Pediatric Multivitamins
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 |
|---|---|---|---|---|---|---|---|
| 37205038472 | MULTIVITAMIN PLUS CALCIUM | calcium carbonate/multivitamin | TAB CHEW | Y | |||
| 65219033910 | VITALIPID N INFANT | fat emuls/vit A/vit D2/E/vit K | AMPUL | 69 mcg-1 mcg-0.64 mg-20 mcg/mL | Y | ||
| 65219033964 | VITALIPID N INFANT | fat emuls/vit A/vit D2/E/vit K | AMPUL | 69 mcg-1 mcg-0.64 mg-20 mcg/mL | Y | ||
| 65219033710 | VITLIPID N INFANT | fat emuls/vit A/vit D2/E/vit K | AMPUL | 69 mcg-1 mcg-0.64 mg-20 mcg/mL | Y | ||
| 65219033762 | VITLIPID N INFANT | fat emuls/vit A/vit D2/E/vit K | AMPUL | 69 mcg-1 mcg-0.64 mg-20 mcg/mL | Y | ||
| 65219033510 | VITLIPID N ADULT | fat emuls/vit A/vit D2/E/vit K | AMPUL | 990 mcg-5 mcg-9.1 mg-150 mcg/10 mL | Y | ||
| 65219033582 | VITLIPID N ADULT | fat emuls/vit A/vit D2/E/vit K | AMPUL | 990 mcg-5 mcg-9.1 mg-150 mcg/10 mL | Y | ||
| 00254945548 | TRI-VIT W/FLUORIDE & IRON | fluoride/iron/vitamins A,C,D | DROPS | 0.25 mg/mL | Y | ||
| 54643564601 | INFUVITE PEDIATRIC | multivit infusion,pedi 1,vit K | VIAL | 80 mg-2,300 unit-400 unit-1.2 mg-1.4 mg-1 mg-200 mcg/5 mL | Y | ||
| 54643564700 | INFUVITE PEDIATRIC | multivit infusion,pedi 1,vit K | VIAL | 80 mg-2,300 unit-400 unit-1.2 mg-1.4 mg-1 mg-200 mcg/5 mL | Y | ||
| 54643788601 | INFUVITE PEDIATRIC | multivit infusion,pedi 1,vit K | VIAL | 80 mg-2,300 unit-400 unit-1.2 mg-1.4 mg-1 mg-200 mcg/5 mL | Y | ||
| 54643902301 | INFUVITE PEDIATRIC | multivit infusion,pedi 1,vit K | VIAL | 80 mg-2,300 unit-400 unit-1.2 mg-1.4 mg-1 mg-200 mcg/5 mL | Y | ||
| 54643903100 | INFUVITE PEDIATRIC | multivit infusion,pedi 1,vit K | VIAL | 80 mg-2,300 unit-400 unit-1.2 mg-1.4 mg-1 mg-200 mcg/5 mL | Y | ||
| 54643564901 | INFUVITE ADULT | multivit infusn,adult 4,vit K | VIAL | 3,300 unit-200 unit-10 unit-150 mcg-200 mg-40 mg/10 mL | Y | ||
| 54643565002 | INFUVITE ADULT | multivit infusn,adult 4,vit K | VIAL | 3,300 unit-200 unit-10 unit-150 mcg-200 mg-40 mg/10 mL | Y | ||
| 54643786201 | INFUVITE ADULT | multivit infusn,adult 4,vit K | VIAL | 3,300 unit-200 unit-10 unit-150 mcg-200 mg-40 mg/10 mL | Y | ||
| 54643900701 | INFUVITE ADULT | multivit infusn,adult 4,vit K | VIAL | 3,300 unit-200 unit-10 unit-150 mcg-200 mg-40 mg/10 mL | Y | ||
| 54643901502 | INFUVITE ADULT | multivit infusn,adult 4,vit K | VIAL | 3,300 unit-200 unit-10 unit-150 mcg-200 mg-40 mg/10 mL | Y | ||
| 00904262180 | CHILD CHEW VITAMIN | multivitamin | TAB CHEW | Y | |||
| 00904767060 | CHILDRENS CHEWABLE | multivitamin | TAB CHEW | Y | |||
| 00904768652 | CHILDRENS VITAMIN | multivitamin | TAB CHEW | Y | |||
| 00074451913 | VI-DAYLIN | multivitamin | TAB CHEW | Y | |||
| 00338040360 | MULTIVITAMIN 12 | multivitamin | VIAL | Y | |||
