ALABAMA MEDICAID AGENCY Prenatal Vitamins Preferred Status

Transcription

1 Prenatal Vitamins Status Effective January 4, 2010, the prenatal vitamins were included in the Alabama Medicaid Drug Program. The list below includes the current preferred status of the covered prenatal vitamins. Brand preferred drugs, generics and over-the-counter (OTC) drugs covered by Medicaid are available without prior approval. The list is subject to change. For additional PDL and coverage information, visit our drug look-up site at ACTIVE OB SOFTGEL PNV NO.66/IRON,CARBONYL/FA/DHA ORAL MG CAPSULE Non BAL-CARE DHA COMBO BAL-CARE DHA ESSENTIAL PNV81/SOD IRON EDTA& PS/FA/OM3 ORAL MG CMBDRCP PNV100/IRON EDTA&PS/FA/OMEGA3 ORAL MG CMBDRCP Non CALCIUM-PNV MG SFTGL PNV WITH CA,NO.70/IRON/FA/DHA ORAL MG CAPSULE CHOICE-OB + DHA COMBO PRENATAL VITS #33/IRON/FA/DHA ORAL MG COMBO CITRANATAL 90 DHA COMBO CITRANATAL 90 DHA CITRANATAL ASSURE COMBO CITRANATAL ASSURE COMBO PNV72/IRON,CARB&GLU/FA/DSS/DHA ORAL MG COMBO. PNV73/IRON,CARB&GLU/FA/DSS/DHA ORAL MG COMBO. Non- Non- Non- Non CITRANATAL B-CALM COMBO PRENATAL #48/IRON CB&GLU/FA/B6 ORAL MG TABLET SEQ Non CITRANATAL DHA PNV76/IRON,CARB&GLU/FA/DSS/DHA ORAL MG COMBO. Non CITRANATAL HARMONY CAPSULE PNV59/IRON,CARB&FUM/FA/DSS/DHA ORAL MG CAPSULE Non CITRANATAL RX TABLET PNV NO.81/IRON CBN&GLUC/FA/DSS ORAL MG TABLET Non CITRANATAL RX TABLET PNV NO.22/IRON CBN&GLUC/FA/DSS ORAL MG TABLET Non C-NATE DHA SOFTGEL PNV 11-IRON FUM-FOLIC ACID-OM3 ORAL MG CAPSULE COMPLETE NATAL DHA PNV2/IRON B-G SUC-P/FA/OMEGA-3 ORAL MG COMBO COMPLETENATE TABLET CHEW PNV #14/FERROUS FUM/FOLIC ACID ORAL 29 MG-1 MG TAB CHEW CONCEPT DHA CAPSULE PNV#16/IRON FUM & PS/FA/OM-3 ORAL MG CAPSULE Non CONCEPT OB CAPSULE PNV NO.15/IRON FUM & PS CMP/FA ORAL 85 MG-1 MG CAPSULE Non EXTRA-VIRT PLUS DHA SOFTGEL PRENATAL #57/IRON/FA/DSS/DHA ORAL CAPSULE FOLCAL DHA CAPSULE PNV66/IRON FUMARATE/FA/DSS/DHA ORAL CAPSULE FOLCAPS OMEGA-3 CAPSULE PNV W-CA NO.37/IRON/FA/OMEGA-3 ORAL MG CAPSULE FOLIVANE-OB CAPSULE PNV NO.15/IRON FUM & PS CMP/FA ORAL 85 MG-1 MG CAPSULE FOLIVANE-PRX DHA NF CAPSULE PNV39/IRON FUMARATE/FA/DSS/DHA ORAL CAPSULE HEMENATAL OB + DHA COMBO