Calcium/Vit D Replacement, Oral
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 & Updates |
---|---|---|---|---|---|
calcium carbonate | CALCIUM CARBONATE | ORAL SUSP | Y | ||
calcium carbonate | CALCIUM CARBONATE | ORAL SUSP | Y | ||
calcium carbonate | OYSTER SHELL CALCIUM | TABLET | Y | ||
calcium carbonate | HI-CALCIUM | TABLET | Y | ||
calcium carbonate | CALCIUM 500 | TABLET | Y | ||
calcium carbonate | CALCIUM | TABLET | Y | ||
calcium carbonate | CALCIUM CARBONATE | TABLET | Y | ||
calcium carbonate | OYSTER SHELL CALCIUM | TABLET | Y | ||
calcium carbonate | CALCIUM CARBONATE | TABLET | Y | ||
calcium carbonate | CALCIUM | TABLET | Y | ||
calcium carbonate | CALCIUM 500 | TABLET | Y | ||
calcium carbonate/vitamin D3 | CALCIUM 500-VIT D3 | TAB CHEW | Y | ||
calcium carbonate/vitamin D3 | OS-CAL 500+D | TAB CHEW | Y | ||
calcium carbonate/vitamin D3 | CALCIUM 500-VIT D3 | TABLET | Y | ||
calcium carbonate/vitamin D3 | OS-CAL 500-VIT D3 | TABLET | Y | ||
cholecalciferol (vitamin D3) | VITAMIN D3 | CAPSULE | Y | ||
cholecalciferol (vitamin D3) | DECARA | CAPSULE | Y | ||
cholecalciferol (vitamin D3) | VITAMIN D3 | CAPSULE | Y | ||
cholecalciferol (vitamin D3) | WEEKLY-D | CAPSULE | Y | ||
cholecalciferol (vitamin D3) | VITAMIN D3 | DROPS | Y | ||
cholecalciferol (vitamin D3) | VITAMIN D | TABLET | Y | ||
cholecalciferol (vitamin D3) | DIALYVITE VITAMIN D3 MAX | TABLET | Y | ||
cholecalciferol (vitamin D3) | VITAMIN D3 | TABLET | Y | ||
ergocalciferol (vitamin D2) | VITAMIN D2 | CAPSULE | Y | ||
calcium carb/D3/magnesium/zinc | CAL MAG ZINC-D3 | TABLET | N | PA Document | |
calcium carbonate | CALCIUM ANTACID | TAB CHEW | N | PA Document | |
calcium carbonate | SMOOTH ANTACID | TAB CHEW | N | PA Document | |
calcium carbonate | ANTACID EXTRA STRENGTH | TAB CHEW | N | PA Document | |
calcium carbonate | CALCIUM | TAB CHEW | N | PA Document | |
calcium carbonate/vitamin D2 | CALCIUM CARBONATE W/VITAMIN D | TABLET | N | PA Document | |
calcium carbonate/vitamin D3 | CALCIUM 500-VIT D3 | TABLET | N | PA Document | |
calcium carbonate/vitamin D3 | CALCIUM 250-VIT D3 | TABLET | N | PA Document | |
calcium carbonate/vitamin D3 | ULTRA CALCIUM 600-VIT D3 | TABLET | N | PA Document | |
calcium carbonate/vitamin D3 | CALCIUM 600 + VIT D | TABLET | N | PA Document | |
calcium carbonate/vitamin D3 | CALCIUM 600-VIT D3 | TABLET | N | PA Document | |
calcium carbonate/vitamin D3 | OYSTER SHELL-D | TABLET | N | PA Document | |
calcium carbonate/vitamin D3 | OYSTER SHELL CALCIUM-VIT D3 | TABLET | N | PA Document | |
calcium carbonate/vitamin D3 | OYSTER SHELL + D | TABLET | N | PA Document | |
calcium carbonate/vitamin D3 | OYSCO 500-VIT D3 | TABLET | N | PA Document | |
