Iron 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
73059000160 ACCRUFER ferric maltol CAPSULE 30 mg iron N Y  
00456037200 FEOSTAT ferrous fumarate TAB CHEW 100 mg (33 mg) N Y  
00456037201 FEOSTAT ferrous fumarate TAB CHEW 100 mg (33 mg) N Y  
69367025901 FERROUS FUMARATE ferrous fumarate TABLET 324 mg (106 mg iron) N Y  
69367025920 FERROUS FUMARATE ferrous fumarate TABLET 324 mg (106 mg iron) N Y  
10542008012 FERRIMIN 150 ferrous fumarate TABLET 456 mg (150 mg) N Y  
00904640360 FERATE ferrous gluconate TABLET 240 mg (27 mg iron) N Y  
00024101510 FERGON ferrous gluconate TABLET 240 mg (27 mg iron) N Y  
10135012901 FERROUS GLUCONATE ferrous gluconate TABLET 324 mg (36 mg iron) Y N  
54868424600 FERROUS GLUCONATE ferrous gluconate TABLET 324 mg (38 mg iron) Y N  
00574050801 FERROUS GLUCONATE ferrous gluconate TABLET 324 mg (38 mg iron) Y Y  
00574050810 FERROUS GLUCONATE ferrous gluconate TABLET 324 mg (38 mg iron) Y Y  
00574050811 FERROUS GLUCONATE ferrous gluconate TABLET 324 mg (38 mg iron) Y Y  
00904213782 FERATE ferrous gluconate TABLET 325 mg (~37 mg iron) Y Y  
04000000185 FERROUS GLUCONATE ferrous gluconate TABLET 325 mg (~37 mg iron) Y N  
05000000647 FERROUS GLUCONATE ferrous gluconate TABLET 325 mg (~37 mg iron) Y N  
60814055601 FERROUS GLUCONATE ferrous gluconate TABLET 325 mg (~37 mg iron) Y N  
87701071246 FERROUS GLUCONATE ferrous gluconate TABLET 325 mg (~37 mg iron) Y N  
00024101710 FERGON PLUS ferrous gluconate/vit C/B12-if TABLET Y  
24385063050 FERROUS SULFATE ferrous sulfate DROPS 15 mg iron (75 mg)/0.6 mL N Y  
39328005750 CHILDREN'S IRON ferrous sulfate DROPS 15 mg iron (75 mg)/mL N Y  
39328055750 FERROUS SULFATE ferrous sulfate DROPS 15 mg iron (75 mg)/mL N Y  
54838001150 FERROUS SULFATE ferrous sulfate DROPS 15 mg iron (75 mg)/mL N Y  
00536134480 INFANT-TODDLER IRON ferrous sulfate DROPS 15 mg iron (75 mg)/mL N Y  
39328005816 FERROUS SULFATE ferrous sulfate ELIXIR 220 mg (44 mg iron)/5 mL N Y  
54838000180 FERROUS SULFATE ferrous sulfate ELIXIR 220 mg (44 mg iron)/5 mL N Y  
69367040216 FERROUS SULFATE ferrous sulfate ELIXIR 220 mg (44 mg iron)/5 mL N Y  
00904146528 FERROUS SULFATE ferrous sulfate ELIXIR 220 mg/5 mL N Y  
00121053005 FERROUS SULFATE ferrous sulfate LIQUID 300 mg (60 mg iron)/5 mL Y Y  
00904727741 FERROUS SULFATE ferrous sulfate LIQUID 300 mg (60 mg iron)/5 mL Y Y  
00904727770 FERROUS SULFATE ferrous sulfate LIQUID 300 mg (60 mg iron)/5 mL Y Y  
39328015705 FERROUS SULFATE ferrous sulfate LIQUID 300 mg (60 mg iron)/5 mL Y Y  
50268033611 FERROUS SULFATE ferrous sulfate LIQUID 300 mg (60 mg iron)/5 mL Y Y  
50268033624 FERROUS SULFATE ferrous sulfate LIQUID 300 mg (60 mg iron)/5 mL Y Y  
57237031105 FERROUS SULFATE ferrous sulfate LIQUID 300 mg (60 mg iron)/5 mL Y Y  
57237031151 FERROUS SULFATE ferrous sulfate LIQUID 300 mg (60 mg iron)/5 mL Y Y  