PNV COMBO #22/IRON/FA/OM3/DHA ORAL COMBO HEMENATAL OB TABLET PNV#21/IRON PS& HEME POLYP/FA ORAL MG TABLET INATAL ADVANCE TABLET PRENATAL VIT 15/IRON CB/FA/DSS ORAL MG TABLET INATAL ADVANCE TABLET PRENATAL VIT 15/IRON CB/FA/DSS ORAL MG TABLET INATAL ULTRA TABLET PRENATAL VIT 18/IRON CB/FA/DSS ORAL MG TABLET INATAL ULTRA TABLET PRENATAL VIT 18/IRON CB/FA/DSS ORAL MG TABLET INFANATE BALANCE SOFTGEL PNV34/IRON,CARBONYL/FA/DSS/DHA ORAL MG CAPSULE INFANATE PLUS SOFTGEL PNV59/IRON,CARB&FUM/FA/DSS/DHA ORAL MG CAPSULE MARNATAL-F CAPSULE PNV WITH CA NO.65/IRON POLY/FA ORAL 60 MG-1 MG CAPSULE MATERNITY VITAMIN PNV/FERROUS FUMARATE/FA/SE ORAL 27 MG-1 MG TABLET 1 Effective 04/01/2015

2 Prenatal Vitamins Status NATALVIRT 90 DHA COMBO NATALVIRT CA COMBO NATALVIT TABLET PRENATAL VIT/IRON FUMARATE/FA ORAL 75-1MG TABLET Non NATELLE ONE CAPSULE PNV WITH CA,NO.70/IRON/FA/DHA ORAL MG CAPSULE Non NESTABS ABC PRENATAL COMBO PK PNV #86/IRON POLY/FA/DHA/EPA ORAL MG COMBO. Non NESTABS DHA COMBO PNV #87/IRON BISGLY/FA/DHA ORAL MG COMBO. Non NESTABS TABLET PRENATAL VIT#86/IRON BISGLY/FA ORAL 32 MG-1 MG TABLET Non NEWGEN TABLET PRENATAL VIT#86/IRON BISGLY/FA ORAL 32 MG-1 MG TABLET NEXA PLUS SOFTGEL PNV53/IRON FUM/FA/DOCUSATE/DHA ORAL CAPSULE Non NEXA PLUS SOFTGEL PNV53/IRON FUM/FA/DOCUSATE/DHA ORAL CAPSULE Non OB COMPLETE CAPLET IRON,CARBONYL/FA/MULTIVIT-MIN ORAL MG TABLET Non OB COMPLETE ONE SOFTGEL PN85/IRON CB&ASP G/FA/DHA/FISH ORAL MG CAPSULE Non OB COMPLETE PETITE SOFTGEL PNV #56/IRON CARB&ASPG/FA/DHA ORAL MG CAPSULE Non OB COMPLETE PREMIER TABLET PNV83/IRON,CARB/IRON ASP GL/FA ORAL MG TABLET Non OB COMPLETE WITH DHA SOFTGEL PNV #30/IRON CARB&ASPG/FA/OM3 ORAL MG CAPSULE Non O-CAL FA TABLET PRENATAL VIT/IRON FUMARATE/FA ORAL 66-1MG TABLET O-CAL PRENATAL TABLET PRENATAL VIT/IRON FUMARATE/FA ORAL 15-1MG TABLET PAIRE OB PLUS DHA COMBO PNV #8/IRON PS CMP&ASPG/FA/DHA ORAL COMBO. Non PNV 29-1 TABLET PRENATAL VIT #76/IRON,CARB/FA ORAL 29 MG-1 MG TABLET PNV FOLIC ACID + IRON TABLET PRENATAL VIT #60/IRON FUM/FA ORAL 27 MG-1 MG TABLET Non PNV FOLIC ACID + IRON TABLET PRENATAL VIT #60/IRON FUM/FA ORAL 27 MG-1 MG TABLET Non PNV FOLIC ACID + IRON TABLET