Infant Formulas
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 |