Pediatric Multivitamins

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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
pedi multivit 40/phytonadione AQUADEKS DROPS Y    
pedi multivit no.130/fluoride FLORIVA PLUS DROPS Y    
fluoride/iron/vitamins A,C,D TRI-VIT WITH FLUORIDE-IRON DROPS    
multivit infusion,pedi 1,vit K INFUVITE PEDIATRIC VIAL    
multivit infusion,pedi 2,vit K M.V.I. PEDIATRIC VIAL    
multivit infusn,adult 1,vit K M.V.I. ADULT VIAL    
multivit infusn,adult 4,vit K INFUVITE ADULT VIAL    
ped multivit 142/iron/fluoride QUFLORA FE TAB CHEW    
ped multivit 151/iron/fluoride QUFLORA FE DROPS    
ped mvit A,C,D3 no.21/fluoride TRI-VITAMIN WITH FLUORIDE DROPS    
ped mvit A,C,D3 no.21/fluoride VITAMINS A,C,D AND FLUORIDE DROPS    
ped mvit A,C,D3 no.38/fluoride TRI-VI-FLOR DRPS SP BP    
pedi multivit 33/fluoride/iron POLY-VI-FLOR WITH IRON TAB CHEW    
pedi multivit 37/fluoride/iron POLY-VI-FLOR WITH IRON DRPS SP BP    
pedi multivit 45/fluoride/iron MULTIVITAMIN-IRON-FLUORIDE DROPS    
pedi multivit 45/fluoride/iron MULTI-VITAMIN W-FLUORIDE-IRON DROPS    
pedi multivit 47/iron/fluoride ESCAVITE TAB CHEW    
pedi multivit 75/fluoride/iron MULTIVITAMINS W-FLUORIDE-IRON DROPS    
pedi multivit 78/iron/fluoride ESCAVITE D TAB CH BPH    
pedi multivit 84 with fluoride QUFLORA DROPS    
pedi multivit 86/iron/fluoride ESCAVITE LQ DROPS    
pedi multivit no.12 w-fluoride MVC-FLUORIDE TAB CHEW    
pedi multivit no.157/fluoride QUFLORA TAB CHEW    
pedi multivit no.16 w-fluoride MULTIVITAMIN WITH FLUORIDE TAB CHEW    
pedi multivit no.17 w-fluoride MULTIVITAMIN WITH FLUORIDE TAB CHEW    
pedi multivit no.2 w-fluoride MULTIVITAMIN WITH FLUORIDE DROPS    
pedi multivit no.33/fluoride POLY-VI-FLOR TAB CHEW    
pedi multivit no.37 w-fluoride POLY-VI-FLOR DRPS SP BP    
pedi multivit no.63 w-fluoride QUFLORA TAB CHEW    
pedi multivit no.82 w-fluoride MULTIVITAMINS WITH FLUORIDE DROPS    
pedi multivit no.83 w-fluoride QUFLORA DROPS    
pedi multivit no.85/fluoride FLORIVA TAB CHEW