Prenatal Vitamins

← Back to Class List

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
PNV 11/IRON FUM/FOLIC ACID/OM3 C-NATE DHA CAPSULE Y    
PNV 11/IRON FUM/FOLIC ACID/OM3 RELNATE DHA CAPSULE Y    
PNV 11/IRON FUM/FOLIC ACID/OM3 VIRT-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 VIRT-C DHA CAPSULE Y    
PNV 16/IRON FUM,PS/FOLIC/OM-3 TARON-C DHA CAPSULE Y    
PNV 16/IRON FUM,PS/FOLIC/OM-3 DOTHELLE 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 PREFERA OB TABLET Y    
PNV 21/IRON PS,HEME PPEP/FOLIC VP-HEME 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 66/IRON/FOLIC/DOCUSATE/DHA VEMAVITE-PRX 2 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 VIRT-SELECT CAPSULE Y    
PNV 80/IRON FUM/FOLIC/DSS/DHA PRENAISSANCE CAPSULE Y    
PNV 85/IRON/FOLIC/DHA/FISH OIL OB COMPLETE 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 70/IRON/FOLIC/DHA NATELLE ONE CAPSULE 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,CALCIUM 72/IRON/FOLIC ACID PREPLUS TABLET Y    
PNV,CALCIUM37/IRON/FOLIC/OMEG3 ULTIMATECARE ONE CAPSULE Y    
PNV/FOLIC AC/B6/CALCIUM/GINGER VP-GGR-B6 TABLET Y    
PNV19/IRON BG,S.P/FOLIC AC/OM3 PR NATAL 400 EC CMBPKGDRCP Y    
PNV20/IRON/FOLIC/DOCUSATE/OM3S TRICARE PRENATAL DHA ONE CAPSULE Y    
PNV53/IRON FUM/FA/DOCUSATE/DHA NEXA PLUS CAPSULE Y    
PNV59/IRON,CARB,FUM/FA/DSS/DHA CITRANATAL HARMONY CAPSULE Y    
PNV72/IRON,GLUC/FOLIC/DSS/DHA FOCALGIN 90 DHA COMBO. PKG Y    
PNV72/IRON,GLUC/FOLIC/DSS/DHA CITRANATAL 90 DHA COMBO. PKG Y    
PNV73/IRON,GLUC/FOLIC/DSS/DHA FOCALGIN CA COMBO. PKG Y    
PNV73/IRON,GLUC/FOLIC/DSS/DHA CITRANATAL ASSURE COMBO. PKG Y    
PNV81/IRON EDTA,PS/FOLIC/OMEG3 BAL-CARE DHA CMBPKGDRCP 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 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 VITAFOL-ONE CAPSULE Y    
PRENATAL 34/IRON/FOLIC/DSS/DHA VP-CH-PNV 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 47/IRON/FOLATE 1/DHA PNV-DHA CAPSULE Y    
PRENATAL 53/IRON/FOLIC AC/OMG3 TRIVEEN-DUO DHA COMBO. PKG Y    
PRENATAL 53/IRON/FOLIC AC/OMG3 PR NATAL 400 COMBO. PKG Y    
PRENATAL 57/IRON/FOLIC/DSS/DHA EXTRA-VIRT PLUS DHA CAPSULE Y    
PRENATAL 68/IRON/FOLIC NO1/DHA ZATEAN-PN PLUS CAPSULE Y    
PRENATAL 68/IRON/FOLIC NO1/DHA VIRT-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 55/IRON/FOLIC/OM3 PR NATAL 430 EC CMBPKGDRCP 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 73/IRON/FOLIC VOL-NATE TABLET Y    
PRENATAL VIT,CAL 74/IRON/FOLIC VOL-PLUS TABLET Y    
PRENATAL VIT,CAL 74/IRON/FOLIC NIVA-PLUS TABLET Y    
PRENATAL VIT,CALC76/IRON/FOLIC VOL-TAB RX TABLET Y    
PRENATAL VIT,CALC76/IRON/FOLIC THRIVITE RX TABLET Y    
PRENATAL VIT,CALC76/IRON/FOLIC PNV 29-1 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,CALC NO.65/IRON/FOLIC MARNATAL-F CAPSULE Y    
PRENATAL,CALC.40/IRON/FOLATE 1 VIRT-PN TABLET Y    
PRENATAL,CALC.40/IRON/FOLATE 1 PNV-SELECT TABLET Y    
PRENATAL56/IRON/FOLIC ACID/DHA OB COMPLETE PETITE CAPSULE Y    
PRENATAL81/IRON/FOLIC/DOCUSATE CITRANATAL RX TABLET Y    
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 SE-NATAL 19 TABLET    
PNV119/IRON FUM/FOLIC/DOCUSATE THRIVITE 19 TABLET    
PRENATAL 54/IRON/FOLIC AC/OMG3 PR NATAL 430 COMBO. PKG    
PRENATAL 93/IRON/FOLATE 9/DHA TRISTART DHA CAPSULE    
PRENATAL92/IRON/FOLATE8/PS-DHA ENBRACE HR CAP IR DR