| 00904767160 | CHILDRENS CHEWABLE + IRON | multivitamin with iron | TAB CHEW | Y | |||
| 00904419060 | CHILDS CHEW + IRON | multivitamin with iron | TAB CHEW | Y | |||
| 00074452013 | VI-DAYLIN PLUS IRON | multivitamin with iron | TAB CHEW | Y | |||
| 00254929848 | MULTI-VIT W/FLUORIDE | Multivitamins with Fluoride | DROPS | 0.25 mg/mL | Y | ||
| 00254929948 | MULTI-VIT W/FLUORIDE | Multivitamins with Fluoride | DROPS | 0.5 mg/mL | Y | ||
| 00254930248 | MULTI-VIT/IRON & FLUORIDE | Multivits with Iron & Fluoride | DROPS | 0.25 mg/mL | Y | ||
| 00254930348 | MULTI-VIT/IRON & FLUORIDE | Multivits with Iron & Fluoride | DROPS | 0.5 mg/mL | Y | ||
| 61703042381 | M.V.I.-12 | mv infus,adult 2 without vit K | VIAL | 3,300 unit-200 unit-10 unit-200 mg-40 mg-6 mg-600 mcg/10 mL | Y | ||
| 61703042602 | M.V.I. ADULT VIAL 1 | mvi, adult no.1, vit K, 1 of 2 | VIAL | 3,300 unit-200 unit-10 unit-150 mcg-200 mg-40 mg/5 mL | Y | ||
| 54643786208 | INFUVITE ADULT VIAL 1 | mvi, adult no.4, vit K, 1 of 2 | VIAL | 3,300 unit-200 unit-10 unit-150 mcg-200 mg-40 mg/5 mL | Y | ||
| 54643900708 | INFUVITE ADULT VIAL 1 | mvi, adult no.4, vit K, 1 of 2 | VIAL | 3,300 unit-200 unit-10 unit-150 mcg-200 mg-40 mg/5 mL | Y | ||
| 54643901508 | INFUVITE ADULT VIAL 1 | mvi, adult no.4, vit K, 1 of 2 | VIAL | 3,300 unit-200 unit-10 unit-150 mcg-200 mg-40 mg/5 mL | Y | ||
| 54643786209 | INFUVITE ADULT VIAL 2 | mvi, adult no.4, vit K, 2 of 2 | VIAL | 600 mcg-60 mcg-5 mcg/5 mL | Y | ||
| 54643900709 | INFUVITE ADULT VIAL 2 | mvi, adult no.4, vit K, 2 of 2 | VIAL | 600 mcg-60 mcg-5 mcg/5 mL | Y | ||
| 54643901509 | INFUVITE ADULT VIAL 2 | mvi, adult no.4, vit K, 2 of 2 | VIAL | 600 mcg-60 mcg-5 mcg/5 mL | Y | ||
| 54643788608 | INFUVITE PEDIATRIC VIAL 1 | mvi,pedi no.1,component 1 of 2 | VIAL | 80 mg-2,300 unit-400 unit-1.2 mg-1.4 mg-1 mg-200 mcg/4 mL | Y | ||
| 54643902308 | INFUVITE PEDIATRIC VIAL 1 | mvi,pedi no.1,component 1 of 2 | VIAL | 80 mg-2,300 unit-400 unit-1.2 mg-1.4 mg-1 mg-200 mcg/4 mL | Y | ||
| 54643903108 | INFUVITE PEDIATRIC VIAL 1 | mvi,pedi no.1,component 1 of 2 | VIAL | 80 mg-2,300 unit-400 unit-1.2 mg-1.4 mg-1 mg-200 mcg/4 mL | Y | ||
| 54643788609 | INFUVITE PEDIATRIC VIAL 2 | mvi,pedi no.1,component 2 of 2 | VIAL | 140 mcg-20 mcg-1 mcg/mL | Y | ||
| 54643902309 | INFUVITE PEDIATRIC VIAL 2 | mvi,pedi no.1,component 2 of 2 | VIAL | 140 mcg-20 mcg-1 mcg/mL | Y | ||
| 54643903109 | INFUVITE PEDIATRIC VIAL 2 | mvi,pedi no.1,component 2 of 2 | VIAL | 140 mcg-20 mcg-1 mcg/mL | Y | ||
| 15370012030 | QUFLORA FE | ped multivit 142/iron/fluoride | TAB CHEW | 9 mg iron-0.25 mg fluoride | Y | ||
| 15370010250 | QUFLORA FE | ped multivit 151/iron/fluoride | DROPS | 9.5 mg iron-0.25 mg fluoride/mL | Y | ||
| 23594052530 | POLY-VI-FLOR WITH IRON | ped multivit 175/fluoride/iron | TAB CHEW | 0.5 mg fluoride-10 mg iron | Y | ||
