Prenatal Vitamins

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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.
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
PNV 11/iron fum/folic acid/om3 C-NATE DHA CAPSULE Y    
PNV 11/iron fum/folic acid/om3 WESNATE DHA CAPSULE Y    
PNV 11/iron fum/folic acid/om3 VIRT-NATE DHA CAPSULE Y    
PNV 119/iron fum/folic acid SE-NATAL-19 TABLET Y    
pnv 156/iron/lmfol/om3/dha/epa TRICARE PRENATAL DHA ONE CAPSULE Y    
PNV 30/iron carb,ag/folic/om3 OB COMPLETE WITH DHA CAPSULE Y    
PNV 66/iron/folic/docusate/dha PNV-DHA + DOCUSATE CAPSULE Y    
PNV 67/iron ps/folate no.1/dha VITAFOL ULTRA CAPSULE Y    
PNV 69/iron/folic/docusate/dha PRENAISSANCE PLUS CAPSULE Y    
PNV 76/iron,gluc/folic/dss/dha CITRANATAL DHA COMBO. PKG Y    
PNV 80/iron fum/folic/dss/dha PRENAISSANCE CAPSULE Y    
PNV 85/iron/folic/dha/fish oil OB COMPLETE ONE CAPSULE Y    
PNV cmb 52/iron/FA/omega-3/dha TRUST NATAL DHA COMBO. PKG Y    
PNV cmb 52/iron/FA/omega-3/dha COMPLETE NATAL DHA COMBO. PKG Y    
PNV no.118/iron fumarate/FA SE-NATAL 19 TAB CHEW Y    
PNV w-CA8/iron/FA/Lmefolate Ca PNV-IRON TABLET Y    
PNV,Ca42/iron/FA/Lmefolate/dha PNV-DHA PLUS CAPSULE Y    
PNV,calcium 72/iron/folic acid M-NATAL PLUS TABLET Y    
PNV,calcium 72/iron/folic acid WESTAB PLUS TABLET Y    
PNV,calcium 72/iron/folic acid PREPLUS TABLET Y    
PNV,calcium 72/iron/folic acid PRENATAL VITAMIN PLUS LOW IRON TABLET Y    
PNV/iron fum,b-g/folic acid VINATE II TABLET Y    
PNV/iron ps cplx/folic acid NIFEREX-PN FORTE TABLET Y    
PNV/iron ps cplx/folic acid NIFEREX-PN TABLET Y    
PNV59/iron,carb,fum/FA/dss/dha CITRANATAL HARMONY CAPSULE Y    
PNV72/iron,gluc/folic/dss/dha CITRANATAL 90 DHA COMBO. PKG Y    
PNV73/iron,gluc/folic/dss/dha CITRANATAL ASSURE COMBO. PKG Y    
PNV83/iron,carb,asp/folic acid OB COMPLETE PREMIER TABLET Y    
prenatal 114/iron a-g/folate 1 PRENATE ELITE TABLET Y    
prenatal 118/iron/folate 6/dha PRIMACARE CAPSULE Y    
prenatal 26/iron ps/folic/dha VITAFOL-ONE CAPSULE Y    
prenatal 34/iron/folic/dss/dha VP-CH-PNV CAPSULE Y    
prenatal 59/iron/folic/dss/dha VP-CH PLUS CAPSULE Y    
prenatal 78/iron/folate 1/dha PRENATE DHA CAPSULE Y    
prenatal 87/iron bis/folic/dha NESTABS DHA COMBO. PKG Y    
prenatal no.52/iron/FA/dha VP-PNV-DHA CAPSULE Y    
prenatal no.75/iron/folate no1 VITAFOL NANO TABLET Y    
prenatal no.77/iron asp gly/FA PRENATE STAR TABLET Y    
prenatal no13/iron ps/folate 1 SELECT-OB TAB CHEW Y    
prenatal vit 10/iron fum/folic VITAFOL-OB TABLET Y    
prenatal vit 10/iron/folic/dha VITAFOL-OB+DHA COMBO. PKG Y    
