Multivitamins, Oral

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Drug Use Review 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 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
beta-carotene(A)-vits C,E/mins PROTEC TABLET Y PA Document  
beta-carotene(A)-vits C,E/mins HP ZINC W/ANTIOXIDANTS TABLET Y PA Document  
beta-carotene(A)-vits C,E/mins EYE-VITES TABLET Y PA Document  
beta-carotene(A)-vits C,E/mins EYE HEALTH TABLET Y PA Document  
beta-carotene(A)-vits C,E/mins ANTI-OXIDANT PLUS TABLET Y PA Document  
beta-carotene(A)-vits C,E/mins HP ZINC WITH ANTIOXIDANTS TABLET Y PA Document  
beta-carotene(A)-vits C,E/mins OCUMIN TABLET Y PA Document  
beta-carotene(A)-vits C,E/mins OCUTABS TABLET Y PA Document  
beta-carotene(A)-vits C,E/mins OCUVITE TABLET Y PA Document  
beta-carotene(A)-vits C,E/mins OPTIC-VITE TABLET Y PA Document  
beta-carotene(A)-vits C,E/mins OPTIC-VITES TABLET Y PA Document  
beta-carotene(A)-vits C,E/mins OPTIMIZE TABLET Y PA Document  
beta-carotene(A)-vits C,E/mins OPTI-MULTI TABLET Y PA Document  
beta-carotene(A)-vits C,E/mins OPTI-VITAMINS TABLET Y PA Document  
beta-carotene(A)-vits C,E/mins VISION-VITE TABLET Y PA Document  
beta-carotene(A)-vits C,E/mins VISION VITE TABLET Y PA Document  
beta-carotene(A)-vits C,E/mins VISION TABLET Y PA Document  
folic acid/vit B complex and C FULL SPECTRUM B TABLET Y PA Document  
folic acid/vit B complex and C RENA-VITE TABLET Y PA Document  
folic acid/vit B complex and C RENAVIT TABLET Y PA Document  
folic acid/vit B complex and C RENAL-VITE TABLET Y PA Document  
folic acid/vit B complex and C RENAL VITAMIN TABLET Y PA Document  
folic acid/vit B complex and C NEPHRO-VITE TABLET Y PA Document  
folic acid/vit B complex and C FOLIC ACID XTRA TABLET Y PA Document  
folic acid/vit B complex and C DIALYVITE 800 TABLET Y PA Document  
folic acid/vit B complex and C RENAL MULTIVITAMIN TABLET Y PA Document  
multivit with minerals/lutein MULTIVITAMIN 50 PLUS TABLET Y PA Document  
multivit with minerals/lutein CENTRAL-VITE SELECT TABLET Y PA Document  
multivit with minerals/lutein CENTRUM SILVER TABLET Y PA Document  
multivit with minerals/lutein CENTURY MATURE TABLET Y PA Document  
multivit with minerals/lutein CENTURY SENIOR TABLET Y PA Document  
multivit with minerals/lutein CENTURY VITAMIN TABLET Y PA Document  
multivit with minerals/lutein CENTURY W/LUTEIN TABLET Y PA Document  
multivit with minerals/lutein CENTURY WITH LUTEIN TABLET Y PA Document  
multivit with minerals/lutein CEROVITE SENIOR TABLET Y PA Document  
multivit with minerals/lutein CEROVITE SILVER TABLET Y PA Document  
multivit with minerals/lutein CERTA PLUS SENIOR TABLET Y PA Document  
multivit with minerals/lutein COMPLETE SENIOR TABLET Y PA Document  
multivit with minerals/lutein FORMULA TWENTY-ONE SENIOR TABLET Y PA Document  
multivit with minerals/lutein CENTRAL VITE TABLET Y PA Document  
multivit with minerals/lutein THERATRUM COMPLETE 50 PLUS TABLET Y PA Document  
multivit with minerals/lutein VITRUM SENIOR TABLET Y PA Document  
multivit with minerals/lutein VITATRUM W-LUTEIN TABLET Y PA Document  
multivit with minerals/lutein VITATRUM TABLET Y PA Document  