| 23594001003 | POLY-VI-FLOR WITH IRON | ped multivit 205/fluoride/iron | TAB CHEW | 0.5 mg fluoride-10 mg iron | Y | ||
| 23594006005 | POLY-VI-FLOR WITH IRON | ped multivit 214/fluoride/iron | DROPS | 0.25 mg fluoride-7 mg iron/mL | Y | ||
| 23594060550 | POLY-VI-FLOR WITH IRON | ped multivit 220/fluoride/iron | DROPS | 0.25 mg fluoride-7 mg iron/mL | Y | ||
| 81279010150 | FLORAFOL FE PEDIATRIC | ped multivit 257/fluoride/iron | DROPS | 0.25 mg fluoride-7 mg iron/mL | Y | ||
| 39328000550 | SOLUVITA A,C,D WITH FLUORIDE | ped mvit A,C,D3 no.21/fluoride | DROPS | 0.25 mg fluoride (0.55 mg sodium fluoride)/mL | Y | ||
| 58657032350 | TRI-VITE WITH FLUORIDE | ped mvit A,C,D3 no.21/fluoride | DROPS | 0.25 mg fluoride (0.55 mg sodium fluoride)/mL | Y | ||
| 61269016450 | VITAMINS A,C,D AND FLUORIDE | ped mvit A,C,D3 no.21/fluoride | DROPS | 0.25 mg fluoride (0.55 mg sodium fluoride)/mL | Y | ||
| 58657032450 | TRI-VITE WITH FLUORIDE | ped mvit A,C,D3 no.21/fluoride | DROPS | 0.5 mg fluoride (1.1 mg sodium fluoride)/mL | Y | ||
| 61269016750 | VITAMINS A,C,D AND FLUORIDE | ped mvit A,C,D3 no.21/fluoride | DROPS | 0.5 mg fluoride (1.1 mg sodium fluoride)/mL | Y | ||
| 23594007005 | TRI-VI-FLOR | ped mvit A,C,D3 no.38/fluoride | DRPS SP BP | 0.25 mg/mL fluoride | Y | ||
| 23594070050 | TRI-VI-FLOR | ped mvit A,C,D3 no.38/fluoride | DRPS SP BP | 0.25 mg/mL fluoride | Y | ||
| 23594008005 | TRI-VI-FLOR | ped mvit A,C,D3 no.38/fluoride | DRPS SP BP | 0.5 mg/mL fluoride | Y | ||
| 23594080050 | TRI-VI-FLOR | ped mvit A,C,D3 no.38/fluoride | DRPS SP BP | 0.5 mg/mL fluoride | Y | ||
| 23594005005 | POLY-VI-FLOR | pedi multivit 213 w-fluoride | DROPS | 0.25 mg/mL fluoride | Y | ||
| 58657032750 | MULTI-VITAMIN W-FLUORIDE-IRON | pedi multivit 45/fluoride/iron | DROPS | 0.25 mg fluoride-10 mg iron/mL | Y | ||
| 61269016350 | MULTIVITAMIN-IRON-FLUORIDE | pedi multivit 45/fluoride/iron | DROPS | 0.25 mg fluoride-10 mg iron/mL | Y | ||
| 15370010150 | QUFLORA | pedi multivit 84 with fluoride | DROPS | 0.5 mg fluoride (1.1 mg sodium fluoride)/mL | Y | ||
| 15370021060 | QUFLORA | pedi multivit no.157/fluoride | TAB CHEW | 0.125 mg fluoride | Y | ||
| 59088001754 | FLOTREX | pedi multivit no.17 w-fluoride | TAB CHEW | 0.25 mg | Y | ||
| 58657016301 | MULTIVITAMIN WITH FLUORIDE | pedi multivit no.17 w-fluoride | TAB CHEW | 0.25 mg | Y | ||
| 58657016390 | MULTIVITAMIN WITH FLUORIDE | pedi multivit no.17 w-fluoride | TAB CHEW | 0.25 mg | Y | ||
| 61269015501 | MULTIVITAMIN WITH FLUORIDE | pedi multivit no.17 w-fluoride | TAB CHEW | 0.25 mg | Y | ||
| 59088001554 | FLOTREX | pedi multivit no.17 w-fluoride | TAB CHEW | 0.5 mg | Y | ||
| 58657016401 | MULTIVITAMIN WITH FLUORIDE | pedi multivit no.17 w-fluoride | TAB CHEW | 0.5 mg | Y | ||
