Pediatric Multivitamins

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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 Carveout
‐ Bill FFS		 Current Drug Use Criteria
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 N  
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 N  
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 N  
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 N  
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 N  
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 N  
00254945548 TRI-VIT W/FLUORIDE & IRON fluoride/iron/vitamins A,C,D DROPS 0.25 mg/mL Y N  
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 N  
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 N  
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 N  
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 N  
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 N  
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 N  
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 N  
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 N  
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 N  
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 N  
00904262180 CHILD CHEW VITAMIN multivitamin TAB CHEW Y N  
00904767060 CHILDRENS CHEWABLE multivitamin TAB CHEW Y N  
00904768652 CHILDRENS VITAMIN multivitamin TAB CHEW Y N  
00074451913 VI-DAYLIN multivitamin TAB CHEW Y N  
00338040360 MULTIVITAMIN 12 multivitamin VIAL Y N  
00904767160 CHILDRENS CHEWABLE + IRON multivitamin with iron TAB CHEW Y N  
00904419060 CHILDS CHEW + IRON multivitamin with iron TAB CHEW Y N  
00074452013 VI-DAYLIN PLUS IRON multivitamin with iron TAB CHEW Y N  
00254929848 MULTI-VIT W/FLUORIDE Multivitamins with Fluoride DROPS 0.25 mg/mL Y N  
00254929948 MULTI-VIT W/FLUORIDE Multivitamins with Fluoride DROPS 0.5 mg/mL Y N  
00254930248 MULTI-VIT/IRON & FLUORIDE Multivits with Iron & Fluoride DROPS 0.25 mg/mL Y N  
00254930348 MULTI-VIT/IRON & FLUORIDE Multivits with Iron & Fluoride DROPS 0.5 mg/mL Y N  
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 N  
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 N  
54643565701 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 N  
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 N  
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 N  
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 N  
54643565901 INFUVITE ADULT VIAL 2 mvi, adult no.4, vit K, 2 of 2 VIAL 600 mcg-60 mcg-5 mcg/5 mL Y N  
54643786209 INFUVITE ADULT VIAL 2 mvi, adult no.4, vit K, 2 of 2 VIAL 600 mcg-60 mcg-5 mcg/5 mL Y N  
54643900709 INFUVITE ADULT VIAL 2 mvi, adult no.4, vit K, 2 of 2 VIAL 600 mcg-60 mcg-5 mcg/5 mL Y N  
54643901509 INFUVITE ADULT VIAL 2 mvi, adult no.4, vit K, 2 of 2 VIAL 600 mcg-60 mcg-5 mcg/5 mL Y N  
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 N  
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 N  
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 N  
54643788609 INFUVITE PEDIATRIC VIAL 2 mvi,pedi no.1,component 2 of 2 VIAL 140 mcg-20 mcg-1 mcg/mL Y N  
54643902309 INFUVITE PEDIATRIC VIAL 2 mvi,pedi no.1,component 2 of 2 VIAL 140 mcg-20 mcg-1 mcg/mL Y N  
54643903109 INFUVITE PEDIATRIC VIAL 2 mvi,pedi no.1,component 2 of 2 VIAL 140 mcg-20 mcg-1 mcg/mL Y N  
15370012030 QUFLORA FE ped multivit 142/iron/fluoride TAB CHEW 9 mg iron-0.25 mg fluoride Y N  
15370010250 QUFLORA FE ped multivit 151/iron/fluoride DROPS 9.5 mg iron-0.25 mg fluoride/mL Y N  
