Iron 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 | Carveout ‐ Bill FFS |
New Drug Evaluation & Updates |
|---|---|---|---|---|---|---|
| ferrous gluconate | FERROUS GLUCONATE | TABLET | Y | N | ||
| ferrous gluconate | FERATE | TABLET | Y | N | ||
| ferrous gluconate | FERROUS GLUCONATE | TABLET | Y | N | ||
| ferrous sulfate | FERROUS SULFATE | LIQUID | Y | N | ||
| ferrous sulfate | IRON | TABLET | Y | N | ||
| ferrous sulfate | FEROSUL | TABLET | Y | N | ||
| ferrous sulfate | FERRO-TIME | TABLET | Y | N | ||
| ferrous sulfate | FERROUS SULFATE | TABLET | Y | N | ||
| ferrous sulfate | IROMAR | TABLET | Y | N | ||
| ferrous sulfate | FERROUS SULFATE | TABLET | Y | N | ||
| ferrous sulfate | FERROUS SULFATE | TABLET DR | Y | N | ||
| ferrous sulfate | SLOW RELEASE IRON | TABLET ER | Y | N | ||
| ferric maltol | ACCRUFER | CAPSULE | N | N | ||
| ferrous fumarate | FEOSTAT | TAB CHEW | N | N | ||
| ferrous fumarate | HEMOCYTE | TABLET | N | N | ||
| ferrous fumarate | FERROUS FUMARATE | TABLET | N | N | ||
| ferrous fumarate | FERRIMIN 150 | TABLET | N | N | ||
| ferrous fumarate/iron ps cplx | TANDEM DUAL ACTION | CAPSULE | N | N | ||
| ferrous gluconate | FERATE | TABLET | N | N | ||
| ferrous gluconate | FERGON | TABLET | N | N | ||
| ferrous sulfate | FERROUS SULFATE | DROPS | N | N | ||
| ferrous sulfate | INFANT-TODDLER IRON | DROPS | N | N | ||
| ferrous sulfate | FERROUS SULFATE | ELIXIR | N | N | ||
| ferrous sulfate | FERROUS SULFATE | SOLUTION | N | N | ||
| ferrous sulfate, dried | IRON | TABLET ER | N | N | ||
| ferrous sulfate/folic acid | BENTIVITE BX | TABLET | N | N | ||
| ferrous sulfate/folic acid | TULIVITE | TABLET | N | N | ||
| ferrous sulfate/vit C/folic ac | FOLITAB 500 | TABLET ER | N | N | ||
| iron ag,ps/C/FA6/B12/Zn/sa/sto | NIFEREX | TABLET | N | N | ||
| iron bg,ps/folic/B,C no.12/suc | IROSPAN | TABLET | N | N | ||
| iron bg,ps/vitC/B12/FA/calcium | TARON FORTE | CAPSULE | N | N | ||
| iron carb,gl/FA/B12/C/docusate | FERRALET 90 | TABLET | N | N | ||
| iron fum,polysac/vit C/L.casei | FUSION | CAPSULE | N | N | ||
| iron fum,ps cmp/vit C/niacin | INTEGRA | CAPSULE | N | N | ||
| iron fum,ps/folic acid/vitC/B3 | IRON FOLATE-F | CAPSULE | N | N | ||
| iron fum,ps/folic acid/vitC/B3 | FOLIVANE-F | CAPSULE | N | N | ||
| iron fum,ps/folic acid/vitC/B3 | INTEGRA F | CAPSULE | N | N | ||
| iron fum,ps/folic/Bcomp,C no.9 | INTEGRA PLUS | CAPSULE | N | N | ||
| iron fum,ps/folic/Bcomp,C no.9 | IRON FOLATE PLUS | CAPSULE | N | N | ||
| iron fumarate/vit C/Vit B12/FA | TRIGELS-F FORTE | CAPSULE | N | N | ||
| iron polysaccharide complex | POLYSACCHARIDE IRON | CAPSULE | N | N | ||
| iron polysaccharide complex | HEMATEX | LIQUID | N | N | ||
| iron,carb/folate6/mv-min no.41 | CORVITE 150 | TABLET | N | N | ||
| iron,carbonyl | IRON CHEWS | TAB CHEW | N | N | ||
| iron,carbonyl/folic acid/mv-mn | ACTIVE FE | TABLET | N | N | ||
| iron,fm,ps/folic/B,C18/L.casei | FUSION PLUS | CAPSULE | N | N | ||
| iron/C/B12/folate/zinc/succin | FERIVA 21-7 | TABLET | N | N | ||
| iron/C/folate 6/B12/Zn/stomach | CHROMAGEN | CAPSULE | N | N | ||
| iron/C/folate/B12/biot/cupric | FERIVA FA | CAPSULE | N | N | ||
| iron/folate 9/vit C/D3/B6/B12 | NUFERA | TABLET | N | N | ||
| iron/folate no.6/mv-min no.40 | CORVITE FE | TABLET | N | N | ||
| iron/folic acid/B12/C/docusate | FERRAPLUS 90 | TABLET | N | N | ||
| iron/folic acid/C/B6/B12/zinc | CORVITA 150 | TABLET | N | N | ||
| mv-mins no.73/iron fum/folic | HEMOCYTE PLUS | CAPSULE | N | N | ||
| ferrous gluconate/vit C/B12-if | FERGON PLUS | TABLET | N | |||
| ferrous sulfate/vit Bcomp,C | IBERET | LIQUID | N | |||
| iron | FEROSUL | TABLET | N | |||
| iron asp gly/C/B12/FA/Zn/succ | NIFEREX | TABLET | N | |||
| iron polysaccharide complex | HEMATEX | TABLET | N | |||
| iron/C/B12/folate/zinc/succin | FERIVA 21-7 | TABLET | N | |||
| iron/FA/C/E/B12/bio/copper/dss | TL-HEM 150 | TABLET | N | |||
| iron/vitamin B comp and C | IBERET-500 | LIQUID | N |