Multivitamins, Oral
PDL Reference Documents
Drug Use Review 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 |
|---|---|---|---|---|---|---|
| beta-carotene(A)-vits C,E/mins | OCUTABS | TABLET | Y | Pharmacy PA | N | |
| beta-carotene(A)-vits C,E/mins | OPTI-VITAMINS | TABLET | Y | Pharmacy PA | N | |
| folic acid/vit B complex and C | NEPHRO-VITE | TABLET | Y | Pharmacy PA | N | |
| multivit 47/iron/folate 1/dha | WESCAP-PN DHA | CAPSULE | Y | Pharmacy PA | N | |
| multivit 47/iron/folate 1/dha | ZATEAN-PN DHA | CAPSULE | Y | Pharmacy PA | N | |
| multivit no.42/iron/folate/dha | NESTABS ONE | CAPSULE | Y | Pharmacy PA | N | |
| multivit no.48/iron fum/FA/dha | CALCIUM PNV | CAPSULE | Y | Pharmacy PA | N | |
| multivit with minerals/lutein | SUPER AYTINAL | TABLET | Y | Pharmacy PA | N | |
| multivit with minerals/lutein | CENTRAL-VITE SELECT | TABLET | Y | Pharmacy PA | N | |
| multivit with minerals/lutein | CENTURY WITH LUTEIN | TABLET | Y | Pharmacy PA | N | |
| multivit with minerals/lutein | MULTIVITAMINS WITH MINERALS | TABLET | Y | Pharmacy PA | N | |
| multivit-min/FA/lycopen/lutein | CENTRAL-VITE | TABLET | Y | Pharmacy PA | N | |
| multivit-min69/iron/folic acid | OB COMPLETE | TABLET | Y | Pharmacy PA | N | |
| multivitamin | ULTRA-MEGA | TABLET | Y | Pharmacy PA | N | |
| multivitamin | TAB-A-VITE | TABLET | Y | Pharmacy PA | N | |
| multivitamin | OPTIVITE P.M.T. | TABLET | Y | Pharmacy PA | N | |
| multivitamin | MULTIVITAMIN | TABLET | Y | Pharmacy PA | N | |
| multivitamin | MULTIPLE DAILY W/BETA | TABLET | Y | Pharmacy PA | N | |
| multivitamin | ESSENTIAL ONE DAILY | TABLET | Y | Pharmacy PA | N | |
| multivitamin | CENTRAL VITE | TABLET | Y | Pharmacy PA | N | |
| multivitamin | DAILY MULTIPLE VITAMIN | TABLET | Y | Pharmacy PA | N | |
| multivitamin/iron/folic acid | MULTI-VITE | TABLET | Y | Pharmacy PA | N | |
| mv-mins 71/iron/folic no.1/dha | ZATEAN-PN PLUS | CAPSULE | Y | Pharmacy PA | N | |
| mvn no.53/iron/folic/dss/dha | TARON-PREX PRENATAL | CAPSULE | Y | Pharmacy PA | N | |
| mvn-min 74/iron fum/iron/FA | FOLIVANE-OB | CAPSULE | Y | Pharmacy PA | N | |
| mvn-min75/iron/iron ps/om3/dha | TARON-C DHA | CAPSULE | Y | Pharmacy PA | N | |
| mvn-min75/iron/iron ps/om3/dha | WESCAP-C DHA | CAPSULE | Y | Pharmacy PA | N | |
| vitamin B complex | BALANCED B-50 | CAPSULE | Y | Pharmacy PA | N | |
| vitamin B complex | VITAMIN B COMPLEX | CAPSULE | Y | Pharmacy PA | N | |
| C/E/zinc/copper/lut/zeax/coQ10 | PRESERVISION AREDS 2 CO Q-10 | CAPSULE | N | Pharmacy PA | N | |
| lmefolate/B3/copp/Zn/sel/chrom | NICOMIDE | TABLET | N | Pharmacy PA | N | |
| multivit no.18/iron no.1/folic | TANDEM PLUS | CAPSULE | N | Pharmacy PA | N | |
| multivit no.18/iron no.1/folic | PUREVIT DUALFE PLUS | CAPSULE | N | Pharmacy PA | N | |
| multivit no.35/levomefolate | DERMACINRX MULTIVITAMIN | TAB CHEW | N | Pharmacy PA | N | |
| multivit no.62/iron/levomefol | DAVIMET WITH IRON | TAB CHEW | N | Pharmacy PA | N | |
| multivit-min no.86/folic acid | DERMACINRX VITREXATE | TABLET | N | Pharmacy PA | N | |
| multivit-min no.86/folic acid | DERMACINRX VITRAMYN | TABLET | N | Pharmacy PA | N | |
| multivit-min no.86/folic acid | DERMACINRX VENEXA | TABLET | N | Pharmacy PA | N | |
| multivit-min/ferrous gluconate | LIQUID MULTIVITAMIN | LIQUID | N | Pharmacy PA | N | |
| multivit-mins no.20/iron/folic | BACMIN | TABLET | N | Pharmacy PA | N | |
| multivit,calc,mins/iron/folic | THERA M PLUS | TABLET | N | Pharmacy PA | N | |
| multivitamin no.58/folic acid | DERMACINRX DAVIMET | TAB CHEW | N | Pharmacy PA | N | |
