Multivitamins, Oral

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PDL Reference Documents

Drug Use Review Documents

PDL Status Values

Y = preferred
N = non-preferred. Non-preferred drugs listed as N but without clinical drug use criteria are subject to the Non-Preferred Drugs in Select PDL Classes prior authorization criteria. New drugs will be listed as N until reviewed by the P&T Committee and are subject to the New Drug Policy.
V = voluntary non-preferred. Non-preferred mental health drugs are listed as V and prior authorization is not required.
Null (i.e. blank) = indicates the class or specific drug has not been reviewed for PDL placement.

To request a Prior Authorization, please use this form.

Generic Name Brand Name Form PDL
Status		 Current Drug Use Criteria New Drug Evaluation
beta-carotene(A)-vits C,E/mins HP ZINC WITH ANTIOXIDANTS TABLET Y PA Document  
beta-carotene(A)-vits C,E/mins OCUVITE TABLET Y PA Document  
beta-carotene(A)-vits C,E/mins EYE HEALTH TABLET Y PA Document  
beta-carotene(A)-vits C,E/mins HP ZINC W/ANTIOXIDANTS TABLET Y PA Document  
beta-carotene(A)-vits C,E/mins OCUTABS TABLET Y PA Document  
beta-carotene(A)-vits C,E/mins OPTI-VITAMINS TABLET Y PA Document  
folic acid/vit B complex and C WEST-VITE WITH FOLIC ACID TABLET Y PA Document  
folic acid/vit B complex and C DIALYVITE 800 TABLET Y PA Document  
folic acid/vit B complex and C RENAL-VITE TABLET Y PA Document  
multivit 38/folate no.6/ginger PRENATE AM TABLET Y PA Document  
multivit 47/iron/folate 1/dha PNV-DHA CAPSULE Y PA Document  
multivit 47/iron/folate 1/dha WESCAP-PN DHA CAPSULE Y PA Document  
multivit 47/iron/folate 1/dha VIRT-PN DHA CAPSULE Y PA Document  
multivit 47/iron/folate 1/dha ZATEAN-PN DHA CAPSULE Y PA Document  
multivit no.40/iron/folat1/dha PRENATE ESSENTIAL CAPSULE Y PA Document  
multivit no.42/iron/folate/dha NESTABS ONE CAPSULE Y PA Document  
multivit no.48/iron fum/FA/dha CALCIUM PNV CAPSULE Y PA Document  
multivit with minerals/lutein VITATRUM TABLET Y PA Document  
multivit with minerals/lutein ULTRA CHOICE TABLET Y PA Document  
multivit with minerals/lutein SUPER AYTINAL TABLET Y PA Document  
multivit with minerals/lutein HIGH POTENCY MULTIVITAMIN TABLET Y PA Document  
multivit with minerals/lutein MULTI-VITE 50 & OVER TABLET Y PA Document  
multivit with minerals/lutein CENTRAL VITE SR W-LUTEIN TAB TABLET Y PA Document  
multivit with minerals/lutein CENTRAL-VITE SELECT TABLET Y PA Document  
multivit with minerals/lutein CENTURY W/LUTEIN TABLET Y PA Document  
multivit with minerals/lutein MULTIVITAMINS WITH MINERALS TABLET Y PA Document  
multivit with minerals/lutein CENTURY WITH LUTEIN TABLET Y PA Document  
multivit-min/FA/lycopen/lutein CERTAVITE SENIOR TABLET Y PA Document  
multivit-min/FA/lycopen/lutein SENTRY SENIOR TABLET Y PA Document  
multivit-min/FA/lycopen/lutein CENTRAL-VITE TABLET Y PA Document  
multivit-min/FA/lycopen/lutein COMPLETE 50 PLUS TABLET Y PA Document  
