Water Soluble Vitamins, Parenteral
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 |
|---|---|---|---|---|---|---|---|
| 81033000805 | ASCORBIC ACID | ascorbic acid | SYRUP | 500 mg/5 mL | Y | ||
| 81033000850 | ASCORBIC ACID | ascorbic acid | SYRUP | 500 mg/5 mL | Y | ||
| 49348038710 | VITAMIN C | ascorbic acid | TAB CHEW | 250 mg | Y | ||
| 51645091801 | VITAMIN C | ascorbic acid | TAB CHEW | 250 mg | Y | ||
| 50268086111 | C-500 | ascorbic acid | TAB CHEW | 500 mg | Y | ||
| 50268086115 | C-500 | ascorbic acid | TAB CHEW | 500 mg | Y | ||
| 00904052672 | VITAMIN C | ascorbic acid | TAB CHEW | 500 mg | Y | ||
| 50268086211 | VITAMIN C | ascorbic acid | TABLET | 1,000 mg | Y | ||
| 50268086215 | VITAMIN C | ascorbic acid | TABLET | 1,000 mg | Y | ||
| 71085007804 | VITAMIN C | ascorbic acid | TABLET | 1,000 mg | Y | ||
| 83035184001 | VITAMIN C | ascorbic acid | TABLET | 1,000 mg | Y | ||
| 83035184005 | VITAMIN C | ascorbic acid | TABLET | 1,000 mg | Y | ||
| 83592001505 | VITAMIN C | ascorbic acid | TABLET | 1,000 mg | Y | ||
| 00904425060 | VITAMIN C W/ROSE HIPS | ascorbic acid | TABLET | 1,000 mg | Y | ||
| 00904425072 | VITAMIN C W/ROSE HIPS | ascorbic acid | TABLET | 1,000 mg | Y | ||
| 50268086011 | VITAMIN C | ascorbic acid | TABLET | 250 mg | Y | ||
| 50268086015 | VITAMIN C | ascorbic acid | TABLET | 250 mg | Y | ||
| 83035183801 | VITAMIN C | ascorbic acid | TABLET | 250 mg | Y | ||
| 00904052360 | VITAMIN C | ascorbic acid | TABLET | 500 mg | Y | ||
| 00904052361 | VITAMIN C | ascorbic acid | TABLET | 500 mg | Y | ||
| 00904052372 | VITAMIN C | ascorbic acid | TABLET | 500 mg | Y | ||
| 00904052380 | VITAMIN C | ascorbic acid | TABLET | 500 mg | Y | ||
| 00904761560 | VITAMIN C | ascorbic acid | TABLET | 500 mg | Y | ||
| 51079000423 | VITAMIN C | ascorbic acid | TABLET | 500 mg | Y | ||
| 68094011361 | VITAMIN C | ascorbic acid | TABLET | 500 mg | Y | ||
| 83035183901 | VITAMIN C | ascorbic acid | TABLET | 500 mg | Y | ||
| 83035183905 | VITAMIN C | ascorbic acid | TABLET | 500 mg | Y | ||
| 83592006005 | VITAMIN C | ascorbic acid | TABLET | 500 mg | Y | ||
| 85633003136 | VITAMIN C | ascorbic acid | TABLET | 500 mg | Y | ||
| 85633003160 | VITAMIN C | ascorbic acid | TABLET | 500 mg | Y | ||
| 00904424970 | VITAMIN C W/ROSE HIPS | ascorbic acid | TABLET | 500 mg | Y | ||
| 37205014472 | VITAMIN C WITH ROSE HIPS | ascorbic acid | TABLET | 500 mg | Y | ||
| 00904274972 | VITAMIN C | ascorbic acid | TABLET ER | 1,000 mg | Y | ||
| 00904425152 | VITAMIN C W/ROSE HIPS | ascorbic acid | TABLET ER | 1,500 mg | Y | ||
| 00904418652 | VITAMIN C | ascorbic acid | TABLET ER | 2,000 mg | Y | ||
| 00904052872 | VITAMIN C | ascorbic acid | TABLET ER | 500 mg | Y | ||
| 49348038910 | VITAMIN C | ascorbic acid | TABLET ER | 500 mg | Y | ||
| 00338029999 | VI-CERT C500 | ascorbic acid | VIAL | 500 mg/mL | Y | ||