prenatal vit 14/iron fum/folic COMPLETENATE TAB CHEW Y    
prenatal vit 33/iron/folic/dha SELECT-OB + DHA COMBO. PKG Y    
prenatal vit 85/iron/FA 1/dha PRENATE PIXIE CAPSULE Y    
prenatal vit 87/iron/folic/dha PRENATE MINI CAPSULE Y    
prenatal vit,calc76/iron/folic PNV 29-1 TABLET Y    
prenatal vit,calc76/iron/folic THRIVITE RX TABLET Y    
prenatal vit,calc78/iron/folic PRETAB TABLET Y    
prenatal vit/iron carb&sulf/FA VINATAL FORTE TABLET Y    
prenatal vit/iron fum/folic ac MISSION PRENATAL RX TABLET Y    
prenatal vit103/iron fum/folic TRICARE TABLET Y    
prenatal vit128/iron/folic acd SELECT-OB TAB CHEW Y    
prenatal vit136/iron/folic acd MATERNITY TABLET Y    
prenatal vit27,calcium/iron/FA TRINATAL RX 1 TABLET Y    
prenatal vit68/iron/FA no6/dha PRENATE ENHANCE CAPSULE Y    
prenatal vit69/iron/folate6/dh PRENATE RESTORE CAPSULE Y    
prenatal vit86/iron/folic acid NESTABS TABLET Y    
prenatal,calc.40/iron/folate 1 PNV-SELECT TABLET Y    
prenatal56/iron/folic acid/dha OB COMPLETE PETITE CAPSULE Y    
prenatal81/iron/folic/docusate CITRANATAL RX TABLET Y    
Pv w-o Vit A/iron/docus/FA/Zn PRENATAL COMBOPAK CAP SEQ Y    
iron/FA/dha/epa/FAD/NADH/mv47 ENLYTE CAP IR DR N    
PNV 102/iron/folate/dha VITAFOL FE PLUS CAPSULE N    
PNV 112/iron/folic/om3/dha/epa VITAFOL GUMMIES TAB CHEW N    
PNV no.63/iron,carb/folic/dha STUART ONE CAPSULE N    
PNV no.95/ferrous fum/folic ac PRENATAL VITAMINS TABLET N    
prenatal 148/iron/folate 6/dha TENDERA-OB CAPSULE N    
prenatal 181/iron fum/folate MULTI-MAC TABLET N    
prenatal 48/iron/folic acid/B6 CITRANATAL B-CALM TABLET SEQ N    
prenatal 48/iron/folic acid/B6 VINACAL B TABLET SEQ N    
prenatal no.116/iron/folic/dha EXPECTA PRENATAL COMBO. PKG N    
prenatal no.137/iron/folic acd PRENATAL VITAMIN TABLET N    
prenatal vit calc,iron,folic PRENATAL OTC TABLET N    
prenatal vit no.126/iron/folic CLASSIC PRENATAL TABLET N    
prenatal vit no.170/iron/folic DERMACINRX PRENATRIX TABLET N    
prenatal vit no.170/iron/folic DERMACINRX PRENATRYL TABLET N    
prenatal vit no.170/iron/folic DERMACINRX PRETRATE TABLET N    
prenatal vit no.180/iron/folic PRENATAL PLUS VITAMIN-MINERAL TABLET N    
prenatal vit/iron fum/folic ac O-CAL FA TABLET N    
prenatl vit6/iron/FA/B12/Ca/D3 MTERYTI FOLIC 5 TABLET SEQ N    
prenatl vit6/iron/FA/B12/Ca/D3 MTERYTI TABLET SEQ N    
folic/calcium/D3/Mg cit/a-cyst FOLITE TABLET    
PNV 102/iron/folate 1/dss/dha VITAFOL FE+ CAPSULE    
prenatal 93/iron/folate 9/dha WESTGEL DHA CAPSULE    
prenatal 93/iron/folate 9/dha TRISTART DHA CAPSULE    
prenatal vit no.124/iron/folic PRENATAL VITAMIN TABLET