B-vitamins, 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 |
|---|---|---|---|---|---|
| cyanocobalamin (vitamin B-12) | VITAMIN B-12 | TABLET | Y | ||
| cyanocobalamin (vitamin B-12) | B-12 | TABLET | Y | ||
| cyanocobalamin (vitamin B-12) | VITAMIN B12 | TABLET | Y | ||
| cyanocobalamin (vitamin B-12) | VITAMIN B-12 | TABLET | Y | ||
| pyridoxine HCl (vitamin B6) | PYRIDOXINE HCL | TABLET | Y | ||
| pyridoxine HCl (vitamin B6) | VITAMIN B-6 | TABLET | Y | ||
| pyridoxine HCl (vitamin B6) | VITAMIN B-6 | TABLET | Y | ||
| pyridoxine HCl (vitamin B6) | B-6 | TABLET | Y | ||
| thiamine HCl | VITAMIN B-1 | TABLET | Y | ||
| thiamine HCl | THIAMINE HCL | TABLET | Y | ||
| thiamine HCl | HM VITAMIN B1 | TABLET | Y | ||
| thiamine HCl | VITAMIN B-1 | TABLET | Y | ||
| thiamine mononitrate (vit B1) | VITAMIN B-1 | TABLET | Y | ||
| thiamine mononitrate (vit B1) | VITAMIN B-1 | TABLET | Y | ||
| acetylcyst/methylB12/levomefol | METAFOLBIC PLUS | TABLET | N | ||
| B cmplx 4/vit D3/C/folic/zinc | VITAL-D RX | TABLET | N | ||
| B comp no3/folic/C/biotin/zinc | NEPHPLEX RX | TABLET | N | ||
| B complex 11/folic/C/biot/zinc | DIALYVITE ZINC | TABLET | N | ||
| B complex w-C no.20/folic acid | WESCAPS | CAPSULE | N | ||
| B complex w-C no.20/folic acid | VIRT-CAPS | CAPSULE | N | ||
| B complex w-C no.20/folic acid | TRIPHROCAPS | CAPSULE | N | ||
| B,C/folic/zinc/selenometh/D3/E | RENAPLEX-D | TABLET | N | ||
| cyanocobalamin (vitamin B-12) | CYANOCOBALAMIN | SPRAY | N | ||
| cyanocobalamin (vitamin B-12) | NASCOBAL | SPRAY | N | ||
| cyanocobalamin/folic ac/vit B6 | WESTAB MAX | TABLET | N | ||
| cyanocobalamin/folic ac/vit B6 | FOLTABS 800 | TABLET | N | ||
| cyanocobalamin/folic ac/vit B6 | WESTAB MINI | TABLET | N | ||
| cyanocobalamin/folic ac/vit B6 | WESTAB ONE | TABLET | N | ||
| cyanocobalamin/folic acid | FOLTRATE | TABLET | N | ||
| folic acid/B cplx/C/selen/zinc | DIALYVITE 3000 | TABLET | N | ||
| folic acid/vit B complex and C | DIALYVITE 800 | TAB CHEW | N | ||
| folic acid/vit B complex and C | DIALYVITE | TABLET | N | ||
| mecobal/levomefolat Ca/B6 phos | L-METHYL-B6-B12 | TABLET | N | ||
| mecobal/levomefolat Ca/B6 phos | FOLTANX | TABLET | N | ||
| multivit-mins 25/folic acid/D3 | DIALYVITE SUPREME D | TABLET | N | ||
| multivit-mins no.11/folic acid | DIALYVITE 5000 | TABLET | N | ||
| vit B comp C no.24/iron/folic | NEPHRON FA | TABLET | N | ||
| vit B complx C/folic acid/zinc | RENAPLEX | TABLET | N | ||
| vit B complx/folic ac/C/biotin | FOLIKA-BC | TABLET | N | ||
| B,C/ferrous fum/FA/D3/zinc ox | PRORENAL | TABLET | |||
| B12/levomefolate calcium/B-6 | FOLBIC RF | TABLET | |||
| biotin | BIOTIN | TABLET | |||
| cobama/FA/leucov/L-mefolate/mv | PAXLYTE | CAPSULE | |||
| cyanocobalamin (vitamin B-12) | VITAMIN B-12 | TABLET | |||
| FA/B1/B2/B3/B5/B6/B7/B12/C | MI-VITE RX | TABLET | |||
| folic ac/vit Bcomp,C/Zn/vit D3 | DIALYVITE 800-ULTRA D | TABLET | |||
| folic acid | FOLIC ACID | TABLET | |||
| folic/arginine/B12/B6/b.pepper | FOLBEE AR | TABLET | |||
| l-mefol/a-cyst/meB12/algal oil | METAFOLBIC PLUS RF | TABLET | |||
| l-mefol/a-cyst/meB12/algal oil | LEVOMEFOLATE-NAC-MECOBAL-ALGAL | TABLET | |||
| levomefolate calcium | L-METHYLFOLATE | TABLET | |||
| levomefolate calcium | L-METHYLFOLATE CALCIUM | TABLET | |||
| levomefolate/algal oil | L-METHYLFOLATE FORTE | CAPSULE | |||
| levomefolate/B6/B12/algal oil | FOLTANX RF | CAPSULE | |||
| levomefolate/B6/B12/algal oil | LEVOMEFOL-PYRIDOXAL-MEC-ALGAL | CAPSULE | |||
| pyridoxine HCl (vitamin B6) | VITAMIN B-6 | TABLET | |||
| pyridoxine HCl (vitamin B6) | VITAMIN B-6 | TABLET ER | |||
| thiamine mononitrate (vit B1) | VITAMIN B-1 | TABLET | |||
| vit B comp C/folic acid/vit D3 | DIALYVITE 800 PLUS D | TAB CHEW | |||
| vit B complex,vit C/folic acid | TM-VITE RX | TABLET | |||
| vit B complx C/folic acid/zinc | DIALYVITE 800 WITH ZINC | TABLET | |||
| vit B complx/folic ac/C/biotin | FOLIKA-NC | TABLET | |||
| vit B12/levomefolate/vit B6/B2 | METAFOLBIC | TABLET | |||
| vit D3/folic/B6/B12/acetylcyst | MINCORA | TABLET | |||
| vitamin B complex | B-COMPLEX MEGA | TABLET | |||
| vitamin B complex | B-COMPLEX SUPER | TABLET | |||
| vitamin B complex | VITAMIN B COMPLEX | TABLET | |||
| vitamin B complex/folic acid | BALANCE B-50 | TABLET | |||
| yeast,dried (S. cerevisiae) | BREWER'S YEAST | TABLET |