Iron Replacement, Oral

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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
ferrous gluconate FERATE TABLET Y    
ferrous gluconate FERROUS GLUCONATE TABLET Y    
ferrous gluconate FERROUS GLUCONATE TABLET Y    
ferrous sulfate FERROUS SULFATE LIQUID Y    
ferrous sulfate FEROSUL TABLET Y    
ferrous sulfate FERROUSUL TABLET Y    
ferrous sulfate IRON TABLET Y    
ferrous sulfate FERROUS SULFATE TABLET Y    
ferrous sulfate FEOSOL TABLET Y    
ferrous sulfate FERRO-TIME TABLET Y    
ferrous sulfate FERROUS SULFATE TABLET Y    
ferrous sulfate IROMAR TABLET Y    
ferrous sulfate FERROUS SULFATE TABLET DR Y    
ferrous sulfate SLOW RELEASE IRON TABLET ER Y    
ferric maltol ACCRUFER CAPSULE N    
ferrous fumarate FEOSTAT TAB CHEW N    
ferrous fumarate FERROUS FUMARATE TABLET N    
ferrous fumarate FERRIMIN 150 TABLET N    
ferrous gluconate FERATE TABLET 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 FERROUS SULFATE SOLUTION N    
ferrous sulfate 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 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 CITRANATAL BLOOM TABLET N    
iron carb,gl/FA/B12/C/docusate FERRALET 90 TABLET N    
iron fm,ps no.1/folic/mv no.18 PUREVIT DUALFE PLUS CAPSULE N    
iron fm,ps no.1/folic/mv no.18 SE-TAN PLUS CAPSULE N    
iron fum,ps/folic acid/vitC/B3 FOLIVANE-F CAPSULE N    
iron fum,ps/folic/Bcomp,C no.9 VIRT-FEFA PLUS CAPSULE N    
iron fum/folic acid/mv,min 15 CENTRATEX CAPSULE N    
iron fumarate/vit C/Vit B12/FA TRIGELS-F FORTE CAPSULE N    
iron polysacch/iron heme polyp FEOSOL TABLET N    
iron polysaccharide complex POLYSACCHARIDE IRON CAPSULE N    
iron polysaccharide complex HEMATEX LIQUID N    
iron succinyl-protein complex FERRETTS IPS CAPSULE 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,carbonyl IRON CHEWS TAB CHEW N    
iron,carbonyl FEOSOL TABLET N    
iron,carbonyl/ascorbic acid IRON-VITAMIN C TABLET N    
iron,carbonyl/folic acid/mv-mn ACTIVE FE TABLET N    
iron/C/folate 6/B12/Zn/stomach CHROMAGEN CAPSULE N    
iron/C/folate/B12/biot/cupric FERIVA FA CAPSULE N    
iron/C/folate/B12/zinc/succin FERIVA 21-7 TABLET N    
iron/calcium/E/folic acid/mvit VITAFOL TABLET 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/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 polysaccharide complex HEMATEX TABLET    
iron/FA/C/E/B12/bio/copper/dss TL-HEM 150 TABLET    
iron/vitamin B comp and C IBERET-500 LIQUID