Pediatric Multivitamins

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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 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
pedi multivit 40/phytonadione AQUADEKS DROPS Y    
pedi multivit no.130/fluoride FLORIVA PLUS DROPS Y    
calcium carbonate/multivitamin MULTIVITAMIN PLUS CALCIUM TAB CHEW    
fluoride/iron/vitamins A,C,D TRI-VIT W/FLUORIDE & IRON DROPS    
multivit infusion,pedi 1,vit K INFUVITE PEDIATRIC VIAL    
multivit infusion,pedi 2,vit K M.V.I. PEDIATRIC VIAL    
multivit infusn,adult 1,vit K M.V.I. ADULT VIAL    
multivit infusn,adult 4,vit K INFUVITE ADULT VIAL    
multivit with iron,minerals POLY-VI-SOL W/IRON & ZINC TAB CHEW    
multivitamin ANIMAL SHAPES TAB CHEW    
multivitamin ZOO CHEWS TAB CHEW    
multivitamin VI-DAYLIN TAB CHEW    
multivitamin POLY-VITAMIN TAB CHEW    
multivitamin POLY-VI-SOL TAB CHEW    
multivitamin CHILDRENS VITAMIN TAB CHEW    
multivitamin CHILDREN'S CHEWABLE VITAMIN TAB CHEW    
multivitamin CHILD CHEW VITAMIN TAB CHEW    
multivitamin ANIMAL CHEWS TAB CHEW    
multivitamin CHILDRENS CHEWABLE TAB CHEW    
multivitamin MULTIVITAMIN 12 VIAL    
multivitamin with iron VI-DAYLIN PLUS IRON TAB CHEW    
multivitamin with iron CHEWABLE-VITE WITH IRON TAB CHEW    
multivitamin with iron CHILD CHEW + IRON TAB CHEW    
multivitamin with iron CHILDRENS CHEWABLE + IRON TAB CHEW    
multivitamin with iron CHILDS CHEW + IRON TAB CHEW    
multivitamin with iron CHILDREN'S VITAMINS WITH IRON TAB CHEW    
Multivitamins with Fluoride MULTI-VIT W/FLUORIDE DROPS    
Multivits with Iron & Fluoride MULTI-VIT/IRON & FLUORIDE DROPS    
mv infus,adult 2 without vit K M.V.I.-12 VIAL    
mvi, adult no.1, vit K, 1 of 2 M.V.I. ADULT VIAL 1 VIAL    
mvi, adult no.1, vit K, 2 of 2 M.V.I. ADULT VIAL 2 VIAL    
mvi, adult no.4, vit K, 1 of 2 INFUVITE ADULT VIAL 1 VIAL    
mvi, adult no.4, vit K, 2 of 2 INFUVITE ADULT VIAL 2 VIAL    
mvi,pedi no.1,component 1 of 2 INFUVITE PEDIATRIC VIAL 1 VIAL    
mvi,pedi no.1,component 2 of 2 INFUVITE PEDIATRIC VIAL 2 VIAL    
ped multivit 108/iron/fluoride TEXAVITE LQ DROPS    
ped multivit 142/iron/fluoride QUFLORA FE TAB CHEW    
ped multivit 151/iron/fluoride QUFLORA FE DROPS    
ped mvit A,C,D3 no.21/fluoride VITAMINS A,C,D AND FLUORIDE DROPS    
ped mvit A,C,D3 no.21/fluoride TRI-VITE WITH FLUORIDE DROPS    
ped mvit A,C,D3 no.38/fluoride TRI-VI-FLOR DRPS SP BP    
pedi multivit 158/iron/vit K1 CEROVITE JR TAB CHEW    
pedi multivit 33/fluoride/iron POLY-VI-FLOR WITH IRON TAB CHEW    
pedi multivit 37/fluoride/iron POLY-VI-FLOR WITH IRON DRPS SP BP    
pedi multivit 45/fluoride/iron MULTI-VITAMIN W-FLUORIDE-IRON DROPS    
pedi multivit 45/fluoride/iron MULTIVITAMIN-IRON-FLUORIDE DROPS    
pedi multivit 47/iron/fluoride ESCAVITE TAB CHEW    
pedi multivit 65/vit D3/vit K MULTIVITAMINS-A,B,D,E,K,ZN DROPS    
pedi multivit 78/iron/fluoride ESCAVITE D TAB CH BPH    
pedi multivit 84 with fluoride QUFLORA DROPS    
pedi multivit 86/iron/fluoride ESCAVITE LQ DROPS    
pedi multivit A,C,and D3 no.21 TRI-VITAMIN DROPS    
pedi multivit A,C,and D3 no.21 TRI-VITA DROPS    
pedi multivit no.156/iron fum POLYVITAMIN WITH IRON TAB CHEW    
pedi multivit no.157/fluoride QUFLORA TAB CHEW    
pedi multivit no.16 w-fluoride MULTIVITAMIN WITH FLUORIDE TAB CHEW    
pedi multivit no.161/fluoride FLORIVA PLUS DROPS    
pedi multivit no.17 w-fluoride MULTI-VITAMIN WITH FLUORIDE TAB CHEW    
pedi multivit no.17 w-fluoride MULTIVITAMIN WITH FLUORIDE TAB CHEW    
pedi multivit no.17/iron sulf CHILDREN'S CHEWABLES TAB CHEW    
pedi multivit no.2 w-fluoride MULTIVITAMIN WITH FLUORIDE DROPS    
pedi multivit no.23/folic acid CHILDREN'S CHEWABLES TAB CHEW    
pedi multivit no.25/folic acid CHILDREN'S CHEWABLE MULTIVITMN TAB CHEW    
pedi multivit no.25/folic acid ZOO FRIENDS ORIGINAL TAB CHEW    
pedi multivit no.25/folic acid CHILDREN'S CHEWABLES TAB CHEW    
pedi multivit no.31/iron/folic CHILDREN'S CHEWABLE TAB CHEW    
pedi multivit no.33/fluoride POLY-VI-FLOR TAB CHEW    
pedi multivit no.37 w-fluoride POLY-VI-FLOR DRPS SP BP    
pedi multivit no.46/iron sulf POLYVITAMIN WITH IRON DROPS    
pedi multivit no.46/iron sulf POLY-VITA WITH IRON DROPS    
pedi multivit no.63 w-fluoride QUFLORA TAB CHEW    
pedi multivit no.83 w-fluoride QUFLORA DROPS    
pedi multivit no.85/fluoride FLORIVA TAB CHEW    
pedi multivit no.91/iron fum CHILDREN'S CHEW MULTIVIT-IRON TAB CHEW    
pedi mv no.164/ferrous sulfate INFANT-TODDLER MULTIVIT-IRON DROPS    
pedi mv no.80/ferrous sulfate POLY-VI-SOL WITH IRON DROPS    
pediatric multivit 152/D3/K ABDEK MULTIVITAMIN DROPS    
pediatric multivit no.153/D3/K ABDEK MULTIVITAMIN TAB CHEW    
pediatric multivitamin no.165 INFANT-TODDLER MULTIVITAMIN DROPS    
pediatric multivitamin no.20 POLY-VITAMIN DROPS    
pediatric multivitamin no.20 POLY-VITA DROPS    
pediatric multivitamin no.81 POLY-VI-SOL DROPS    
vit A palmitate/vit C/vit D3 TRI-VI-SOL DROPS    
vit A palmitate/vit C/vit D3 INFANT-TODDLER TRI-VITAMIN DROPS