PRENATAL VIT #60/IRON FUM/FA ORAL 27 MG-1 MG TABLET Non PNV OB+DHA COMBO PNV22/IRON CBN&GLUC/FA/DSS/DHA ORAL MG COMBO PNV PRENATAL PLUS MULTIVIT TAB PNV WITH CA,NO.72/IRON/FA ORAL 27 MG-1 MG TABLET PNV PRENATAL PLUS MULTIVIT TAB PNV WITH CA,NO.72/IRON/FA ORAL 27 MG-1 MG TABLET PNV PRENATAL PLUS MULTIVIT TAB PNV WITH CA,NO.72/IRON/FA ORAL 27 MG-1 MG TABLET PNV-DHA SOFTGEL PNV COMBO#47/IRON/FA #1/DHA ORAL MG CAPSULE PNV-FERROUS FUMARATE-DOCU- FA PNV-FERROUS FUMARATE-DOCU- FA PNV115/IRON FUMARATE/FA/DSS ORAL MG TABLET PNV115/IRON FUMARATE/FA/DSS ORAL MG TABLET PNV-FIRST SOFTGEL PNV#26/IRON POLY/FA/DHA ORAL MG CAPSULE PNV-OB WITH DHA COMBO PRENAT VIT COMB.10/IRON/FA/DHA ORAL MG COMBO PNV-SELECT TABLET PNV W-CA #40/IRON FUM/FA CMB#1 ORAL 27 MG-1 MG TABLET PNV-VP-U CAPSULE PNV W-O CA NO5/FE FUMARATE/FA ORAL MG CAPSULE PR NATAL 400 COMBO PNV53/IRON B-G HCL-P/FA/OMEGA3 ORAL MG COMBO. Non PR NATAL 400 EC COMBO PNV19/IRON BG HC&SUCC-P/FA/OM3 ORAL MG CMBDRCP Non PR NATAL 430 COMBO PNV54/IRON B-G HCL-P/FA/OMEGA3 ORAL MG COMBO. Non PR NATAL 430 EC COMBO PNV55/IRON BG HC&SUCC-P/FA/OM3 ORAL MG CMBDRCP Non- 2 Effective 04/01/2015

3 Prenatal Vitamins Status PREFERA OB TABLET PNV#21/IRON PS& HEME POLYP/FA ORAL MG TABLET Non PREFERA-OB ONE SOFTGEL PNV #19/IRON PS&HEME/FOLIC/DHA ORAL CAPSULE Non PREFERA-OB PLUS DHA COMBO PRENAISSANCE 90 DHA COMBO PRENAISSANCE BALANCE SOFTGEL PRENAISSANCE DHA COMBO PRENAISSANCE PROMISE COMBO PCK PNV COMBO #22/IRON/FA/OM3/DHA ORAL COMBO. PNV34/IRON,CARBONYL/FA/DSS/DHA ORAL MG CAPSULE PNV22/IRON CBN&GLUC/FA/DSS/DHA ORAL MG COMBO. Non PRENATA CHEWABLE TABLET PRENATAL VIT37/IRON/FOLIC ACID ORAL 29 MG-1 MG TAB CHEW Non PRENATABS RX TABLET PRENATAL VIT #76/IRON,CARB/FA ORAL 29 MG-1 MG TABLET PRENATAL PLUS MULTIVITAMIN TAB PRENATAL PLUS MULTIVITAMIN TAB PNV WITH CA,NO.72/IRON/FA ORAL 27 MG-1 MG TABLET PNV WITH CA,NO.72/IRON/FA ORAL 27 MG-1 MG TABLET PRENATAL PLUS TABLET PNV WITH CA,NO.72/IRON/FA ORAL 27 MG-1 MG TABLET PRENATAL PLUS TABLET PNV WITH CA,NO.72/IRON/FA ORAL 27 MG-1 MG TABLET PRENATAL PLUS TABLET PNV WITH CA,NO.72/IRON/FA ORAL 27 MG-1 MG TABLET PRENATAL PLUS TABLET PNV WITH CA,NO.72/IRON/FA ORAL 27 MG-1 MG