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 EYE HEALTH TABLET Y PA Document  
BETA-CAROTENE(A)-VITS C,E/MINS VISION TABLET Y PA Document  
BETA-CAROTENE(A)-VITS C,E/MINS OPTI-VITAMINS TABLET Y PA Document  
BETA-CAROTENE(A)-VITS C,E/MINS OCUVITE TABLET Y PA Document  
BETA-CAROTENE(A)-VITS C,E/MINS OCUTABS 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 HP ZINC WITH ANTIOXIDANTS TABLET Y PA Document  
FOLIC ACID/VIT B COMPLEX AND C RENAL VITAMIN TABLET Y PA Document  
FOLIC ACID/VIT B COMPLEX AND C RENA-VITE TABLET Y PA Document  
FOLIC ACID/VIT B COMPLEX AND C RENAL-VITE TABLET Y PA Document  
FOLIC ACID/VIT B COMPLEX AND C NEPHRO-VITE 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 DIALYVITE 800 TABLET Y PA Document  
MULTIVIT WITH MINERALS/LUTEIN CEROVITE SENIOR TABLET Y PA Document  
MULTIVIT WITH MINERALS/LUTEIN CENTURY W/LUTEIN TABLET Y PA Document  
MULTIVIT WITH MINERALS/LUTEIN CENTRAL-VITE SELECT 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 SELECT TABLET Y PA Document  
MULTIVIT WITH MINERALS/LUTEIN A THRU Z TABLET Y PA Document  
MULTIVIT WITH MINERALS/LUTEIN CENTURY WITH LUTEIN TABLET Y PA Document  
MULTIVIT WITH MINERALS/LUTEIN HIGH POTENCY MULTIVITAMIN TABLET Y PA Document  
MULTIVIT WITH MINERALS/LUTEIN MILLTRIUM SENIOR TABLET Y PA Document  
MULTIVIT WITH MINERALS/LUTEIN MULTI-VITE 50 & OVER TABLET Y PA Document  
MULTIVIT WITH MINERALS/LUTEIN MULTIVITAMIN 50 PLUS TABLET Y PA Document  
MULTIVIT WITH MINERALS/LUTEIN MULTIVITAMINS WITH MINERALS TABLET Y PA Document  
MULTIVIT WITH MINERALS/LUTEIN SUPER AYTINAL TABLET Y PA Document  
MULTIVIT WITH MINERALS/LUTEIN THERATRUM COMPLETE 50 PLUS TABLET Y PA Document  
MULTIVIT WITH MINERALS/LUTEIN ULTRA CHOICE TABLET Y PA Document  
MULTIVIT WITH MINERALS/LUTEIN VISION PLUS LUTEIN TABLET Y PA Document  
MULTIVIT WITH MINERALS/LUTEIN VITATRUM TABLET Y PA Document  
MULTIVIT WITH MINERALS/LUTEIN VITRUM SENIOR TABLET Y PA Document  
MULTIVIT-MIN/FA/LYCOPEN/LUTEIN COMPLETE SENIOR TABLET Y PA Document  
MULTIVIT-MIN/FA/LYCOPEN/LUTEIN A THRU Z SELECT TABLET Y PA Document  
MULTIVIT-MIN/FA/LYCOPEN/LUTEIN A THRU Z SELECT 50+ FORMULA TABLET Y PA Document  
MULTIVIT-MIN/FA/LYCOPEN/LUTEIN ABC PLUS TABLET Y PA Document  
MULTIVIT-MIN/FA/LYCOPEN/LUTEIN ADULTS 50 PLUS DAILY FORMULA TABLET Y PA Document  
MULTIVIT-MIN/FA/LYCOPEN/LUTEIN ADULTS 50 PLUS MULTIVITAMIN TABLET Y PA Document  
MULTIVIT-MIN/FA/LYCOPEN/LUTEIN CENTRAL-VITE TABLET Y PA Document  
MULTIVIT-MIN/FA/LYCOPEN/LUTEIN CENTRUM SILVER TABLET Y PA Document  
MULTIVIT-MIN/FA/LYCOPEN/LUTEIN CENTURY MATURE TABLET Y PA Document  
MULTIVIT-MIN/FA/LYCOPEN/LUTEIN CERTAVITE SENIOR-ANTIOXIDANT TABLET Y PA Document  
MULTIVIT-MIN/FA/LYCOPEN/LUTEIN COMPLETE MULTIVITAMIN TABLET Y PA Document  
MULTIVIT-MIN/FA/LYCOPEN/LUTEIN CENTRAVITES 50 PLUS 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 COMPLETE 50+ TABLET Y PA Document  
MULTIVIT-MIN/FA/LYCOPEN/LUTEIN CENTURY TABLET Y PA Document  
MULTIVIT,TX WITH IRON,MINERALS THEREMS-M TABLET Y PA Document  
MULTIVITAMIN ULTRA-MEGA TABLET Y PA Document  
MULTIVITAMIN VIMAR TABLET Y PA Document  
MULTIVITAMIN TAB-A-VITE TABLET Y PA Document  
MULTIVITAMIN VITAMINS FOR HAIR TABLET Y PA Document  
