Multivitamins, Oral

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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 New Drug Evaluation & Updates
beta-carotene(A)-vits C,E/mins OPTI-VITAMINS TABLET Y PA Document  
beta-carotene(A)-vits C,E/mins OCUVITE TABLET Y PA Document  
beta-carotene(A)-vits C,E/mins OCUTABS TABLET Y PA Document  
beta-carotene(A)-vits C,E/mins HP ZINC WITH ANTIOXIDANTS TABLET Y PA Document  
beta-carotene(A)-vits C,E/mins HP ZINC W/ANTIOXIDANTS TABLET Y PA Document  
beta-carotene(A)-vits C,E/mins EYE HEALTH TABLET Y PA Document  
folic acid/vit B complex and C RENAL-VITE TABLET Y PA Document  
folic acid/vit B complex and C NEPHRO-VITE TABLET Y PA Document  
folic acid/vit B complex and C DIALYVITE 800 TABLET Y PA Document  
multivit 38/folate no.6/ginger PRENATE AM TABLET Y PA Document  
multivit 47/iron/folate 1/dha PNV-DHA CAPSULE Y PA Document  
multivit 47/iron/folate 1/dha WESCAP-PN DHA CAPSULE Y PA Document  
multivit 47/iron/folate 1/dha ZATEAN-PN DHA CAPSULE Y PA Document  
multivit no.40/iron/folat1/dha PRENATE ESSENTIAL CAPSULE Y PA Document  
multivit no.42/iron/folate/dha NESTABS ONE CAPSULE Y PA Document  
multivit no.48/iron fum/FA/dha CALCIUM PNV CAPSULE Y PA Document  
multivit with minerals/lutein MULTIVITAMINS WITH MINERALS TABLET Y PA Document  
multivit with minerals/lutein HIGH POTENCY MULTIVITAMIN TABLET Y PA Document  
multivit with minerals/lutein CENTURY WITH LUTEIN TABLET Y PA Document  
multivit with minerals/lutein CENTURY W/LUTEIN TABLET Y PA Document  
multivit with minerals/lutein CENTRAL-VITE SELECT TABLET Y PA Document  
multivit with minerals/lutein ULTRA CHOICE TABLET Y PA Document  
multivit with minerals/lutein CENTRAL VITE SR W-LUTEIN TAB TABLET Y PA Document  
multivit with minerals/lutein MULTI-VITE 50 & OVER TABLET Y PA Document  
multivit with minerals/lutein SUPER AYTINAL TABLET Y PA Document  
multivit with minerals/lutein VITATRUM TABLET Y PA Document  
multivit-min/FA/lycopen/lutein CENTRAL-VITE TABLET Y PA Document  
multivit-min/FA/lycopen/lutein CERTAVITE SENIOR TABLET Y PA Document  
multivit-min/FA/lycopen/lutein COMPLETE 50 PLUS TABLET Y PA Document  
multivit-min/FA/lycopen/lutein SENTRY SENIOR TABLET Y PA Document  
multivit-min69/iron/folic acid ELITE-OB TABLET Y PA Document  
multivit-min69/iron/folic acid OB COMPLETE TABLET Y PA Document  
multivit37/iron/Lmfolate/algal VINATE DHA RF CAPSULE Y PA Document  
multivit41/iron/folate8/ps-dha ENBRACE HR CAP IR DR Y PA Document  
multivitamin CENTRAL VITE TABLET Y PA Document  
multivitamin DAILY VITAMIN TABLET Y PA Document  
multivitamin MULTIVITAMIN TABLET Y PA Document  
multivitamin DAILY MULTIPLE VITAMIN TABLET Y PA Document  
multivitamin OPTIVITE P.M.T. TABLET Y PA Document  
multivitamin TAB-A-VITE TABLET Y PA Document  
multivitamin ULTRA-MEGA TABLET Y PA Document  
multivitamin ONE DAILY TABLET Y PA Document  
multivitamin SIGTAB TABLET Y PA Document  
multivitamin SUPER MEDI-VITE TABLET Y PA Document  
multivitamin VIMAR TABLET Y PA Document  
multivitamin MULTIPLE VITAMIN TABLET Y PA Document  
multivitamin ESSENTIAL ONE DAILY TABLET Y PA Document  
multivitamin MULTIDAY VITES TABLET Y PA Document  
multivitamin MULTIPLE DAILY W/BETA TABLET Y PA Document  
multivitamin no.36/folate no.6 PRENATE CHEWABLE TAB CHEW Y PA Document  
multivitamin,therapeutic ONCOVITE TABLET Y PA Document  
multivitamin/iron/folic acid MULTI-VITE TABLET Y PA Document  
multivitamin/iron/folic acid ONE DAILY WITH IRON TABLET Y PA Document  
multivitamin/iron/folic acid CENTRUM ADULTS TABLET Y PA Document  
multivitamin/iron/folic acid CERTAVITE-ANTIOXIDANT TABLET Y PA Document  
