Magnesium Replacement, Oral

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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
05000000688 MAGNESIUM magnesium TABLET 250 mg Y N  
24385096778 MAGNESIUM magnesium TABLET 250 mg Y N  
87701013660 MAGNESIUM magnesium TABLET 250 mg Y N  
69315020906 NU-MAG magnesium chloride TABLET DR 71.5 mg N Y  
67618011220 SLOW-MAG magnesium chloride TABLET DR 71.5 mg N Y  
67618000005 SLOWMAG magnesium chloride TABLET DR 71.5 mg N Y  
67618011760 SLOWMAG magnesium citrate TAB CHEW 85 mg N Y  
71321080010 MAGNESIUM L-LACTATE DIHYD SR magnesium L-lactate TABLET ER 84 mg N Y  
71321080060 MAGNESIUM L-LACTATE DIHYD SR magnesium L-lactate TABLET ER 84 mg N Y  
28595071040 MAGNESIUM OXIDE magnesium oxide TABLET 265.3 mg magnesium (440 mg) N Y  
83035182301 MAGNESIUM OXIDE magnesium oxide TABLET 300 mg magnesium N Y  
00603020922 MAGNESIUM OXIDE magnesium oxide TABLET 400 mg N Y  
24689013201 MAGNESIUM OXIDE magnesium oxide TABLET 400 mg N Y  
58657012012 MAGNESIUM OXIDE magnesium oxide TABLET 400 mg N Y  
69367029820 MAGNESIUM OXIDE magnesium oxide TABLET 400 mg N Y  
81033002712 MAGNESIUM OXIDE magnesium oxide TABLET 400 mg N Y  
63739005802 MAGNESIUM OXIDE magnesium oxide TABLET 400 mg (241.3 mg magnesium) N Y  
64980033901 MAGNESIUM OXIDE magnesium oxide TABLET 400 mg (241.3 mg magnesium) N Y  
64980033912 MAGNESIUM OXIDE magnesium oxide TABLET 400 mg (241.3 mg magnesium) N Y  
64980033990 MAGNESIUM OXIDE magnesium oxide TABLET 400 mg (241.3 mg magnesium) N Y  
69367027102 MAGNESIUM OXIDE magnesium oxide TABLET 400 mg (241.3 mg magnesium) N Y  
71800001301 MAGNESIUM OXIDE magnesium oxide TABLET 400 mg (241.3 mg magnesium) N Y  
83035182201 MAGNESIUM OXIDE magnesium oxide TABLET 400 mg (241.3 mg magnesium) N Y  
83035182205 MAGNESIUM OXIDE magnesium oxide TABLET 400 mg (241.3 mg magnesium) N Y  
83592025905 MAGNESIUM OXIDE magnesium oxide TABLET 400 mg (241.3 mg magnesium) N Y  
85633004030 MAGNESIUM OXIDE magnesium oxide TABLET 400 mg (241.3 mg magnesium) N Y  
85633004036 MAGNESIUM OXIDE magnesium oxide TABLET 400 mg (241.3 mg magnesium) N Y  
00603021321 MAGNESIUM OXIDE magnesium oxide TABLET 420 mg N Y  
00904423960 MAGNESIUM OXIDE magnesium oxide TABLET 500 mg magnesium Y  
00486113201 BEELITH magnesium oxide/vit B6 TABLET 362 mg-20 mg Y Y  
68585001201 MAGBEE magnesium oxide/vit B6 TABLET 362 mg-20 mg Y N  
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