Prenatal Vitamins

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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
methyltetrahydrofolate glucosa FALESSA TABLET Y    
methyltetrahydrofolate glucosa Q-TABS TABLET Y    
methyltetrahydrofolate glucosa FALESSA TABLET Y    
PNV 11/iron fum/folic acid/om3 VIRT-NATE DHA CAPSULE Y    
PNV 11/iron fum/folic acid/om3 RELNATE DHA CAPSULE Y    
PNV 11/iron fum/folic acid/om3 C-NATE DHA CAPSULE Y    
PNV 15/iron fum,ps/folic acid FOLIVANE-OB CAPSULE Y    
PNV 15/iron fum,ps/folic acid CONCEPT OB CAPSULE Y    
PNV 16/iron fum,ps/folic/om-3 TARON-C DHA CAPSULE Y    
PNV 16/iron fum,ps/folic/om-3 VIRT-C DHA CAPSULE Y    
PNV 16/iron fum,ps/folic/om-3 CONCEPT DHA CAPSULE Y    
PNV 19/iron ps,heme/folic/dha VP-HEME ONE CAPSULE Y    
PNV 19/iron ps,heme/folic/dha PREFERA-OB ONE CAPSULE Y    
PNV 21/iron ps,heme ppep/folic VP-HEME OB TABLET Y    
PNV 21/iron ps,heme ppep/folic PREFERA OB TABLET Y    
PNV 22/iron,gluc/folic/dss/dha PNV OB+DHA COMBO. PKG Y    
PNV 30/iron carb,ag/folic/om3 OB COMPLETE WITH DHA CAPSULE Y    
PNV 39/iron/folic/docusate/dha TARON-PREX PRENATAL CAPSULE Y    
PNV 66/iron/folic/docusate/dha VIRTPREX CAPSULE Y    
PNV 67/iron ps/folate no.1/dha VITAFOL ULTRA CAPSULE Y    
PNV 69/iron/folic/docusate/dha PRENAISSANCE PLUS CAPSULE Y    
PNV 76/iron,gluc/folic/dss/dha CITRANATAL DHA COMBO. PKG Y    
PNV 80/iron fum/folic/dss/dha PRENAISSANCE CAPSULE Y    
PNV 80/iron fum/folic/dss/dha VIRT-SELECT CAPSULE Y    
PNV 85/iron/folic/dha/fish oil OB COMPLETE ONE CAPSULE Y    
PNV no.111/iron/folate/dha NESTABS ONE CAPSULE Y    
PNV no.118/iron fumarate/FA SE-NATAL 19 TAB CHEW Y    
PNV no.118/iron fumarate/FA PRENATAL 19 TAB CHEW Y    
PNV,calcium 72/iron/folic acid PREPLUS TABLET Y    
PNV,calcium 72/iron/folic acid PRENATAL VITAMIN PLUS LOW IRON TABLET Y    
PNV,calcium 72/iron/folic acid PRENATAL PLUS TABLET Y    
PNV/folic ac/B6/calcium/ginger VP-GGR-B6 TABLET Y    
pnv20/iron/folic/docusate/om3s TRICARE PRENATAL DHA ONE CAPSULE Y    
PNV59/iron,carb,fum/FA/dss/dha CITRANATAL HARMONY CAPSULE Y    
PNV72/iron,gluc/folic/dss/dha CITRANATAL 90 DHA COMBO. PKG Y    
PNV73/iron,gluc/folic/dss/dha CITRANATAL ASSURE COMBO. PKG Y    
PNV83/iron,carb,asp/folic acid OB COMPLETE PREMIER TABLET Y    
prenat 115/iron fum/folic/dss PNV-FERROUS FUMARATE-DOCU-FA TABLET Y    
prenat90/iron fum,ps/folic/dha PROVIDA DHA CAPSULE Y    
prenatal 113/iron/lmfol/omeg3s TRICARE PRENATAL WITH DHA CMB TABAMP Y    
prenatal 114/iron a-g/folate 1 PRENATE ELITE TABLET Y    
prenatal 118/iron/folate 6/dha PRIMACARE CAPSULE Y    
prenatal 123/iron/folic/omeg3s ONE-A-DAY WOMEN'S PRENATAL 1 CAPSULE Y    
prenatal 2/iron/folic acid/om3 COMPLETE NATAL DHA COMBO. PKG Y    
prenatal 26/iron ps/folic/dha REAPHIRM CAPSULE Y    
prenatal 26/iron ps/folic/dha VITAFOL-ONE CAPSULE Y    
prenatal 34/iron/folic/dss/dha VP-CH-PNV CAPSULE Y    
prenatal 47/iron/folate 1/dha PNV-DHA CAPSULE Y    
prenatal 47/iron/folate 1/dha RULAVITE DHA CAPSULE Y    
prenatal 47/iron/folate 1/dha ZATEAN-PN DHA CAPSULE Y    
prenatal 47/iron/folate 1/dha VIRT-PN DHA CAPSULE Y    
prenatal 53/iron/folic ac/omg3 TRIVEEN-DUO DHA COMBO. PKG Y    
prenatal 57/iron/folic/dss/dha EXTRA-VIRT PLUS DHA CAPSULE Y    
prenatal 68/iron/folic no1/dha VIRT-PN PLUS CAPSULE Y    
