ALABAMA MEDICAID AGENCY Prenatal Vitamins

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ALABAMA MEDICAID AGENCY
Prenatal Vitamins – Preferred Status
Effective January 4, 2010, the prenatal vitamins were included in the Alabama Medicaid Preferred 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 https://www.medicaid.alabamaservices.org/ALPortal/NDC%20Look%20Up/tabId/39/Default.aspx.
NDC Code
58809028730
Label Name
ACTIVE OB SOFTGEL
Generic Drug Name
PDL Status
PNV NO.66/IRON,CARBONYL/FA/DHA ORAL 20-1-320MG CAPSULE
Non-Preferred
PNV81/SOD IRON EDTA& PS/FA/OM3 ORAL 27-1-430MG
CMBPKGDRCP
PNV100/IRON EDTA&PS/FA/OMEGA3 ORAL 27-1-374MG
CMBPKGDRCP
42546018030
BAL-CARE DHA COMBO PACK
42546018530
BAL-CARE DHA ESSENTIAL PACK
76439034430
CALCIUM-PNV 28-1-250 MG SFTGL
PNV WITH CA,NO.70/IRON/FA/DHA ORAL 28-1-250MG CAPSULE
00178082130
CITRANATAL 90 DHA COMBO PACK
PNV72/IRON,CARB&GLU/FA/DSS/DHA ORAL 90-1-300MG COMBO.
PKG
Non-Preferred
00178089130
CITRANATAL ASSURE COMBO PACK
PNV73/IRON,CARB&GLU/FA/DSS/DHA ORAL 35-1-50 MG COMBO. PKG
Non-Preferred
00178083230
CITRANATAL B-CALM COMBO PACK
PRENATAL #48/IRON CB&GLU/FA/B6 ORAL 20-1-25 MG TABLET SEQ
Non-Preferred
00178089430
CITRANATAL DHA PACK
PNV76/IRON,CARB&GLU/FA/DSS/DHA ORAL 27-1-50 MG COMBO. PKG
Non-Preferred
00178079630
CITRANATAL HARMONY CAPSULE
PNV59/IRON,CARB&FUM/FA/DSS/DHA ORAL 27-1-50 MG CAPSULE
Non-Preferred
00178085890
CITRANATAL RX TABLET
PNV NO.81/IRON CBN&GLUC/FA/DSS ORAL 27-1-50 MG TABLET
Non-Preferred
00178085990
CITRANATAL RX TABLET
PNV NO.22/IRON CBN&GLUC/FA/DSS ORAL 27-1-50 MG TABLET
Non-Preferred
23359010530
C-NATE DHA SOFTGEL
PNV 11-IRON FUM-FOLIC ACID-OM3 ORAL 28-1-200MG CAPSULE
Preferred
13811001030
COMPLETE NATAL DHA
PNV2/IRON B-G SUC-P/FA/OMEGA-3 ORAL 29-1-250MG COMBO. PKG
Preferred
13811001490
COMPLETENATE TABLET CHEW
PNV #14/FERROUS FUM/FOLIC ACID ORAL 29 MG-1 MG TAB CHEW
Preferred
52747062130
CONCEPT DHA CAPSULE
PNV#16/IRON FUM & PS/FA/OM-3 ORAL 35-1-200MG CAPSULE
Non-Preferred
52747062030
CONCEPT OB CAPSULE
PNV NO.15/IRON FUM & PS CMP/FA ORAL 85 MG-1 MG CAPSULE
Non-Preferred
64661065030
ENBRACE HR SOFTGEL
PRENATAL #92/IRON/FA #8/PS-DHA ORAL 1.5-8.73MG CAP IR DR
Non-Preferred
76439025130
EXTRA-VIRT PLUS DHA SOFTGEL
PRENATAL #57/IRON/FA/DSS/DHA ORAL 29-1.25-55 CAPSULE
Preferred
58657011160
FOCALGIN CA COMBO PACK