multivit with minerals/lutein MATURE ADULT CENTURY TABLET Y PA Document  
multivit with minerals/lutein ULTRA CHOICE TABLET Y PA Document  
multivit with minerals/lutein MULTIVITAL PLATINUM TABLET Y PA Document  
multivit with minerals/lutein THERATRUM TABLET Y PA Document  
multivit with minerals/lutein SUPER AYTINAL TABLET Y PA Document  
multivit with minerals/lutein SPECTRAVITE SENIOR TABLET Y PA Document  
multivit with minerals/lutein MULTI-VITE 50 & OVER TABLET Y PA Document  
multivit with minerals/lutein MULTIVITAMINS WITH MINERALS TABLET Y PA Document  
multivit with minerals/lutein A THRU Z SELECT TABLET Y PA Document  
multivit with minerals/lutein VISION PLUS LUTEIN TABLET Y PA Document  
multivit with minerals/lutein CENTRAL VITE SR W-LUTEIN TAB TABLET Y PA Document  
multivit with minerals/lutein A THRU Z TABLET Y PA Document  
multivit with minerals/lutein MILLTRIUM SENIOR TABLET Y PA Document  
multivit with minerals/lutein HIGH POTENCY MULTIVITAMIN TABLET Y PA Document  
multivit-min/FA/lycopen/lutein COMPLETE MULTIVITAMIN TABLET Y PA Document  
multivit-min/FA/lycopen/lutein CERTAVITE SENIOR-ANTIOXIDANT TABLET Y PA Document  
multivit-min/FA/lycopen/lutein CENTRAVITES 50 PLUS TABLET Y PA Document  
multivit-min/FA/lycopen/lutein CENTRUM SILVER TABLET Y PA Document  
multivit-min/FA/lycopen/lutein CENTURY TABLET Y PA Document  
multivit-min/FA/lycopen/lutein CENTURY MATURE TABLET Y PA Document  
multivit-min/FA/lycopen/lutein CENTURY MATURE FORMULA TABLET Y PA Document  
multivit-min/FA/lycopen/lutein CENTURY SENIOR TABLET Y PA Document  
multivit-min/FA/lycopen/lutein COMPLETE 50+ TABLET Y PA Document  
multivit-min/FA/lycopen/lutein COMPLETE SENIOR TABLET Y PA Document  
multivit-min/FA/lycopen/lutein SENIOR TABS TABLET Y PA Document  
multivit-min/FA/lycopen/lutein SENTRY SENIOR TABLET Y PA Document  
multivit-min/FA/lycopen/lutein SPECTRAVITE ADULT 50+ TABLET Y PA Document  
multivit-min/FA/lycopen/lutein SPECTRAVITE ADVANCED FORM TABLET Y PA Document  
multivit-min/FA/lycopen/lutein CENTRAL-VITE TABLET Y PA Document  
multivit-min/FA/lycopen/lutein THERATRUM COMPLETE 50 PLUS TABLET Y PA Document  
multivit-min/FA/lycopen/lutein ADVANCED FORMULA TABLET Y PA Document  
multivit-min/FA/lycopen/lutein CENTRAL-VITE SENIOR TABLET Y PA Document  
multivit-min/FA/lycopen/lutein ADULTS' 50+ DAILY FORMULA TABLET Y PA Document  
multivit-min/FA/lycopen/lutein ADULTS 50 PLUS MULTIVITAMIN TABLET Y PA Document  
multivit-min/FA/lycopen/lutein ADULTS 50 PLUS DAILY FORMULA TABLET Y PA Document  
multivit-min/FA/lycopen/lutein ABC PLUS TABLET Y PA Document  
multivit-min/FA/lycopen/lutein A THRU Z SELECT 50+ FORMULA TABLET Y PA Document  
multivit-min/FA/lycopen/lutein A THRU Z SELECT TABLET Y PA Document  
multivit,min52/folic/vitK/cQ10 AQUADEKS CAPSULE Y PA Document  
multivit,tx with iron,minerals THEREMS-M TABLET Y PA Document  
multivit,tx with iron,minerals THERAPEUTIC M TABLET Y PA Document  
multivitamin THERAPEUTIC VITAMINS TABLET Y PA Document  
multivitamin PHARMACIST FAVORITE MULTI-VITE TABLET Y PA Document  
multivitamin PLENAMINS PLUS TABLET Y PA Document  
multivitamin ROVITE TABLET Y PA Document  
multivitamin SIGTAB TABLET Y PA Document  