TABLET PRENATAL PLUS TABLET PNV WITH CA,NO.72/IRON/FA ORAL 27 MG-1 MG TABLET PRENATAL PLUS TABLET PNV WITH CA,NO.72/IRON/FA ORAL 27 MG-1 MG TABLET PRENATE AM TABLET PRENATAL VIT NO.114/FA/GINGER ORAL 1MG-500MG TABLET Non PRENATE CHEWABLE TABLET PRENATAL VIT NO.112/FOLIC ACID ORAL 1 MG TAB CHEW Non PRENATE DHA SOFTGEL PNV #38/IRON FUM/FOLATE/DHA ORAL MG CAPSULE Non PRENATE DHA SOFTGEL PNV #78/IRON ASP GLY/FA#1/DHA ORAL MG CAPSULE Non PRENATE ELITE TABLET PRENATAL #79/IRON ASP GLY/FA#1 ORAL 20 MG-1 MG TABLET Non PRENATE ENHANCE SOFTGEL PRENATAL VIT #68/IRON/FA#6/DHA ORAL MG CAPSULE Non PRENATE ESSENTIAL SOFTGEL PNV #35/IRON/FA #6/DHA ORAL MG CAPSULE Non PRENATE ESSENTIAL SOFTGEL PRENATAL VIT#84/IRON/FA#1/DHA ORAL MG CAPSULE Non PRENATE MINI SOFTGEL PRENATAL VIT NO.44/IRON/FA/DHA ORAL MG CAPSULE Non PRENATE MINI SOFTGEL PRENATAL VIT NO.87/IRON/FA/DHA ORAL MG CAPSULE Non PRENATE PIXIE SOFTGEL PRENATAL VIT#85/IRON/FA#1/DHA ORAL MG CAPSULE Non PRENATE RESTORE SOFTGEL PRENATAL VIT #69/IRON/FA#6/DHA ORAL MG CAPSULE Non PRENATE STAR TABLET PRENATAL NO.77/IRON ASP GLY/FA ORAL 20 MG-1 MG TABLET Non PREPLUS CA-FE 27 MG-FA 1 MG TB PNV WITH CA,NO.72/IRON/FA ORAL 27 MG-1 MG TABLET PREPLUS CA-FE 27 MG-FA 1 MG TB PNV WITH CA,NO.72/IRON/FA ORAL 27 MG-1 MG TABLET PREQUE 10 TABLET PNV 18/FE,CARB/FA/DSS/UBI/DHA ORAL TABLET Non PRETAB 29 MG-1 MG TABLET PRENATAL VIT NO.78/IRON/FA ORAL 29 MG-1 MG TABLET PROVIDA OB CAPSULE PRENATAL VIT#65/IRON FUM&PS/FA ORAL MG CAPSULE Non PUREFE OB PLUS CAPSULE PRENATAL VIT#4/IRON FUM &PS/FA ORAL 106 MG-1MG CAPSULE PUREFE PLUS CAPSULE PRENATAL VITS#4/IRON FUM/FA ORAL 106 MG-1MG CAPSULE RELNATE DHA PRENATAL SOFTGEL PNV 11-IRON FUM-FOLIC ACID-OM3 ORAL MG CAPSULE Non- 3 Effective 04/01/2015

4 Prenatal Vitamins Status SELECT-OB + DHA PRENATAL VITS #33/IRON/FA/DHA ORAL MG COMBO. Non SELECT-OB CHEWABLE CAPLET PV W-O CAL/IRON PS CPLX/FA ORAL 29 MG-1 MG TAB CHEW Non SELECT-OB CHEWABLE CAPLET PRENATAL NO.13/IRON PS/FA CB#1 ORAL 29 MG-1 MG TAB CHEW Non SE-NATAL 19 CHEWABLE TABLET PNV NO.118/IRON FUMARATE/FA ORAL 29 MG-1 MG TAB CHEW SE-NATAL 19 TABLET PNV119/IRON FUMARATE/FA/DSS ORAL MG TABLET SE-TAN DHA CAPSULE PNV