MULTIVITAMIN SUPER MULTIVITAMIN TABLET Y PA Document  
MULTIVITAMIN SUPER MEDI-VITE TABLET Y PA Document  
MULTIVITAMIN SIGTAB TABLET Y PA Document  
MULTIVITAMIN OPTIVITE P.M.T. TABLET Y PA Document  
MULTIVITAMIN ONE-TABLET-DAILY TABLET Y PA Document  
MULTIVITAMIN ONE DAILY ESSENTIAL TABLET Y PA Document  
MULTIVITAMIN MULTIPLE VITAMIN TABLET Y PA Document  
MULTIVITAMIN ONCE DAILY TABLET Y PA Document  
MULTIVITAMIN ONE-A-DAY ESSENTIAL TABLET Y PA Document  
MULTIVITAMIN ONE DAILY MULTIVITAMIN TABLET Y PA Document  
MULTIVITAMIN ONE DAILY TABLET Y PA Document  
MULTIVITAMIN MULTIVITAMINS TABLET Y PA Document  
MULTIVITAMIN MULTI-VITAMIN DAILY TABLET Y PA Document  
MULTIVITAMIN MULTIPLE VITAMINS TABLET Y PA Document  
MULTIVITAMIN MULTIPLE DAILY W/BETA TABLET Y PA Document  
MULTIVITAMIN MULTIDAY VITES TABLET Y PA Document  
MULTIVITAMIN MEN'S MULTI-VITAMIN TABLET Y PA Document  
MULTIVITAMIN ESSENTIAL ONE DAILY TABLET Y PA Document  
MULTIVITAMIN DAILY VITE TABLET Y PA Document  
MULTIVITAMIN DAILY VITAMIN FORMULA TABLET Y PA Document  
MULTIVITAMIN MULTIVITAMIN TABLET Y PA Document  
MULTIVITAMIN DAILY VITAMIN TABLET Y PA Document  
MULTIVITAMIN DAILY VALUE TABLET Y PA Document  
MULTIVITAMIN CENTRAL VITE TABLET Y PA Document  
MULTIVITAMIN DAILY MULTIPLE VITAMIN TABLET Y PA Document  
MULTIVITAMIN,THERAPEUTIC THERA-TABS TABLET Y PA Document  
MULTIVITAMIN,THERAPEUTIC ONCOVITE TABLET Y PA Document  
MULTIVITAMIN,THERAPEUTIC THEREMS TABLET Y PA Document  
MULTIVITAMIN,THERAPEUTIC THERA TABLET Y PA Document  
MULTIVITAMIN/IRON/FOLIC ACID A THRU Z ADVANCED FORMULA TABLET Y PA Document  
MULTIVITAMIN/IRON/FOLIC ACID CENTRUM ADULTS TABLET Y PA Document  
MULTIVITAMIN/IRON/FOLIC ACID CENTRUM COMPLETE TABLET Y PA Document  
MULTIVITAMIN/IRON/FOLIC ACID CENTRUM WOMEN TABLET Y PA Document  
MULTIVITAMIN/IRON/FOLIC ACID CENTURY TABLET Y PA Document  
MULTIVITAMIN/IRON/FOLIC ACID CENTURY ULTIMATE WOMEN'S TABLET Y PA Document  
MULTIVITAMIN/IRON/FOLIC ACID YELETS TABLET Y PA Document  
MULTIVITAMIN/IRON/FOLIC ACID SPECTRAVITE ULTRA WOMEN TABLET Y PA Document  
MULTIVITAMIN/IRON/FOLIC ACID CEROVITE ADVANCED FORMULA TABLET Y PA Document  
MULTIVITAMIN/IRON/FOLIC ACID DAILY MULTIPLE TABLET Y PA Document  
MULTIVITAMIN/IRON/FOLIC ACID CERTAVITE-ANTIOXIDANT TABLET Y PA Document  
MULTIVITAMIN/IRON/FOLIC ACID COMPLETE MULTIVITAMIN TABLET Y PA Document  
MULTIVITAMIN/IRON/FOLIC ACID COMPLETE MULTI-VIT-MINERAL TABLET Y PA Document  
MULTIVITAMIN/IRON/FOLIC ACID COMPLETE WOMEN TABLET Y PA Document  
MULTIVITAMIN/IRON/FOLIC ACID DAILY MULTIVITAMIN-IRON 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 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 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 SENTRY TABLET Y PA Document  
MULTIVITAMIN/IRON/FOLIC ACID SPECTRAVITE ADVANCED FORMULA TABLET Y PA Document  
MV-MIN 51/FOLIC ACID/VIT K/UBI AQUADEKS TAB CHEW Y PA Document  
VITAMIN B COMPLEX BALANCED 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 VITAMIN B COMPLEX W/VIT B-12 CAPSULE Y PA Document  
FOLIC/MVI THER-MIN/LYCOP/LUT CORVITA TABLET N PA Document  
FOLIC/MVI THER-MIN/LYCOP/LUT CORVITE 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