Prenatal Vitamins
PDL Reference Documents
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 | Carveout ‐ Bill FFS |
New Drug Evaluation & Updates |
|---|---|---|---|---|---|---|
| PNV 11/iron fum/folic acid/om3 | C-NATE DHA | CAPSULE | Y | N | ||
| PNV 67/iron ps/folate no.1/dha | VITAFOL ULTRA | CAPSULE | Y | N | ||
| PNV 80/iron fum/folic/dss/dha | PRENAISSANCE | CAPSULE | Y | N | ||
| PNV no.118/iron fumarate/FA | SE-NATAL 19 | TAB CHEW | Y | N | ||
| PNV no.164/iron/folate no.6 | NATAL PNV | TABLET | Y | N | ||
| PNV no.52/iron/FA/omega-3/dha | WESNATAL DHA COMPLETE | COMBO. PKG | Y | N | ||
| PNV,Ca42/iron/FA/lmefolate/dha | PNV-DHA PLUS | CAPSULE | Y | N | ||
| PNV/iron b-g,fum/folic acid | VINATE II | TABLET | Y | N | ||
| PNV/iron ps cplx/folic acid | NIFEREX-PN FORTE | TABLET | Y | N | ||
| PNV72/iron,gluc/folic/dss/dha | CITRANATAL 90 DHA | COMBO. PKG | Y | N | ||
| PNV73/iron,gluc/folic/dss/dha | CITRANATAL ASSURE | COMBO. PKG | Y | N | ||
| prenatal 114/iron a-g/folate 1 | PRENATE ELITE | TABLET | Y | N | ||
| prenatal 118/iron/folate 6/dha | PRIMACARE | CAPSULE | Y | N | ||
| prenatal 136/iron/folic acid | MATERNITY | TABLET | Y | N | ||
| prenatal 199/iron/folate no.10 | FOLATEXCEL | TABLET | Y | N | ||
| prenatal 25/iron/folate 6/dha | VITAMEDMD ONE RX | CAPSULE | Y | N | ||
| prenatal 56/iron/folic ac/dha | OB COMPLETE PETITE | CAPSULE | Y | N | ||
| prenatal 71/iron/folic ac/dha | VITAPEARL | CAP IR DR | Y | N | ||
| prenatal 78/iron/folate 1/dha | PRENATE DHA | CAPSULE | Y | N | ||
| prenatal 87/iron bis/folic/dha | NESTABS DHA | COMBO. PKG | Y | N | ||
| prenatal no.103/iron fum/folic | TRICARE | TABLET | Y | N | ||
| prenatal vit 10/iron/folic/dha | VITAFOL-OB+DHA | COMBO. PKG | Y | N | ||
| prenatal vit 128/iron/folic ac | SELECT-OB | TAB CHEW | Y | N | ||
| prenatal vit 27,calc/iron/FA | TRINATAL RX 1 | TABLET | Y | N | ||
| prenatal vit 65/iron fum,ps/FA | PROVIDA OB | CAPSULE | Y | N | ||
| prenatal vit/iron fum/folic ac | MISSION PRENATAL RX | TABLET | Y | N | ||
| prenatal vits 86/iron/folic ac | NESTABS | TABLET | Y | N | ||
| iron/FA/dha/epa/FAD/NADH/mv47 | ENLYTE | CAP IR DR | N | N | ||
| PNV 112/iron/folic/om3/dha/epa | VITAFOL GUMMIES | TAB CHEW | N | N | ||
| PNV no.63/iron,carb/folic/dha | STUART ONE | CAPSULE | N | N | ||
| PNV no.95/ferrous fum/folic ac | PRENATAL VITAMINS | TABLET | N | N | ||
| prenatal no.137/iron/folic ac | PRENATAL VITAMIN | TABLET | N | N | ||
| prenatal vit calc,iron,folic | PRENATAL OTC | TABLET | N | N | ||
| prenatal vit no.170/iron/folic | DERMACINRX PRENATRIX | TABLET | N | N | ||
| prenatal vit no.170/iron/folic | DERMACINRX PRENATRYL | TABLET | N | N | ||
| prenatal vit no.180/iron/folic | PRENATAL PLUS VITAMIN-MINERAL | TABLET | N | N | ||
| FA/B1/B2/B3/B5/B6/B7/B12/C | MI-VITE RX | TABLET | N | |||
| folic/calcium/D3/Mg cit/a-cyst | FOLCYTEINE | TABLET | N | |||
| prenatal 93/iron/folate 9/dha | WESTGEL DHA | CAPSULE | N |