| 58657016490 | MULTIVITAMIN WITH FLUORIDE | pedi multivit no.17 w-fluoride | TAB CHEW | 0.5 mg | Y | ||
| 61269015601 | MULTIVITAMIN WITH FLUORIDE | pedi multivit no.17 w-fluoride | TAB CHEW | 0.5 mg | Y | ||
| 59088002054 | FLOTREX | pedi multivit no.17 w-fluoride | TAB CHEW | 1 mg | Y | ||
| 58657016501 | MULTIVITAMIN WITH FLUORIDE | pedi multivit no.17 w-fluoride | TAB CHEW | 1 mg | Y | ||
| 58657016590 | MULTIVITAMIN WITH FLUORIDE | pedi multivit no.17 w-fluoride | TAB CHEW | 1 mg | Y | ||
| 61269015701 | MULTIVITAMIN WITH FLUORIDE | pedi multivit no.17 w-fluoride | TAB CHEW | 1 mg | Y | ||
| 23594022530 | POLY-VI-FLOR | pedi multivit no.175/fluoride | TAB CHEW | 0.25 mg fluoride | Y | ||
| 23594032530 | POLY-VI-FLOR | pedi multivit no.175/fluoride | TAB CHEW | 0.5 mg fluoride | Y | ||
| 23594042530 | POLY-VI-FLOR | pedi multivit no.175/fluoride | TAB CHEW | 1 mg fluoride | Y | ||
| 58657032550 | MULTIVITAMIN WITH FLUORIDE | pedi multivit no.2 w-fluoride | DROPS | 0.25 mg/mL fluoride | Y | ||
| 61269016150 | MULTIVITAMIN WITH FLUORIDE | pedi multivit no.2 w-fluoride | DROPS | 0.25 mg/mL fluoride | Y | ||
| 75826016655 | MULTIVITAMIN WITH FLUORIDE | pedi multivit no.2 w-fluoride | DROPS | 0.25 mg/mL fluoride | Y | ||
| 58657032650 | MULTIVITAMIN WITH FLUORIDE | pedi multivit no.2 w-fluoride | DROPS | 0.5 mg/mL fluoride | Y | ||
| 61269016250 | MULTIVITAMIN WITH FLUORIDE | pedi multivit no.2 w-fluoride | DROPS | 0.5 mg/mL fluoride | Y | ||
| 23594035030 | POLY-VI-FLOR | pedi multivit no.217/fluoride | TAB CHEW | 0.5 mg fluoride | Y | ||
| 62542020030 | MULTIVITAMIN WITH FLUORIDE | pedi multivit no.219/fluoride | TAB CHEW | 0.25 mg fluoride | Y | ||
| 23594002003 | POLY-VI-FLOR | pedi multivit no.219/fluoride | TAB CHEW | 0.25 mg fluoride | Y | ||
| 23594020030 | POLY-VI-FLOR | pedi multivit no.219/fluoride | TAB CHEW | 0.25 mg fluoride | Y | ||
| 62542030030 | MULTIVITAMIN WITH FLUORIDE | pedi multivit no.219/fluoride | TAB CHEW | 0.5 mg fluoride | Y | ||
| 23594003003 | POLY-VI-FLOR | pedi multivit no.219/fluoride | TAB CHEW | 0.5 mg fluoride | Y | ||
| 62542040030 | MULTIVITAMIN WITH FLUORIDE | pedi multivit no.219/fluoride | TAB CHEW | 1 mg fluoride | Y | ||
| 23594004003 | POLY-VI-FLOR | pedi multivit no.219/fluoride | TAB CHEW | 1 mg fluoride | Y | ||
| 23594040030 | POLY-VI-FLOR | pedi multivit no.219/fluoride | TAB CHEW | 1 mg fluoride | Y | ||
| 62542080550 | MULTIVITAMIN WITH FLUORIDE | pedi multivit no.220/fluoride | DROPS | 0.25 mg/mL fluoride | Y | ||
| 23594055050 | POLY-VI-FLOR | pedi multivit no.220/fluoride | DROPS | 0.25 mg/mL fluoride | Y | ||
| 23594080550 | POLY-VI-FLOR | pedi multivit no.220/fluoride | DROPS | 0.25 mg/mL fluoride | Y | ||
| 42494043430 | MULTI-VIT-FLOR | pedi multivit no.228/fluoride | TAB CHEW | 0.25 mg fluoride | Y | ||