multivit-min69/iron/folic acid ELITE-OB TABLET Y PA Document  
multivit-min69/iron/folic acid OB COMPLETE TABLET Y PA Document  
multivit37/iron/Lmfolate/algal VINATE DHA RF CAPSULE Y PA Document  
multivit41/iron/folate8/ps-dha ENBRACE HR CAP IR DR Y PA Document  
multivitamin TAB-A-VITE TABLET Y PA Document  
multivitamin ULTRA-MEGA TABLET Y PA Document  
multivitamin SUPER MEDI-VITE TABLET Y PA Document  
multivitamin CENTRAL VITE TABLET Y PA Document  
multivitamin DAILY MULTIPLE VITAMIN TABLET Y PA Document  
multivitamin ESSENTIAL ONE DAILY TABLET Y PA Document  
multivitamin MULTIPLE DAILY W/BETA TABLET Y PA Document  
multivitamin MULTIPLE VITAMIN TABLET Y PA Document  
multivitamin MULTIVITAMIN TABLET Y PA Document  
multivitamin ONE DAILY TABLET Y PA Document  
multivitamin SIGTAB TABLET Y PA Document  
multivitamin DAILY VITAMIN TABLET Y PA Document  
multivitamin VIMAR TABLET Y PA Document  
multivitamin OPTIVITE P.M.T. TABLET Y PA Document  
multivitamin MULTIDAY VITES TABLET Y PA Document  
multivitamin no.36/folate no.6 PRENATE CHEWABLE TAB CHEW Y PA Document  
multivitamin,therapeutic ONCOVITE TABLET Y PA Document  
multivitamin/iron/folic acid CERTAVITE-ANTIOXIDANT TABLET Y PA Document  
multivitamin/iron/folic acid CENTRUM ADULTS TABLET Y PA Document  
multivitamin/iron/folic acid MULTI-VITE TABLET Y PA Document  
multivitamin/iron/folic acid ONE DAILY WITH IRON TABLET Y PA Document  
mv-min 51/folic acid/vit K/ubi AQUADEKS TAB CHEW Y PA Document  
mv-mins 71/iron/folic no.1/dha PNV-OMEGA CAPSULE Y PA Document  
mv-mins 71/iron/folic no.1/dha ZATEAN-PN PLUS CAPSULE Y PA Document  
mvn no.53/iron/folic/dss/dha TARON-PREX PRENATAL CAPSULE Y PA Document  
mvn-min 74/iron fum/iron/FA FOLIVANE-OB CAPSULE Y PA Document  
mvn-min75/iron/iron ps/om3/dha TARON-C DHA CAPSULE Y PA Document  
mvn-min75/iron/iron ps/om3/dha WESCAP-C DHA CAPSULE Y PA Document  
vitamin B complex VITAMIN B COMPLEX CAPSULE Y PA Document  
vitamin B complex BALANCED B-50 CAPSULE Y PA Document  
vitamin B complex VITAMIN B COMPLEX W/VIT B-12 CAPSULE Y PA Document  
folic/mvi ther-min/lycop/lut CORVITA TABLET N PA Document  
lmefolate/B3/copp/Zn/sel/chrom NICOTINAMIDE TABLET N PA Document  
lmefolate/B3/copp/Zn/sel/chrom NICOMIDE TABLET N PA Document  
multivit no.35/levomefolate DAVIMET-M TAB CHEW N PA Document  
multivit-min no.86/folic acid DERMACINRX MULTITAM TABLET N PA Document  
multivit-min no.86/folic acid DERMACINRX VENEXA TABLET N PA Document  
multivit-min no.86/folic acid DERMACINRX VENTRIXYL TABLET N PA Document  
multivit-min no.86/folic acid DERMACINRX VITRAMYN TABLET N PA Document  
multivit-min no.86/folic acid DERMACINRX VITRANOL TABLET N PA Document  
multivit-min no.86/folic acid DERMACINRX VITREXATE TABLET N PA Document  
multivit-min no.86/folic acid VITREXYL TABLET N PA Document  
multivit-min/ferrous gluconate LIQUID MULTIVITAMIN LIQUID N PA Document  
multivit-min/ferrous gluconate MULTIVITAMIN-MULTIMINERAL LIQUID N PA Document  