PNV73/IRON,CARB&GLU/FA/DSS/DHA ORAL 35-1-50 MG COMBO. PKG
Preferred
13811053530
FOLIVANE-OB CAPSULE
PNV NO.15/IRON FUM & PS CMP/FA ORAL 85 MG-1 MG CAPSULE
Preferred
13811054430
FOLIVANE-PRX DHA NF CAPSULE
PNV39/IRON FUMARATE/FA/DSS/DHA ORAL 30-1.24-55 CAPSULE
Preferred
76331090430
HEMENATAL OB + DHA COMBO PACK
PNV COMBO #22/IRON/FA/OM3/DHA ORAL 28-6-1-203 COMBO. PKG
Preferred
76331090190
HEMENATAL OB TABLET
PNV#21/IRON PS& HEME POLYP/FA ORAL 28-6-1 MG TABLET
Preferred
63044015301
INATAL ADVANCE TABLET
PRENATAL VIT 15/IRON CB/FA/DSS ORAL 90-1-50 MG TABLET
Preferred
63044015364
INATAL ADVANCE TABLET
PRENATAL VIT 15/IRON CB/FA/DSS ORAL 90-1-50 MG TABLET
Preferred
63044015401
INATAL ULTRA TABLET
PRENATAL VIT 18/IRON CB/FA/DSS ORAL 90-1-50 MG TABLET
Preferred
63044015463
INATAL ULTRA TABLET
PRENATAL VIT 18/IRON CB/FA/DSS ORAL 90-1-50 MG TABLET
Preferred
42192036230
INFANATE BALANCE SOFTGEL
PNV34/IRON,CARBONYL/FA/DSS/DHA ORAL 29-1-50 MG CAPSULE
Preferred
42192036730
INFANATE PLUS SOFTGEL
PNV59/IRON,CARB&FUM/FA/DSS/DHA ORAL 27-1-50 MG CAPSULE
Preferred
00682157001
MARNATAL-F CAPSULE
PNV WITH CA NO.65/IRON POLY/FA ORAL 60 MG-1 MG CAPSULE
Preferred
10267199101
MATERNITY VITAMIN
PNV/FERROUS FUMARATE/FA/SE ORAL 27 MG-1 MG TABLET
Preferred
76439024560
NATALVIRT 90 DHA COMBO PACK
PN W-CA64/IRON CB&GL/FA/DSS/DH ORAL 90-1-300MG COMBO. PKG
Preferred
76439024460
NATALVIRT CA COMBO PACK
PNV38/IRON CBN&GLUC/FA/DSS/DHA ORAL 35-1-50 MG COMBO. PKG
Preferred
54859070912
NATALVIT TABLET
PRENATAL VIT/IRON FUMARATE/FA ORAL 75-1MG TABLET
Non-Preferred
00037607230
NATELLE ONE CAPSULE
PNV WITH CA,NO.70/IRON/FA/DHA ORAL 28-1-250MG CAPSULE
Non-Preferred
1
Preferred
Non-Preferred
Preferred
Effective 07/01/2015
ALABAMA MEDICAID AGENCY
Prenatal Vitamins – Preferred Status
NDC Code
Label Name
50967030930
NESTABS ABC PRENATAL COMBO PK
PNV #86/IRON POLY/FA/DHA/EPA ORAL 32-1-120MG COMBO. PKG
Generic Drug Name
Non-Preferred
50967031730
NESTABS DHA COMBO PACK
PNV #87/IRON BISGLY/FA/DHA ORAL 32-1-230MG COMBO. PKG
Non-Preferred
50967021990
NESTABS TABLET
PRENATAL VIT#86/IRON BISGLY/FA ORAL 32 MG-1 MG TABLET
Non-Preferred
42546031090
NEWGEN TABLET
PRENATAL VIT#86/IRON BISGLY/FA ORAL 32 MG-1 MG TABLET
Preferred
00245037430
NEXA PLUS SOFTGEL
PNV53/IRON FUM/FA/DOCUSATE/DHA ORAL 29-1.25-55 CAPSULE
Non-Preferred
68025006430
NEXA PLUS SOFTGEL
