Iron Replacement, Oral

← 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
ferrous gluconate FERROUS GLUCONATE TABLET Y    
ferrous gluconate FERRONATE TABLET Y    
ferrous gluconate FERATE TABLET Y    
ferrous gluconate FERROUS GLUCONATE TABLET Y    
ferrous gluconate IRON TABLET Y    
ferrous gluconate FE-40 TABLET Y    
ferrous sulfate FEROSUL ELIXIR Y    
ferrous sulfate FERROUS SULFATE ELIXIR Y    
ferrous sulfate FERROUS SULFATE LIQUID Y    
ferrous sulfate RIDOSOL TABLET Y    
ferrous sulfate FERROUSUL TABLET Y    
ferrous sulfate HM IRON TABLET Y    
ferrous sulfate IRON TABLET Y    
ferrous sulfate FERROUS SULFATE TABLET Y    
ferrous sulfate IRON-F TABLET Y    
ferrous sulfate FE-TABS TABLET Y    
ferrous sulfate IRON SUPPLEMENT TABLET Y    
ferrous sulfate IROMAR TABLET Y    
ferrous sulfate ALBAFORT TABLET Y    
ferrous sulfate FEOSOL TABLET Y    
ferrous sulfate FEROSUL TABLET Y    
ferrous sulfate FERRO-BOB TABLET Y    
ferrous sulfate FERRO-TIME TABLET Y    
ferrous sulfate FERROUS SULFATE TABLET DR Y    
ferrous sulfate FERROUS SULFATE TABLET DR Y    
ferrous sulfate FERROUS SULFATE TABLET ER Y    
ferrous sulfate SLOW FE TABLET ER Y    
ferrous sulfate SLOW RELEASE IRON TABLET ER Y    
iron fum, ps/FA/vit C/L. casei FUSION SPRINKLES POWD PACK Y    
ferrous fum/vit C/B12-if/folic TRICON CAPSULE N    
ferrous fum/vit C/B12/stomc HEMATOGEN CAPSULE N    
ferrous fumarate/folic acid HEMOCYTE-F TABLET N    
ferrous fumarate/iron ps cplx TANDEM DUAL ACTION CAPSULE N    
iron ag,ps/C/FA6/B12/Zn/sa/sto NIFEREX TABLET N    
iron bg,ps/folic/B,C no.12/suc IROSPAN TABLET N    
iron bg,ps/vitC/B12/FA/calcium TARON FORTE CAPSULE N    
iron carb,gl/FA/B12/C/docusate FERRALET 90 TABLET N    
iron carb,gl/FA/B12/C/docusate CITRANATAL BLOOM TABLET N    
iron fm,ps no.1/folic/mv no.18 TANDEM PLUS CAPSULE N    
iron fm,ps no.1/folic/mv no.18 SE-TAN PLUS CAPSULE N    
iron fm,ps no.1/folic/mv no.18 PUREVIT DUALFE PLUS CAPSULE N    
iron fum,ps cmp/vit C/niacin INTEGRA CAPSULE N    
iron fum,ps no.1/vit C/L.casei FUSION CAPSULE N    
iron fum,ps/folic acid/vitC/B3 INTEGRA F CAPSULE N    
iron fum,ps/folic acid/vitC/B3 FOLIVANE-F CAPSULE N    
iron fum,ps/folic/Bcomp,C no.9 INTEGRA PLUS CAPSULE N    
iron fum/docusat/folic/Bcomp,C NEPHRON FA TABLET N    
iron fum/folic acid/mv,min 15 CENTRATEX CAPSULE N    
iron fum/folic acid/mv,min 15 HEMOCYTE PLUS CAPSULE N    
iron fumarate/vit C/Vit B12/FA HEMATOGEN FA CAPSULE N    
iron fumarate/vit C/Vit B12/FA HEMATOGEN FORTE CAPSULE N    
iron fumarate/vit C/Vit B12/FA TRIGELS-F FORTE CAPSULE N    
iron polysaccharide complex IFEREX 150 CAPSULE N    
iron ps complex/B12/folic acid IFEREX 150 FORTE CAPSULE N    
iron,carb/folate6/mv,min no.41 CORVITE 150 TABLET N    
iron,carbonyl WEE CARE ORAL SUSP N    
iron,carbonyl/folic acid/mv-mn ACTIVE FE TABLET N    
iron,fm,ps/folic/B,C18/L.casei FUSION PLUS CAPSULE N    
iron/C/folate 6/B12/Zn/stomach CHROMAGEN CAPSULE N    
iron/calcium/E/folic acid/mvit VITAFOL TABLET N    
iron/folat1/C/B12/biot/docusat FERIVA FA CAPSULE N    
iron/folate 9/vit C/D3/B6/B12 NUFERA TABLET N    
iron/folate no.6/mv,mins no.40 CORVITE FE TABLET N    
iron/folate no1/C/B12/zinc/dss FERIVA 21-7 TABLET N    
iron/folic acid/B12/C/docusate FERRAPLUS 90 TABLET N    
iron/folic acid/C/B6/B12/zinc CORVITA 150 TABLET N