multivit-mins no.20/iron/folic BACMIN TABLET N PA Document  
multivit-mins60/iron fum/folic NIVA-PLUS TABLET N PA Document  
multivit,calc,mins/iron/folic THERA M PLUS TABLET N PA Document  
multivit,calc,mins/iron/folic THERA-M TABLET N PA Document  
multivit,calc,mins/iron/folic THERAPEUTIC-M TABLET N PA Document  
multivit,iron,min 5/folic acid STROVITE FORTE TABLET N PA Document  
multivit/iron sulf/folic acid TAB-A-VITE MULTIVIT WITH IRON TABLET N PA Document  
multivitamin no.58/folic acid DERMACINRX DAVIMET TAB CHEW N PA Document  
multivitamin with folic acid TAB-A-VITE TABLET N PA Document  
multivitamin with folic acid THERA TABLET N PA Document  
multivitamin with folic acid TM-DAILY VITE TABLET N PA Document  
multivitamin with folic acid TRUE MULTIVITAMIN TABLET N PA Document  
mv-min102/iron carb,fum/FA/dha CITRANATAL MEDLEY CAPSULE N PA Document  
mv-mins no.73/iron fum/folic DERMACINRX DEXATRAN CAPSULE N PA Document  
mv-mn no.86/iron/folic acid VITREXYL PLUS IRON TABLET N PA Document  
mv-mn no.86/iron/folic acid DERMACINRX VENEXA FE TABLET N PA Document  
mv-mn no.86/iron/folic acid DERMACINRX VENTRIXYL FE TABLET N PA Document  
mv-mn no.86/iron/folic acid DERMACINRX VITRANOL FE TABLET N PA Document  
mv-mn no.86/iron/folic acid DERMACINRX VITREXATE FE TABLET N PA Document  
mv-mn no.89/iron/folic acid DERMACINRX RIBOTIN-E TABLET N PA Document  
mv-mn no.89/iron/folic acid DERMACINRX ZINTREXYL-C TABLET N PA Document  
mv-mn no.89/iron/folic acid DERMACINRX FOLITIN-Z TABLET N PA Document  
mv-mn no.89/iron/folic acid DERMACINRX FOLIFLEX TABLET N PA Document  
mv-mn/folic/Q10/lycopen/lutein ONE-DAILY MULTI CAPSULE N PA Document  
mv,min10/folic acid/D3/ALA/lut STROVITE ONE TABLET N PA Document  
om-3/dha/epa/B12/FA/B6/phytost VIT 3 CAPSULE N PA Document  
vit A/C/E ac/ZnOx/cupric oxide EYEPROTECT TABLET N PA Document  
vit C/E/cuperic/zinc/lutein EYE MULTIVITAMIN WITH LUTEIN CAPSULE N PA Document  
vits A,C,E/lutein/minerals HEALTHY EYES TABLET N PA Document  
vits A,C,E/lutein/minerals OCUVITE WITH LUTEIN TABLET N PA Document  
A/C/E/zinc/sod selenate/copper PROSIGHT TABLET PA Document  
antiox.mv no.10/omeg3s/lut/zea I-CAPS CAPSULE PA Document  
B-complex with vitamin C B-COMPLEX PLUS VITAMIN C TABLET PA Document  
B-complex with vitamin C VITAMIN B COMPLEX W/C TABLET PA Document  
B-complex with vitamin C BEROCCA TABLET PA Document  
B-complex with vitamin C FORMULA-B TABLET PA Document  
B1,B2,B3,B6,B12/dexpan/Zn/mang ELDERTONIC ELIXIR PA Document  
B1/B2/B3/B5/B6/iron/meth/choln GERITOL TONIC LIQUID PA Document  
B2/vits A,C,E/lut/zeaxanth/min ICAPS TABLET ER PA Document  
ferrous fum/folic acid/Bcomp,C DIALYVITE 800 WITH IRON TABLET PA Document  
iron/vitamin B comp and C GERI-TABS TABLET PA Document  
lecithin/pyridoxine/kelp ALL-IN-ONE TABLET PA Document  
m-vit,tx,iron,mins/calc/folic THERA-M TABLET PA Document  
multivit with iron,hematinic CERTA-VITE TABLET PA Document  
multivit with iron,hematinic CENTURY TABLET PA Document  