multivitamin SMOKEGUARD TABLET Y PA Document  
multivitamin SPECTRAVITE TABLET Y PA Document  
multivitamin SPECTRUM TABLET Y PA Document  
multivitamin SUPER MULTIVITAMIN TABLET Y PA Document  
multivitamin SUPER POTENCY TABLET Y PA Document  
multivitamin TAB A VITE TABLET Y PA Document  
multivitamin SUPER-MULTIPLE FORMULA TABLET Y PA Document  
multivitamin THERAPEUTIC M TABLET Y PA Document  
multivitamin WESTVITE TABLET Y PA Document  
multivitamin TOTAL FORMULA-3 WITHOUT IRON TABLET Y PA Document  
multivitamin TOTAL FORMULA-3 W-O IRON TABLET Y PA Document  
multivitamin ULTRA-MEGA TABLET Y PA Document  
multivitamin UNICAP TABLET Y PA Document  
multivitamin UNI-DAILY TABLET Y PA Document  
multivitamin VIMAR TABLET Y PA Document  
multivitamin VIODAY TABLET Y PA Document  
multivitamin VITA-HAIR TABLET Y PA Document  
multivitamin VITAMIN A DAY TABLET Y PA Document  
multivitamin VITAMIN A TO Z TABLET Y PA Document  
multivitamin VITAMINS FOR HAIR TABLET Y PA Document  
multivitamin VITAMINS FOR SMOKERS TABLET Y PA Document  
multivitamin VITE-ONE TABLET Y PA Document  
multivitamin TAB-A-VITE TABLET Y PA Document  
multivitamin SUPER MEDI-VITE TABLET Y PA Document  
multivitamin PHARMACIST FAVORITE MULTI-VIT TABLET Y PA Document  
multivitamin SUPER NU-THERA TABLET Y PA Document  
multivitamin ORIGINAL FORMULA TABLET Y PA Document  
multivitamin MULTIVITAMIN TABLET Y PA Document  
multivitamin MULTI-DAY TABLET Y PA Document  
multivitamin MYAVITE TABLET Y PA Document  
multivitamin MULTIVITAMINS HI-PO TABLET Y PA Document  
multivitamin MULTIVITAMINS TABLET Y PA Document  
multivitamin MULTIVITAMIN-20 TABLET Y PA Document  
multivitamin ADDED PROTECTION-III VITAMIN TABLET Y PA Document  
multivitamin MULTI-VITAMIN DAILY TABLET Y PA Document  
multivitamin OMNI-TECH TABLET Y PA Document  
multivitamin MULTIPLE VITAMINS DAILY TABLET Y PA Document  
multivitamin MULTIPLE VITAMINS TABLET Y PA Document  
multivitamin MULTIPLE VITAMIN TABLET Y PA Document  
multivitamin MULTIPLE DAILY W/BETA TABLET Y PA Document  
multivitamin MULTIDAY VITES TABLET Y PA Document  
multivitamin MULTI-DAY VITAMINS TABLET Y PA Document  
multivitamin MULTI-VITAMIN NATURAL TABLET Y PA Document  
multivitamin ONE DAILY MULTI-VITAMIN TABLET Y PA Document  
multivitamin OPTIVITE P.M.T. TABLET Y PA Document  
multivitamin OPTIMUM PMS TABLET Y PA Document  
multivitamin OPTILETS-500 TABLET Y PA Document  
multivitamin ONE-TABLET-DAILY TABLET Y PA Document  
multivitamin ONE-A-DAY PLUS EXTRA C TABLET Y PA Document  
multivitamin NATURAL RDA MULTIVITAMIN TABLET Y PA Document  
multivitamin ONE DAILY VITAMIN TABLET Y PA Document  
multivitamin NUTRIMIN-PLUS TABLET Y PA Document  
multivitamin ONE DAILY MULTIVITAMIN TABLET Y PA Document  
multivitamin ONE DAILY ESSENTIAL TABLET Y PA Document  
multivitamin ONE DAILY TABLET Y PA Document  
multivitamin ONE A DAY TABLET Y PA Document  
multivitamin ONCE DAILY MULTIVITAMIN TABLET Y PA Document  
multivitamin ONE-A-DAY ESSENTIAL TABLET Y PA Document  
multivitamin CENTURION TABLET Y PA Document  
multivitamin DAILY VITE TABLET Y PA Document  
multivitamin DAILY VITAMINS TABLET Y PA Document  
multivitamin DAILY VITAMIN FORMULA TABLET Y PA Document  