PNV53/IRON FUM/FA/DOCUSATE/DHA ORAL 29-1.25-55 CAPSULE
Non-Preferred
75834005001
NIVA-PLUS TABLET
PNV WITH CA,NO.74/IRON/FA ORAL 27 MG-1 MG TABLET
Non-Preferred
68025001010
OB COMPLETE CAPLET
IRON,CARBONYL/FA/MULTIVIT-MIN ORAL 50-1.25MG TABLET
Non-Preferred
68025004430
OB COMPLETE ONE SOFTGEL
PN85/IRON CB&ASP G/FA/DHA/FISH ORAL 40-10-1 MG CAPSULE
Non-Preferred
68025005930
OB COMPLETE PETITE SOFTGEL
PNV #56/IRON CARB&ASPG/FA/DHA ORAL 35-5-1 MG CAPSULE
Non-Preferred
68025004330
OB COMPLETE PREMIER TABLET
PNV83/IRON,CARB/IRON ASP GL/FA ORAL 30-20-1 MG TABLET
Non-Preferred
68025004960
OB COMPLETE WITH DHA SOFTGEL
PNV #30/IRON CARB&ASPG/FA/OM3 ORAL 30-10-1 MG CAPSULE
Non-Preferred
00813931601
O-CAL FA TABLET
PRENATAL VIT/IRON FUMARATE/FA ORAL 66-1MG TABLET
00813020201
O-CAL PRENATAL TABLET
PRENATAL VIT/IRON FUMARATE/FA ORAL 15-1MG TABLET
11528009503
PAIRE OB PLUS DHA COMBO PACK
PNV #8/IRON PS CMP&ASPG/FA/DHA ORAL 22-6-1-200 COMBO. PKG
76439026790
PNV 29-1 TABLET
PRENATAL VIT #76/IRON,CARB/FA ORAL 29 MG-1 MG TABLET
44946104600
PNV FOLIC ACID + IRON TABLET
PRENATAL VIT #60/IRON FUM/FA ORAL 27 MG-1 MG TABLET
Non-Preferred
44946104602
PNV FOLIC ACID + IRON TABLET
PRENATAL VIT #60/IRON FUM/FA ORAL 27 MG-1 MG TABLET
Non-Preferred
44946104604
PNV FOLIC ACID + IRON TABLET
PRENATAL VIT #60/IRON FUM/FA ORAL 27 MG-1 MG TABLET
Non-Preferred
59088011560
PNV OB+DHA COMBO PACK
PNV22/IRON CBN&GLUC/FA/DSS/DHA ORAL 27-1-50 MG COMBO. PKG
Preferred
44946104501
PNV PRENATAL PLUS MULTIVIT TAB
PNV WITH CA,NO.72/IRON/FA ORAL 27 MG-1 MG TABLET
Preferred
44946104504
PNV PRENATAL PLUS MULTIVIT TAB
PNV WITH CA,NO.72/IRON/FA ORAL 27 MG-1 MG TABLET
Preferred
44946104509
PNV PRENATAL PLUS MULTIVIT TAB
PNV WITH CA,NO.72/IRON/FA ORAL 27 MG-1 MG TABLET
Preferred
76439025410
PNV-FERROUS FUMARATE-DOCU-FA
PNV115/IRON FUMARATE/FA/DSS ORAL 29-1-25 MG TABLET
Preferred
76439027310
PNV-FERROUS FUMARATE-DOCU-FA
PNV115/IRON FUMARATE/FA/DSS ORAL 29-1-25 MG TABLET
Preferred
76439026510
PNV-VP-U CAPSULE
PNV W-O CA NO5/FE FUMARATE/FA ORAL 106.5-1MG CAPSULE
Preferred
42546081130
PR NATAL 400 COMBO PACK
PNV53/IRON B-G HCL-P/FA/OMEGA3 ORAL 29-1-400MG COMBO. PKG
Non-Preferred
42546051730
PR NATAL 400 EC COMBO PACK
PNV19/IRON BG HC&SUCC-P/FA/OM3 ORAL 29-1-400MG
CMBPKGDRCP
Non-Preferred
42546081230
PR NATAL 430 COMBO PACK
PNV54/IRON B-G HCL-P/FA/OMEGA3 ORAL 29-1-430MG COMBO. PKG
