ANTIEMETIC/ANTIVERTIGO AGENTS | Vendor Drug Program

Brand Name/Generic Name	NDC/Manufacturer	FFS Clinical Prior Auth Required	PDL Prior Auth Required	Programs
DICLEGIS DR 10-10 MG TABLET doxylamine succinate/vit B6	55494010010 DUCHESNAY USA,	No	No	Medicaid CHIP CSHCN
DRIMINATE 50 MG TABLET dimenhydrinate	00904677212 MAJOR PHARMACEU	No	No	Medicaid CSHCN
MECLIZINE 12.5 MG CAPLET meclizine HCl	00536129701 RUGBY	Yes	No	Medicaid CSHCN
MECLIZINE 12.5 MG CAPLET meclizine HCl	00536129710 RUGBY	Yes	No	Medicaid CSHCN
MECLIZINE 12.5 MG TABLET meclizine HCl	59746012206 JUBILANT CADIST	Yes	No	Medicaid CHIP CSHCN
MECLIZINE 12.5 MG TABLET meclizine HCl	53746044101 AMNEAL PHARMACE	Yes	No	Medicaid CHIP CSHCN KHC
MECLIZINE 12.5 MG TABLET meclizine HCl	59746012210 JUBILANT CADIST	Yes	No	Medicaid CHIP CSHCN
MECLIZINE 12.5 MG TABLET meclizine HCl	16571066001 RISING PHARM	Yes	No	Medicaid CHIP CSHCN
MECLIZINE 12.5 MG TABLET meclizine HCl	53746044110 AMNEAL PHARMACE	Yes	No	Medicaid CHIP CSHCN KHC
MECLIZINE 12.5 MG TABLET meclizine HCl	16571066050 RISING PHARM	Yes	No	Medicaid CHIP CSHCN