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