prenatal 68/iron/folic no1/dha ZATEAN-PN PLUS CAPSULE Y    
prenatal 78/iron/folate 1/dha PRENATE DHA CAPSULE Y    
prenatal 86/iron/folic/dha/epa NESTABS ABC COMBO. PKG Y    
prenatal 87/iron bis/folic/dha NESTABS DHA COMBO. PKG Y    
prenatal no.123/iron/folic ac OB COMPLETE TABLET Y    
prenatal no.123/iron/folic ac ELITE-OB TABLET Y    
prenatal no.52/iron/FA/dha VP-PNV-DHA CAPSULE Y    
prenatal no.75/iron/folate no1 VITAFOL NANO TABLET Y    
prenatal no.77/iron asp gly/FA PRENATE STAR TABLET Y    
prenatal no13/iron ps/folate 1 SELECT-OB TAB CHEW Y    
prenatal no4/iron fum,ps/folic PUREFE OB PLUS CAPSULE Y    
prenatal vit 10/iron fum/folic VITAFOL-OB TABLET Y    
prenatal vit 10/iron/folic/dha VITAFOL-OB+DHA COMBO. PKG Y    
prenatal vit 113/iron/lmfolate TRICARE PRENATAL TAB CHEW Y    
prenatal vit 14/iron fum/folic COMPLETENATE TAB CHEW Y    
prenatal vit 33/iron/folic/dha SELECT-OB + DHA COMBO. PKG Y    
prenatal vit 65/iron fum,ps/FA PROVIDA OB CAPSULE Y    
prenatal vit 84/iron/FA 1/dha PRENATE ESSENTIAL CAPSULE Y    
prenatal vit 85/iron/FA 1/dha PRENATE PIXIE CAPSULE Y    
prenatal vit 87/iron/folic/dha PRENATE MINI CAPSULE Y    
prenatal vit no.112/folate no6 PRENATE CHEWABLE TAB CHEW Y    
prenatal vit no.127/iron/folic O-CAL PRENATAL TABLET Y    
prenatal vit,cal 73/iron/folic VIRT-NATE TABLET Y    
prenatal vit,cal 74/iron/folic NIVA-PLUS TABLET Y    
prenatal vit,cal 74/iron/folic VOL-PLUS TABLET Y    
prenatal vit,calc76/iron/folic PNV 29-1 TABLET Y    
prenatal vit,calc76/iron/folic THRIVITE RX TABLET Y    
prenatal vit,calc78/iron/folic PRETAB TABLET Y    
prenatal vit/iron fum/folic ac PRENATAL VITAMINS TABLET Y    
prenatal vit103/iron fum/folic TRICARE TABLET Y    
prenatal vit114/folate6/ginger PRENATE AM TABLET Y    
prenatal vit27,calcium/iron/FA TRINATAL RX 1 TABLET Y    
prenatal vit37/iron/folic acid PRENATA TAB CHEW Y    
prenatal vit68/iron/FA no6/dha PRENATE ENHANCE CAPSULE Y    
prenatal vit69/iron/folate6/dh PRENATE RESTORE CAPSULE Y    
prenatal vit86/iron/folic acid NESTABS TABLET Y    
prenatal vits 4/iron fum/folic PUREFE PLUS CAPSULE Y    
prenatal vits/iron/folic acid SELECT-OB TAB CHEW Y    
prenatal vits15/iron/folic/dss VIRT-ADVANCE TABLET Y    
prenatal vits16/iron/folic/dss VIRT-VITE GT TABLET Y    
prenatal vits18/iron/folic/dss INATAL ULTRA TABLET Y    
prenatal,calc.40/iron/folate 1 PNV-SELECT TABLET Y    
prenatal,calc.40/iron/folate 1 VIRT-PN TABLET Y    
prenatal56/iron/folic acid/dha OB COMPLETE PETITE CAPSULE Y    
prenatal81/iron/folic/docusate CITRANATAL RX TABLET Y    
FA7/pc,pe dha/nac/pap/if/mv46 PURALOR CI TAB CH BPH N    
iron/FA/dha/epa/FAD/NADH/mv47 ENLYTE CAP IR DR N    
levomefolate calcium L-METHYLFOLATE CALCIUM TABLET N    
PNV 112/iron/folic/om3/dha/epa VITAFOL GUMMIES TAB CHEW N    
prenatal 48/iron/folic acid/B6 CITRANATAL B-CALM TABLET SEQ N    
prenatal vit/iron fum/folic ac O-CAL FA TABLET N    
PNV 102/iron/folate 1/dss/dha VITAFOL FE+ CAPSULE    
PNV no.88/iron ps,heme/FA/dha PREFERA-OB PLUS DHA COMBO. PKG    
PNV119/iron fum/folic/docusate THRIVITE 19 TABLET    
PNV119/iron fum/folic/docusate SE-NATAL 19 TABLET    
prenatal 93/iron/folate 9/dha TRISTART DHA CAPSULE    
prenatal vit 60/iron fum/folic PNV FOLIC ACID + IRON TABLET    
prenatal92/iron/folate8/ps-dha ENBRACE HR CAP IR DR