Iron Replacement, Oral

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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.

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Generic Name Brand Name Form PDL
Status		 Current Drug Use Criteria Carveout
‐ Bill FFS		 New Drug Evaluation & Updates
ferrous fumarate FEOSTAT TAB CHEW Y    
ferrous fumarate HEMOCYTE TABLET Y    
ferrous fumarate FERROUS FUMARATE TABLET Y    
ferrous fumarate FERRIMIN 150 TABLET Y    
ferrous gluconate FERATE TABLET Y    
ferrous gluconate FERROUS GLUCONATE TABLET Y    
ferrous gluconate FERGON TABLET Y    
ferrous gluconate FERROUS GLUCONATE TABLET Y    
ferrous sulfate INFANT-TODDLER IRON DROPS Y    
ferrous sulfate YIERO-GOTA DROPS Y    
ferrous sulfate FERROUS SULFATE DROPS Y    
ferrous sulfate FERROUS SULFATE DROPS Y    
ferrous sulfate FERROUS SULFATE ELIXIR Y    
ferrous sulfate YIERONIA ELIXIR Y    
ferrous sulfate FERROUS SULFATE ELIXIR Y    
ferrous sulfate FEOSOL ELIXIR Y    
ferrous sulfate FERROUS SULFATE LIQUID Y    
ferrous sulfate FERROUS SULFATE SOLUTION Y    
ferrous sulfate IRON TABLET Y    
ferrous sulfate FERROUS SULFATE TABLET Y    
ferrous sulfate IROMAR TABLET Y    
ferrous sulfate FERROUS SULFATE TABLET Y    
ferrous sulfate FERRO-TIME TABLET Y    
ferrous sulfate FEROSUL TABLET Y    
ferrous sulfate FERROUS SULFATE TABLET DR Y    
ferrous sulfate SLOW RELEASE IRON TABLET ER Y    
ferrous sulfate, dried IRON TABLET ER Y    
ferrous sulfate, dried SLOW RELEASE IRON TABLET ER Y    
iron polysaccharide complex POLYSACCHARIDE IRON CAPSULE Y    
iron polysaccharide complex HEMATEX LIQUID Y    
iron polysaccharide complex HEMATEX TABLET Y    
ferric maltol ACCRUFER CAPSULE N    
ferrous fumarate/iron ps cplx TANDEM DUAL ACTION CAPSULE N    
ferrous sulfate/folic acid TULIVITE TABLET N    
ferrous sulfate/folic acid BENTIVITE BX TABLET N    
ferrous sulfate/vit C/folic ac FOLITAB 500 TABLET ER N    
iron bg,ps/folic/B,C no.12/suc IROSPAN TABLET N    
iron bg,ps/vitC/B12/FA/calcium TARON FORTE CAPSULE N    
iron carb,gl/FA/B12/C/docusate FERRALET 90 TABLET N    
iron fum,polysac/vit C/L.casei FUSION CAPSULE N    
iron fum,ps cmp/vit C/niacin INTEGRA CAPSULE N    
iron fum,ps/folic acid/vitC/B3 IRON FOLATE-F CAPSULE N    
iron fum,ps/folic acid/vitC/B3 INTEGRA F CAPSULE N    
iron fum,ps/folic acid/vitC/B3 FOLIVANE-F CAPSULE N    
iron fum,ps/folic/Bcomp,C no.9 INTEGRA PLUS CAPSULE N    
iron fum,ps/folic/Bcomp,C no.9 IRON FOLATE PLUS CAPSULE N    
iron fumarate/vit C/Vit B12/FA TRIGELS-F FORTE CAPSULE N    
iron,carb/folate6/mv-min no.41 CORVITE 150 TABLET N    
iron,carbonyl IRON CHEWS TAB CHEW N    
iron,fm,ps/folic/B,C18/L.casei FUSION PLUS CAPSULE N    
iron/C/B12/folate/zinc/succin FERIVA 21-7 TABLET N    
iron/C/folate 6/B12/Zn/stomach CHROMAGEN CAPSULE N    
iron/C/folate/B12/biot/cupric FERIVA FA CAPSULE N    
iron/folate no.6/mv-min no.40 CORVITE FE TABLET N    
iron/folic acid/C/B6/B12/zinc CORVITA 150 TABLET N    
mv-mins no.73/iron fum/folic HEMOCYTE PLUS CAPSULE N    
ferrous gluconate/vit C/B12-if FERGON PLUS TABLET    
ferrous sulfate/vit Bcomp,C IBERET LIQUID    
iron FEROSUL TABLET    
iron asp gly/C/B12/FA/Zn/succ NIFEREX TABLET    
iron/C/B12/folate/zinc/succin FERIVA 21-7 TABLET    
iron/vitamin B comp and C IBERET-500 LIQUID    
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