63739015710 FERROUS SULFATE ferrous sulfate LIQUID 300 mg (60 mg iron)/5 mL Y Y  
63739015770 FERROUS SULFATE ferrous sulfate LIQUID 300 mg (60 mg iron)/5 mL Y Y  
81033001105 FERROUS SULFATE ferrous sulfate LIQUID 300 mg (60 mg iron)/5 mL Y Y  
81033001150 FERROUS SULFATE ferrous sulfate LIQUID 300 mg (60 mg iron)/5 mL Y Y  
00536140085 FERROUS SULFATE ferrous sulfate SOLUTION 220 mg (44 mg iron)/5 mL N Y  
54859081016 FERROUS SULFATE ferrous sulfate SOLUTION 220 mg (44 mg iron)/5 mL N Y  
69339015401 FERROUS SULFATE ferrous sulfate SOLUTION 220 mg (44 mg iron)/5 mL N Y  
69339015419 FERROUS SULFATE ferrous sulfate SOLUTION 220 mg (44 mg iron)/5 mL N Y  
71321080116 FERROUS SULFATE ferrous sulfate SOLUTION 220 mg (44 mg iron)/5 mL N Y  
37205041478 FERROUS SULFATE ferrous sulfate TABLET 134 mg (27 mg) Y  
00904759060 FEROSUL ferrous sulfate TABLET 325 mg (65 mg iron) Y Y  
00904759080 FEROSUL ferrous sulfate TABLET 325 mg (65 mg iron) Y Y  
00904759160 FEROSUL ferrous sulfate TABLET 325 mg (65 mg iron) Y Y  
00904759180 FEROSUL ferrous sulfate TABLET 325 mg (65 mg iron) Y Y  
00904759182 FEROSUL ferrous sulfate TABLET 325 mg (65 mg iron) Y Y  
49483006301 FERRO-TIME ferrous sulfate TABLET 325 mg (65 mg iron) Y Y  
49483006401 FERRO-TIME ferrous sulfate TABLET 325 mg (65 mg iron) Y Y  
10135012201 FERROUS SULFATE ferrous sulfate TABLET 325 mg (65 mg iron) Y N  
10135012210 FERROUS SULFATE ferrous sulfate TABLET 325 mg (65 mg iron) Y N  
10135016113 FERROUS SULFATE ferrous sulfate TABLET 325 mg (65 mg iron) Y N  
10135024213 FERROUS SULFATE ferrous sulfate TABLET 325 mg (65 mg iron) Y N  
10135024219 FERROUS SULFATE ferrous sulfate TABLET 325 mg (65 mg iron) Y N  
10135024313 FERROUS SULFATE ferrous sulfate TABLET 325 mg (65 mg iron) Y N  
10135024319 FERROUS SULFATE ferrous sulfate TABLET 325 mg (65 mg iron) Y N  
11845054401 FERROUS SULFATE ferrous sulfate TABLET 325 mg (65 mg iron) Y N  
11845054402 FERROUS SULFATE ferrous sulfate TABLET 325 mg (65 mg iron) Y N  
11845093801 FERROUS SULFATE ferrous sulfate TABLET 325 mg (65 mg iron) Y N  
11845093804 FERROUS SULFATE ferrous sulfate TABLET 325 mg (65 mg iron) Y N  
54868018900 FERROUS SULFATE ferrous sulfate TABLET 325 mg (65 mg iron) Y N  
60346061430 FERROUS SULFATE ferrous sulfate TABLET 325 mg (65 mg iron) Y N  
60346061490 FERROUS SULFATE ferrous sulfate TABLET 325 mg (65 mg iron) Y N  
63868068201 FERROUS SULFATE ferrous sulfate TABLET 325 mg (65 mg iron) Y N  
87701071249 FERROUS SULFATE ferrous sulfate TABLET 325 mg (65 mg iron) Y N  
00536100901 FERROUS SULFATE ferrous sulfate TABLET 325 mg (65 mg iron) Y Y  
00904216390 FERROUS SULFATE ferrous sulfate TABLET 325 mg (65 mg iron) Y Y  
00904216490 FERROUS SULFATE ferrous sulfate TABLET 325 mg (65 mg iron) Y Y  
00904759161 FERROUS SULFATE ferrous sulfate TABLET 325 mg (65 mg iron) Y Y  
49483006310 FERROUS SULFATE ferrous sulfate TABLET 325 mg (65 mg iron) Y Y  
