Vitamin D Analogs

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PDL Reference Documents

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.

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NDC Brand Name Generic Name Form Strength PDL
Status		 Rebate Carveout
‐ Bill FFS		 Current Drug Use Criteria
70301100201 RAYALDEE calcifediol CAP SA 24H 30 mcg N Y N  
00054000713 CALCITRIOL calcitriol CAPSULE 0.25 mcg Y Y N  
00054000725 CALCITRIOL calcitriol CAPSULE 0.25 mcg Y Y N  
00093735201 CALCITRIOL calcitriol CAPSULE 0.25 mcg Y Y N  
23155066201 CALCITRIOL calcitriol CAPSULE 0.25 mcg Y Y N  
23155066203 CALCITRIOL calcitriol CAPSULE 0.25 mcg Y Y N  
60687034501 CALCITRIOL calcitriol CAPSULE 0.25 mcg Y Y N  
60687034511 CALCITRIOL calcitriol CAPSULE 0.25 mcg Y Y N  
62135061090 CALCITRIOL calcitriol CAPSULE 0.25 mcg Y Y N  
62756096783 CALCITRIOL calcitriol CAPSULE 0.25 mcg Y Y N  
62756096788 CALCITRIOL calcitriol CAPSULE 0.25 mcg Y Y N  
64380072304 CALCITRIOL calcitriol CAPSULE 0.25 mcg Y Y N  
64380072306 CALCITRIOL calcitriol CAPSULE 0.25 mcg Y Y N  
69452020713 CALCITRIOL calcitriol CAPSULE 0.25 mcg Y Y N  
69452020720 CALCITRIOL calcitriol CAPSULE 0.25 mcg Y Y N  
00093735301 CALCITRIOL calcitriol CAPSULE 0.5 mcg Y Y N  
23155066301 CALCITRIOL calcitriol CAPSULE 0.5 mcg Y Y N  
62135061190 CALCITRIOL calcitriol CAPSULE 0.5 mcg Y Y N  
62756096888 CALCITRIOL calcitriol CAPSULE 0.5 mcg Y Y N  
64380072406 CALCITRIOL calcitriol CAPSULE 0.5 mcg Y Y N  
69452020820 CALCITRIOL calcitriol CAPSULE 0.5 mcg Y Y N  
00054312041 CALCITRIOL calcitriol SOLUTION 1 mcg/mL Y Y N  
64980044715 CALCITRIOL calcitriol SOLUTION 1 mcg/mL Y Y N  
30698091115 ROCALTROL calcitriol SOLUTION 1 mcg/mL Y Y N  
72266025101 CALCITRIOL calcitriol VIAL 1 mcg/mL N Y N  
72266025110 CALCITRIOL calcitriol VIAL 1 mcg/mL N Y N  
23155053825 DOXERCALCIFEROL doxercalciferol CAPSULE 0.5 mcg N Y N  
62135045030 DOXERCALCIFEROL doxercalciferol CAPSULE 0.5 mcg N Y N  
23155053925 DOXERCALCIFEROL doxercalciferol CAPSULE 1 mcg N Y N  
62135045130 DOXERCALCIFEROL doxercalciferol CAPSULE 1 mcg N Y N  
23155054025 DOXERCALCIFEROL doxercalciferol CAPSULE 2.5 mcg N Y N  
62135045230 DOXERCALCIFEROL doxercalciferol CAPSULE 2.5 mcg N Y N  
43598085011 DOXERCALCIFEROL doxercalciferol VIAL 4 mcg/2 mL N Y N  
43598085050 DOXERCALCIFEROL doxercalciferol VIAL 4 mcg/2 mL N Y N  
55150035901 DOXERCALCIFEROL doxercalciferol VIAL 4 mcg/2 mL N Y N  
55150035950 DOXERCALCIFEROL doxercalciferol VIAL 4 mcg/2 mL N Y N  
62332069002 DOXERCALCIFEROL doxercalciferol VIAL 4 mcg/2 mL N Y N  
62332069030 DOXERCALCIFEROL doxercalciferol VIAL 4 mcg/2 mL N Y N  
68180071801 DOXERCALCIFEROL doxercalciferol VIAL 4 mcg/2 mL N Y N  
68180071852 DOXERCALCIFEROL doxercalciferol VIAL 4 mcg/2 mL N Y N  
70121140801 DOXERCALCIFEROL doxercalciferol VIAL 4 mcg/2 mL N Y N  
70121140805 DOXERCALCIFEROL doxercalciferol VIAL 4 mcg/2 mL N Y N  
71288080202 DOXERCALCIFEROL doxercalciferol VIAL 4 mcg/2 mL N Y N  
71288080204 DOXERCALCIFEROL doxercalciferol VIAL 4 mcg/2 mL N Y N  
49483068703 PARICALCITOL paricalcitol CAPSULE 1 mcg N Y N  
65862093630 PARICALCITOL paricalcitol CAPSULE 1 mcg N Y N  
69452014513 PARICALCITOL paricalcitol CAPSULE 1 mcg N Y N  
00074903630 ZEMPLAR paricalcitol CAPSULE 1 mcg N Y N  
49483068803 PARICALCITOL paricalcitol CAPSULE 2 mcg N Y N  
65862093730 PARICALCITOL paricalcitol CAPSULE 2 mcg N Y N  
69452014613 PARICALCITOL paricalcitol CAPSULE 2 mcg N Y N  
00074903730 ZEMPLAR paricalcitol CAPSULE 2 mcg N Y N  
49483068903 PARICALCITOL paricalcitol CAPSULE 4 mcg N Y N  
65862093830 PARICALCITOL paricalcitol CAPSULE 4 mcg N Y N  
16729031008 PARICALCITOL paricalcitol VIAL 2 mcg/mL N Y N  
16729031063 PARICALCITOL paricalcitol VIAL 2 mcg/mL N Y N  
43598056311 PARICALCITOL paricalcitol VIAL 2 mcg/mL N Y N  
43598056325 PARICALCITOL paricalcitol VIAL 2 mcg/mL N Y N  
00074463701 ZEMPLAR paricalcitol VIAL 2 mcg/mL N Y N  
16729031108 PARICALCITOL paricalcitol VIAL 5 mcg/mL N Y N  
16729031130 PARICALCITOL paricalcitol VIAL 5 mcg/mL N Y N  
16729031163 PARICALCITOL paricalcitol VIAL 5 mcg/mL N Y N  
16729031193 PARICALCITOL paricalcitol VIAL 5 mcg/mL N Y N  
43598056411 PARICALCITOL paricalcitol VIAL 5 mcg/mL N Y N  
43598056425 PARICALCITOL paricalcitol VIAL 5 mcg/mL N Y N  
43598056508 PARICALCITOL paricalcitol VIAL 5 mcg/mL N Y N  
43598056510 PARICALCITOL paricalcitol VIAL 5 mcg/mL N Y N  
00074165801 ZEMPLAR paricalcitol VIAL 5 mcg/mL N Y N  
00074165805 ZEMPLAR paricalcitol VIAL 5 mcg/mL N Y N  
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