Fat Soluble Vitamins and Analogs
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 |
|---|---|---|---|---|---|---|---|
| 00003091450 | COD LIVER OIL | cod liver oil | CAPSULE | Y | |||
| 37205010878 | VITAMIN A | vitamin A | CAPSULE | 2,400 mcg | Y | ||
| 00904208560 | VITAMIN A | vitamin A | CAPSULE | 3,000 mcg (10,000 unit) | Y | ||
| 00904421260 | VITAMIN A | vitamin A | CAPSULE | 3,000 mcg (10,000 unit) | Y | ||
| 00904426060 | VITAMIN A | vitamin A | CAPSULE | 7,500 mcg (25,000 unit) | Y | ||
| 50268084911 | VITAMIN A | vitamin A palmitate | CAPSULE | 3,000 mcg (10,000 unit) | Y | ||
| 50268084915 | VITAMIN A | vitamin A palmitate | CAPSULE | 3,000 mcg (10,000 unit) | Y | ||
| 70199002611 | AQUASOL A | vitamin A palmitate | VIAL | 50,000 unit/mL | Y | ||
| 00904027072 | VITAMIN E | vitamin E | CAPSULE | 100 unit | Y | ||
| 00904027272 | VITAMIN E | vitamin E | CAPSULE | 200 unit | Y | ||
| 00904275272 | VITAMIN E | vitamin E | CAPSULE | 268 mg (400 unit) | Y | ||
| 00904533146 | VITAMIN E | vitamin E | CAPSULE | 268 mg (400 unit) | Y | ||
| 00536135201 | VITAMIN E | vitamin E (dl,tocopheryl acet) | CAPSULE | 180 mg (400 unit) | Y | ||
| 37205049678 | VITAMIN E | vitamin E (dl,tocopheryl acet) | CAPSULE | 180 mg (400 unit) | Y | ||
| 50268087011 | VITAMIN E | vitamin E (dl,tocopheryl acet) | CAPSULE | 180 mg (400 unit) | Y | ||
| 50268087013 | VITAMIN E | vitamin E (dl,tocopheryl acet) | CAPSULE | 180 mg (400 unit) | Y | ||
| 68094011759 | VITAMIN E | vitamin E (dl,tocopheryl acet) | CAPSULE | 180 mg (400 unit) | Y | ||
| 68094011761 | VITAMIN E | vitamin E (dl,tocopheryl acet) | CAPSULE | 180 mg (400 unit) | Y | ||
| 83035185201 | VITAMIN E | vitamin E (dl,tocopheryl acet) | CAPSULE | 180 mg (400 unit) | Y | ||
| 00904027746 | VITAMIN E | vitamin E (dl,tocopheryl acet) | CAPSULE | 450 mg (1,000 unit) | Y | ||
| 00904027760 | VITAMIN E | vitamin E (dl,tocopheryl acet) | CAPSULE | 450 mg (1,000 unit) | Y | ||
| 83035185301 | VITAMIN E | vitamin E (dl,tocopheryl acet) | CAPSULE | 450 mg (1,000 unit) | Y | ||
| 83035185305 | VITAMIN E | vitamin E (dl,tocopheryl acet) | CAPSULE | 450 mg (1,000 unit) | Y | ||
| 83592002105 | VITAMIN E | vitamin E (dl,tocopheryl acet) | CAPSULE | 450 mg (1,000 unit) | Y | ||
| 83035185101 | VITAMIN E | vitamin E (dl,tocopheryl acet) | CAPSULE | 90 mg (200 unit) | Y | ||
| 50268086911 | VITAMIN E-200 | vitamin E (dl,tocopheryl acet) | CAPSULE | 90 mg (200 unit) | Y | ||
| 50268086915 | VITAMIN E-200 | vitamin E (dl,tocopheryl acet) | CAPSULE | 90 mg (200 unit) | Y | ||
| 71321080230 | VITAMIN E | vitamin E (dl,tocopheryl acet) | DROPS | 22.5 mg (50 unit)/mL | Y | ||
| 00904425860 | WHEAT GERM OIL | wheat germ oil | CAPSULE | 14 minim | Y |