Calcium/Vit D Replacement, Oral

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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 but eligible patients will encounter a co-pay at the pharmacy.
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
calcium carbonate CALCI-MIX CAPSULE Y    
calcium carbonate CALCIUM CARBONATE ORAL SUSP Y    
calcium carbonate CALCIUM CARBONATE ORAL SUSP Y    
calcium carbonate CAL-MINT TAB CHEW Y    
calcium carbonate CALCIUM CARBONATE TAB CHEW Y    
calcium carbonate CALCIUM 500 TABLET Y    
calcium carbonate CALCIUM TABLET Y    
calcium carbonate OYSTER SHELL CALCIUM TABLET Y    
calcium carbonate CALCIUM TABLET Y    
calcium carbonate CALCIUM 500 TABLET Y    
calcium carbonate CALCIUM CARBONATE TABLET Y    
calcium carbonate OYSCO-500 TABLET Y    
calcium carbonate CALCIUM CARBONATE TABLET Y    
calcium carbonate SUPER CALCIUM TABLET Y    
calcium carbonate OYSTER SHELL CALCIUM TABLET Y    
calcium carbonate OYST-CAL-500 TABLET Y    
calcium carbonate NATURAL CALCIUM TABLET Y    
calcium carbonate HI-CALCIUM TABLET Y    
calcium carbonate/vitamin D3 CALCIUM CARBONATE/VITAMIN D3 CAPSULE Y    
calcium carbonate/vitamin D3 LIQUID CALCIUM 600-VIT D3 CAPSULE Y    
calcium carbonate/vitamin D3 LIQUID CALCIUM + VITAMIN D CAPSULE Y    
calcium carbonate/vitamin D3 CALCIUM 600-VIT D3 CAPSULE Y    
calcium carbonate/vitamin D3 CAL-QUICK LIQUID Y    
calcium carbonate/vitamin D3 OS-CAL 500+D TAB CHEW Y    
calcium carbonate/vitamin D3 CALCIUM 500 + VIT D TAB CHEW Y    
calcium carbonate/vitamin D3 CALCIUM TAB CHEW Y    
calcium carbonate/vitamin D3 CALTRATE 600 + D TAB CHEW Y    
calcium carbonate/vitamin D3 CALCIUM TAB CHEW Y    
calcium carbonate/vitamin D3 CALCIUM 500 + VIT D TAB CHEW Y    
calcium carbonate/vitamin D3 CALCIUM 500-VIT D3 TABLET Y 500 mg calcium (1,250 mg)-200 unit, 500 mg calcium (1,250 mg)-400 unit Require PA  
calcium carbonate/vitamin D3 CALCIUM 600 + VIT D TABLET Y 600 mg calcium (1,500 mg)-200 unit, 600 mg calcium (1,500 mg)-400 unit Require PA  
calcium carbonate/vitamin D3 OS-CAL 500-VIT D3 TABLET Y 500 mg calcium (1,250 mg)-200 unit Require PA  
calcium carbonate/vitamin D3 OSTEO-PORETICAL TABLET Y    
calcium carbonate/vitamin D3 CALCIUM 1000 + D3 TABLET Y    
calcium citrate CALCIUM CITRATE TABLET Y    
cholecalciferol (vitamin D3) VITAMIN D3 CAPSULE Y 2,000 unit, 400 unit, 5,000 unit Require PA  
cholecalciferol (vitamin D3) MAXIMUM D3 CAPSULE Y    
cholecalciferol (vitamin D3) DECARA CAPSULE Y    
cholecalciferol (vitamin D3) OPTIMAL D3 CAPSULE Y    
cholecalciferol (vitamin D3) D3-50 CAPSULE Y    
cholecalciferol (vitamin D3) VITAMIN D3 TABLET Y 10,000 unit, 400 unit Require PA  
cholecalciferol (vitamin D3) DIALYVITE VITAMIN D3 MAX TABLET Y    
cholecalciferol (vitamin D3) VITAMIN D TABLET Y    
cholecalciferol (vitamin D3) THERA-D TABLET Y    
cholecalciferol (vitamin D3) D3 DOTS TABLET Y    
ergocalciferol (vitamin D2) DRISDOL CAPSULE Y    
ergocalciferol (vitamin D2) VITAMIN D2 CAPSULE Y    
ergocalciferol (vitamin D2) VITAMIN D2 TABLET Y    
calcium carb/D3/magnesium/zinc CAL MAG ZINC-D3 TABLET N PA Document  
calcium carb/magnesium oxid/D3 CALCIUM MAGNESIUM + D TABLET N PA Document  
calcium carb/vit D3/minerals CALCIUM +D & MINERALS TAB CHEW N PA Document  
calcium carb/vit D3/minerals CALCIUM 600+MINERALS TABLET N PA Document  