| multivitamin with folic acid | THERA | TABLET | N | Pharmacy PA | N | |
| mv-min no.83/iron/folate no.10 | NUTRALYN | TABLET | N | Pharmacy PA | N | |
| mv-min no.83/iron/folate no.10 | AFLORA | TABLET | N | Pharmacy PA | N | |
| mv-mins no.109/iron/lmefolate | FINAZOL | TABLET | N | Pharmacy PA | N | |
| mv-mins no.73/iron fum/folic | DERMACINRX DEXATRAN | CAPSULE | N | Pharmacy PA | N | |
| mv-mn no.105/levomefol calc/K1 | DIATROL | TABLET | N | Pharmacy PA | N | |
| mv-mn no.86/iron/folic acid | DERMACINRX VENTRIXYL FE | TABLET | N | Pharmacy PA | N | |
| mv-mn no.86/iron/folic acid | DERMACINRX VENEXA FE | TABLET | N | Pharmacy PA | N | |
| mv-mn no.89/iron/folic acid | DERMACINRX RIBOTIN-E | TABLET | N | Pharmacy PA | N | |
| mv,min10/folic acid/D3/ALA/lut | STROVITE ONE | TABLET | N | Pharmacy PA | N | |
| vits A,C,E/lutein/minerals | OCUVITE WITH LUTEIN | TABLET | N | Pharmacy PA | N | |
| A/C/E/zinc/sod selenate/copper | PROSIGHT | TABLET | Pharmacy PA | N | ||
| B-complex with vitamin C | FORMULA-B | TABLET | Pharmacy PA | N | ||
| B2/vits A,C,E/lut/zeaxanth/min | ICAPS | TABLET ER | Pharmacy PA | N | ||
| ferrous fum/folic acid/Bcomp,C | DIALYVITE 800 WITH IRON | TABLET | Pharmacy PA | N | ||
| iron/vitamin B comp and C | GERI-TABS | TABLET | Pharmacy PA | N | ||
| m-vit,tx,iron,mins/calc/folic | THERA-M | TABLET | Pharmacy PA | N | ||
| multivit with iron,minerals | MAY-VITA | ELIXIR | Pharmacy PA | N | ||
| multivit with iron,minerals | GEVRATONIC | LIQUID | Pharmacy PA | N | ||
| multivit with iron,minerals | CERTA-VITE SILVER | TABLET | Pharmacy PA | N | ||
| multivit with iron,minerals | VITA DEC | TABLET | Pharmacy PA | N | ||
| multivit with iron,minerals | COMPETE | TABLET | Pharmacy PA | N | ||
| multivit-min/FA/lutein/zeaxant | ICAPS MV | TABLET DR | Pharmacy PA | N | ||
| multivit-min/iron/FA/vit K/lut | CENTRUM SILVER WOMEN | TABLET | Pharmacy PA | N | ||
| multivit,stress formula/zinc | STRESS-600 WITH ZINC | TABLET | Pharmacy PA | N | ||
| multivit,stress formula/zinc | STRESS FORMULA W/ZINC | TABLET | Pharmacy PA | N | ||
| multivit,ther.w-iron,hematinic | THERAGRAN HEMATINIC | TABLET | Pharmacy PA | N | ||
| multivit,ther.w-iron,hematinic | BEROCCA PLUS | TABLET | Pharmacy PA | N | ||
| multivit/iron/folic acid/hb179 | MEGA MULTI | TABLET | Pharmacy PA | N | ||
| multivitamin with iron | PMS | TABLET | Pharmacy PA | N | ||
| multivitamin with iron | TAB-A-VITE W/IRON | TABLET | Pharmacy PA | N | ||
| multivitamin with minerals | MEDIPLEX PLUS | TABLET | Pharmacy PA | N | ||
| multivitamin with minerals | ICAPS PLUS | TABLET | Pharmacy PA | N | ||
| mv-min no.9/folic/saw palm frt | UDAMIN SP | TABLET | Pharmacy PA | N | ||
| mv-min/folic/K1/lycopen/lutein | CENTURY ULTIMATE MEN'S | TABLET | Pharmacy PA | N | ||
| mv-mn/folic acid/lutein/hrb178 | MEGA MULTI | TABLET | Pharmacy PA | N | ||
| mv-mn/om3/dha/epa/fish/lut/zea | OCUVITE EYE PERFORMANCE | CAPSULE | Pharmacy PA | N | ||
| mv-mn/om3/dha/epa/fish/lut/zea | OCUVITE ADULT 50 PLUS | CAPSULE | Pharmacy PA | N | ||
| mv,iron/folic/D3/om-3/dha/epa | PRORENAL QD | CAPSULE | Pharmacy PA | N | ||
| vit A/vit C/vit E/zinc/copper | ICAPS AREDS | CAPSULE | Pharmacy PA | N | ||
| vit A/vit C/vit E/zinc/copper | PRESERVISION AREDS | CAPSULE | Pharmacy PA | N | ||
| vit A/vit C/vit E/zinc/copper | PRESERVISION AREDS | TABLET | Pharmacy PA | N | ||
| vit C/E/cuperic/zinc/lutein | PRESERVISION LUTEIN | CAPSULE | Pharmacy PA | N | ||
| vitC/E/zinc/copper/lutein/zeax | ICAPS AREDS2 | TAB CHEW | Pharmacy PA | N | ||
| vitC/E/zinc/copper/lutein/zeax | ICAPS AREDS2 | TABLET | Pharmacy PA | N |