multivitamin DAILY VITAMIN TABLET Y PA Document  
multivitamin DAILY VALUE TABLET Y PA Document  
multivitamin DAYALETS TABLET Y PA Document  
multivitamin DAILY DIET SUPPORT TABLET Y PA Document  
multivitamin DAILY MULTI-VITAMIN TABLET Y PA Document  
multivitamin CENTRAL-VITE HP TABLET Y PA Document  
multivitamin CENTRAL VITE TABLET Y PA Document  
multivitamin MULTI-DAILY TABLET Y PA Document  
multivitamin ONCE DAILY TABLET Y PA Document  
multivitamin BASIC PREVENTIVE VITAMIN TABLET Y PA Document  
multivitamin CEBRINE TABLET Y PA Document  
multivitamin DAILY MULTIVITAMIN TABLET Y PA Document  
multivitamin HIGH POTENCY MULTI-VITAMIN TABLET Y PA Document  
multivitamin MEGAVITE-100 TABLET Y PA Document  
multivitamin MEGA-DOSE TABLET Y PA Document  
multivitamin DAILY MULTIPLE VITAMIN TABLET Y PA Document  
multivitamin MAXI-VITE NF TABLET Y PA Document  
multivitamin MEN'S MULTI-VITAMIN TABLET Y PA Document  
multivitamin HM MULTIPLE VITAMIN ESSENTIAL TABLET Y PA Document  
multivitamin MEGA MULTIVITAMIN TABLET Y PA Document  
multivitamin FORMULA TWENTY-ONE TABLET Y PA Document  
multivitamin FAMILY MULTIVITAMIN TABLET Y PA Document  
multivitamin EVERYDAY BASIC TABLET Y PA Document  
multivitamin ESSENTIAL ONE DAILY TABLET Y PA Document  
multivitamin ESSENTIAL BALANCE TABLET Y PA Document  
multivitamin KENTRON TABLET Y PA Document  
multivitamin no.58/vit D3/K ABDEK MULTIVITAMIN CAPSULE Y PA Document  
multivitamin,therapeutic HI-PO-VITES TABLET Y PA Document  
multivitamin,therapeutic THERAPEUTIC FORMULA TABLET Y PA Document  
multivitamin,therapeutic THERAGRAN TABLET Y PA Document  
multivitamin,therapeutic THERADEX TABLET Y PA Document  
multivitamin,therapeutic ADAVITE TABLET Y PA Document  
multivitamin,therapeutic CEB PLUS T TABLET Y PA Document  
multivitamin,therapeutic ONCOVITE TABLET Y PA Document  
multivitamin,therapeutic THERABASIC M TABLET Y PA Document  
multivitamin,therapeutic THERAPEUTIC MULTIVITAMIN TABLET Y PA Document  
multivitamin,therapeutic THERA TABLET Y PA Document  
multivitamin,therapeutic SUPER PLENAMINS EXTRA STRENGTH TABLET Y PA Document  
multivitamin,therapeutic GERETREX TABLET Y PA Document  
multivitamin,therapeutic THERAPEUTIC VITAMIN TABLET Y PA Document  
multivitamin,therapeutic THEREMS TABLET Y PA Document  
multivitamin,therapeutic THERA-TABS TABLET Y PA Document  
multivitamin/FA/zinc ascorbate SOURCECF CAPSULE Y PA Document  
multivitamin/iron/folic acid CENTRUM ULTRA WOMEN'S TABLET Y PA Document  
multivitamin/iron/folic acid CENTRUM COMPLETE TABLET Y PA Document  
multivitamin/iron/folic acid COMPLETE MULTIVITAMIN TABLET Y PA Document  
multivitamin/iron/folic acid CERTAVITE-ANTIOXIDANT TABLET Y PA Document  
multivitamin/iron/folic acid CEROVITE ADVANCED FORMULA TABLET Y PA Document  
multivitamin/iron/folic acid CENTURY ULTIMATE WOMEN'S TABLET Y PA Document  
multivitamin/iron/folic acid CENTRUM ADULTS TABLET Y PA Document  
multivitamin/iron/folic acid CENTRUM WOMEN TABLET Y PA Document  
multivitamin/iron/folic acid CENTRAL-VITE TABLET Y PA Document  
multivitamin/iron/folic acid ADULTS' DAILY FORMULA TABLET Y PA Document  
multivitamin/iron/folic acid A THRU Z ADVANCED FORMULA TABLET Y PA Document  
