Prenatal Vitamins

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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.

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NDC Brand Name Generic Name Form Strength PDL
Status		 Rebate Current Drug Use Criteria
50228027790 MI-VITE RX FA/B1/B2/B3/B5/B6/B7/B12/C TABLET 1 mg-1.5 mg-1.7 mg-20 mg-5 mg-10 mg-150 mcg-6 mcg-100 mg Y  
50991097730 FOLITE folic/calcium/D3/Mg cit/a-cyst TABLET 1 mg-200 mg-50 mcg-100 mg-200 mg Y  
59088079554 FOLCYTEINE folic/calcium/D3/Mg cit/a-cyst TABLET 1 mg-47 mg-20 mcg-16 mg-200 mg Y  
64661071130 ENLYTE iron/FA/dha/epa/FAD/NADH/mv47 CAP IR DR 1.5 mg iron-8.73 mg-6.4 mg-800 mcg-25 mcg-25 mcg-500 mcg N Y  
00642747330 VITAFOL FE PLUS PNV 102/iron/folate/dha CAPSULE 90 mg iron-1 mg-200 mg N Y  
23359010530 C-NATE DHA PNV 11/iron fum/folic acid/om3 CAPSULE 28 mg iron-1 mg-200 mg Y Y  
69367031730 WESNATE DHA PNV 11/iron fum/folic acid/om3 CAPSULE 28 mg iron-1 mg-200 mg Y Y  
00642012590 VITAFOL GUMMIES PNV 112/iron/folic/om3/dha/epa TAB CHEW 3.33 mg iron-0.33 mg-34.83 mg (25 mg-5.1 mg-4.73 mg) N Y  
13925011601 SE-NATAL 19 PNV 119/iron fum/folic acid TABLET 29 mg iron-1 mg Y Y  
68025004960 OB COMPLETE WITH DHA PNV 30/iron carb,ag/folic/om3 CAPSULE 30 mg iron-10 mg iron-1 mg-200 mg Y Y  
42192032330 PNV-DHA + DOCUSATE PNV 66/iron/folic/docusate/dha CAPSULE 27 mg-1.25 mg-55 mg-300 mg Y Y  
00642009330 VITAFOL ULTRA PNV 67/iron ps/folate no.1/dha CAPSULE 29 mg iron-1 mg-200 mg Y Y  
42192034330 PRENAISSANCE PLUS PNV 69/iron/folic/docusate/dha CAPSULE 28 mg-1 mg-50 mg-250 mg Y Y  
42192034130 PRENAISSANCE PNV 80/iron fum/folic/dss/dha CAPSULE 29 mg iron-1.25 mg-55 mg-325 mg Y Y  
68025004430 OB COMPLETE ONE PNV 85/iron/folic/dha/fish oil CAPSULE 40 mg-10 mg-1 mg-300 mg-476 mg Y Y  
13925011701 SE-NATAL 19 PNV no.118/iron fumarate/FA TAB CHEW 29 mg iron-1 mg Y Y  
50228027690 NEO-VITAL RX PNV no.154/iron fum/folic acid TABLET 27 mg iron-1 mg Y  
15370028060 NATAL PNV PNV no.164/iron/folate no.6 TABLET 6 mg iron-833.5 mcg DFE Y Y  
73352089130 NEOMATERNA PNV no.197/iron/folate no.10 TABLET 20 mg iron-1,670 mcg DFE N Y  
13811001030 COMPLETE NATAL DHA PNV no.52/iron/FA/omega-3/dha COMBO. PKG 29 mg iron-1 mg-200 mg Y Y  
69367025130 WESNATAL DHA COMPLETE PNV no.52/iron/FA/omega-3/dha COMBO. PKG 29 mg iron-1 mg-200 mg Y Y  
00642403030 STUART ONE PNV no.63/iron,carb/folic/dha CAPSULE 27 mg iron-800 mcg-200 mg N Y  
46122009878 PRENATAL PNV no.95/ferrous fum/folic ac TABLET 28 mg iron-800 mcg N Y  
00536408501 PRENATAL VITAMINS PNV no.95/ferrous fum/folic ac TABLET 28 mg iron-800 mcg N Y  