Non-Preferred
42546051830
PR NATAL 430 EC COMBO PACK
PNV55/IRON BG HC&SUCC-P/FA/OM3 ORAL 29-1-430MG
CMBPKGDRCP
Non-Preferred
68220008490
PREFERA OB TABLET
PNV#21/IRON PS& HEME POLYP/FA ORAL 28-6-1 MG TABLET
Non-Preferred
68220008630
PREFERA-OB ONE SOFTGEL
PNV #19/IRON PS&HEME/FOLIC/DHA ORAL 22-6-1-200 CAPSULE
Non-Preferred
00037008330
PREFERA-OB PLUS DHA COMBO PACK
PNV NO.88/IRON PS,HEME/FA/DHA ORAL 28-6-1 MG COMBO. PKG
Non-Preferred
68220008330
PREFERA-OB PLUS DHA COMBO PACK
PNV COMBO #22/IRON/FA/OM3/DHA ORAL 28-6-1-203 COMBO. PKG
Non-Preferred
42192035560
PRENAISSANCE 90 DHA COMBO PACK
PN W-CA64/IRON CB&GL/FA/DSS/DH ORAL 90-1-300MG COMBO. PKG
Preferred
42192034730
PRENAISSANCE BALANCE SOFTGEL
PNV34/IRON,CARBONYL/FA/DSS/DHA ORAL 30-1-50 MG CAPSULE
Preferred
42192035660
PRENAISSANCE DHA COMBO PACK
PNV22/IRON CBN&GLUC/FA/DSS/DHA ORAL 27-1-50 MG COMBO. PKG
Preferred
42192035460
PRENAISSANCE PROMISE COMBO PCK
PNV38/IRON CBN&GLUC/FA/DSS/DHA ORAL 35-1-50 MG COMBO. PKG
Preferred
44946104105
PRENATA CHEWABLE TABLET
PRENATAL VIT37/IRON/FOLIC ACID ORAL 29 MG-1 MG TAB CHEW
2
PDL Status
Preferred
Preferred
Non-Preferred
Preferred
Non-Preferred
Effective 07/01/2015
ALABAMA MEDICAID AGENCY
Prenatal Vitamins – Preferred Status
NDC Code
Label Name
Generic Drug Name
PDL Status
60258019309
PRENATABS RX TABLET
PRENATAL VIT #76/IRON,CARB/FA ORAL 29 MG-1 MG TABLET
Preferred
60258016301
PRENATAL PLUS MULTIVITAMIN TAB
PNV WITH CA,NO.72/IRON/FA ORAL 27 MG-1 MG TABLET
Preferred
60258016305
PRENATAL PLUS MULTIVITAMIN TAB
PNV WITH CA,NO.72/IRON/FA ORAL 27 MG-1 MG TABLET
Preferred
13925050910
PRENATAL PLUS TABLET
PNV WITH CA,NO.72/IRON/FA ORAL 27 MG-1 MG TABLET
Preferred
13925050950
PRENATAL PLUS TABLET
PNV WITH CA,NO.72/IRON/FA ORAL 27 MG-1 MG TABLET
Preferred
65162066810
PRENATAL PLUS TABLET
PNV WITH CA,NO.72/IRON/FA ORAL 27 MG-1 MG TABLET
Preferred
65162066850
PRENATAL PLUS TABLET
PNV WITH CA,NO.72/IRON/FA ORAL 27 MG-1 MG TABLET
Preferred
75854030730
PRENATE AM TABLET
PRENATAL VIT NO.114/FA/GINGER ORAL 1MG-500MG TABLET
Non-Preferred
75854030630
PRENATE CHEWABLE TABLET
PRENATAL VIT NO.112/FOLIC ACID ORAL 1 MG TAB CHEW
Non-Preferred
75854030230
PRENATE DHA SOFTGEL
PNV #38/IRON FUM/FOLATE/DHA ORAL 28-1-300MG CAPSULE
Non-Preferred
75854031230
PRENATE DHA SOFTGEL
PNV #78/IRON ASP GLY/FA#1/DHA ORAL 18-1-300MG CAPSULE
Non-Preferred
