Iron 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
FERROUS GLUCONATE IRON TABLET Y    
FERROUS GLUCONATE FERROUS GLUCONATE TABLET Y    
FERROUS GLUCONATE FERATE TABLET Y    
FERROUS SULFATE FEROSUL ELIXIR Y    
FERROUS SULFATE FERROUS SULFATE LIQUID Y    
FERROUS SULFATE IRON TABLET Y    
FERROUS SULFATE FERROUSUL TABLET Y    
FERROUS SULFATE FERROUS SULFATE TABLET Y    
FERROUS SULFATE FERRO-TIME TABLET Y    
FERROUS SULFATE FEROSUL TABLET Y    
FERROUS SULFATE FEOSOL TABLET Y    
FERROUS SULFATE IROMAR TABLET Y    
FERROUS SULFATE FERROUS SULFATE TABLET DR Y    
FERROUS SULFATE FERROUS SULFATE TABLET ER Y    
FERROUS SULFATE SLOW RELEASE IRON TABLET ER Y    
FERROUS SULFATE SLOW FE TABLET ER Y    
IRON FUM, PS/FA/VIT C/L. CASEI FUSION SPRINKLES POWD PACK Y    
FERROUS FUM/VIT C/B12-IF/FOLIC TL ICON CAPSULE N    
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 FOCALGIN DSS 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 FOLIVANE-F CAPSULE N    
IRON FUM,PS/FOLIC ACID/VITC/B3 INTEGRA 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 HEMOCYTE PLUS CAPSULE N    
IRON FUM/FOLIC ACID/MV,MIN 15 CENTRATEX 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