Iron Replacement, Oral

← Back to Class List

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 but eligible patients will encounter a co-pay at the pharmacy.
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
ferrous gluconate FERATE TABLET Y 240 mg (27 mg iron) Require PA  
ferrous gluconate FERROUS GLUCONATE TABLET Y    
ferrous gluconate IRON TABLET Y    
ferrous gluconate IRON TABLET Y    
ferrous gluconate FERROUS GLUCONATE TABLET Y    
ferrous sulfate FEROSUL ELIXIR Y    
ferrous sulfate FERROUS SULFATE LIQUID Y    
ferrous sulfate FERROUS SULFATE TABLET Y    
ferrous sulfate IRON TABLET Y    
ferrous sulfate FERROUSUL TABLET Y    
ferrous sulfate FERROUS SULFATE TABLET Y    
ferrous sulfate IROMAR TABLET Y    
ferrous sulfate IRON TABLET Y    
ferrous sulfate IRON SUPPLEMENT TABLET Y    
ferrous sulfate FERRO-TIME TABLET Y    
ferrous sulfate FEROSUL TABLET Y    
ferrous sulfate FEOSOL TABLET Y    
ferrous sulfate FERROUS SULFATE TABLET DR Y    
ferrous sulfate FERROUS SULFATE TABLET DR Y    
ferrous sulfate FERROUS SULFATE TABLET ER Y    
ferrous sulfate SLOW FE TABLET ER Y    
ferrous sulfate SLOW RELEASE IRON TABLET ER Y    
iron fum, ps/FA/vit C/L. casei FUSION SPRINKLES POWD PACK Y    
ferrous fum/vit C/B12-if/folic TL ICON CAPSULE N    
ferrous fum/vit C/B12-if/folic TRICON CAPSULE N    
ferrous fum/vit C/B12-if/folic FEROCON CAPSULE N    
ferrous fum/vit C/B12/stomc HEMATOGEN CAPSULE N    
ferrous fumarate FEOSTAT TAB CHEW N    
ferrous fumarate FERRETTS TABLET N    
ferrous fumarate FERRIMIN 150 TABLET N    
ferrous fumarate FERROCITE TABLET N    
ferrous fumarate FERROUS FUMARATE TABLET N    
ferrous fumarate HEMOCYTE TABLET N    
ferrous fumarate/folic acid HEMOCYTE-F TABLET N    
ferrous fumarate/folic acid HEMATINIC WITH FOLIC ACID TABLET N    
ferrous fumarate/iron ps cplx TANDEM DUAL ACTION CAPSULE N    
ferrous gluconate FERGON TABLET N    
ferrous sulfate FERROUS SULFATE DROPS N    
ferrous sulfate CHILDREN'S IRON DROPS N    
ferrous sulfate CHILDREN'S FERROUS SULFATE DROPS N    
ferrous sulfate FER-IN-SOL DROPS N    
ferrous sulfate FERROUS SULFATE ELIXIR N    
ferrous sulfate FEROSUL ELIXIR N    
ferrous sulfate MYKIDZ IRON 10 ORAL SUSP N    
ferrous sulfate FERROUS SULFATE SOLUTION N    
ferrous sulfate SLOW RELEASE IRON TABLET ER N    
ferrous sulfate, dried SLOW RELEASE IRON TABLET ER N    
ferrous sulfate, dried IRON TABLET ER N    
ferrous sulfate/vit C/folic ac FOLITAB 500 TABLET ER N    
iron ag,ps/C/FA6/B12/Zn/sa/sto NIFEREX TABLET N    
iron aspgly,ps/C/B12/FA/Ca/suc FERREX 150 FORTE PLUS CAPSULE N    
iron aspgly,ps/C/succinic acid FERREX 150 PLUS CAPSULE N    
Iron AspGly/C/B12/FA/Ca-th/Suc MULTIGEN FOLIC TABLET 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 carb,gl/FA/B12/C/docusate CITRANATAL BLOOM TABLET N    
iron fm,ps no.1/folic/mv no.18 TANDEM PLUS CAPSULE N    
iron fm,ps no.1/folic/mv no.18 SE-TAN PLUS CAPSULE N    
iron fm,ps no.1/folic/mv no.18 PUREVIT DUALFE PLUS CAPSULE N    
iron fum,ag/C/B12/folic/Ca/suc MULTIGEN PLUS TABLET N    