| 00143961901 | CYANOCOBALAMIN INJECTION | cyanocobalamin (vitamin B-12) | VIAL | 1,000 mcg/mL | Y | Y | |
| 00143961910 | CYANOCOBALAMIN INJECTION | cyanocobalamin (vitamin B-12) | VIAL | 1,000 mcg/mL | Y | Y | |
| 00143962001 | CYANOCOBALAMIN INJECTION | cyanocobalamin (vitamin B-12) | VIAL | 1,000 mcg/mL | Y | Y | |
| 00143962010 | CYANOCOBALAMIN INJECTION | cyanocobalamin (vitamin B-12) | VIAL | 1,000 mcg/mL | Y | Y | |
| 00143962101 | CYANOCOBALAMIN INJECTION | cyanocobalamin (vitamin B-12) | VIAL | 1,000 mcg/mL | Y | Y | |
| 00143962125 | CYANOCOBALAMIN INJECTION | cyanocobalamin (vitamin B-12) | VIAL | 1,000 mcg/mL | Y | Y | |
| 00517003101 | CYANOCOBALAMIN INJECTION | cyanocobalamin (vitamin B-12) | VIAL | 1,000 mcg/mL | Y | Y | |
| 00517003125 | CYANOCOBALAMIN INJECTION | cyanocobalamin (vitamin B-12) | VIAL | 1,000 mcg/mL | Y | Y | |
| 00517003201 | CYANOCOBALAMIN INJECTION | cyanocobalamin (vitamin B-12) | VIAL | 1,000 mcg/mL | Y | Y | |
| 00517003225 | CYANOCOBALAMIN INJECTION | cyanocobalamin (vitamin B-12) | VIAL | 1,000 mcg/mL | Y | Y | |
| 00517013001 | CYANOCOBALAMIN INJECTION | cyanocobalamin (vitamin B-12) | VIAL | 1,000 mcg/mL | Y | Y | |
| 25021050201 | CYANOCOBALAMIN INJECTION | cyanocobalamin (vitamin B-12) | VIAL | 1,000 mcg/mL | Y | Y | |
| 63323004400 | CYANOCOBALAMIN INJECTION | cyanocobalamin (vitamin B-12) | VIAL | 1,000 mcg/mL | Y | Y | |
| 63323004401 | CYANOCOBALAMIN INJECTION | cyanocobalamin (vitamin B-12) | VIAL | 1,000 mcg/mL | Y | Y | |
| 63323004441 | CYANOCOBALAMIN INJECTION | cyanocobalamin (vitamin B-12) | VIAL | 1,000 mcg/mL | Y | Y | |
| 63323004444 | CYANOCOBALAMIN INJECTION | cyanocobalamin (vitamin B-12) | VIAL | 1,000 mcg/mL | Y | Y | |
| 67457040005 | CYANOCOBALAMIN INJECTION | cyanocobalamin (vitamin B-12) | VIAL | 1,000 mcg/mL | Y | Y | |
| 67457040031 | CYANOCOBALAMIN INJECTION | cyanocobalamin (vitamin B-12) | VIAL | 1,000 mcg/mL | Y | Y | |
| 68001054259 | CYANOCOBALAMIN INJECTION | cyanocobalamin (vitamin B-12) | VIAL | 1,000 mcg/mL | Y | Y | |
| 68001054260 | CYANOCOBALAMIN INJECTION | cyanocobalamin (vitamin B-12) | VIAL | 1,000 mcg/mL | Y | Y | |
| 68001064059 | CYANOCOBALAMIN INJECTION | cyanocobalamin (vitamin B-12) | VIAL | 1,000 mcg/mL | Y | Y | |
| 68001064060 | CYANOCOBALAMIN INJECTION | cyanocobalamin (vitamin B-12) | VIAL | 1,000 mcg/mL | Y | Y | |
| 69680011201 | CYANOCOBALAMIN INJECTION | cyanocobalamin (vitamin B-12) | VIAL | 1,000 mcg/mL | Y | Y | |
| 69680011210 | CYANOCOBALAMIN INJECTION | cyanocobalamin (vitamin B-12) | VIAL | 1,000 mcg/mL | Y | Y | |
| 69680011225 | CYANOCOBALAMIN INJECTION | cyanocobalamin (vitamin B-12) | VIAL | 1,000 mcg/mL | Y | Y | |
| 69680011310 | CYANOCOBALAMIN INJECTION | cyanocobalamin (vitamin B-12) | VIAL | 1,000 mcg/mL | Y | Y | |
| 69680011399 | CYANOCOBALAMIN INJECTION | cyanocobalamin (vitamin B-12) | VIAL | 1,000 mcg/mL | Y | Y | |
| 69680012105 | CYANOCOBALAMIN INJECTION | cyanocobalamin (vitamin B-12) | VIAL | 1,000 mcg/mL | Y | Y | |
