Parenteral Vitamins
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.
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 |
|---|---|---|---|---|---|
| B-complex with vitamin C | NUTRIJECT | VIAL | |||
| B-complex with vitamin C | VI-CERT C1000 WITH B12 | VIAL | |||
| folic acid | FOLIC ACID | VIAL | |||
| iron dextran complex | INFED | VIAL | |||
| phytonadione (vit K1) | AQUA-MEPHYTON | AMPUL | |||
| phytonadione (vit K1) | PHYTONADIONE | AMPUL | |||
| phytonadione (vit K1) | VITAMIN K1 | AMPUL | |||
| phytonadione (vit K1) | PHYTONADIONE | SYRINGE | |||
| phytonadione (vit K1) | PHYTONADIONE | VIAL |