Calcium/Vit D Replacement, Oral

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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.
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.

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Generic Name Brand Name Form PDL
Status
Current Drug Use Criteria Carveout
‐ Bill FFS
New Drug Evaluation & Updates
calcium carbonate CALCIUM CARBONATE ORAL SUSP Y   N  
calcium carbonate CALCIUM CARBONATE TABLET Y   N  
calcium carbonate CALCIUM TABLET Y   N  
calcium carbonate CALCIUM 500 TABLET Y   N  
calcium carbonate OYSTER SHELL CALCIUM TABLET Y   N  
calcium carbonate/vitamin D3 OS-CAL 500-VIT D3 TABLET Y   N  
cholecalciferol (vitamin D3) VITAMIN D3 CAPSULE Y   N  
cholecalciferol (vitamin D3) VITAMIN D3 CAPSULE Y   N  
cholecalciferol (vitamin D3) DIALYVITE VITAMIN D3 MAX TABLET Y   N  
cholecalciferol (vitamin D3) VITAMIN D3 TABLET Y   N  
ergocalciferol (vitamin D2) VITAMIN D2 CAPSULE Y   N  
calcium carb/D3/magnesium/zinc CAL MAG ZINC-D3 TABLET N Pharmacy PA N  
calcium carbonate ANTACID EXTRA STRENGTH TAB CHEW N Pharmacy PA N  
calcium carbonate CALCIUM TAB CHEW N Pharmacy PA N  
calcium carbonate SMOOTH ANTACID TAB CHEW N Pharmacy PA N  
calcium carbonate/vitamin D2 CALCIUM CARBONATE W/VITAMIN D TABLET N Pharmacy PA N  
calcium carbonate/vitamin D3 OYSCO 500-VIT D3 TABLET N Pharmacy PA N  
calcium carbonate/vitamin D3 ULTRA CALCIUM 600-VIT D3 TABLET N Pharmacy PA N  
calcium carbonate/vitamin D3 CALCIUM 600-VIT D3 TABLET N Pharmacy PA N  
calcium carbonate/vitamin D3 CALCIUM 500-VIT D3 TABLET N Pharmacy PA N  
calcium cit/magnesium/D3/zinc LIQUICAL PLUS LIQUID N Pharmacy PA N  
calcium citrate/vitamin D3 CALCIUM CITRATE - VITAMIN D3 TABLET N Pharmacy PA N  
calcium/magnesium/zinc CALCIUM/MAGNESIUM/ZINC TABLET N Pharmacy PA N  
cholecalciferol (vitamin D3) OSTEO-VIT3 DROPS N Pharmacy PA N  
cholecalciferol (vitamin D3) VITAMIN D3 SYRINGE N Pharmacy PA N  
cholecalciferol (vitD3)/vit K2 DECARA K CAPSULE N Pharmacy PA N  
ergocalciferol (vitamin D2) ERGOCALCIFEROL DROPS N Pharmacy PA N  
vitamin D3/folic acid DERMACINRX DOTREMIN TABLET N Pharmacy PA N  
vitamin D3/folic acid DERMACINRX FOLIXAPURE TABLET N Pharmacy PA N  
vitamin D3/folic acid DERMACINRX FOLTAMIN TABLET N Pharmacy PA N  
vitamin D3/folic acid DERMACINRX PUREFOLTIN TABLET N Pharmacy PA N  
calcium carbonate CALCIUM ANTACID TAB CHEW   N  
calcium carbonate/vitamin D2 OYSTER SHELL CALCIUM W-VIT D TABLET   N  
calcium carbonate/vitamin D2 OYSTER SHELL CALCIUM TABLET   N  
calcium carbonate/vitamin D2 OYSTER + D TABLET   N  
calcium/D3/mag/K2/min/herb 326 ALGAE BASED CALCIUM TABLET   N  
dihydrotachysterol DHT TABLET   N