Prenatal Vitamins
PDL Reference 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 |
|---|---|---|---|---|---|
| PNV 11/iron fum/folic acid/om3 | C-NATE DHA | CAPSULE | Y | ||
| PNV 11/iron fum/folic acid/om3 | VIRT-NATE DHA | CAPSULE | Y | ||
| PNV 11/iron fum/folic acid/om3 | WESNATE DHA | CAPSULE | Y | ||
| PNV 119/iron fum/folic acid | SE-NATAL-19 | TABLET | 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 | WESNATAL DHA COMPLETE | 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 no.164/iron/folate no.6 | NATAL PNV | TABLET | 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 | WESTAB PLUS | TABLET | Y | ||
| PNV,calcium 72/iron/folic acid | PRENATAL VITAMIN PLUS LOW IRON | TABLET | Y | ||
| PNV,calcium 72/iron/folic acid | M-NATAL PLUS | TABLET | Y | ||
| PNV/iron fum,b-g/folic acid | VINATE II | TABLET | Y | ||
| PNV/iron ps cplx/folic acid | NIFEREX-PN | TABLET | Y | ||
| PNV/iron ps cplx/folic acid | NIFEREX-PN FORTE | 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 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 | ||
| 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.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 PRETRATE | TABLET | N | ||
| prenatal vit no.170/iron/folic | DERMACINRX PRENATRYL | TABLET | N | ||
| prenatal vit no.170/iron/folic | DERMACINRX PRENATRIX | 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 | ||
| 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 | TRISTART DHA | CAPSULE | |||
| prenatal 93/iron/folate 9/dha | WESTGEL DHA | CAPSULE | |||
| prenatal vit no.124/iron/folic | PRENATAL VITAMIN | TABLET |