Magnesium 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
MAGNESIUM MAGNESIUM TABLET Y    
MAGNESIUM AMINO ACID CHELATE MAGNESIUM TABLET Y    
MAGNESIUM CARBONATE MAGONATE LIQUID Y    
MAGNESIUM CITRATE MAGNESIUM CITRATE TABLET Y    
MAGNESIUM GLUCONATE MAG-G TABLET Y    
MAGNESIUM GLUCONATE MAGNESIUM GLUCONATE TABLET Y    
MAGNESIUM OXIDE UROMAG CAPSULE Y    
MAGNESIUM OXIDE MAGNESIUM CAPSULE Y    
MAGNESIUM OXIDE/MAGNESIUM MG-PLUS-PROTEIN TABLET Y    
MAGNESIUM OXIDE/VIT B6 BEELITH TABLET Y    
MAGNESIUM OXIDE/VIT B6 MAGBEE TABLET Y    
MAGNESIUM OXIDE MAGNESIUM OXIDE TABLET N