mv-mins 71/iron/folic no.1/dha PNV-OMEGA CAPSULE Y PA Document  
mv-mins 71/iron/folic no.1/dha ZATEAN-PN PLUS CAPSULE Y PA Document  
mvn no.53/iron/folic/dss/dha TARON-PREX PRENATAL CAPSULE Y PA Document  
mvn-min 74/iron fum/iron/FA FOLIVANE-OB CAPSULE Y PA Document  
mvn-min75/iron/iron ps/om3/dha WESCAP-C DHA CAPSULE Y PA Document  
mvn-min75/iron/iron ps/om3/dha TARON-C DHA CAPSULE Y PA Document  
vitamin B complex VITAMIN B COMPLEX CAPSULE Y PA Document  
vitamin B complex BALANCED B-50 CAPSULE Y PA Document  
vitamin B complex VITAMIN B COMPLEX W/VIT B-12 CAPSULE Y PA Document  
folic/mvi ther-min/lycop/lut CORVITA TABLET N PA Document  
lmefolate/B3/copp/Zn/sel/chrom NICOTINAMIDE TABLET N PA Document  
lmefolate/B3/copp/Zn/sel/chrom NICOMIDE TABLET N PA Document  
multivit comb no.61/folic acid ALTRIXA TABLET N PA Document  
multivit no.35/levomefolate DAVIMET-M TAB CHEW N PA Document  
multivit no.62/iron/levomefol DAVIMET WITH IRON TAB CHEW N PA Document  
multivit-min 103/levomefol/inu LIVITA FOR ADULT LIQUID N PA Document  
multivit-min no.86/folic acid DERMACINRX MULTITAM TABLET N PA Document  
multivit-min no.86/folic acid DERMACINRX VENEXA TABLET N PA Document  
multivit-min no.86/folic acid DERMACINRX VITRAMYN TABLET N PA Document  
multivit-min no.86/folic acid DERMACINRX VITREXATE TABLET N PA Document  
multivit-min no.86/folic acid DERMACINRX VENTRIXYL TABLET N PA Document  
multivit-min no.86/folic acid VITREXYL TABLET N PA Document  
multivit-min no.86/folic acid DERMACINRX VITRANOL TABLET N PA Document  
multivit-min/ferrous gluconate LIQUID MULTIVITAMIN LIQUID N PA Document  
multivit-min/ferrous gluconate MULTIVITAMIN-MULTIMINERAL LIQUID N PA Document  
multivit-mins no.20/iron/folic BACMIN TABLET N PA Document  
multivit,calc,mins/iron/folic THERA M PLUS TABLET N PA Document  
multivit,calc,mins/iron/folic THERA-M TABLET N PA Document  
multivit,iron,min 5/folic acid STROVITE FORTE TABLET N PA Document  
multivitamin no.58/folic acid DERMACINRX DAVIMET TAB CHEW N PA Document  
multivitamin with folic acid TAB-A-VITE TABLET N PA Document  
multivitamin with folic acid THERA TABLET N PA Document  
multivitamin with folic acid TM-DAILY VITE TABLET N PA Document  
multivitamin with folic acid TRUE MULTIVITAMIN TABLET N PA Document  
mv-min no.83/iron/folate no.10 FOLIKA-MG TABLET N PA Document  
mv-min no.84/iron gluc/folic FOLIKA-CI TABLET N PA Document  
mv-min102/iron carb,fum/FA/dha CITRANATAL MEDLEY CAPSULE N PA Document  
mv-mins no.109/iron/lmefolate FINAZOL TABLET N PA Document  
mv-mins no.73/iron fum/folic DERMACINRX DEXATRAN CAPSULE N PA Document  
mv-mn no.105/levomefol calc/K1 DIATROL TABLET N PA Document  
mv-mn no.106/levomefolate calc MULTITOL-M TABLET N PA Document  
mv-mn no.86/iron/folic acid VITREXYL PLUS IRON TABLET N PA Document  
mv-mn no.86/iron/folic acid DERMACINRX VITREXATE FE TABLET N PA Document  
mv-mn no.86/iron/folic acid DERMACINRX VITRANOL FE TABLET N PA Document  
mv-mn no.86/iron/folic acid DERMACINRX VENEXA FE TABLET N PA Document  
mv-mn no.86/iron/folic acid DERMACINRX VENTRIXYL FE TABLET N PA Document  
mv-mn no.89/iron/folic acid DERMACINRX FOLITIN-Z TABLET N PA Document  
mv-mn no.89/iron/folic acid DERMACINRX RIBOTIN-E TABLET N PA Document  
mv-mn no.89/iron/folic acid DERMACINRX ZINTREXYL-C TABLET N PA Document  
mv-mn no.89/iron/folic acid DERMACINRX FOLIFLEX TABLET N PA Document  
mv-mn/folic/Q10/lycopen/lutein ONE-DAILY MULTI CAPSULE N PA Document  
mv,min10/folic acid/D3/ALA/lut STROVITE ONE TABLET N PA Document  
om-3/dha/epa/B12/FA/B6/phytost VIT 3 CAPSULE N PA Document  
vit A/C/E ac/ZnOx/cupric oxide EYEPROTECT TABLET N PA Document  
vit C/E/cuperic/zinc/lutein EYE MULTIVITAMIN WITH LUTEIN CAPSULE N PA Document  
