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 | Carveout ‐ Bill FFS |
New Drug Evaluation & Updates |
|---|---|---|---|---|---|---|
| PNV 11/iron fum/folic acid/om3 | C-NATE DHA | CAPSULE | Y | N | ||
| PNV 30/iron carb,ag/folic/om3 | OB COMPLETE WITH DHA | CAPSULE | Y | N | ||
| PNV 66/iron/folic/docusate/dha | PNV-DHA + DOCUSATE | CAPSULE | Y | N | ||
| PNV 80/iron fum/folic/dss/dha | PRENAISSANCE | CAPSULE | Y | N | ||
| PNV no.52/iron/FA/omega-3/dha | WESNATAL DHA COMPLETE | COMBO. PKG | Y | N | ||
| PNV w-CA8/iron/FA/lmefolate Ca | PNV-IRON | TABLET | Y | N | ||
| PNV,calcium 72/iron/folic acid | M-NATAL PLUS | TABLET | Y | N | ||
| PNV,calcium 72/iron/folic acid | WESTAB PLUS | TABLET | Y | N | ||
| PNV/iron b-g,fum/folic acid | VINATE II | TABLET | Y | N | ||
| PNV/iron ps cplx/folic acid | NIFEREX-PN FORTE | TABLET | Y | N | ||
| PNV72/iron,gluc/folic/dss/dha | CITRANATAL 90 DHA | COMBO. PKG | Y | N | ||
| PNV83/iron,carb,asp/folic acid | OB COMPLETE PREMIER | TABLET | Y | N | ||
| prenatal 147/iron/folic acid | EMBRIVA | TABLET | Y | N | ||
| prenatal 199/iron/folate no.10 | FOLATEXCEL | TABLET | Y | N | ||
| prenatal 25/iron/folate 6/dha | VITAMEDMD ONE RX | CAPSULE | Y | N | ||
| prenatal 26/iron ps/folic/dha | VITAFOL-ONE | CAPSULE | Y | N | ||
| prenatal 56/iron/folic ac/dha | OB COMPLETE PETITE | CAPSULE | Y | N | ||
| prenatal 59/iron/folic/dss/dha | VP-CH PLUS | CAPSULE | Y | N | ||
| prenatal 71/iron/folic ac/dha | VITAPEARL | CAP IR DR | Y | N | ||
| prenatal 78/iron/folate 1/dha | PRENATE DHA | CAPSULE | Y | N | ||
| prenatal no.77/iron asp gly/FA | PRENATE STAR | TABLET | Y | N | ||
| prenatal vit 27,calc/iron/FA | TRINATAL RX 1 | TABLET | Y | N | ||
| prenatal vit 65/iron fum,ps/FA | PROVIDA OB | CAPSULE | Y | N | ||
| prenatal vit 87/iron/folic/dha | PRENATE MINI | CAPSULE | Y | N | ||
| prenatal vit,cal 76/iron/folic | THRIVITE RX | TABLET | Y | N | ||
| prenatal vit/iron carb,sulf/FA | VINATAL FORTE | TABLET | Y | N | ||
| prenatal vits 85/iron/FA 1/dha | PRENATE PIXIE | CAPSULE | Y | N | ||
| prenatal,calc 40/iron/folate 1 | PNV-SELECT | TABLET | Y | N | ||
| iron/FA/dha/epa/FAD/NADH/mv47 | ENLYTE | CAP IR DR | N | N | ||
| PNV 112/iron/folic/om3/dha/epa | VITAFOL GUMMIES | TAB CHEW | N | N | ||
| PNV no.197/iron/folate no.10 | NEOMATERNA | TABLET | N | N | ||
| PNV no.95/ferrous fum/folic ac | PRENATAL VITAMINS | TABLET | N | N | ||
| prenatal 181/iron fum/folate | ALTRIXA OB | TABLET | N | N | ||
| prenatal no.137/iron/folic ac | PRENATAL VITAMIN | TABLET | N | N | ||
| prenatal vit no.126/iron/folic | CLASSIC PRENATAL | TABLET | N | N | ||
| prenatal vit no.180/iron/folic | PRENATAL PLUS VITAMIN-MINERAL | TABLET | N | N | ||
| folic/calcium/D3/Mg cit/a-cyst | FOLCYTEINE | TABLET | N | |||
| PNV no.154/iron fum/folic acid | NEO-VITAL RX | TABLET | N | |||
| prenatal 93/iron/folate 9/dha | WESTGEL DHA | CAPSULE | N |