49483006410 FERROUS SULFATE ferrous sulfate TABLET 325 mg (65 mg iron) Y Y  
51079011623 FERROUS SULFATE ferrous sulfate TABLET 325 mg (65 mg iron) Y Y  
51660030101 FERROUS SULFATE ferrous sulfate TABLET 325 mg (65 mg iron) Y Y  
51660030301 FERROUS SULFATE ferrous sulfate TABLET 325 mg (65 mg iron) Y Y  
51660030310 FERROUS SULFATE ferrous sulfate TABLET 325 mg (65 mg iron) Y Y  
57664007001 FERROUS SULFATE ferrous sulfate TABLET 325 mg (65 mg iron) Y Y  
57664007010 FERROUS SULFATE ferrous sulfate TABLET 325 mg (65 mg iron) Y Y  
57664007101 FERROUS SULFATE ferrous sulfate TABLET 325 mg (65 mg iron) Y Y  
57664007110 FERROUS SULFATE ferrous sulfate TABLET 325 mg (65 mg iron) Y Y  
12939014710 IROMAR ferrous sulfate TABLET 325 mg (65 mg iron) Y N  
46122008402 IRON ferrous sulfate TABLET 325 mg (65 mg iron) Y Y  
00574060801 FERROUS SULFATE ferrous sulfate TABLET DR 324 mg (65 mg iron) Y Y  
00574060810 FERROUS SULFATE ferrous sulfate TABLET DR 324 mg (65 mg iron) Y Y  
00574060811 FERROUS SULFATE ferrous sulfate TABLET DR 324 mg (65 mg iron) Y Y  
45861007001 FERROUS SULFATE ferrous sulfate TABLET DR 324 mg (65 mg iron) Y Y  
83035185801 FERROUS SULFATE ferrous sulfate TABLET DR 324 mg (65 mg iron) Y Y  
83035185805 FERROUS SULFATE ferrous sulfate TABLET DR 324 mg (65 mg iron) Y Y  
83035185806 FERROUS SULFATE ferrous sulfate TABLET DR 324 mg (65 mg iron) Y Y  
83592020105 FERROUS SULFATE ferrous sulfate TABLET DR 324 mg (65 mg iron) Y Y  
00245010801 FERROUS SULFATE ferrous sulfate TABLET DR 325 mg (65 mg iron) Y Y  
00245010810 FERROUS SULFATE ferrous sulfate TABLET DR 325 mg (65 mg iron) Y Y  
00245010811 FERROUS SULFATE ferrous sulfate TABLET DR 325 mg (65 mg iron) Y Y  
00245010889 FERROUS SULFATE ferrous sulfate TABLET DR 325 mg (65 mg iron) Y Y  
00904216660 FERROUS SULFATE ferrous sulfate TABLET DR 325 mg (65 mg iron) Y Y  
00904216680 FERROUS SULFATE ferrous sulfate TABLET DR 325 mg (65 mg iron) Y Y  
62584069733 FERROUS SULFATE ferrous sulfate TABLET DR 325 mg (65 mg iron) Y Y  
85633001160 FERROUS SULFATE ferrous sulfate TABLET DR 325 mg (65 mg iron) Y Y  
52569013423 SLOW RELEASE IRON ferrous sulfate TABLET ER 142 mg (45 mg iron) Y N  
37205003965 SLOW RELEASE IRON ferrous sulfate TABLET ER 160 mg N Y  
46122008365 IRON ferrous sulfate, dried TABLET ER 159 mg (45 mg iron) N Y  
72336001401 BENTIVITE BX ferrous sulfate/folic acid TABLET 35 mg iron-1 mg N Y  
72336001901 TULIVITE ferrous sulfate/folic acid TABLET 35 mg iron-1 mg N Y  
00074717301 IBERET ferrous sulfate/vit Bcomp,C LIQUID Y  
64980017303 FOLITAB 500 ferrous sulfate/vit C/folic ac TABLET ER 105 mg iron-500 mg-800 mcg N Y  
00904067752 FEROSUL iron TABLET 50 mg Y  
75854032130 NIFEREX iron ag,ps/C/FA6/B12/Zn/sa/sto TABLET 150 mg iron-60 mg-1 mg-25 mcg-15 mg-50 mg-100 mg N Y  