vits A,C,E/lutein/minerals HEALTHY EYES TABLET N PA Document  
vits A,C,E/lutein/minerals OCUVITE WITH LUTEIN TABLET N PA Document  
A/C/E/zinc/sod selenate/copper PROSIGHT TABLET PA Document  
antiox.mv no.10/omeg3s/lut/zea I-CAPS CAPSULE PA Document  
B-complex with vitamin C VITAMIN B COMPLEX W/C TABLET PA Document  
B-complex with vitamin C FORMULA-B TABLET PA Document  
B-complex with vitamin C BEROCCA TABLET PA Document  
B1,B2,B3,B6,B12/dexpan/Zn/mang ELDERTONIC ELIXIR PA Document  
B2/vits A,C,E/lut/zeaxanth/min ICAPS TABLET ER PA Document  
ferrous fum/folic acid/Bcomp,C DIALYVITE 800 WITH IRON TABLET PA Document  
iron/vitamin B comp and C GERI-TABS TABLET PA Document  
lecithin/pyridoxine/kelp ALL-IN-ONE TABLET PA Document  
m-vit,tx,iron,mins/calc/folic THERA-M TABLET PA Document  
multivit with iron,hematinic CENTURY TABLET PA Document  
multivit with iron,hematinic CERTA-VITE TABLET PA Document  
multivit with iron,minerals MAY-VITA ELIXIR PA Document  
multivit with iron,minerals GEVRATONIC LIQUID PA Document  
multivit with iron,minerals CERTA-VITE SILVER TABLET PA Document  
multivit with iron,minerals VITA DEC TABLET PA Document  
multivit with iron,minerals COMPETE TABLET PA Document  
multivit with iron,minerals SUPER MEGA PLEX TABLET ER PA Document  
multivit-min/FA/lutein/zeaxant ICAPS MV TABLET DR PA Document  
multivit-min/iron/FA/vit K/lut CENTRUM SILVER WOMEN TABLET PA Document  
multivit-minerals/FA/lycopene ONE DAILY TABLET PA Document  
multivit,calc,mins/iron/folic ONE DAILY WOMEN'S HEALTH TABLET PA Document  
multivit,stress formula/zinc STRESS-600 WITH ZINC TABLET PA Document  
multivit,stress formula/zinc STRESS FORMULA W/ZINC TABLET PA Document  
multivit,ther.w-iron,hematinic VITALIZE PLUS TABLET PA Document  
multivit,ther.w-iron,hematinic THERAGRAN HEMATINIC TABLET PA Document  
multivit,ther.w-iron,hematinic BEROCCA PLUS TABLET PA Document  
multivit/iron/folic acid/hb179 MEGA MULTI TABLET PA Document  
multivit/iron/folic acid/hb179 MEGA MULTIVITAMIN TABLET PA Document  
multivitamin with iron PMS TABLET PA Document  
multivitamin with iron TAB-A-VITE W/IRON TABLET PA Document  
multivitamin with minerals L-TONIC ELIXIR PA Document  
multivitamin with minerals HAIR, SKIN & NAILS TABLET PA Document  
multivitamin with minerals ICAPS PLUS TABLET PA Document  
multivitamin with minerals TAB-A-VITE W/MINERALS TABLET PA Document  
multivitamin,stress formula STRESS FORMULA TABLET PA Document  
mv-min no.9/folic/saw palm frt UDAMIN SP TABLET PA Document  
mv-min/FA/D3/om-3/dha/epa/fish CARDIAMIN CAPSULE PA Document  
mv-min/FA/vit K/lutein/zeaxant PRESERVISION AREDS 2 PLUS MV CAPSULE PA Document  
mv-min/FA/vit K/lycop/lut/zeax OCUVITE EYE PLUS MULTI TABLET PA Document  
mv-min/folic/K1/lycopen/lutein CENTURY ULTIMATE MEN'S TABLET PA Document  
mv-mins/folic/lycopene/ginkgo ONE DAILY MEN'S 50+ TABLET PA Document  
mv-mn/folic acid/lutein/hrb178 MEGA MULTI TABLET PA Document  
mv-mn/om3/dha/epa/fish/lut/zea OCUVITE ADULT 50 PLUS CAPSULE PA Document  
mv,iron/folic/D3/om-3/dha/epa PRORENAL QD CAPSULE PA Document  
vit A/vit C/vit E/zinc/copper ICAPS AREDS CAPSULE PA Document  
vit A/vit C/vit E/zinc/copper PRESERVISION AREDS CAPSULE PA Document  
vit A/vit C/vit E/zinc/copper PRESERVISION AREDS TABLET PA Document  
vit C/E/cuperic/zinc/lutein PRESERVISION LUTEIN CAPSULE PA Document  
vit C/E/zinc ox/copp/lut/zeax ICAPS AREDS2 CAPSULE PA Document  
vitamins A and D VITAMIN A AND D CAPSULE PA Document  
vitC/E/zinc/copper/lutein/zeax ICAPS AREDS2 TAB CHEW PA Document  
vitC/E/zinc/copper/lutein/zeax ICAPS AREDS2 TABLET PA Document  
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