B-vitamins, 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
cyanocobalamin (vitamin B-12) B-12 DROPS Y    
cyanocobalamin (vitamin B-12) VITAMIN B-12 LOZENGE Y    
cyanocobalamin (vitamin B-12) B-12 LOZENGE Y    
cyanocobalamin (vitamin B-12) B-12 DUAL SPECTRUM TAB IR ER Y    
cyanocobalamin (vitamin B-12) B-12 TAB RAPDIS Y    
cyanocobalamin (vitamin B-12) VITAMIN B12 TAB RAPDIS Y    
cyanocobalamin (vitamin B-12) VITAMIN B-12 TAB RAPDIS Y    
cyanocobalamin (vitamin B-12) VITAMIN B-12 TAB SUBL Y    
cyanocobalamin (vitamin B-12) B-12 TAB SUBL Y    
cyanocobalamin (vitamin B-12) VITAMIN B-12 TABLET Y    
cyanocobalamin (vitamin B-12) B-12 TABLET Y    
cyanocobalamin (vitamin B-12) B-12 DOTS TABLET Y    
cyanocobalamin (vitamin B-12) VITAMIN B12 TABLET Y    
cyanocobalamin (vitamin B-12) VITAMIN B-12 TABLET Y    
pyridoxine HCl (vitamin B6) VITAMIN B-6 TABLET Y    
pyridoxine HCl (vitamin B6) PYRIDOXINE HCL TABLET Y    
pyridoxine HCl (vitamin B6) B-6 TABLET Y    
pyridoxine HCl (vitamin B6) PYRIDOXINE HCL TABLET Y    
pyridoxine HCl (vitamin B6) VITAMIN B-6 TABLET Y    
thiamine HCl VITAMIN B-1 TABLET Y    
thiamine HCl HM VITAMIN B1 TABLET Y    
thiamine HCl THIAMINE HCL TABLET Y    
thiamine HCl B-1 TABLET Y    
thiamine HCl VITAMIN B-1 TABLET Y    
thiamine mononitrate (vit B1) VITAMIN B-1 TABLET Y    
thiamine mononitrate (vit B1) VITAMIN B-1 TABLET Y    
acetylcyst/methylB12/levomefol L-METHYL-MC NAC TABLET N    
acetylcyst/methylB12/levomefol METAFOLBIC PLUS TABLET N    
B cmplx 4/vit D3/C/folic/zinc VITAL-D RX TABLET N    
B comp no3/folic/C/biotin/zinc NEPHPLEX RX TABLET N    
B complex 11/folic/C/biot/zinc DIALYVITE ZINC TABLET N    
B complex w-C no.20/folic acid NEPHROCAPS CAPSULE N    
B complex w-C no.20/folic acid RENAL CAPS CAPSULE N    
B complex w-C no.20/folic acid RENO CAPS CAPSULE N    
B complex w-C no.20/folic acid TRIPHROCAPS CAPSULE N    
B complex w-C no.20/folic acid VIRT-CAPS CAPSULE N    
B,C/folic/zinc/selenometh/D3/E RENAPLEX-D TABLET N    
cyanocobalamin (vitamin B-12) NASCOBAL SPRAY N    
cyanocobalamin (vitamin B-12) VITAMIN B-12 TABLET ER N    
cyanocobalamin/folic ac/vit B6 FABB TABLET N    
cyanocobalamin/folic ac/vit B6 FOLBEE TABLET N    
cyanocobalamin/folic ac/vit B6 FOLGARD RX TABLET N    
cyanocobalamin/folic ac/vit B6 FOLTABS 800 TABLET N    
cyanocobalamin/folic ac/vit B6 VIRT-VITE TABLET N    
cyanocobalamin/folic ac/vit B6 VIRT-GARD TABLET N    
cyanocobalamin/folic ac/vit B6 TL GARD RX TABLET N    
cyanocobalamin/folic acid FOLTRATE TABLET N    
FA7/pc,pe dha/nac/pap/if/mv46 PURALOR CI TAB CH BPH N    
folic acid/B complex C no.17 VIRT-VITE PLUS TABLET N    
folic acid/B cplx/C/selen/zinc DIALYVITE 3000 TABLET N    
folic acid/mv-mn/yohim/gin/dam UROSEX TABLET N    
folic acid/vit B complex and C DIALYVITE 800 TAB CHEW N    
folic acid/vit B complex and C DIALYVITE TABLET N    
iron/FA/dha/epa/FAD/NADH/mv47 ENLYTE CAP IR DR N    
levomefolate calcium L-METHYLFOLATE TABLET N    
levomefolate calcium L-METHYLFOLATE CALCIUM TABLET N    