NO10/IRON FUM&P/FA/OMEGA-3 ORAL CAPSULE TARON-BC TABLET PNV WITH CA,NO63/IRON/FA/B6 ORAL MG TABLET SEQ TARON-C DHA CAPSULE PNV#16/IRON FUM & PS/FA/OM-3 ORAL MG CAPSULE TARON-PREX PRENATAL DHA CAP PNV39/IRON FUMARATE/FA/DSS/DHA ORAL CAPSULE TL FOLATE TABLET PRENATAL NO.82/IRON/FOLATE #2 ORAL 27 MG-1 MG TABLET TL FOLATE TABLET PRENATAL NO.82/IRON/FOLATE #2 ORAL 27 MG-1 MG TABLET TL-SELECT CAPSULE PNV80/IRON FUMARATE/FA/DSS/DHA ORAL CAPSULE TL-SELECT DHA SOFTGEL PRENATAL #57/IRON/FA/DSS/DHA ORAL CAPSULE Non TRIADVANCE TABLET PRENATAL VIT 15/IRON CB/FA/DSS ORAL MG TABLET TRICARE PRENATAL COMPLEAT TRICARE PRENATAL DHA ONE SFTGL TRICARE PRENATAL DHA ONE SFTGL PNV103/FE/FA/DHA/EPA/OTHER OM3 ORAL 27 MG-1 MG CMB TAB CP PNV#20/IRON/FA/DS/FISH/DHA/EPA ORAL MG CAPSULE PNV#20/IRON/FA/DS/FISH/DHA/EPA ORAL MG CAPSULE Non- Non- Non TRICARE PRENATAL TABLET PRENATAL #103/IRON FUMARATE/FA ORAL 27 MG-1 MG TABLET Non TRICARE PRENATAL TABLET PRENATAL #103/IRON FUMARATE/FA ORAL 27 MG-1 MG TABLET Non TRICARE PRENATAL TABLET PRENATAL #103/IRON FUMARATE/FA ORAL 27 MG-1 MG TABLET Non TRINATAL GT TABLET PRENATAL VIT 16/IRON CB/FA/DSS ORAL MG TABLET TRINATAL RX 1 TABLET PRENATAL VIT27&CALCIUM/IRON/FA ORAL 60 MG-1 MG TABLET TRI-TABS DHA COMBO PNV #87/IRON BISGLY/FA/DHA ORAL MG COMBO TRIVEEN-DUO DHA COMBO PNV53/IRON B-G HCL-P/FA/OMEGA3 ORAL MG COMBO TRIVEEN-PRX RNF CAPSULE PNV66/IRON FUMARATE/FA/DSS/DHA ORAL CAPSULE TRIVEEN-PRX RNF CAPSULE PNV66/IRON FUMARATE/FA/DSS/DHA ORAL CAPSULE TRUST NATAL DHA PNV2/IRON B-G SUC-P/FA/OMEGA-3 ORAL MG COMBO ULTIMATECARE ONE CAPSULE PNV W-CA NO.37/IRON/FA/OMEGA-3 ORAL MG CAPSULE ULTIMATECARE ONE NF CAPSULE PNV,CA,NO.35/IRON/FA/DS/OMEG-3 ORAL MG CAPSULE VEMAVITE-PRX 2 CAPSULE PNV66/IRON FUMARATE/FA/DSS/DHA ORAL CAPSULE VENA-BAL DHA COMBO PNV81/SOD IRON EDTA& PS/FA/OM3 ORAL MG CMBDRCP VINATE DHA RF GELCAP PNV#64/IRON/LMFOLATE/ALGAL/SOY ORAL MG CAPSULE Non VINATE II TABLET PRENATAL VIT/IRON BISGLYCIN/FA ORAL 29 MG-1 MG TABLET Non VINATE-M TABLET PNV/FERROUS FUMARATE/FA/SE ORAL 27 MG-1 MG TABLET Non VIRT NATE TABLET PRENATAL VIT NO.73/IRON/FA ORAL 28 MG-1 MG TABLET VIRT-ADVANCE TABLET PRENATAL VIT 15/IRON CB/FA/DSS ORAL MG TABLET VIRT-BAL DHA COMBO PNV94/SOD IRON EDTA& PS/FA/OM3 ORAL MG CMBDRCP VIRT-C DHA SOFTGEL PNV#16/IRON FUM & PS/FA/OM-3 ORAL MG CAPSULE 4 Effective 04/01/2015

