 8-40-2.5 mg tablet extended release 12 hr; 6-40 mg tablet extended release 12 hr   $$ Rescon-MX dexchlorpheniram-phenylephrine 8-40-2.5 mg tablet extended release 12 hr; 6-40 mg tablet extended release 12 hr   $$ REZIRA pseudoephedrine-hydrocodone 60-5 mg/5 mL Solution   Not Applicable Robitussin A-C Guaifenesin-Codeine   $ Robitussin DAC Pseudoephedrine-Codeine-GG   $$ Rondec-DM Pseudoeph-Carbinox-DM   $$ Ry-Tann chlorpheniramine-PE tannates 9-25 mg tablet   $$ Rynatuss cpm-PE-ephed-carbetapentane 5-10-10-60 mg tablet   $$$ Rynatuss Pediatric cpm-PE-ephed-carbetapentane 4-5-5-30 mg/5 mL Suspension   Not Applicable Tetra Tannate Pediatric cpm-PE-ephed-carbetapentane 4-5-5-30 mg/5 mL Suspension   Not Applicable Tri-Vent HC carbinox-pseudoeph-hydrocod 2-30-5 mg/5 mL Liquid   Not Applicable Trinalin Repetabs Azatadine-Pseudoephedrine   $ TussiCaps chlorpheniramine-hydrocodone 8-10 mg capsule,extended release 12 hr; 4-5 mg capsule,extended release 12 hr   Not Applicable Tussionex Pennkinetic ER chlorpheniramine-hydrocodone 8-10 mg/5 mL suspension,extended rel 12 hr   Not Applicable Zutripro cpm-pseudoephed-hydrocodone 4-60-5 mg/5 mL Solution   Not Applicable

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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