Calcium/Vit D Replacement, Oral

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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
CALCIUM CARBONATE CALCI-MIX CAPSULE Y    
CALCIUM CARBONATE CALCIUM CARBONATE ORAL SUSP Y    
CALCIUM CARBONATE CALCIUM CARBONATE ORAL SUSP Y    
CALCIUM CARBONATE CALCIUM CARBONATE TAB CHEW Y    
CALCIUM CARBONATE CAL-MINT TAB CHEW Y    
CALCIUM CARBONATE OYSCO-500 TABLET Y    
CALCIUM CARBONATE CALCIUM TABLET Y    
CALCIUM CARBONATE CALCIUM 500 TABLET Y    
CALCIUM CARBONATE CALCIUM CARBONATE TABLET Y    
CALCIUM CARBONATE NATURAL CALCIUM TABLET Y    
CALCIUM CARBONATE OYST-CAL-500 TABLET Y    
CALCIUM CARBONATE HI-CALCIUM TABLET Y    
CALCIUM CARBONATE CALCIUM CARBONATE TABLET Y    
CALCIUM CARBONATE OYSTER SHELL CALCIUM TABLET Y    
CALCIUM CARBONATE SUPER CALCIUM TABLET Y    
CALCIUM CARBONATE/VITAMIN D3 CALCIUM 600-VIT D3 CAPSULE Y    
CALCIUM CARBONATE/VITAMIN D3 CALCIUM CARBONATE/VITAMIN D3 CAPSULE Y    
CALCIUM CARBONATE/VITAMIN D3 LIQUID CALCIUM + VITAMIN D CAPSULE Y    
CALCIUM CARBONATE/VITAMIN D3 LIQUID CALCIUM 600-VIT D3 CAPSULE Y    
CALCIUM CARBONATE/VITAMIN D3 CAL-QUICK LIQUID Y    
CALCIUM CARBONATE/VITAMIN D3 CALCIUM TAB CHEW Y    
CALCIUM CARBONATE/VITAMIN D3 CALCIUM 500 + VIT D TAB CHEW Y    
CALCIUM CARBONATE/VITAMIN D3 CALTRATE 600 + D TAB CHEW Y    
CALCIUM CARBONATE/VITAMIN D3 OS-CAL 500+D TAB CHEW Y    
CALCIUM CARBONATE/VITAMIN D3 CALCIUM 600 + VIT D TABLET Y    
CALCIUM CARBONATE/VITAMIN D3 CALCIUM 500-VIT D3 TABLET Y    
CALCIUM CARBONATE/VITAMIN D3 OSTEO-PORETICAL TABLET Y    
CALCIUM CARBONATE/VITAMIN D3 OS-CAL 500-VIT D3 TABLET Y    
CALCIUM CARBONATE/VITAMIN D3 CALCIUM 1000 + D3 TABLET Y    
CALCIUM CITRATE CALCIUM CITRATE TABLET Y    
CHOLECALCIFEROL (VITAMIN D3) VITAMIN D3 CAPSULE Y    
CHOLECALCIFEROL (VITAMIN D3) D3-50 CAPSULE Y    
CHOLECALCIFEROL (VITAMIN D3) DECARA CAPSULE Y    
CHOLECALCIFEROL (VITAMIN D3) MAXIMUM D3 CAPSULE Y    
CHOLECALCIFEROL (VITAMIN D3) OPTIMAL D3 CAPSULE Y    
CHOLECALCIFEROL (VITAMIN D3) VITAMIN D3 CAPSULE Y    
CHOLECALCIFEROL (VITAMIN D3) VITAMIN D3 SPRAY SUSP Y    
CHOLECALCIFEROL (VITAMIN D3) D3 DOTS TABLET Y    
CHOLECALCIFEROL (VITAMIN D3) DIALYVITE VITAMIN D3 MAX TABLET Y    
CHOLECALCIFEROL (VITAMIN D3) THERA-D TABLET Y    
CHOLECALCIFEROL (VITAMIN D3) VITAMIN D3 TABLET Y    
CHOLECALCIFEROL (VITAMIN D3) VITAMIN D TABLET Y    
ERGOCALCIFEROL (VITAMIN D2) VITAMIN D2 CAPSULE Y    
ERGOCALCIFEROL (VITAMIN D2) VITAMIN D2 TABLET Y    
CALCIUM GLUCONATE CALCIUM GLUCONATE TABLET N PA Document  
CALCIUM/MAG/D3/B12/FA/B6/BORON TL G-FOL OS TABLET N PA Document  
CALCIUM/MAG/D3/B12/FA/B6/BORON CALCIUM-FOLIC ACID PLUS D WAFER N PA Document  
CALCIUM CHLORIDE CALCIUM CHLORIDE SYRINGE    
CALCIUM CHLORIDE CALCIUM CHLORIDE VIAL    
CALCIUM GLUCONATE CALCIUM GLUCONATE VIAL