| 42494043330 | MULTI-VIT-FLOR | pedi multivit no.228/fluoride | TAB CHEW | 0.5 mg fluoride | Y | ||
| 42494043230 | MULTI-VIT-FLOR | pedi multivit no.228/fluoride | TAB CHEW | 1 mg fluoride | Y | ||
| 46122009072 | CHILDREN'S CHEWABLES | pedi multivit no.23/folic acid | TAB CHEW | 300 mcg | Y | ||
| 75826016910 | MULTIVITAMIN WITH FLUORIDE | pedi multivit no.242/fluoride | TAB CHEW | 0.25 mg fluoride | Y | ||
| 75826017010 | MULTIVITAMIN WITH FLUORIDE | pedi multivit no.242/fluoride | TAB CHEW | 0.5 mg fluoride | Y | ||
| 75826017110 | MULTIVITAMIN WITH FLUORIDE | pedi multivit no.242/fluoride | TAB CHEW | 1 mg fluoride | Y | ||
| 51645071201 | CHILDREN'S CHEWABLE MULTIVITMN | pedi multivit no.25/folic acid | TAB CHEW | 300 mcg | Y | ||
| 46122008972 | CHILDREN'S CHEWABLES | pedi multivit no.25/folic acid | TAB CHEW | 300 mcg | Y | ||
| 81279010230 | FLORAFOL PEDIATRIC | pedi multivit no.251/fluoride | TAB CHEW | 0.5 mg fluoride | Y | ||
| 81279010330 | FLORAFOL PEDIATRIC | pedi multivit no.251/fluoride | TAB CHEW | 1 mg fluoride | Y | ||
| 62542070050 | TRI-VITAMIN WITH FLUORIDE | pedi multivit no.265/fluoride | DROPS | 0.25 mg/mL fluoride | Y | ||
| 46122008872 | CHILDREN'S CHEWABLE | pedi multivit no.31/iron/folic | TAB CHEW | 9 mg iron-200 mcg | Y | ||
| 15370010330 | QUFLORA | pedi multivit no.63 w-fluoride | TAB CHEW | 0.25 mg fluoride (0.55 mg sodium fluoride) | Y | ||
| 15370010430 | QUFLORA | pedi multivit no.63 w-fluoride | TAB CHEW | 0.5 mg fluoride (1.1 mg sodium fluoride) | Y | ||
| 15370010530 | QUFLORA | pedi multivit no.63 w-fluoride | TAB CHEW | 1 mg fluoride (2.2 mg sodium fluoride) | Y | ||
| 39328000350 | SOLUVITA MULTIVITAMIN FLUORIDE | pedi multivit no.82 w-fluoride | DROPS | 0.25 mg/mL fluoride | Y | ||
| 39328000450 | SOLUVITA MULTIVITAMIN FLUORIDE | pedi multivit no.82 w-fluoride | DROPS | 0.5 mg/mL fluoride | Y | ||
| 15370010050 | QUFLORA | pedi multivit no.83 w-fluoride | DROPS | 0.25 mg fluoride (0.55 mg sodium fluoride)/mL | Y | ||
| 51645099210 | CHILDREN'S CHEW MULTIVIT-IRON | pedi multivit no.91/iron fum | TAB CHEW | 15 mg iron | Y | ||
| 00536134680 | INFANT-TODDLER MULTIVIT-IRON | pedi mv no.207/ferrous sulfate | DROPS | 11 mg iron/mL | Y | ||
| 59088017054 | DAVIMET WITH FLUORIDE | pedi mv no.247/fluoride | TAB CHEW | 0.75 mg fluoride | Y | ||
| 81279010050 | FLORAFOL PEDIATRIC | pedi mv no.257/sodium fluoride | DROPS | 0.25 mg/mL fluoride | Y | ||
| 00536134580 | INFANT-TODDLER MULTIVITAMIN | pediatric multivitamin no.192 | DROPS | 250 mcg-50 mg-10 mcg-5 mg/mL | Y | ||
| 59088066016 | LIVITA FOR CHILDREN | pediatric multivitamin no.245 | LIQUID | Y | |||
| 00536134780 | INFANT-TODDLER VITAMIN A-C-D | vit A palmitate/vit C/vit D3 | DROPS | 250 mcg-50 mg-10 mcg/mL | Y |