75854031430
PRENATE ELITE TABLET
PRENATAL #79/IRON ASP GLY/FA#1 ORAL 20 MG-1 MG TABLET
Non-Preferred
75854030930
PRENATE ENHANCE SOFTGEL
PRENATAL VIT #68/IRON/FA#6/DHA ORAL 28-1-400MG CAPSULE
Non-Preferred
75854030330
PRENATE ESSENTIAL SOFTGEL
PNV #35/IRON/FA #6/DHA ORAL 29-1-300MG CAPSULE
Non-Preferred
75854031330
PRENATE ESSENTIAL SOFTGEL
PRENATAL VIT#84/IRON/FA#1/DHA ORAL 18-1-300MG CAPSULE
Non-Preferred
75854030430
PRENATE MINI SOFTGEL
PRENATAL VIT NO.44/IRON/FA/DHA ORAL 29-1-350MG CAPSULE
Non-Preferred
75854031530
PRENATE MINI SOFTGEL
PRENATAL VIT NO.87/IRON/FA/DHA ORAL 18-1-350MG CAPSULE
Non-Preferred
75854031630
PRENATE PIXIE SOFTGEL
PRENATAL VIT#85/IRON/FA#1/DHA ORAL 10-1-200MG CAPSULE
Non-Preferred
75854030830
PRENATE RESTORE SOFTGEL
PRENATAL VIT #69/IRON/FA#6/DHA ORAL 27-1-400MG CAPSULE
Non-Preferred
75854031130
PRENATE STAR TABLET
PRENATAL NO.77/IRON ASP GLY/FA ORAL 20 MG-1 MG TABLET
Non-Preferred
76439025810
PREPLUS CA-FE 27 MG-FA 1 MG TB
PNV WITH CA,NO.72/IRON/FA ORAL 27 MG-1 MG TABLET
76439025850
PREPLUS CA-FE 27 MG-FA 1 MG TB
PNV WITH CA,NO.72/IRON/FA ORAL 27 MG-1 MG TABLET
Preferred
52544007960
PREQUE 10 TABLET
PNV 18/FE,CARB/FA/DSS/UBI/DHA ORAL 15-0.5-25 TABLET
Non-Preferred
76439025910
PRETAB 29 MG-1 MG TABLET
PRENATAL VIT NO.78/IRON/FA ORAL 29 MG-1 MG TABLET
Preferred
52747050330
PROVIDA DHA CAPSULE
PNV NO.90/IRON FUM & PS/FA/DHA ORAL 32-1.25 MG CAPSULE
Non-Preferred
52747050430
PROVIDA OB CAPSULE
PRENATAL VIT#65/IRON FUM&PS/FA ORAL 40-1.25 MG CAPSULE
Non-Preferred
59088011366
PUREFE OB PLUS CAPSULE
PRENATAL VIT#4/IRON FUM &PS/FA ORAL 106 MG-1MG CAPSULE
Preferred
59088011459
PUREFE PLUS CAPSULE
PRENATAL VITS#4/IRON FUM/FA ORAL 106 MG-1MG CAPSULE
Preferred
35573020030
RELNATE DHA PRENATAL SOFTGEL
PNV 11-IRON FUM-FOLIC ACID-OM3 ORAL 28-1-200MG CAPSULE
Non-Preferred
00642007530
SELECT-OB + DHA PACK
PRENATAL VITS #33/IRON/FA/DHA ORAL 29-1-250MG COMBO. PKG
Non-Preferred
00642007790
SELECT-OB CHEWABLE CAPLET
PV W-O CAL/IRON PS CPLX/FA ORAL 29 MG-1 MG TAB CHEW
Non-Preferred
00642012090
SELECT-OB CHEWABLE CAPLET
PRENATAL NO.13/IRON PS/FA CB#1 ORAL 29 MG-1 MG TAB CHEW
Non-Preferred
13925011701
SE-NATAL 19 CHEWABLE TABLET
PNV NO.118/IRON FUMARATE/FA ORAL 29 MG-1 MG TAB CHEW
Preferred
13925011601
SE-NATAL 19 TABLET
PNV119/IRON FUMARATE/FA/DSS ORAL 29-1-25 MG TABLET
Preferred
13925011990
