Parenteral Vitamins

← 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.
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
Current Drug Use Criteria New Drug Evaluation
B-complex with vitamin C NUTRIJECT VIAL    
B-complex with vitamin C VI-CERT C1000 WITH B12 VIAL    
folic acid FOLIC ACID VIAL    
iron dextran complex INFED VIAL    
phytonadione (vit K1) PHYTONADIONE AMPUL    
phytonadione (vit K1) VITAMIN K1 AMPUL    
phytonadione (vit K1) AQUA-MEPHYTON AMPUL    
phytonadione (vit K1) PHYTONADIONE SYRINGE    
phytonadione (vit K1) PHYTONADIONE VIAL