COUGH AND COLD: COLD | Vendor Drug Program

Brand Name/Generic Name	NDC/Manufacturer	FFS Clinical Prior Auth Required	PDL Prior Auth Required	Programs
ALA-HIST IR 2 MG TABLET dexbrompheniramine maleate	50991078360 POLY PHARMACEUT	Yes	No	Medicaid CSHCN
ALAHIST PE 2-7.5 MG TABLET dexbrompheniramin/phenylephrin	50991078890 POLY PHARMACEUT	Yes	No	Medicaid CSHCN
APRODINE TABLET triprolidine/pseudoephedrine	00904730224 MAJOR PHARMACEU	Yes	No	Medicaid CSHCN
APRODINE TABLET triprolidine/pseudoephedrine	00904730260 MAJOR PHARMACEU	Yes	No	Medicaid CSHCN
CHEST CONGEST RLF 400 MG TAB guaifenesin	00536131108 RUGBY	Yes	No	Medicaid CSHCN
CHEST CONGEST RLF 400 MG TAB guaifenesin	70000005501 LEADER	Yes	No	Medicaid CSHCN
CHEST CONGESTION RELIEF SOLN guaifenesin	00536131485 RUGBY	Yes	No	Medicaid CSHCN
CHILD COLD-ALLERGY LIQUID brompheniramine/phenylephrine	70000005701 LEADER	Yes	No	Medicaid CSHCN
DECONEX IR 385-10 MG TABLET guaifenesin/phenylephrine HCl	50991073690 POLY PHARMACEUT	Yes	No	Medicaid CSHCN
ED BRON GP LIQUID guaifenesin/phenylephrine HCl	00485020816 EDWARDS PHARM.	Yes	No	Medicaid CSHCN