Pediatric Multivitamins
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 |
|---|---|---|---|---|---|
| pedi multivit 40/phytonadione | AQUADEKS | DROPS | Y | ||
| calcium carbonate/multivitamin | MULTIVITAMIN PLUS CALCIUM | TAB CHEW | |||
| fat emuls/vit A/vit D2/E/vit K | VITLIPID N INFANT | AMPUL | |||
| fat emuls/vit A/vit D2/E/vit K | VITALIPID N INFANT | AMPUL | |||
| fat emuls/vit A/vit D2/E/vit K | VITLIPID N ADULT | AMPUL | |||
| fluoride/iron/vitamins A,C,D | TRI-VIT W/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 4,vit K | INFUVITE ADULT | VIAL | |||
| multivitamin | VI-DAYLIN | TAB CHEW | |||
| multivitamin | CHILDRENS VITAMIN | TAB CHEW | |||
| multivitamin | CHILDRENS CHEWABLE | TAB CHEW | |||
| multivitamin | CHILD CHEW VITAMIN | TAB CHEW | |||
| multivitamin | MULTIVITAMIN 12 | VIAL | |||
| multivitamin with iron | CHILD CHEW + IRON | TAB CHEW | |||
| multivitamin with iron | CHILDRENS CHEWABLE + IRON | TAB CHEW | |||
| multivitamin with iron | CHILDS CHEW + IRON | TAB CHEW | |||
| multivitamin with iron | VI-DAYLIN PLUS IRON | TAB CHEW | |||
| Multivitamins with Fluoride | MULTI-VIT W/FLUORIDE | DROPS | |||
| Multivits with Iron & Fluoride | MULTI-VIT/IRON & FLUORIDE | DROPS | |||
| mv infus,adult 2 without vit K | M.V.I.-12 | VIAL | |||
| mvi, adult no.1, vit K, 1 of 2 | M.V.I. ADULT VIAL 1 | VIAL | |||
| mvi, adult no.1, vit K, 2 of 2 | M.V.I. ADULT VIAL 2 | VIAL | |||
| mvi, adult no.4, vit K, 1 of 2 | INFUVITE ADULT VIAL 1 | VIAL | |||
| mvi, adult no.4, vit K, 2 of 2 | INFUVITE ADULT VIAL 2 | VIAL | |||
| mvi,pedi no.1,component 1 of 2 | INFUVITE PEDIATRIC VIAL 1 | VIAL | |||
| mvi,pedi no.1,component 2 of 2 | INFUVITE PEDIATRIC VIAL 2 | VIAL | |||
| ped multivit 142/iron/fluoride | QUFLORA FE | TAB CHEW | |||
| ped multivit 151/iron/fluoride | QUFLORA FE | DROPS | |||
| ped multivit 175/fluoride/iron | POLY-VI-FLOR WITH IRON | TAB CHEW | |||
| ped multivit 205/fluoride/iron | POLY-VI-FLOR WITH IRON | TAB CHEW | |||
| ped multivit 214/fluoride/iron | POLY-VI-FLOR WITH IRON | DROPS | |||
| ped multivit 220/fluoride/iron | POLY-VI-FLOR WITH IRON | DROPS | |||
| ped mvit A,C,D3 no.21/fluoride | TRI-VITE 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 213 w-fluoride | POLY-VI-FLOR | DROPS | |||
| pedi multivit 45/fluoride/iron | MULTIVITAMIN-IRON-FLUORIDE | DROPS | |||
| pedi multivit 45/fluoride/iron | MULTI-VITAMIN W-FLUORIDE-IRON | DROPS | |||
| pedi multivit 84 with fluoride | QUFLORA | DROPS | |||
| pedi multivit no.157/fluoride | QUFLORA | TAB CHEW | |||
| pedi multivit no.161/fluoride | FLORIVA PLUS | DROPS | |||
| pedi multivit no.17 w-fluoride | MULTIVITAMIN WITH FLUORIDE | TAB CHEW | |||
| pedi multivit no.175/fluoride | POLY-VI-FLOR | TAB CHEW | |||
| pedi multivit no.2 w-fluoride | MULTIVITAMIN WITH FLUORIDE | DROPS | |||
| pedi multivit no.217/fluoride | POLY-VI-FLOR | TAB CHEW | |||
| pedi multivit no.219/fluoride | MULTIVITAMIN WITH FLUORIDE | TAB CHEW | |||
| pedi multivit no.219/fluoride | POLY-VI-FLOR | TAB CHEW | |||
| pedi multivit no.220/fluoride | POLY-VI-FLOR | DROPS | |||
| pedi multivit no.228/fluoride | MULTI-VIT-FLOR | TAB CHEW | |||
| pedi multivit no.23/folic acid | CHILDREN'S CHEWABLES | TAB CHEW | |||
| pedi multivit no.242/fluoride | MULTIVITAMIN WITH FLUORIDE | TAB CHEW | |||
| pedi multivit no.25/folic acid | CHILDREN'S CHEWABLES | TAB CHEW | |||
| pedi multivit no.25/folic acid | CHILDREN'S CHEWABLE MULTIVITMN | TAB CHEW | |||
| pedi multivit no.31/iron/folic | CHILDREN'S CHEWABLE | TAB CHEW | |||
| pedi multivit no.63 w-fluoride | QUFLORA | TAB CHEW | |||
| pedi multivit no.83 w-fluoride | QUFLORA | DROPS | |||
| pedi multivit no.85/fluoride | FLORIVA | TAB CHEW | |||
| pedi multivit no.91/iron fum | CHILDREN'S CHEW MULTIVIT-IRON | TAB CHEW | |||
| pedi mv no.207/ferrous sulfate | INFANT-TODDLER MULTIVIT-IRON | DROPS | |||
| pediatric multivitamin no.212 | INFANT-TODDLER MULTIVITAMIN | DROPS | |||
| pediatric multivitamin no.245 | LIVITA FOR CHILDREN | LIQUID | |||
| vit A palmitate/vit C/vit D3 | INFANT-TODDLER VITAMIN A-C-D | DROPS |