23594052530 POLY-VI-FLOR WITH IRON ped multivit 175/fluoride/iron TAB CHEW 0.5 mg fluoride-10 mg iron Y N  
23594001003 POLY-VI-FLOR WITH IRON ped multivit 205/fluoride/iron TAB CHEW 0.5 mg fluoride-10 mg iron Y N  
23594006005 POLY-VI-FLOR WITH IRON ped multivit 214/fluoride/iron DROPS 0.25 mg fluoride-7 mg iron/mL Y N  
23594060550 POLY-VI-FLOR WITH IRON ped multivit 220/fluoride/iron DROPS 0.25 mg fluoride-7 mg iron/mL Y N  
81279010150 FLORAFOL FE PEDIATRIC ped multivit 257/fluoride/iron DROPS 0.25 mg fluoride-7 mg iron/mL Y N  
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 N  
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 N  
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 N  
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 N  
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 N  
23594007005 TRI-VI-FLOR ped mvit A,C,D3 no.38/fluoride DRPS SP BP 0.25 mg/mL fluoride Y N  
23594070050 TRI-VI-FLOR ped mvit A,C,D3 no.38/fluoride DRPS SP BP 0.25 mg/mL fluoride Y N  
23594008005 TRI-VI-FLOR ped mvit A,C,D3 no.38/fluoride DRPS SP BP 0.5 mg/mL fluoride Y N  
23594080050 TRI-VI-FLOR ped mvit A,C,D3 no.38/fluoride DRPS SP BP 0.5 mg/mL fluoride Y N  
23594005005 POLY-VI-FLOR pedi multivit 213 w-fluoride DROPS 0.25 mg/mL fluoride Y N  
58657032750 MULTI-VITAMIN W-FLUORIDE-IRON pedi multivit 45/fluoride/iron DROPS 0.25 mg fluoride-10 mg iron/mL Y N  
61269016350 MULTIVITAMIN-IRON-FLUORIDE pedi multivit 45/fluoride/iron DROPS 0.25 mg fluoride-10 mg iron/mL Y N  
15370010150 QUFLORA pedi multivit 84 with fluoride DROPS 0.5 mg fluoride (1.1 mg sodium fluoride)/mL Y N  
15370021060 QUFLORA pedi multivit no.157/fluoride TAB CHEW 0.125 mg fluoride Y N  
59088001754 FLOTREX pedi multivit no.17 w-fluoride TAB CHEW 0.25 mg Y N  
58657016301 MULTIVITAMIN WITH FLUORIDE pedi multivit no.17 w-fluoride TAB CHEW 0.25 mg Y N  
58657016390 MULTIVITAMIN WITH FLUORIDE pedi multivit no.17 w-fluoride TAB CHEW 0.25 mg Y N  
61269015501 MULTIVITAMIN WITH FLUORIDE pedi multivit no.17 w-fluoride TAB CHEW 0.25 mg Y N  
59088001554 FLOTREX pedi multivit no.17 w-fluoride TAB CHEW 0.5 mg Y N  
58657016401 MULTIVITAMIN WITH FLUORIDE pedi multivit no.17 w-fluoride TAB CHEW 0.5 mg Y N  
58657016490 MULTIVITAMIN WITH FLUORIDE pedi multivit no.17 w-fluoride TAB CHEW 0.5 mg Y N  
61269015601 MULTIVITAMIN WITH FLUORIDE pedi multivit no.17 w-fluoride TAB CHEW 0.5 mg Y N  
59088002054 FLOTREX pedi multivit no.17 w-fluoride TAB CHEW 1 mg Y N  
58657016501 MULTIVITAMIN WITH FLUORIDE pedi multivit no.17 w-fluoride TAB CHEW 1 mg Y N  
58657016590 MULTIVITAMIN WITH FLUORIDE pedi multivit no.17 w-fluoride TAB CHEW 1 mg Y N  
61269015701 MULTIVITAMIN WITH FLUORIDE pedi multivit no.17 w-fluoride TAB CHEW 1 mg Y N  
23594022530 POLY-VI-FLOR pedi multivit no.175/fluoride TAB CHEW 0.25 mg fluoride Y N  
23594032530 POLY-VI-FLOR pedi multivit no.175/fluoride TAB CHEW 0.5 mg fluoride Y N  
23594042530 POLY-VI-FLOR pedi multivit no.175/fluoride TAB CHEW 1 mg fluoride Y N  
58657032550 MULTIVITAMIN WITH FLUORIDE pedi multivit no.2 w-fluoride DROPS 0.25 mg/mL fluoride Y N  
61269016150 MULTIVITAMIN WITH FLUORIDE pedi multivit no.2 w-fluoride DROPS 0.25 mg/mL fluoride Y N  
75826016655 MULTIVITAMIN WITH FLUORIDE pedi multivit no.2 w-fluoride DROPS 0.25 mg/mL fluoride Y N  
58657032650 MULTIVITAMIN WITH FLUORIDE pedi multivit no.2 w-fluoride DROPS 0.5 mg/mL fluoride Y N  
61269016250 MULTIVITAMIN WITH FLUORIDE pedi multivit no.2 w-fluoride DROPS 0.5 mg/mL fluoride Y N  