42192031409 PNV-IRON PNV w-CA8/iron/FA/lmefolate Ca TABLET 29 mg-0.4 mg-1.13 mg (1 mg folic acid) Y Y  
42192031503 PNV-DHA PLUS PNV,Ca42/iron/FA/lmefolate/dha CAPSULE 27 mg-0.4 mg-1.13 mg (1 mg folic acid)-250 mg Y Y  
58657017001 M-NATAL PLUS PNV,calcium 72/iron/folic acid TABLET 27 mg iron-1 mg Y Y  
39328010610 PRENATAL VITAMIN PLUS LOW IRON PNV,calcium 72/iron/folic acid TABLET 27 mg iron-1 mg Y Y  
69367026701 WESTAB PLUS PNV,calcium 72/iron/folic acid TABLET 27 mg iron-1 mg Y Y  
51991014301 VINATE II PNV/iron b-g,fum/folic acid TABLET 29 mg iron-1 mg Y Y  
00131220906 NIFEREX-PN PNV/iron ps cplx/folic acid TABLET 60 mg iron-1 mg Y Y  
00131230906 NIFEREX-PN FORTE PNV/iron ps cplx/folic acid TABLET 60 mg iron-1 mg Y Y  
00178079630 CITRANATAL HARMONY PNV59/iron,carb,fum/FA/dss/dha CAPSULE 27 mg iron-1 mg-50 mg-260 mg Y Y  
00178082130 CITRANATAL 90 DHA PNV72/iron,gluc/folic/dss/dha COMBO. PKG 90 mg iron-1 mg-50 mg-300 mg Y Y  
00178089130 CITRANATAL ASSURE PNV73/iron,gluc/folic/dss/dha COMBO. PKG 35 mg iron-1 mg-50 mg-300 mg Y Y  
68025004330 OB COMPLETE PREMIER PNV83/iron,carb,asp/folic acid TABLET 30 mg-20 mg-1 mg Y Y  
75854031430 PRENATE ELITE prenatal 114/iron a-g/folate 1 TABLET 20 mg iron-1 mg Y Y  
75854032230 PRIMACARE prenatal 118/iron/folate 6/dha CAPSULE 30 mg iron-1 mg-300 mg Y Y  
10267199101 MATERNITY prenatal 136/iron/folic acid TABLET 27 mg iron-1 mg Y Y  
28595072130 ALTRIXA OB prenatal 181/iron fum/folate TABLET 15 mg iron-1,750 mcg DFE N Y  
68308076030 VITAMEDMD ONE RX prenatal 25/iron/folate 6/dha CAPSULE 30 mg iron-1 mg-200 mg Y Y  
00642007030 VITAFOL-ONE prenatal 26/iron ps/folic/dha CAPSULE 29 mg iron-1 mg-200 mg Y Y  
51991076491 VINACAL B prenatal 48/iron/folic acid/B6 TABLET SEQ 20 mg iron-1 mg-25 mg/25 mg N Y  
68025005930 OB COMPLETE PETITE prenatal 56/iron/folic ac/dha CAPSULE 35 mg iron-5 mg iron-1 mg-200 mg Y Y  
76439024230 VP-CH PLUS prenatal 59/iron/folic/dss/dha CAPSULE 29 mg iron-1 mg-50 mg-265 mg Y Y  
75854030830 PRENATE RESTORE prenatal 69/iron/folate 6/dha CAPSULE 27 mg iron-1 mg (600 mcg-400 mcg)-400 mg Y Y  
68308076230 VITAPEARL prenatal 71/iron/folic ac/dha CAP IR DR 30 mg iron-1.4 mg-200 mg Y Y  
75854031230 PRENATE DHA prenatal 78/iron/folate 1/dha CAPSULE 18 mg iron-1 mg-300 mg Y Y  
50967031730 NESTABS DHA prenatal 87/iron bis/folic/dha COMBO. PKG 32 mg iron-1,000 mcg-230 mg Y Y  
15370025030 TRISTART DHA prenatal 93/iron/folate 9/dha CAPSULE 31 mg iron-1 mg-200 mg Y  
69367023430 WESTGEL DHA prenatal 93/iron/folate 9/dha CAPSULE 31 mg iron-1 mg-200 mg Y  
