Infant Formulas

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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
inf form for tyrosinemia, iron TYROS 1 POWDER    
inf form,iron,spc.met,lac-free NUTRAMIGEN ENFLORA-LGG POWDER    
inf form,iron,spc.met,lac-free NUTRAMIGEN TODDLER ENFLORA-LGG POWDER    
inf form,iron/dha/ara/poly/gos ENFAMIL REGULINE LIQUID    
inf form,iron/dha/ara/poly/gos ENFAMIL REGULINE POWDER    
inf form,soy,iron,lf/dha/ara ENFAMIL PROSOBEE LIQUID    
inf form,soy,iron,lf/dha/ara ENFAGROW TODDLR TRANSITION SOY POWDER    
inf form,soy,iron,lf/dha/ara ENFAMIL PROSOBEE POWDER    
inf form/iron/amino ac/dha/ara PURAMINO DHA-ARA POWDER    
inf.form,metab,iron methion-fr HCY 1 POWDER    
inf.formula,iron,sp.met.lac-fr NUTRAMIGEN DHA-ARA LIQUID    
inf.formula,iron,sp.met.lac-fr NUTRAMIGEN DHA-ARA ORAL CONC    
inf.formula,urea cycle disordr WND 1 POWDER    
infant form,iron,lac-fr,hypoal PRODUCT 3232A POWDER    
infant form,propionic acidemia OA 1 POWDER    
infant form.iron,human milk ft ENFAMIL HUMAN MILK FORTIFIER LIQUID PKT    
infant form.iron,human milk ft ENFAMIL HUMAN MILK FORTIFIER POWD PACK    
infant form.soy-iron,lact-free ENFAMIL PROSOBEE LIPIL LIQUID    
infant form.soy-iron,lact-free ENFAMIL PROSOBEE LIPIL ORAL CONC    
infant formula with iron PREGESTIMIL LIQUID    
infant formula with iron ENFAMIL ENFACARE POWDER    
infant formula with iron PREGESTIMIL POWDER    
infant formula with iron ENFAMIL POWDER    
infant formula with iron, MSUD BCAD 1 POWDER    
infant formula, iron/dha/ara ENFAMIL NEURO ENFACARE NON-GMO LIQUID    
infant formula, iron/dha/ara ENFAMIL ENFACARE LIQUID    
infant formula, iron/dha/ara ENFAMIL GENTLEASE LIPIL LIQUID    
infant formula, iron/dha/ara ENFAMIL INFANT LIQUID    
infant formula, iron/dha/ara ENFAMIL NEWBORN LIQUID    
infant formula, iron/dha/ara ENFAMIL PREMATURE LIQUID    
infant formula, iron/dha/ara ENFAMIL PREMATURE LOW IRON LIQUID    
infant formula, iron/dha/ara ENFAMIL FOR SUPPLEMENTING LIQUID    
infant formula, iron/dha/ara ENFAMIL A.R. LIQUID    
infant formula, iron/dha/ara ENFAMIL 24 LIQUID    
infant formula, iron/dha/ara ENFAMIL GENTLEASE LIQUID    
infant formula, iron/dha/ara ENFAGROW TODDLER TRANSITIONS LIQUID    
infant formula, iron/dha/ara ENFAMIL INFANT ORAL CONC    
infant formula, iron/dha/ara ENFAMIL GENTLEASE POWD PACK    
infant formula, iron/dha/ara ENFAMIL INFANT POWD PACK    
infant formula, iron/dha/ara ENFAMIL A.R. POWDER    
infant formula, iron/dha/ara ENFAMIL ENFACARE POWDER    
infant formula, iron/dha/ara ENFAMIL ENSPIRE INFANT FORMULA POWDER    
infant formula, iron/dha/ara ENFAMIL FOR SUPPLEMENTING POWDER    
infant formula, iron/dha/ara ENFAMIL GENTLEASE POWDER    
infant formula, iron/dha/ara ENFAMIL GENTLEASE NON-GMO POWDER    
infant formula, iron/dha/ara ENFAMIL INFANT NON-GMO POWDER    
infant formula, iron/dha/ara ENFAMIL NEURO ENFACARE NON-GMO POWDER    
infant formula, iron/dha/ara ENFAMIL NEUROPRO NON-GMO POWDER    
infant formula, iron/dha/ara ENFAMIL NEWBORN POWDER    
infant formula, iron/dha/ara ENFAMIL NEWBORN NON-GMO POWDER    
infant formula, iron/dha/ara ENFAMIL INFANT POWDER    
infant formula, iron/dha/ara ENFAGROW TODDLER TRANSITIONS POWDER    
infant formula, metabolic,iron ENFAPORT LIQUID    
infant formula, metabolic,iron PFD TODDLER POWDER    
infant formula,regular ENFAMIL LIQUID    
infantformula,iron/soy/dha/ara ENFAGROW GENTLEASE FORMULA POWDER