5 Prenatal Vitamins Status VIRT-CARE ONE CAPSULE PNV W-CA NO.37/IRON/FA/OMEGA-3 ORAL MG CAPSULE VIRT-PN DHA SOFTGEL PNV COMBO#47/IRON/FA #1/DHA ORAL MG CAPSULE VIRT-PN PLUS SOFTGEL PNV WITH CA #68/IRON/FA#1/DHA ORAL MG CAPSULE VIRT-PN TABLET PNV W-CA #40/IRON FUM/FA CMB#1 ORAL 27 MG-1 MG TABLET VIRTPREX CAPSULE PNV66/IRON FUMARATE/FA/DSS/DHA ORAL CAPSULE VIRT-SELECT CAPSULE PNV80/IRON FUMARATE/FA/DSS/DHA ORAL CAPSULE VIRT-VITE GT TABLET PRENATAL VIT 16/IRON CB/FA/DSS ORAL MG TABLET VITAFOL NANO TABLET PRENATAL NO.75/IRON/FOLATE #1 ORAL 18 MG-1 MG TABLET Non VITAFOL ULTRA SOFTGEL PNV#67/IRON PS/FA CMB#1/DHA ORAL MG CAPSULE Non VITAFOL-OB CAPLET PRENATAL VIT COMB.10/IRON/FA ORAL 65 MG-1 MG TABLET Non VITAFOL-OB+DHA COMBO PRENAT VIT COMB.10/IRON/FA/DHA ORAL MG COMBO. Non VITAFOL-ONE CAPSULE PNV#26/IRON POLY/FA/DHA ORAL MG CAPSULE Non VOL-NATE TABLET PRENATAL VIT NO.73/IRON/FA ORAL 28 MG-1 MG TABLET VOL-PLUS TABLET PNV WITH CA,NO.71/IRON/FA ORAL 27 MG-1 MG TABLET VOL-PLUS TABLET PNV WITH CA,NO.71/IRON/FA ORAL 27 MG-1 MG TABLET VOL-PLUS TABLET PNV WITH CA,NO.71/IRON/FA ORAL 27 MG-1 MG TABLET VOL-TAB RX TABLET PRENATAL VIT #76/IRON,CARB/FA ORAL 29 MG-1 MG TABLET VP CH ULTRA SOFTGEL PNV34/IRON,CARB&FUM/FA/DSS/DHA ORAL MG CAPSULE Non VP-CH PLUS SOFTGEL PNV59/IRON,CARBONYL/FA/DSS/DHA ORAL MG CAPSULE VP-CH-PNV PRENATAL SOFTGEL PNV34/IRON,CARBONYL/FA/DSS/DHA ORAL MG CAPSULE VP-ERA OB PLUS TABLET PNV #8/IRON PS & HEME POLYP/FA ORAL MG TABLET VP-HEME OB + DHA COMBO PNV COMBO #22/IRON/FA/OM3/DHA ORAL COMBO VP-HEME OB TABLET PNV#21/IRON PS& HEME POLYP/FA ORAL MG TABLET VP-HEME ONE SOFTGEL PNV #19/IRON PS&HEME/FOLIC/DHA ORAL CAPSULE VP-PNV-DHA CAPSULE PRENATAL NO.52/IRON/FA/DHA ORAL MG CAPSULE ZATEAN-CH CAPSULE PNV69/IRON,CARBONYL/FA/DSS/DHA ORAL MG CAPSULE ZATEAN-PN DHA CAPSULE PNV COMBO#47/IRON/FA #1/DHA ORAL MG CAPSULE ZATEAN-PN PLUS SOFTGEL PNV WITH CA #68/IRON/FA#1/DHA ORAL MG CAPSULE ZATEAN-PN TABLET PNV W-CA #40/IRON FUM/FA CMB#1 ORAL 27 MG-1 MG TABLET 5 Effective 04/01/2015