calcium carb/vitamin D3/vit K1 CALCIUM SOFT CHEW TAB CHEW N PA Document  
calcium carbonate CALCI-CHEW TAB CHEW N PA Document  
calcium carbonate CALCIUM TAB CHEW N PA Document  
calcium carbonate CORAL CALCIUM TABLET N PA Document  
calcium carbonate/vitamin D2 CALCIUM CARBONATE W/VITAMIN D TABLET N PA Document  
calcium carbonate/vitamin D3 OYSCO D TABLET N PA Document  
calcium carbonate/vitamin D3 OYSTER SHELL CALCIUM W-VIT D TABLET N PA Document  
calcium carbonate/vitamin D3 OYSTER SHELL CALCIUM-VIT D3 TABLET N PA Document  
calcium carbonate/vitamin D3 OYSTER SHELL-D TABLET N PA Document  
calcium carbonate/vitamin D3 OYSTER SHELL + D TABLET N PA Document  
calcium carbonate/vitamin D3 CALCIUM 250-VIT D3 TABLET N PA Document  
calcium carbonate/vitamin D3 CALCIUM 500 + VIT D TABLET N PA Document  
calcium carbonate/vitamin D3 CALCIUM 600-VIT D3 TABLET N PA Document  
calcium carbonate/vitamin D3 OYSCO 500-VIT D3 TABLET N PA Document  
calcium citrate CALCITRATE TABLET N PA Document  
calcium citrate CITRACAL LIQUITAB TABLET EFF N PA Document  
calcium citrate/vitamin D3 CALCET TAB CHEW N PA Document  
calcium citrate/vitamin D3 CITRUS CALCIUM + D TABLET N PA Document  
calcium citrate/vitamin D3 CALCITRATE + VIT D TABLET N PA Document  
calcium citrate/vitamin D3 CALCIUM CITRATE - VITAMIN D TABLET N PA Document  
calcium citrate/vitamin D3 CALCIUM CITRATE-VITAMIN D3 TABLET N PA Document  
calcium citrate/vitamin D3 CALCIUM CITRATE - VITAMIN D3 TABLET N PA Document  
calcium citrate/vitamin D3 CITRUS CALCIUM-VITAMIN D3 TABLET N PA Document  
calcium glubionate CALCIONATE SYRUP N PA Document  
calcium gluconate CALCIUM GLUCONATE TABLET N PA Document  
calcium lactate CALCIUM LACTATE TABLET N PA Document  
calcium phosphate dibas/vit D3 RISACAL-D TABLET N PA Document  
calcium/mag/D3/B12/FA/B6/boron FOLGARD OS TABLET N PA Document  
calcium/mag/D3/B12/FA/B6/boron TL G-FOL OS TABLET N PA Document  
calcium/mag/D3/B12/FA/B6/boron CALCIUM-FOLIC ACID PLUS D WAFER N PA Document  
calcium/magnesium/zinc CALCIUM-MAGNESIUM-ZINC TABLET N PA Document  
calcium/magnesium/zinc CALCIUM/MAGNESIUM/ZINC TABLET N PA Document  
cholecalciferol (vitamin D3) DIALYVITE VITAMIN D CAPSULE N PA Document  
cholecalciferol (vitamin D3) D-VITA DROPS N PA Document  
cholecalciferol (vitamin D3) D-VI-SOL DROPS N PA Document  
cholecalciferol (vitamin D3) VITAMIN D3 DROPS N PA Document  
cholecalciferol (vitD3)/vit K2 DOSOQUIN TABLET N PA Document  
ergocalciferol (vitamin D2) CALCIDOL DROPS N PA Document  
ergocalciferol (vitamin D2) CALCIFEROL DROPS N PA Document  
ergocalciferol (vitamin D2) DRISDOL DROPS N PA Document  
ergocalciferol (vitamin D2) ERGOCALCIFEROL DROPS N PA Document  
vitamin D3/folic acid DERMACINRX PUREFOLIX TABLET N PA Document  
calcium HI-CAL TABLET    
calcium carb/mag ox/zinc sulf CALCIUM-MAGNESIUM-ZINC TABLET    
calcium carb/vitamin D3/soyb SOY FORMULA TABLET    
calcium carbonate CALCIUM CARBONATE TABLET    
calcium carbonate/vitamin D2 LIQUID CALCIUM CAPSULE    
calcium carbonate/vitamin D2 CALCIUM CARBONATE W/VITAMIN D TABLET    
calcium carbonate/vitamin D2 OYSTER SHELL CALCIUM W/VIT D TABLET    
calcium carbonate/vitamin D2 OYSTER SHELL CALCIUM W-VIT D TABLET    
calcium carbonate/vitamin D2 OYSTER + D TABLET    
calcium carbonate/vitamin D2 OYSTER SHELL CALCIUM TABLET    
calcium/magnesium/zinc CALCIUM-MAGNESIUM-ZINC TABLET    
dihydrotachysterol DHT TABLET