Calcium/Vit D Replacement, Oral
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 |
|---|---|---|---|---|---|---|
| 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 |