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 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.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