B-vitamins, 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
cyanocobalamin (vitamin B-12) B-12 DROPS Y    
cyanocobalamin (vitamin B-12) B-12 LOZENGE Y    
cyanocobalamin (vitamin B-12) VITAMIN B-12 LOZENGE Y    
cyanocobalamin (vitamin B-12) B-12 DUAL SPECTRUM TAB IR ER Y    
cyanocobalamin (vitamin B-12) B-12 TAB RAPDIS Y    
cyanocobalamin (vitamin B-12) VITAMIN B12 TAB RAPDIS Y    
cyanocobalamin (vitamin B-12) VITAMIN B-12 TAB RAPDIS Y    
cyanocobalamin (vitamin B-12) B-12 TAB SUBL Y    
cyanocobalamin (vitamin B-12) VITAMIN B-12 TAB SUBL Y    
cyanocobalamin (vitamin B-12) VITAMIN B-12 TABLET Y    
cyanocobalamin (vitamin B-12) B-12 DOTS TABLET Y    
cyanocobalamin (vitamin B-12) B12-RESIN TABLET Y    
cyanocobalamin (vitamin B-12) CYANOCOBALAMIN TABLET Y    
cyanocobalamin (vitamin B-12) HM VITAMIN B12 TABLET Y    
cyanocobalamin (vitamin B-12) SENIOR VITAMIN B-12 TABLET Y    
cyanocobalamin (vitamin B-12) VITAMIN B12 TABLET Y    
cyanocobalamin (vitamin B-12) B-12 TABLET Y    
cyanocobalamin (vitamin B-12) VITAMIN B-12 TABLET ER Y    
methyltetrahydrofolate glucosa FALESSA TABLET Y    
methyltetrahydrofolate glucosa FALESSA TABLET Y    
methyltetrahydrofolate glucosa Q-TABS TABLET Y    
pyridoxine HCl (vitamin B6) SUPER B-6 TABLET Y    
pyridoxine HCl (vitamin B6) B-6 TABLET Y    
pyridoxine HCl (vitamin B6) HM VITAMIN B6 TABLET Y    
pyridoxine HCl (vitamin B6) NEURO-K TABLET Y    
pyridoxine HCl (vitamin B6) PYRIDOXINE HCL TABLET Y    
pyridoxine HCl (vitamin B6) VITAMIN B6 TABLET Y    
pyridoxine HCl (vitamin B6) VITAMIN B-6 TABLET Y    
thiamine HCl B-1 TABLET Y    
thiamine HCl HM VITAMIN B1 TABLET Y    
thiamine HCl THIAMINE HCL TABLET Y    
thiamine HCl VITAMIN B1 TABLET Y    
thiamine HCl VITAMIN B-1 TABLET Y    
thiamine mononitrate (vit B1) VITAMIN B-1 TABLET Y    
B cmplx 4/vit D3/C/folic/zinc VITAL-D RX TABLET N    
B comp no3/folic/C/biotin/zinc NEPHPLEX RX TABLET N    
B complex 11/folic/C/biot/zinc DIALYVITE ZINC TABLET N    
B complex w-C no.20/folic acid VIRT-CAPS CAPSULE N    
B complex w-C no.20/folic acid RENO CAPS CAPSULE N    
B complex w-C no.20/folic acid RENAL CAPS CAPSULE N    
B complex w-C no.20/folic acid TRIPHROCAPS CAPSULE N    
cyanocobalamin (vitamin B-12) NASCOBAL SPRAY N    
cyanocobalamin/folic ac/vit B6 VIRT-GARD TABLET N    
cyanocobalamin/folic ac/vit B6 TL GARD RX TABLET N    
cyanocobalamin/folic ac/vit B6 FABB TABLET N    
cyanocobalamin/folic ac/vit B6 VIRT-VITE TABLET N    
cyanocobalamin/folic acid FOLTRATE TABLET N    
FA7/pc,pe dha/nac/pap/if/mv46 PURALOR CI TAB CH BPH N    
folic acid/B complex C no.17 VIRT-VITE PLUS TABLET N    
folic acid/B cplx/C/selen/zinc DIALYVITE 3000 TABLET N    
folic acid/vit B complex and C DIALYVITE TABLET N    
iron/FA/dha/epa/FAD/NADH/mv47 ENLYTE CAP IR DR N    
levomefolate calcium L-METHYLFOLATE CALCIUM TABLET N    
multivit-mins 25/folic acid/D3 DIALYVITE SUPREME D TABLET N    
multivit-mins no.11/folic acid DIALYVITE 5000 TABLET N    
vit B comp no.3/folic/C/biotin VP-VITE RX TABLET N    
cyanocobalamin/folic ac/vit B6 NIVA-FOL TABLET    
cyanocobalamin/folic ac/vit B6 VIRT-VITE FORTE TABLET    
folic acid FOLIC ACID TABLET    
vit B12/levomefolate/vit B6/B2 L-METHYL-MC TABLET