levomefolate/algal oil LEVOMEFOLATE CALCIUM-ALGAL CAPSULE N    
levomefolate/algal oil L-METHYLFOLATE FORTE CAPSULE N    
mecobal/levomefolat Ca/B6 phos L-METHYL-B6-B12 TABLET N    
mecobal/levomefolat Ca/B6 phos FOLTANX TABLET N    
multivit-mins 25/folic acid/D3 DIALYVITE SUPREME D TABLET N    
multivit-mins no.11/folic acid DIALYVITE 5000 TABLET N    
vit B comp no.3/folic/C/biotin VP-VITE RX TABLET N    
vit B comp no.3/folic/C/biotin VOL-CARE RX TABLET N    
vit B comp no.3/folic/C/biotin RENA-VITE RX TABLET N    
vit B comp no.3/folic/C/biotin NEPHRO-VITE RX TABLET N    
vit B complx C/folic acid/zinc RENAPLEX TABLET N    
vit B cplx C no.13/folic ac/D3 NEPHROCAPS QT TAB RAPDIS N    
B complex C no.10/folic acid NEPHRONEX LIQUID    
B,C/ferrous fum/FA/D3/zinc ox PRORENAL TABLET    
B12/levomefolate calcium/B-6 FOLBIC RF TABLET    
biotin BIOTIN CAPSULE    
biotin BIOTIN TABLET    
cyanocobalamin (vitamin B-12) VITAMIN B-12 TABLET    
cyanocobalamin/folic ac/vit B6 FOLBIC TABLET    
cyanocobalamin/folic ac/vit B6 FOLIC ACID-VIT B6-VIT B12 TABLET    
cyanocobalamin/folic ac/vit B6 FOLPLEX 2.2 TABLET    
cyanocobalamin/folic ac/vit B6 VIRT-VITE FORTE TABLET    
cyanocobalamin/folic ac/vit B6 NIVA-FOL TABLET    
folic ac/vit Bcomp,C/Zn/vit D3 DIALYVITE 800-ULTRA D TABLET    
folic acid FOLIC ACID TABLET    
folic acid/vit B complex and C FOLBEE PLUS TABLET    
folic acid/vit Bcomp,C/Cu/zinc FOLBEE PLUS CZ TABLET    
folic/arginine/B12/B6/b.pepper FOLBEE AR TABLET    
l-mefol/a-cyst/meB12/algal oil METAFOLBIC PLUS RF TABLET    
l-mefol/a-cyst/meB12/algal oil LEVOMEFOLATE-NAC-MECOBAL-ALGAL TABLET    
leucovorin/pyridox/mecobalamin FOLINIC-PLUS TABLET    
levomefolate calcium DENOVO CAPSULE    
levomefolate calcium L-METHYLFOLATE TABLET    
levomefolate calcium L-METHYLFOLATE CALCIUM TABLET    
levomefolate/B6/B12/algal oil FOLTANX RF CAPSULE    
levomefolate/B6/B12/algal oil LEVOMEFOL-PYRIDOXAL-MEC-ALGAL CAPSULE    
lmefolate/D3/magnesium/nac/cal FOLENE CAPSULE    
pyridoxine HCl (vitamin B6) VITAMIN B-6 TABLET    
pyridoxine HCl (vitamin B6) VITAMIN B-6 TABLET ER    
vit B comp C/folic acid/vit D3 DIALYVITE 800 PLUS D TAB CHEW    
vit B comp/C/folic/iron/vit E STRESS FORMULA WITH IRON TABLET    
vit B complex 100 combo no.2 B100 BALANCED TABLET ER    
vit B complex 100 no.2/herbs NATURAL BALANCED B-100 TABLET    
vit B complex 100 no.3/herbs BALANCED B-100 TABLET    
vit B complx C/folic acid/zinc DIALYVITE 800 WITH ZINC TABLET    
vit B12/levomefolate/vit B6/B2 METAFOLBIC TABLET    
vit B12/levomefolate/vit B6/B2 L-METHYL-MC TABLET    
vit B6/me-thfolate/me-B12/ALA NUFOLA CAPSULE    
vit D3/folic acid/B2/B6/B12 FOLGARD TABLET    
vitamin B complex VITAMIN B COMPLEX TABLET    
vitamin B complex B-COMPLEX SUPER TABLET    
vitamin B complex B-COMPLEX MEGA TABLET    
vitamin B complex BALANCED B-50 TABLET    
vitamin B complex BALANCE B-50 TABLET    
vitamin B complex B50 BALANCED TABLET    
vitamin B complex/minerals STRESS FORMULA TABLET    
yeast,dried (S. cerevisiae) BREWER'S YEAST TABLET