Parenteral Vitamins
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.
| NDC | Brand Name | Generic Name | Form | Strength | PDL Status |
Rebate | Current Drug Use Criteria |
|---|---|---|---|---|---|---|---|
| 54859040110 | NUTRIJECT | B-complex with vitamin C | VIAL | Y | |||
| 00338030199 | VI-CERT C1000 WITH B12 | B-complex with vitamin C | VIAL | Y | |||
| 39822110001 | FOLIC ACID | folic acid | VIAL | 5 mg/mL | Y | ||
| 63323018410 | FOLIC ACID | folic acid | VIAL | 5 mg/mL | Y | ||
| 00023608201 | INFED | iron dextran complex | VIAL | 100 mg/2 mL (50 mg/mL) | Y | ||
| 00023608210 | INFED | iron dextran complex | VIAL | 100 mg/2 mL (50 mg/mL) | Y | ||
| 00409915701 | VITAMIN K1 | phytonadione (vit K1) | AMPUL | 1 mg/0.5 mL | Y | ||
| 00409915731 | VITAMIN K1 | phytonadione (vit K1) | AMPUL | 1 mg/0.5 mL | Y | ||
| 00409915750 | VITAMIN K1 | phytonadione (vit K1) | AMPUL | 1 mg/0.5 mL | Y | ||
| 00006778064 | AQUA-MEPHYTON | phytonadione (vit K1) | AMPUL | 10 mg/mL | Y | ||
| 00006778066 | AQUA-MEPHYTON | phytonadione (vit K1) | AMPUL | 10 mg/mL | Y | ||
| 43598040511 | PHYTONADIONE | phytonadione (vit K1) | AMPUL | 10 mg/mL | Y | ||
| 43598040516 | PHYTONADIONE | phytonadione (vit K1) | AMPUL | 10 mg/mL | Y | ||
| 68462075801 | PHYTONADIONE | phytonadione (vit K1) | AMPUL | 10 mg/mL | Y | ||
| 68462075805 | PHYTONADIONE | phytonadione (vit K1) | AMPUL | 10 mg/mL | Y | ||
| 68462075825 | PHYTONADIONE | phytonadione (vit K1) | AMPUL | 10 mg/mL | Y | ||
| 70700033122 | PHYTONADIONE | phytonadione (vit K1) | AMPUL | 10 mg/mL | Y | ||
| 70700033124 | PHYTONADIONE | phytonadione (vit K1) | AMPUL | 10 mg/mL | Y | ||
| 70700033125 | PHYTONADIONE | phytonadione (vit K1) | AMPUL | 10 mg/mL | Y | ||
| 00409915801 | VITAMIN K1 | phytonadione (vit K1) | AMPUL | 10 mg/mL | Y | ||
| 00409915811 | VITAMIN K1 | phytonadione (vit K1) | AMPUL | 10 mg/mL | Y | ||
| 00409915825 | VITAMIN K1 | phytonadione (vit K1) | AMPUL | 10 mg/mL | Y | ||
| 00409915831 | VITAMIN K1 | phytonadione (vit K1) | AMPUL | 10 mg/mL | Y | ||
| 00409915850 | VITAMIN K1 | phytonadione (vit K1) | AMPUL | 10 mg/mL | Y | ||
| 00409915855 | VITAMIN K1 | phytonadione (vit K1) | AMPUL | 10 mg/mL | Y | ||
| 69097000367 | PHYTONADIONE | phytonadione (vit K1) | SYRINGE | 1 mg/0.5 mL | Y | ||
| 69097000396 | PHYTONADIONE | phytonadione (vit K1) | SYRINGE | 1 mg/0.5 mL | Y | ||
| 76329124001 | PHYTONADIONE | phytonadione (vit K1) | SYRINGE | 1 mg/0.5 mL | Y | ||
| 69097070930 | PHYTONADIONE | phytonadione (vit K1) | VIAL | 1 mg/0.5 mL | Y | ||
| 69097070996 | PHYTONADIONE | phytonadione (vit K1) | VIAL | 1 mg/0.5 mL | Y | ||
| 65145015101 | PHYTONADIONE | phytonadione (vit K1) | VIAL | 10 mg/mL | Y | ||
| 65145015110 | PHYTONADIONE | phytonadione (vit K1) | VIAL | 10 mg/mL | Y | ||
| 65219063500 | PHYTONADIONE | phytonadione (vit K1) | VIAL | 10 mg/mL | Y | ||
| 65219063501 | PHYTONADIONE | phytonadione (vit K1) | VIAL | 10 mg/mL | Y | ||
| 69097070831 | PHYTONADIONE | phytonadione (vit K1) | VIAL | 10 mg/mL | Y | ||
| 69097070896 | PHYTONADIONE | phytonadione (vit K1) | VIAL | 10 mg/mL | Y |