MISSISSIPPI DIVISION OF MEDICAID Antihistamine/Decongestant Product and Active Ingredient Cross-Reference List
The agents listed below are the antihistamine/decongestant drug products listed in the Mississippi Medicaid Preferred Drug List (PDL). This is a cross-reference between the drug product name and its active ingredients to reference the antihistamine/decongestant portion of the PDL. For more information concerning the PDL, including non-preferred agents, the OTC formulary, and other specifics, please visit our website at www.medicaid.ms.gov. List Effective 07/01/09 Therapeutic Class Active Ingredients Preferred Non-Preferred ANTIHISTAMINES - FIRST GENERATION BROMPHENIRAMINE MALEATE BPM J-TAN PD BROMSPIRO LODRANE 24 LOHIST 12HR VAZOL BROMPHENIRAMINE TANNATE P-TEX CONEX J-TAN BROMPHENIRAMINE/DIPHENHYDRAMINE ALA-HIST CARBINOXAMINE MALEATE PALGIC CHLORPHENIRAMINE MALEATE CPM 12 CHLORPHENIRAMINE TANNATE ED CHLORPED ED-CHLOR-TAN MYCI CHLOR-TAN MYCI CHLORPED PEDIATAN TANAHIST-PD CLEMASTINE FUMARATE CLEMASTINE FUMARATE CYPROHEPTADINE HCL CYPROHEPTADINE HCL DEXCHLORPHENIRAMINE MALEATE DEXCHLORPHENIRAMINE MALEATE DIPHENHYDRAMINE HCL DIPHENHYDRAMINE HCL DIPHENHYDRAMINE TANNATE DYTAN chewables DIPHENMAX DOXYLAMINE SUCCINATE DOXYTEX ALDEX AN PYR MAL/DEXBROMPH TAN POLY TAN TRIPROLIDINE HCL TRIPOHIST
ANTIHISTAMINES- FIRST BROMPH/DIPH/PE ALA-HIST D GENERATION/DECONGESTANT PE HCL/CPM C-PHEN DROPS ALERSULE COMBINATIONS C-PHEN SYRUP DALLERGY-JR capsule CENTERGY TUSSANIL CERON RESCON-JR CP DEC DALLERGY drops ED A-HIST MAXICHLOR PEH NASOHIST NOHIST PREHIST SILDEC-PE SONAHIST PE HCL/PE TAN/PYR TAN/CPM PHENA-S 12 PE TAN/PYR MAL/DEXBROMPH TAN POLY TAN D PE/BROMPH BROVEX ADT BROMFED BROVEX PEB BROMFED-PD C-TAN D J-TAN D C-TAN D PLUS SERADEX-LA RESPAHIST-II VAZOBID VAZOTAB
Active Ingredient Abbreviation Key BROMPH=brompheniramine DEXBROMPH=dexbrompheniramine MAL=maleate PSE=pseudoephedrine CPM=chlorpheniramine maleate DEXCHLOR=dexchlorpheniramine METHSCOP=methscopolamine PYR=pyrilamine CPT=chlorpheniramine tannate DIPH=diphenhydramine PE=phenylephrine TAN=tannate
Brand names are designated in bold in the drug product name column; all other agents are considered generic products. MISSISSIPPI DIVISION OF MEDICAID Antihistamine/Decongestant Product and Active Ingredient Cross-Reference List
Therapeutic Class Active Ingredients Preferred Non-Preferred ANTIHISTAMINES- FIRST PE/CPT ALLANTAN ALLERX GENERATION/DECONGESTANT ED CHLORPED D DALLERGY-JR susp COMBINATIONS (CONTINUED) R-TANNA MYCI CHLORPED D TANAHIST D NY-TANNIC TANNATE PEDIATAN D RYNATAN RYNATAN PEDIATRIC PE/DEXCHLORPHENIRAMINE NALDEX PE/DIPH ALAHIST LQ PE/DIPH TAN D-TANN DIPHENMAX D PE/PHENYLTOLOXAMINE/CPM BLANEX-A NALEX-A RHINACON A PE/PROMETHAZINE PROMETHAZINE VC PE/PYR