SE-TAN DHA CAPSULE
PNV NO10/IRON FUM&P/FA/OMEGA-3 ORAL 30-1-310.1 CAPSULE
Preferred
13811056930
TARON-BC TABLET
PNV WITH CA,NO63/IRON/FA/B6 ORAL 20-1-25 MG TABLET SEQ
Preferred
13811053630
TARON-C DHA CAPSULE
PNV#16/IRON FUM & PS/FA/OM-3 ORAL 35-1-200MG CAPSULE
Preferred
13811054330
TARON-PREX PRENATAL DHA CAP
PNV39/IRON FUMARATE/FA/DSS/DHA ORAL 30-1.2-55 CAPSULE
Preferred
13811057410
TL FOLATE TABLET
PRENATAL NO.82/IRON/FOLATE #2 ORAL 27 MG-1 MG TABLET
Preferred
3
Preferred
Effective 07/01/2015
ALABAMA MEDICAID AGENCY
Prenatal Vitamins – Preferred Status
NDC Code
Label Name
Generic Drug Name
PDL Status
13811057450
TL FOLATE TABLET
PRENATAL NO.82/IRON/FOLATE #2 ORAL 27 MG-1 MG TABLET
13811050730
TL-SELECT DHA SOFTGEL
PRENATAL #57/IRON/FA/DSS/DHA ORAL 29-1.25-55 CAPSULE
Non-Preferred
13811052990
TRIADVANCE TABLET
PRENATAL VIT 15/IRON CB/FA/DSS ORAL 90-1-50 MG TABLET
Preferred
67112050131
TRICARE PRENATAL COMPLEAT
PACK
PNV103/FE/FA/DHA/EPA/OTHER OM3 ORAL 27 MG-1 MG CMB TAB CP
Non-Preferred
67112040130
TRICARE PRENATAL DHA ONE SFTGL
PNV#20/IRON/FA/DS/FISH/DHA/EPA ORAL 27-1-500MG CAPSULE
Non-Preferred
67112040190
TRICARE PRENATAL DHA ONE SFTGL
PNV#20/IRON/FA/DS/FISH/DHA/EPA ORAL 27-1-500MG CAPSULE
Non-Preferred
67112010130
TRICARE PRENATAL TABLET
PRENATAL #103/IRON FUMARATE/FA ORAL 27 MG-1 MG TABLET
Non-Preferred
67112010190
TRICARE PRENATAL TABLET
PRENATAL #103/IRON FUMARATE/FA ORAL 27 MG-1 MG TABLET
Non-Preferred
67112010100
TRICARE PRENATAL TABLET
PRENATAL #103/IRON FUMARATE/FA ORAL 27 MG-1 MG TABLET
Non-Preferred
13811061490
TRINATAL GT TABLET
PRENATAL VIT 16/IRON CB/FA/DSS ORAL 90-1-50 MG TABLET
Preferred
13811000710
TRINATAL RX 1 TABLET
PRENATAL VIT27&CALCIUM/IRON/FA ORAL 60 MG-1 MG TABLET
Preferred
13811052130
TRI-TABS DHA COMBO PACK
PNV #87/IRON BISGLY/FA/DHA ORAL 32-1-230MG COMBO. PKG
Preferred
13811059130
TRIVEEN-DUO DHA COMBO PACK
PNV53/IRON B-G HCL-P/FA/OMEGA3 ORAL 29-1-400MG COMBO. PKG
Preferred
13811055830
TRIVEEN-PRX RNF CAPSULE
PNV66/IRON FUMARATE/FA/DSS/DHA ORAL 26-1.2-55 CAPSULE
Preferred
13811055860
TRIVEEN-PRX RNF CAPSULE
PNV66/IRON FUMARATE/FA/DSS/DHA ORAL 26-1.2-55 CAPSULE
Preferred
68025090130
TRUST NATAL DHA
PNV2/IRON B-G SUC-P/FA/OMEGA-3 ORAL 29-1-250MG COMBO. PKG
Preferred
13811004930
ULTIMATECARE ONE CAPSULE
PNV W-CA NO.37/IRON/FA/OMEGA-3 ORAL 27-1-330MG CAPSULE
Preferred
