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) VITAMIN B-12 LOZENGE Y    
CYANOCOBALAMIN (VITAMIN B-12) B-12 LOZENGE Y    
CYANOCOBALAMIN (VITAMIN B-12) B-12 DUAL SPECTRUM TAB IR ER Y    
CYANOCOBALAMIN (VITAMIN B-12) VITAMIN B12 TAB RAPDIS Y    
CYANOCOBALAMIN (VITAMIN B-12) B-12 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) VITAMIN B12 TABLET Y    
CYANOCOBALAMIN (VITAMIN B-12) B-12 DOTS TABLET Y    
CYANOCOBALAMIN (VITAMIN B-12) B-12 TABLET Y    
PYRIDOXINE HCL (VITAMIN B6) B-6 TABLET Y    
PYRIDOXINE HCL (VITAMIN B6) PYRIDOXINE HCL 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 VITAMIN B-1 TABLET Y    
THIAMINE HCL THIAMINE HCL 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 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    
B COMPLEX W-C NO.20/FOLIC ACID VIRT-CAPS CAPSULE N    
CYANOCOBALAMIN (VITAMIN B-12) NASCOBAL SPRAY N    
CYANOCOBALAMIN/FOLIC AC/VIT B6 VIRT-VITE TABLET N    
CYANOCOBALAMIN/FOLIC AC/VIT B6 TL GARD RX TABLET N    
CYANOCOBALAMIN/FOLIC AC/VIT B6 FABB 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    
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 VOL-CARE RX TABLET N    
CYANOCOBALAMIN/FOLIC AC/VIT B6 VIRT-VITE FORTE TABLET    
CYANOCOBALAMIN/FOLIC AC/VIT B6 NIVA-FOL TABLET    
FOLIC ACID FOLIC ACID TABLET