multivit with iron,minerals MAY-VITA ELIXIR PA Document  
multivit with iron,minerals GEVRATONIC LIQUID PA Document  
multivit with iron,minerals VITA DEC TABLET PA Document  
multivit with iron,minerals COMPETE TABLET PA Document  
multivit with iron,minerals CERTA-VITE SILVER TABLET PA Document  
multivit with iron,minerals SUPER MEGA PLEX TABLET ER PA Document  
multivit-min 103/levomefol/inu LIVITA FOR ADULT LIQUID PA Document  
multivit-min/FA/lutein/zeaxant ICAPS MV TABLET DR PA Document  
multivit-min/ferrous gluconate CENTRUM LIQUID PA Document  
multivit-min/iron/FA/vit K/lut CENTRUM SILVER WOMEN TABLET PA Document  
multivit-min36/iron/folic acid GERITOL COMPLETE TABLET PA Document  
multivit-minerals/FA/lycopene ONE DAILY TABLET PA Document  
multivit,calc,mins/iron/folic ONE DAILY WOMEN'S HEALTH TABLET PA Document  
multivit,stress formula/zinc STRESS FORMULA W/ZINC TABLET PA Document  
multivit,stress formula/zinc STRESS-600 WITH ZINC TABLET PA Document  
multivit,ther.w-iron,hematinic BEROCCA PLUS TABLET PA Document  
multivit,ther.w-iron,hematinic THERAGRAN HEMATINIC TABLET PA Document  
multivit,ther.w-iron,hematinic VITALIZE PLUS TABLET PA Document  
multivit/iron/folic acid/hb179 MEGA MULTI TABLET PA Document  
multivit/iron/folic acid/hb179 MEGA MULTIVITAMIN TABLET PA Document  
multivitamin with iron TAB-A-VITE W/IRON TABLET PA Document  
multivitamin with iron PMS TABLET PA Document  
multivitamin with minerals L-TONIC ELIXIR PA Document  
multivitamin with minerals HAIR, SKIN & NAILS TABLET PA Document  
multivitamin with minerals TAB-A-VITE W/MINERALS TABLET PA Document  
multivitamin with minerals ICAPS PLUS TABLET PA Document  
multivitamin,stress formula STRESS FORMULA TABLET PA Document  
mv-min no.9/folic/saw palm frt UDAMIN SP TABLET PA Document  
mv-min/FA/D3/om-3/dha/epa/fish CARDIAMIN CAPSULE PA Document  
mv-min/FA/vit K/lutein/zeaxant PRESERVISION AREDS 2 PLUS MV CAPSULE PA Document  
mv-min/FA/vit K/lycop/lut/zeax OCUVITE EYE PLUS MULTI TABLET PA Document  
mv-min/folic/K1/lycopen/lutein CENTURY ULTIMATE MEN'S TABLET PA Document  
mv-mins/folic/lycopene/ginkgo ONE DAILY MEN'S 50+ TABLET PA Document  
mv-mn/folic acid/lutein/hrb178 MEGA MULTI TABLET PA Document  
mv-mn/om3/dha/epa/fish/lut/zea OCUVITE ADULT 50 PLUS CAPSULE PA Document  
mv,iron/folic/D3/om-3/dha/epa PRORENAL QD CAPSULE PA Document  
vit A/vit C/vit E/zinc/copper PRESERVISION AREDS CAPSULE PA Document  
vit A/vit C/vit E/zinc/copper ICAPS AREDS CAPSULE PA Document  
vit A/vit C/vit E/zinc/copper PRESERVISION AREDS TABLET PA Document  
vit C/E/cuperic/zinc/lutein PRESERVISION LUTEIN CAPSULE PA Document  
vit C/E/zinc ox/copp/lut/zeax ICAPS AREDS2 CAPSULE PA Document  
vitamins A and D VITAMIN A AND D CAPSULE PA Document  
vitC/E/zinc/copper/lutein/zeax ICAPS AREDS2 TAB CHEW PA Document  
vitC/E/zinc/copper/lutein/zeax ICAPS AREDS2 TABLET PA Document  
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