calcium carbonate/vitamin D3 | OS-CAL 500-VIT D3 | TABLET | N | PA Document | |
calcium cit/magnesium/D3/zinc | LIQUICAL PLUS | LIQUID | N | PA Document | |
calcium citrate | CITRACAL LIQUITAB | TABLET EFF | N | PA Document | |
calcium citrate/vitamin D3 | CALCIUM CITRATE-VITAMIN D3 | TABLET | N | PA Document | |
calcium citrate/vitamin D3 | CALCIUM CITRATE - VITAMIN D3 | TABLET | N | PA Document | |
calcium phosphate dibas/vit D3 | RISACAL-D | TABLET | N | PA Document | |
calcium/mag/D3/B12/FA/B6/boron | CALCIUM-FOLIC ACID PLUS D | WAFER | N | PA Document | |
calcium/magnesium/zinc | CALCIUM/MAGNESIUM/ZINC | TABLET | N | PA Document | |
cholecalciferol (vitamin D3) | DIALYVITE VITAMIN D | CAPSULE | N | PA Document | |
cholecalciferol (vitamin D3) | VITAMIN D3 | CAPSULE | N | PA Document | |
cholecalciferol (vitamin D3) | VITAMIN D3 | SYRINGE | N | PA Document | |
cholecalciferol (vitamin D3) | VITAMIN D3 | TABLET | N | PA Document | |
cholecalciferol (vitD3)/vit K2 | DECARA K | CAPSULE | N | PA Document | |
cholecalciferol (vitD3)/vit K2 | DOSOQUIN | TABLET | N | PA Document | |
cholecalciferol (vitD3)/vit K2 | DOSOKAP | TABLET | N | PA Document | |
ergocalciferol (vitamin D2) | CALCIDOL | DROPS | N | PA Document | |
ergocalciferol (vitamin D2) | ERGOCALCIFEROL | DROPS | N | PA Document | |
vitamin D2/vitamin K1 | VITAMIN D2-VITAMIN K1 | DROPS | N | PA Document | |
vitamin D3/folic acid | DERMACINRX FOLTAMIN | TABLET | N | PA Document | |
vitamin D3/folic acid | DERMACINRX FOLIXAPURE | TABLET | N | PA Document | |
vitamin D3/folic acid | DERMACINRX FOLDITAM | TABLET | N | PA Document | |
vitamin D3/folic acid | DERMACINRX DOTREMIN | TABLET | N | PA Document | |
vitamin D3/folic acid | DERMACINRX FOLTREXYL | TABLET | N | PA Document | |
vitamin D3/folic acid | DERMACINRX PUREFOLTIN | TABLET | N | PA Document | |
vitamin D3/levomefolate | DERMACINRX FOLIXATE | TABLET | N | PA Document | |
calcium | HI-CAL | TABLET | |||
calcium carbonate | CAL-GEST | TAB CHEW | |||
calcium carbonate | CALCIUM ANTACID | TAB CHEW | |||
calcium carbonate | ANTACID | TAB CHEW | |||
calcium carbonate | ANTACID ULTRA STRENGTH | TAB CHEW | |||
calcium carbonate | CALCIUM CARBONATE | TABLET | |||
calcium carbonate/vitamin D2 | LIQUID CALCIUM | CAPSULE | |||
calcium carbonate/vitamin D2 | OYSTER SHELL CALCIUM W-VIT D | TABLET | |||
calcium carbonate/vitamin D2 | OYSTER SHELL CALCIUM W/VIT D | TABLET | |||
calcium carbonate/vitamin D2 | OYSTER + D | TABLET | |||
calcium carbonate/vitamin D2 | CALCIUM CARBONATE W/VITAMIN D | TABLET | |||
calcium carbonate/vitamin D2 | OYSTER SHELL CALCIUM | TABLET | |||
calcium/D3/mag/K2/min/herb 326 | ALGAE BASED CALCIUM | TABLET | |||
cholecalciferol (vitamin D3) | VITAMIN D3 | CAPSULE | |||
dihydrotachysterol | DHT | TABLET |