TAN ALLANVAN-S DECONSAL CT RYNESA 12S RYNA-12 RY-T-12 RYNA-12 S PE/PYR/CPM MYHIST-PD ALLERTAN NALEX A 12 PHENA-PLUS RU-HIST FORTE PHENA-S TRI-HIST POLY HIST FORTE POLY HIST PD PSE HCL/BROMPH ANDEHIST HISTEX SR BPM PSEUDO J-TAN D PD BROFED BROMHIST BROMHIST-NR BROVEX PSB BROVEX PSE LODRANE LODRANE 24D LOHIST 12D LOHIST-PD RESPAHIST SILDEC SINUHIST ULTRABROM ULTRABROM PD PSE HCL/CPM COLFED-A ACCUHIST CPM PSE DURATUSS DA DECONAMINE HISTEX LOHIST-D MAXICHLOR PSE NEUTRAHIST TIBAMINE LA PSE-CPM SUDAHIST PSE HCL/DEXBROMPH MAL DISOPHROL PSE HCL/TRIPROLIDINE HCL PEDIATEX TD liquid TRIPOHIST D PSE TAN/BROMPH BROVEX PD LODRANE D PSE TAN/CPT DICEL SUDAL-12 PSE TAN/DEXCHLOR TAN SUTAN ALLERDUR PSE TAN/PYR TAN VIRAVAN-P
Active Ingredient Abbreviation Key BROMPH=brompheniramine DEXBROMPH=dexbrompheniramine MAL=maleate PSE=pseudoephedrine CPM=chlorpheniramine maleate DEXCHLOR=dexchlorpheniramine METHSCOP=methscopolamine PYR=pyrilamine CPT=chlorpheniramine tannate DIPH=diphenhydramine PE=phenylephrine TAN=tannate
Brand names are designated in bold in the drug product name column; all other agents are considered generic products. MISSISSIPPI DIVISION OF MEDICAID Antihistamine/Decongestant Product and Active Ingredient Cross-Reference List
Therapeutic Class Active Ingredients Preferred Non-Preferred
ANTIHISTAMINES- FIRST BROMPH/PSE;CPM/PE/METHSCOP SYMPAK II GENERATION/DECONGESTANT/ CPM/PE/METHSCOP AH-CHEW II ALLERX PE ANTICHOLINERGIC COMBINATIONS ALLERGY DN PE DALLERGY PE CHLOR-MES DURAHIST PE CHLOR-MES D EXTENDRYL chew tab DALLERGY cap, syrup, tab EXTENDRYL JR DEHISTINE EXTENDRYL SR DURADRYL RESCON DURADRYL SR DURAVENT CHEWABLE DURAVENT-DA HISTATAB PH NOHIST-PLUS chew tab NOHIST-PLUS JR NOHIST-PLUS tab SA OMNIHIST II LA OMNIHIST L.A. PREHIST D QV-ALLERGY RE-DRYLEX JR RESCON-MX SCOPOHIST syrup SCOPOHIST-PE SYMPAK PDX TRIALL WE ALLERGY PE/CPM/BELLADONNA ALKALOIDS RESPA A.R. RU-TUSS PE/CPT/METHSCOP AH-CHEW DURATAN PE AH-CHEW ULTRA PE/DEXCHLOR/METHSCOP DEXPHEN M EXTENDRYL syrup RE-DRYLEX PSE/CPM/METHSCOPOL COLDAMINE DALLERGY PSE HISTATAB DURAHIST PCM LA TIME-HIST QD SCOPOHIST tab VISRX PSE/DEXCHLOR/METHSCOP CORYZA-D DURAHIST D D-HIST D HISTATAB D PSE/METHSCOP/CPM/PE ALLERX 10 ALLERX 30
DECONGESTANT-ANTICHOLINERGIC PSE/METHSCOP AMDRY-D ALLERX-D COMBINATIONS RESPIVENT-D EXTENDRYL PSE SUDATRATE PE/METHSCOPOLAMINE EXTENDRYL PEM
Active Ingredient Abbreviation Key BROMPH=brompheniramine DEXBROMPH=dexbrompheniramine MAL=maleate PSE=pseudoephedrine CPM=chlorpheniramine maleate DEXCHLOR=dexchlorpheniramine METHSCOP=methscopolamine PYR=pyrilamine CPT=chlorpheniramine tannate DIPH=diphenhydramine PE=phenylephrine TAN=tannate
Brand names are designated in bold in the drug product name column; all other agents are considered generic products.