75854034430 NIFEREX iron asp gly/C/B12/FA/Zn/succ TABLET 75 mg iron-175 mg-25 mcg-1,700 mcg DFE-15 mg-150 mg Y  
50967012630 IROSPAN iron bg,ps/folic/B,C no.12/suc TABLET 65 mg iron-65 mg iron-1,000 mcg (24)/150 mg (6) N Y  
13811004210 TARON FORTE iron bg,ps/vitC/B12/FA/calcium CAPSULE 150 mg-60 mg-25 mcg-1 mg N Y  
00178008990 FERRALET 90 iron carb,gl/FA/B12/C/docusate TABLET 90 mg-1 mg-12 mcg-120 mg-50 mg N Y  
13811053890 FOLIVANE-F iron fum,ps/folic acid/vitC/B3 CAPSULE 125 mg-1 mg-40 mg-3 mg N Y  
69367021709 IRON FOLATE-F iron fum,ps/folic acid/vitC/B3 CAPSULE 125 mg-1 mg-40 mg-3 mg N Y  
69367021730 IRON FOLATE-F iron fum,ps/folic acid/vitC/B3 CAPSULE 125 mg-1 mg-40 mg-3 mg N Y  
69367021809 IRON FOLATE PLUS iron fum,ps/folic/Bcomp,C no.9 CAPSULE 125 mg iron-1 mg N Y  
69367021830 IRON FOLATE PLUS iron fum,ps/folic/Bcomp,C no.9 CAPSULE 125 mg iron-1 mg N Y  
13811051810 TRIGELS-F FORTE iron fumarate/vit C/Vit B12/FA CAPSULE 460 mg (151 mg)-60 mg-10 mcg-1 mg N Y  
69367021001 POLYSACCHARIDE IRON iron polysaccharide complex CAPSULE 150 mg iron N Y  
69367021020 POLYSACCHARIDE IRON iron polysaccharide complex CAPSULE 150 mg iron N Y  
54859056004 HEMATEX iron polysaccharide complex LIQUID 100 mg iron/5 mL N Y  
54859056210 HEMATEX iron polysaccharide complex TABLET 150 mg iron Y  
68025005230 CORVITE 150 iron,carb/folate6/mv-min no.41 TABLET 150 mg iron-1 mg (700 mcg-300 mcg) N Y  
61269091060 IRON CHEWS iron,carbonyl TAB CHEW 15 mg N Y  
28595043330 ACTIVE FE iron,carbonyl/folic acid/mv-mn TABLET 75 mg iron-1,250 mcg N Y  
75854031828 FERIVA 21-7 iron/C/B12/folate/zinc/succin TABLET 75 mg iron-175 mg-12 mcg-1 mg-10 mg-150 mg N Y  
73352031828 FERIVA 21-7 iron/C/B12/folate/zinc/succin TABLET 75 mg iron-175 mg-12 mcg-1,667 mcg DFE-10 mg-50 mg Y  
75854032030 CHROMAGEN iron/C/folate 6/B12/Zn/stomach CAPSULE 75 mg iron-60 mg-1 mg-10 mcg-12 mg-100 mg N Y  
75854031930 FERIVA FA iron/C/folate/B12/biot/cupric CAPSULE 110 mg iron-175 mg-1 mg-12 mcg-300 mcg-1.5 mg N Y  
00642007212 VITAFOL iron/calcium/E/folic acid/mvit TABLET 65 mg-125 mg-30 unit-1 mg N Y  
13811060990 TL-HEM 150 iron/FA/C/E/B12/bio/copper/dss TABLET 150 mg iron-1 mg-500 mg-30 unit-60 mcg-150 mcg-3 mg-50 mg Y  
15370026530 NUFERA iron/folate 9/vit C/D3/B6/B12 TABLET 125 mg iron-1 mg-170 mg-1,000 unit-15 mg-16 mcg N Y  
68025006030 CORVITE FE iron/folate no.6/mv-min no.40 TABLET 150 mg iron-1 mg (700 mcg-300 mcg) N Y  
13811001290 FERRAPLUS 90 iron/folic acid/B12/C/docusate TABLET 90 mg-1 mg-12 mcg-120 mg-50 mg N Y  
13811006610 CORVITA 150 iron/folic acid/C/B6/B12/zinc TABLET 150 mg-1.25 mg-120 mg-10 mg-15 mcg-25 mg N Y  
00074842202 IBERET-500 iron/vitamin B comp and C LIQUID Y  
23359010010 CENTRATEX mv-mins no.73/iron fum/folic CAPSULE 106 mg iron-1 mg N Y  
23359010030 CENTRATEX mv-mins no.73/iron fum/folic CAPSULE 106 mg iron-1 mg N Y  
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