| 69680012110 | CYANOCOBALAMIN INJECTION | cyanocobalamin (vitamin B-12) | VIAL | 1,000 mcg/mL | Y | Y | |
| 69680012130 | CYANOCOBALAMIN INJECTION | cyanocobalamin (vitamin B-12) | VIAL | 1,000 mcg/mL | Y | Y | |
| 70069000501 | CYANOCOBALAMIN INJECTION | cyanocobalamin (vitamin B-12) | VIAL | 1,000 mcg/mL | Y | Y | |
| 70069000510 | CYANOCOBALAMIN INJECTION | cyanocobalamin (vitamin B-12) | VIAL | 1,000 mcg/mL | Y | Y | |
| 70069017101 | CYANOCOBALAMIN INJECTION | cyanocobalamin (vitamin B-12) | VIAL | 1,000 mcg/mL | Y | Y | |
| 70069017110 | CYANOCOBALAMIN INJECTION | cyanocobalamin (vitamin B-12) | VIAL | 1,000 mcg/mL | Y | Y | |
| 70069017201 | CYANOCOBALAMIN INJECTION | cyanocobalamin (vitamin B-12) | VIAL | 1,000 mcg/mL | Y | Y | |
| 70069017210 | CYANOCOBALAMIN INJECTION | cyanocobalamin (vitamin B-12) | VIAL | 1,000 mcg/mL | Y | Y | |
| 70512084001 | CYANOCOBALAMIN INJECTION | cyanocobalamin (vitamin B-12) | VIAL | 1,000 mcg/mL | Y | Y | |
| 70512084025 | CYANOCOBALAMIN INJECTION | cyanocobalamin (vitamin B-12) | VIAL | 1,000 mcg/mL | Y | Y | |
| 70710166301 | CYANOCOBALAMIN INJECTION | cyanocobalamin (vitamin B-12) | VIAL | 1,000 mcg/mL | Y | Y | |
| 70710166307 | CYANOCOBALAMIN INJECTION | cyanocobalamin (vitamin B-12) | VIAL | 1,000 mcg/mL | Y | Y | |
| 70710166401 | CYANOCOBALAMIN INJECTION | cyanocobalamin (vitamin B-12) | VIAL | 1,000 mcg/mL | Y | Y | |
| 70710166406 | CYANOCOBALAMIN INJECTION | cyanocobalamin (vitamin B-12) | VIAL | 1,000 mcg/mL | Y | Y | |
| 70710166407 | CYANOCOBALAMIN INJECTION | cyanocobalamin (vitamin B-12) | VIAL | 1,000 mcg/mL | Y | Y | |
| 70710166501 | CYANOCOBALAMIN INJECTION | cyanocobalamin (vitamin B-12) | VIAL | 1,000 mcg/mL | Y | Y | |
| 70710166505 | CYANOCOBALAMIN INJECTION | cyanocobalamin (vitamin B-12) | VIAL | 1,000 mcg/mL | Y | Y | |
| 70756063525 | CYANOCOBALAMIN INJECTION | cyanocobalamin (vitamin B-12) | VIAL | 1,000 mcg/mL | Y | Y | |
| 70756063581 | CYANOCOBALAMIN INJECTION | cyanocobalamin (vitamin B-12) | VIAL | 1,000 mcg/mL | Y | Y | |
| 71288030110 | CYANOCOBALAMIN INJECTION | cyanocobalamin (vitamin B-12) | VIAL | 1,000 mcg/mL | Y | Y | |
| 71288030111 | CYANOCOBALAMIN INJECTION | cyanocobalamin (vitamin B-12) | VIAL | 1,000 mcg/mL | Y | Y | |
| 71288030230 | CYANOCOBALAMIN INJECTION | cyanocobalamin (vitamin B-12) | VIAL | 1,000 mcg/mL | Y | Y | |
| 71288030301 | CYANOCOBALAMIN INJECTION | cyanocobalamin (vitamin B-12) | VIAL | 1,000 mcg/mL | Y | Y | |
| 71288030302 | CYANOCOBALAMIN INJECTION | cyanocobalamin (vitamin B-12) | VIAL | 1,000 mcg/mL | Y | Y | |
| 71288030391 | CYANOCOBALAMIN INJECTION | cyanocobalamin (vitamin B-12) | VIAL | 1,000 mcg/mL | Y | Y | |
| 71288030392 | CYANOCOBALAMIN INJECTION | cyanocobalamin (vitamin B-12) | VIAL | 1,000 mcg/mL | Y | Y | |
| 72603065001 | CYANOCOBALAMIN INJECTION | cyanocobalamin (vitamin B-12) | VIAL | 1,000 mcg/mL | Y | Y | |