multivitamin/iron/folic acid CENTURY TABLET Y PA Document  
multivitamin/iron/folic acid COMPLETE MULTI-VIT-MINERAL TABLET Y PA Document  
multivitamin/iron/folic acid SENTRY TABLET Y PA Document  
multivitamin/iron/folic acid DAILY MULTI TABLET Y PA Document  
multivitamin/iron/folic acid DAILY MULTIPLE TABLET Y PA Document  
multivitamin/iron/folic acid DAILY MULTIPLE VITAMINS-IRON TABLET Y PA Document  
multivitamin/iron/folic acid DAILY MULTIVITAMIN-IRON TABLET Y PA Document  
multivitamin/iron/folic acid DAILY TEEN MULTI-VITAMIN TABLET Y PA Document  
multivitamin/iron/folic acid DAILY VITAMIN FORMULA-IRON TABLET Y PA Document  
multivitamin/iron/folic acid ESSENTIA TABLET Y PA Document  
multivitamin/iron/folic acid MULTI COMPLETE-IRON TABLET Y PA Document  
multivitamin/iron/folic acid MULTI-DAY PLUS IRON TABLET Y PA Document  
multivitamin/iron/folic acid MULTIVITAMIN WITH IRON TABLET Y PA Document  
multivitamin/iron/folic acid MULTI-VITE TABLET Y PA Document  
multivitamin/iron/folic acid ONE DAILY MULTIVITAMIN-IRON TABLET Y PA Document  
multivitamin/iron/folic acid ONE DAILY PLUS IRON TABLET Y PA Document  
multivitamin/iron/folic acid YELETS TABLET Y PA Document  
multivitamin/iron/folic acid ONE DAILY WITH IRON TABLET Y PA Document  
multivitamin/iron/folic acid ONE-A-DAY TEEN ADVANTAGE TABLET Y PA Document  
multivitamin/iron/folic acid VITATRUM COMPLETE TABLET Y PA Document  
multivitamin/iron/folic acid TAB A VITE WEIGHT SLIM TABLET Y PA Document  
multivitamin/iron/folic acid SPECTRAVITE ULTRA WOMEN TABLET Y PA Document  
multivitamin/iron/folic acid SPECTRAVITE ADVANCED FORMULA TABLET Y PA Document  
multivitamin/iron/folic acid SENTRY PERFORM TABLET Y PA Document  
multivitamin/iron/folic acid COMPLETE WOMEN TABLET Y PA Document  
multivitamin/zinc gluconate SOURCECF DROPS Y PA Document  
mv-min 51/folic acid/vit K/ubi AQUADEKS TAB CHEW Y PA Document  
pedi multivit 22/vit D3/vit K SOURCECF TAB CHEW Y PA Document  
pedi multivit 32/folic ac/zinc AKEDAMINS TAB CHEW Y PA Document  
vitamin B complex NEURODEP CAPSULE Y PA Document  
vitamin B complex SUPER B-50 CAPSULE Y PA Document  
vitamin B complex SUPER B-50 COMPLEX CAPSULE Y PA Document  
vitamin B complex VITAMIN B COMPLEX CAPSULE Y PA Document  
vitamin B complex SUPER B COMPLEX CAPSULE Y PA Document  
vitamin B complex HI B COMPLEX CAPSULE Y PA Document  
vitamin B complex BALANCED B-50 CAPSULE Y PA Document  
vitamin B complex B-50 GEL CAPSULE Y PA Document  
vitamin B complex B COMPLEX CAPSULE Y PA Document  
vitamin B complex VITAMIN B COMPLEX W/VIT B-12 CAPSULE Y PA Document  
folic/mvi ther-min/lycop/lut CORVITE TABLET N PA Document  
folic/mvi ther-min/lycop/lut CORVITA TABLET N PA Document  
m-tetrahyrofolate/niacin/Cu/Zn NICOMIDE TABLET N PA Document  
multivit-mins no.20/iron/folic BACMIN TABLET N PA Document  
multivit,iron,min 5/folic acid STROVITE FORTE TABLET N PA Document  
mv-mins 6/folic acid/lut/coQ10 CORVITE FREE TABLET N PA Document  
mv,min10/folic acid/D3/ala/lut STROVITE ONE TABLET N PA Document  
om-3/dha/epa/B12/FA/B6/phytost VIT 3 CAPSULE N PA Document  
omeg3/dha/epa/fish oil/L.casei RESTORA CAPSULE N PA Document