iron fum,ps cmp/vit C/niacin INTEGRA CAPSULE N    
iron fum,ps no.1/vit C/L.casei FUSION CAPSULE N    
iron fum,ps/folic acid/vitC/B3 FOLIVANE-F CAPSULE N    
iron fum,ps/folic acid/vitC/B3 INTEGRA F CAPSULE N    
iron fum,ps/folic/Bcomp C 23 VIRT-FEFA PLUS CAPSULE N    
iron fum,ps/folic/Bcomp,C no.9 INTEGRA PLUS CAPSULE N    
iron fum,ps/folic/Bcomp,C no.9 FOLIVANE-PLUS CAPSULE N    
iron fum/docusat/folic/Bcomp,C NEPHRON FA TABLET N    
iron fum/folic acid/mv,min 15 HEMOCYTE PLUS CAPSULE N    
iron fum/folic acid/mv,min 15 CENTRATEX CAPSULE N    
iron fumarate/vit C/Vit B12/FA FERROGELS FORTE CAPSULE N    
iron fumarate/vit C/Vit B12/FA HEMATOGEN FORTE CAPSULE N    
iron fumarate/vit C/Vit B12/FA HEMATOGEN FA CAPSULE N    
iron fumarate/vit C/Vit B12/FA TRIGELS-F FORTE CAPSULE N    
iron polysac/iron heme/FA/B12 BIFERA RX TABLET N    
iron polysacch/iron heme polyp FEOSOL TABLET N    
iron polysacch/iron heme polyp DUOFER TABLET N    
iron polysaccharide complex IFEREX 150 CAPSULE N    
iron polysaccharide complex PRO FE CAPSULE N    
iron polysaccharide complex NU-IRON 150 CAPSULE N    
iron polysaccharide complex FERREX 150 CAPSULE N    
iron polysaccharide complex EZFE 200 CAPSULE N    
iron polysaccharide complex POLY-IRON CAPSULE N    
iron ps complex/B12/folic acid IFEREX 150 FORTE CAPSULE N    
iron ps complex/B12/folic acid POLY-IRON 150 FORTE CAPSULE N    
iron ps complex/B12/folic acid FERREX 150 FORTE CAPSULE N    
iron succinyl-protein complex FERRETTS IPS LIQUID N    
iron,carb/folate6/mv,min no.41 CORVITE 150 TABLET N    
iron,carb/vit C/vit B12/folic IRON 100 PLUS TABLET N    
iron,carb/vit C/vit B12/folic ICAR-C PLUS TABLET N    
iron,carbonyl WEE CARE ORAL SUSP N    
iron,carbonyl ICAR ORAL SUSP N    
iron,carbonyl IRON CHEWS TAB CHEW N    
iron,carbonyl FEOSOL TABLET N    
iron,carbonyl/ascorbic acid IRON 100-VITAMIN C TABLET N    
iron,carbonyl/ascorbic acid ICAR-C TABLET N    
iron,carbonyl/folic acid/mv-mn ACTIVE FE TABLET N    
iron,fm,ps/folic/B,C18/L.casei FUSION PLUS CAPSULE N    
iron/C/B12/calciu/stomach conc MULTIGEN TABLET N    
iron/C/folate 6/B12/Zn/stomach CHROMAGEN CAPSULE N    
iron/C/folic acd/mv cmb11/calc FERREX 28 TABLET N    
iron/calcium/E/folic acid/mvit VITAFOL TABLET N    
iron/dss/B12-if/folic ac/mv-mn TL-HEM 150 TAB ER 24H N    
iron/folat1/C/B12/biot/docusat FERIVA FA CAPSULE N    
iron/folate 9/vit C/D3/B6/B12 NUFERA TABLET N    
iron/folate no.6/mv,mins no.40 CORVITE FE TABLET N    
iron/folate no1/C/B12/zinc/dss FERIVA 21-7 TABLET N    
iron/folic ac/vit Bcomp,C/min HEMATINIC PLUS TABLET N    
iron/folic ac/vit Bcomp,C/min FERROCITE PLUS TABLET N    
iron/folic acid/B12/C/docusate FERRAPLUS 90 TABLET N    
iron/folic acid/C/B6/B12/zinc CORVITA 150 TABLET N    
ferrous gluconate/vit C/B12-if FERGON PLUS TABLET    
ferrous sulfate FERROUS SULFATE TABLET    
ferrous sulfate SLOW RELEASE IRON TABLET ER    
ferrous sulfate/vit Bcomp,C IBERET LIQUID    
iron FEROSUL TABLET    
iron/FA/C/E/B12/bio/copper/dss TL-HEM 150 TABLET    
iron/vitamin B comp and C IBERET-500 LIQUID