| 72603065025 | CYANOCOBALAMIN INJECTION | cyanocobalamin (vitamin B-12) | VIAL | 1,000 mcg/mL | Y | Y | |
| 16729053303 | DODEX | cyanocobalamin (vitamin B-12) | VIAL | 1,000 mcg/mL | Y | Y | |
| 16729053310 | DODEX | cyanocobalamin (vitamin B-12) | VIAL | 1,000 mcg/mL | Y | Y | |
| 00591288830 | HYDROXOCOBALAMIN | hydroxocobalamin | VIAL | 1,000 mcg/mL | Y | ||
| 63323018000 | PYRIDOXINE HCL | pyridoxine HCl (vitamin B6) | VIAL | 100 mg/mL | Y | Y | |
| 63323018001 | PYRIDOXINE HCL | pyridoxine HCl (vitamin B6) | VIAL | 100 mg/mL | Y | Y | |
| 83035183201 | VITAMIN B2 | riboflavin (vitamin B2) | TABLET | 100 mg | Y | ||
| 83035193201 | VITAMIN B2 | riboflavin (vitamin B2) | TABLET | 100 mg | Y | ||
| 83592002905 | VITAMIN B2 | riboflavin (vitamin B2) | TABLET | 100 mg | Y | ||
| 83035183001 | VITAMIN B2 | riboflavin (vitamin B2) | TABLET | 25 mg | Y | ||
| 83035183101 | VITAMIN B2 | riboflavin (vitamin B2) | TABLET | 50 mg | Y | ||
| 00904425225 | RUTIN | rutin | TABLET | 50 mg | Y | ||
| 00641622801 | THIAMINE HCL | thiamine HCl | VIAL | 100 mg/mL | Y | Y | |
| 00641622825 | THIAMINE HCL | thiamine HCl | VIAL | 100 mg/mL | Y | Y | |
| 25021050002 | THIAMINE HCL | thiamine HCl | VIAL | 100 mg/mL | Y | Y | |
| 31722036331 | THIAMINE HCL | thiamine HCl | VIAL | 100 mg/mL | Y | Y | |
| 31722036332 | THIAMINE HCL | thiamine HCl | VIAL | 100 mg/mL | Y | Y | |
| 43598005011 | THIAMINE HCL | thiamine HCl | VIAL | 100 mg/mL | Y | Y | |
| 43598005025 | THIAMINE HCL | thiamine HCl | VIAL | 100 mg/mL | Y | Y | |
| 55150027301 | THIAMINE HCL | thiamine HCl | VIAL | 100 mg/mL | Y | Y | |
| 55150027325 | THIAMINE HCL | thiamine HCl | VIAL | 100 mg/mL | Y | Y | |
| 63323001301 | THIAMINE HCL | thiamine HCl | VIAL | 100 mg/mL | Y | Y | |
| 63323001302 | THIAMINE HCL | thiamine HCl | VIAL | 100 mg/mL | Y | Y | |
| 63323001309 | THIAMINE HCL | thiamine HCl | VIAL | 100 mg/mL | Y | Y | |
| 63323001321 | THIAMINE HCL | thiamine HCl | VIAL | 100 mg/mL | Y | Y | |
| 63323001326 | THIAMINE HCL | thiamine HCl | VIAL | 100 mg/mL | Y | Y | |
| 63323001341 | THIAMINE HCL | thiamine HCl | VIAL | 100 mg/mL | Y | Y | |
| 65145012901 | THIAMINE HCL | thiamine HCl | VIAL | 100 mg/mL | Y | Y | |
| 65145012925 | THIAMINE HCL | thiamine HCl | VIAL | 100 mg/mL | Y | Y | |
| 67457019600 | THIAMINE HCL | thiamine HCl | VIAL | 100 mg/mL | Y | Y | |
| 67457019602 | THIAMINE HCL | thiamine HCl | VIAL | 100 mg/mL | Y | Y | |
| 72485050701 | THIAMINE HCL | thiamine HCl | VIAL | 100 mg/mL | Y | Y | |
| 72485050725 | THIAMINE HCL | thiamine HCl | VIAL | 100 mg/mL | Y | Y | |
| 72603013901 | THIAMINE HCL | thiamine HCl | VIAL | 100 mg/mL | Y | Y | |
| 72603013925 | THIAMINE HCL | thiamine HCl | VIAL | 100 mg/mL | Y | Y | |
| 67457014630 | B-COMPLEX | vitamins B1,B2,B3,B5,and B6 | VIAL | 100 mg-2 mg-100 mg-2 mg-2 mg/mL | Y | ||
| 54859070601 | FLAVOVIT | vitB,C/choline/inositol/bioflv | TABLET | 500 mg | Y |