Water Soluble Vitamins, Parenteral
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) | DODEX | VIAL | Y | ||
| cyanocobalamin (vitamin B-12) | CYANOCOBALAMIN INJECTION | VIAL | Y | ||
| pyridoxine HCl (vitamin B6) | PYRIDOXINE HCL | VIAL | Y | ||
| thiamine HCl | THIAMINE HCL | VIAL | Y | ||
| ascorbic acid | ASCORBIC ACID | SYRUP | |||
| ascorbic acid | C-500 | TAB CHEW | |||
| ascorbic acid | VITAMIN C | TAB CHEW | |||
| ascorbic acid | VITAMIN C WITH ROSE HIPS | TABLET | |||
| ascorbic acid | VITAMIN C | TABLET | |||
| ascorbic acid | VITAMIN C W/ROSE HIPS | TABLET | |||
| ascorbic acid | VITAMIN C | TABLET ER | |||
| ascorbic acid | VITAMIN C W/ROSE HIPS | TABLET ER | |||
| ascorbic acid | VI-CERT C500 | VIAL | |||
| hydroxocobalamin | HYDROXOCOBALAMIN | VIAL | |||
| inositol/choline/biofla/vitB,C | FLAVOVIT | TABLET | |||
| riboflavin (vitamin B2) | VITAMIN B2 | TABLET | |||
| rutin | RUTIN | TABLET | |||
| vitamins B1,B2,B3,B5,and B6 | B-COMPLEX | VIAL |