ANTIHISTAMINES: FIRST GENERATION | Vendor Drug Program

Brand Name/Generic Name	NDC/Manufacturer	FFS Clinical Prior Auth Required	PDL Prior Auth Required	Programs
ALLERGY RELIEF 4 MG TABLET chlorpheniramine maleate	70000016002 LEADER	Yes	No	Medicaid CSHCN
ALLERGY RELIEF 4 MG TABLET chlorpheniramine maleate	70000016001 LEADER	Yes	No	Medicaid CSHCN
BANOPHEN 25 MG CAPSULE diphenhydramine HCl	00904530624 MAJOR PHARMACEU	Yes	No	Medicaid CSHCN KHC
BANOPHEN 25 MG CAPSULE diphenhydramine HCl	00904530680 MAJOR PHARMACEU	Yes	No	Medicaid CSHCN KHC
BANOPHEN 25 MG CAPSULE diphenhydramine HCl	00904723724 MAJOR PHARMACEU	Yes	No	Medicaid CSHCN KHC
BANOPHEN 25 MG CAPSULE diphenhydramine HCl	00904723760 MAJOR PHARMACEU	Yes	No	Medicaid CSHCN KHC
BANOPHEN 25 MG CAPSULE diphenhydramine HCl	00904723780 MAJOR PHARMACEU	Yes	No	Medicaid CSHCN KHC
BANOPHEN 50 MG CAPSULE diphenhydramine HCl	00904530760 MAJOR PHARMACEU	Yes	No	Medicaid CSHCN KHC
BANOPHEN 50 MG CAPSULE diphenhydramine HCl	00904530780 MAJOR PHARMACEU	Yes	No	Medicaid CSHCN KHC
CARBINOXAMINE 4 MG/5 ML LIQUID carbinoxamine maleate	51991033404 BRECKENRIDGE	Yes	No	Medicaid CHIP CSHCN