23594035030 POLY-VI-FLOR pedi multivit no.217/fluoride TAB CHEW 0.5 mg fluoride Y N  
62542020030 MULTIVITAMIN WITH FLUORIDE pedi multivit no.219/fluoride TAB CHEW 0.25 mg fluoride Y N  
23594002003 POLY-VI-FLOR pedi multivit no.219/fluoride TAB CHEW 0.25 mg fluoride Y N  
23594020030 POLY-VI-FLOR pedi multivit no.219/fluoride TAB CHEW 0.25 mg fluoride Y N  
62542030030 MULTIVITAMIN WITH FLUORIDE pedi multivit no.219/fluoride TAB CHEW 0.5 mg fluoride Y N  
23594003003 POLY-VI-FLOR pedi multivit no.219/fluoride TAB CHEW 0.5 mg fluoride Y N  
62542040030 MULTIVITAMIN WITH FLUORIDE pedi multivit no.219/fluoride TAB CHEW 1 mg fluoride Y N  
23594004003 POLY-VI-FLOR pedi multivit no.219/fluoride TAB CHEW 1 mg fluoride Y N  
23594040030 POLY-VI-FLOR pedi multivit no.219/fluoride TAB CHEW 1 mg fluoride Y N  
62542080550 MULTIVITAMIN WITH FLUORIDE pedi multivit no.220/fluoride DROPS 0.25 mg/mL fluoride Y N  
23594055050 POLY-VI-FLOR pedi multivit no.220/fluoride DROPS 0.25 mg/mL fluoride Y N  
23594080550 POLY-VI-FLOR pedi multivit no.220/fluoride DROPS 0.25 mg/mL fluoride Y N  
42494043430 MULTI-VIT-FLOR pedi multivit no.228/fluoride TAB CHEW 0.25 mg fluoride Y N  
42494043330 MULTI-VIT-FLOR pedi multivit no.228/fluoride TAB CHEW 0.5 mg fluoride Y N  
42494043230 MULTI-VIT-FLOR pedi multivit no.228/fluoride TAB CHEW 1 mg fluoride Y N  
46122009072 CHILDREN'S CHEWABLES pedi multivit no.23/folic acid TAB CHEW 300 mcg Y N  
75826016910 MULTIVITAMIN WITH FLUORIDE pedi multivit no.242/fluoride TAB CHEW 0.25 mg fluoride Y N  
75826017010 MULTIVITAMIN WITH FLUORIDE pedi multivit no.242/fluoride TAB CHEW 0.5 mg fluoride Y N  
75826017110 MULTIVITAMIN WITH FLUORIDE pedi multivit no.242/fluoride TAB CHEW 1 mg fluoride Y N  
46122008972 CHILDREN'S CHEWABLES pedi multivit no.25/folic acid TAB CHEW 300 mcg Y N  
81279010230 FLORAFOL PEDIATRIC pedi multivit no.251/fluoride TAB CHEW 0.5 mg fluoride Y N  
81279010330 FLORAFOL PEDIATRIC pedi multivit no.251/fluoride TAB CHEW 1 mg fluoride Y N  
62542070050 TRI-VITAMIN WITH FLUORIDE pedi multivit no.265/fluoride DROPS 0.25 mg/mL fluoride Y N  
46122008872 CHILDREN'S CHEWABLE pedi multivit no.31/iron/folic TAB CHEW 9 mg iron-200 mcg Y N  
15370010330 QUFLORA pedi multivit no.63 w-fluoride TAB CHEW 0.25 mg fluoride (0.55 mg sodium fluoride) Y N  
15370010430 QUFLORA pedi multivit no.63 w-fluoride TAB CHEW 0.5 mg fluoride (1.1 mg sodium fluoride) Y N  
15370010530 QUFLORA pedi multivit no.63 w-fluoride TAB CHEW 1 mg fluoride (2.2 mg sodium fluoride) Y N  
39328000350 SOLUVITA MULTIVITAMIN FLUORIDE pedi multivit no.82 w-fluoride DROPS 0.25 mg/mL fluoride Y N  
39328000450 SOLUVITA MULTIVITAMIN FLUORIDE pedi multivit no.82 w-fluoride DROPS 0.5 mg/mL fluoride Y N  
15370010050 QUFLORA pedi multivit no.83 w-fluoride DROPS 0.25 mg fluoride (0.55 mg sodium fluoride)/mL Y N  
00536134680 INFANT-TODDLER MULTIVIT-IRON pedi mv no.207/ferrous sulfate DROPS 11 mg iron/mL Y N  
59088017054 DAVIMET WITH FLUORIDE pedi mv no.247/fluoride TAB CHEW 0.75 mg fluoride Y N  
81279010050 FLORAFOL PEDIATRIC pedi mv no.257/sodium fluoride DROPS 0.25 mg/mL fluoride Y N  
00536134580 INFANT-TODDLER MULTIVITAMIN pediatric multivitamin no.192 DROPS 250 mcg-50 mg-10 mcg-5 mg/mL Y N  
59088066016 LIVITA FOR CHILDREN pediatric multivitamin no.245 LIQUID Y N  
00536134780 INFANT-TODDLER VITAMIN A-C-D vit A palmitate/vit C/vit D3 DROPS 250 mcg-50 mg-10 mcg/mL Y N  
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