67112010100 TRICARE prenatal no.103/iron fum/folic TABLET 27 mg iron-1 mg Y Y  
67112010130 TRICARE prenatal no.103/iron fum/folic TABLET 27 mg iron-1 mg Y Y  
00904531346 PRENATAL VITAMIN prenatal no.137/iron/folic ac TABLET 27 mg-0.8 mg N Y  
00904531360 PRENATAL VITAMIN prenatal no.137/iron/folic ac TABLET 27 mg-0.8 mg N Y  
75854030930 PRENATE ENHANCE prenatal no.68/iron/FA no6/dha CAPSULE 28 mg iron-1 mg (600 mcg-400 mcg)-400 mg Y Y  
75854031130 PRENATE STAR prenatal no.77/iron asp gly/FA TABLET 20 mg iron-1 mg Y Y  
00642007912 VITAFOL-OB prenatal vit 10/iron fum/folic TABLET 65 mg iron-1 mg Y Y  
00642007630 VITAFOL-OB+DHA prenatal vit 10/iron/folic/dha COMBO. PKG 65 mg iron-1 mg-250 mg Y Y  
00642007790 SELECT-OB prenatal vit 128/iron/folic ac TAB CHEW 29 mg iron-1 mg Y Y  
13811001490 COMPLETENATE prenatal vit 14/iron fum/folic TAB CHEW 29 mg iron-1 mg Y Y  
13811000710 TRINATAL RX 1 prenatal vit 27,calc/iron/FA TABLET 60 mg iron-1 mg Y Y  
00642007530 SELECT-OB + DHA prenatal vit 33/iron/folic/dha COMBO. PKG 29 mg iron-1 mg-250 mg Y Y  
75854031530 PRENATE MINI prenatal vit 87/iron/folic/dha CAPSULE 18 mg iron-1 mg-350 mg Y Y  
00904317872 PRENATAL OTC prenatal vit calc,iron,folic TABLET N Y  
51645084001 PRENATAL VITAMIN prenatal vit no.124/iron/folic TABLET 27 mg iron-800 mcg Y  
51645084003 PRENATAL VITAMIN prenatal vit no.124/iron/folic TABLET 27 mg iron-800 mcg Y  
00536406301 CLASSIC PRENATAL prenatal vit no.126/iron/folic TABLET 28 mg iron-800 mcg N Y  
59088016654 DERMACINRX PRENATRIX prenatal vit no.170/iron/folic TABLET 27 mg iron-1 mg N Y  
59088016954 DERMACINRX PRENATRYL prenatal vit no.170/iron/folic TABLET 27 mg iron-1 mg N Y  
59088017854 DERMACINRX PRETRATE prenatal vit no.170/iron/folic TABLET 27 mg iron-1 mg N Y  
50268067701 PRENATAL PLUS VITAMIN-MINERAL prenatal vit no.180/iron/folic TABLET 27 mg iron-1 mg N Y  
58657013390 THRIVITE RX prenatal vit,cal 76/iron/folic TABLET 29 mg iron-1 mg Y Y  
51991015791 VINATAL FORTE prenatal vit/iron carb,sulf/FA TABLET 60 mg iron-1 mg Y Y  
00178000701 MISSION PRENATAL RX prenatal vit/iron fum/folic ac TABLET 60 mg iron-1 mg Y Y  
75854031630 PRENATE PIXIE prenatal vits 85/iron/FA 1/dha CAPSULE 10 mg iron-1 mg-200 mg Y Y  
50967021990 NESTABS prenatal vits 86/iron/folic ac TABLET 32 mg-1,000 mcg Y Y  
42192032090 PNV-SELECT prenatal,calc 40/iron/folate 1 TABLET 27 mg iron-1 mg Y Y  
00281033818 PRENATAL COMBOPAK Pv w-o Vit A/iron/docus/FA/Zn CAP SEQ 28-1-66MG Y Y  
00281033830 PRENATAL COMBOPAK Pv w-o Vit A/iron/docus/FA/Zn CAP SEQ 28-1-66MG Y Y  
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