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.
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    
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 4,vit K INFUVITE ADULT VIAL    
multivit with iron,minerals POLY-VI-SOL W/IRON & ZINC TAB CHEW    
multivitamin VI-DAYLIN TAB CHEW    
multivitamin POLY-VI-SOL TAB CHEW    
multivitamin CHILDRENS VITAMIN TAB CHEW    
multivitamin CHILDRENS CHEWABLE TAB CHEW    
multivitamin CHILD CHEW VITAMIN TAB CHEW    
multivitamin MULTIVITAMIN 12 VIAL    
multivitamin with iron VI-DAYLIN PLUS IRON TAB CHEW    
multivitamin with iron CHILDS CHEW + IRON TAB CHEW    
multivitamin with iron CHILDRENS CHEWABLE + IRON TAB CHEW    
multivitamin with iron CHILD CHEW + 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 142/iron/fluoride QUFLORA FE TAB CHEW    
ped multivit 151/iron/fluoride QUFLORA FE DROPS    
ped mvit A,C,D3 no.21/fluoride TRI-VITE WITH FLUORIDE DROPS    
ped mvit A,C,D3 no.21/fluoride VITAMINS A,C,D AND FLUORIDE DROPS    
ped mvit A,C,D3 no.38/fluoride TRI-VI-FLOR DRPS SP BP    
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 MULTIVITAMIN-IRON-FLUORIDE DROPS    
pedi multivit 45/fluoride/iron MULTI-VITAMIN W-FLUORIDE-IRON DROPS    
pedi multivit 84 with fluoride QUFLORA DROPS    
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 MULTIVITAMIN WITH FLUORIDE TAB CHEW    
pedi multivit no.2 w-fluoride MULTIVITAMIN WITH FLUORIDE DROPS    
pedi multivit no.205/fluoride MULTI-VIT-FLOR TAB CHEW    
pedi multivit no.23/folic acid CHILDREN'S CHEWABLES TAB CHEW    
pedi multivit no.25/folic acid CHILDREN'S CHEWABLES TAB CHEW    
pedi multivit no.25/folic acid CHILDREN'S CHEWABLE MULTIVITMN 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.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.189/ferrous sulfate POLY-VI-SOL WITH IRON DROPS    
pediatric multivit 152/D3/K ABDEK MULTIVITAMIN DROPS    
pediatric multivitamin no.165 INFANT-TODDLER MULTIVITAMIN DROPS    
pediatric multivitamin no.17 ANIMAL SHAPES TAB CHEW    
pediatric multivitamin no.192 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