13811005030
ULTIMATECARE ONE NF CAPSULE
PNV,CA,NO.35/IRON/FA/DS/OMEG-3 ORAL 27-1-50 MG CAPSULE
Preferred
13811059830
VEMAVITE-PRX 2 CAPSULE
PNV66/IRON FUMARATE/FA/DSS/DHA ORAL 27-1.25-55 CAPSULE
Preferred
13811060130
VENA-BAL DHA COMBO PACK
PNV81/SOD IRON EDTA& PS/FA/OM3 ORAL 27-1-430MG
CMBPKGDRCP
Preferred
51991091290
VINATE DHA RF GELCAP
PNV#64/IRON/LMFOLATE/ALGAL/SOY ORAL 27-1.13 MG CAPSULE
Non-Preferred
51991017801
VINATE II TABLET
PRENATAL VIT/IRON BISGLYCIN/FA ORAL 29 MG-1 MG TABLET
Non-Preferred
51991015501
VINATE-M TABLET
PNV/FERROUS FUMARATE/FA/SE ORAL 27 MG-1 MG TABLET
Non-Preferred
76439026410
VIRT NATE TABLET
PRENATAL VIT NO.73/IRON/FA ORAL 28 MG-1 MG TABLET
Preferred
76439035790
VIRT-ADVANCE TABLET
PRENATAL VIT 15/IRON CB/FA/DSS ORAL 90-1-50 MG TABLET
Preferred
76439024810
VIRT-BAL DHA COMBO PACK
PNV94/SOD IRON EDTA& PS/FA/OM3 ORAL 26-1-374MG
CMBPKGDRCP
Preferred
76439033130
VIRT-C DHA SOFTGEL
PNV#16/IRON FUM & PS/FA/OM-3 ORAL 35-1-200MG CAPSULE
Preferred
76439035530
VIRT-C DHA SOFTGEL
PNV#16/IRON FUM & PS/FA/OM-3 ORAL 35-1-200MG CAPSULE
Preferred
76439034930
VIRT-CARE ONE CAPSULE
PNV W-CA NO.37/IRON/FA/OMEGA-3 ORAL 27-1-330MG CAPSULE
Preferred
76439034030
VIRT-PN DHA SOFTGEL
PNV COMBO#47/IRON/FA #1/DHA ORAL 27-1-300MG CAPSULE
Preferred
76439024330
VIRT-PN PLUS SOFTGEL
PNV WITH CA #68/IRON/FA#1/DHA ORAL 28-1-300MG CAPSULE
Preferred
76439024190
VIRT-PN TABLET
PNV W-CA #40/IRON FUM/FA CMB#1 ORAL 27 MG-1 MG TABLET
Preferred
76439034830
VIRTPREX CAPSULE
PNV66/IRON FUMARATE/FA/DSS/DHA ORAL 26-1.2-55 CAPSULE
Preferred
76439024930
VIRT-SELECT CAPSULE
PNV80/IRON FUMARATE/FA/DSS/DHA ORAL 29-1.25-55 CAPSULE
Preferred
76439027090
VIRT-VITE GT TABLET
PRENATAL VIT 16/IRON CB/FA/DSS ORAL 90-1-50 MG TABLET
Preferred
00642009430
VITAFOL NANO TABLET
PRENATAL NO.75/IRON/FOLATE #1 ORAL 18 MG-1 MG TABLET
Non-Preferred
00642009330
VITAFOL ULTRA SOFTGEL
PNV#67/IRON PS/FA CMB#1/DHA ORAL 29-1-200MG CAPSULE
Non-Preferred
00642007912
VITAFOL-OB CAPLET
PRENATAL VIT COMB.10/IRON/FA ORAL 65 MG-1 MG TABLET
Non-Preferred
00642007630
VITAFOL-OB+DHA COMBO PACK
PRENAT VIT COMB.10/IRON/FA/DHA ORAL 65-1-250MG COMBO. PKG
Non-Preferred
4
Preferred
Effective 07/01/2015
ALABAMA MEDICAID AGENCY
Prenatal Vitamins – Preferred Status
NDC Code
Label Name
Generic Drug Name
PDL Status
00642007030
VITAFOL-ONE CAPSULE
PNV#26/IRON POLY/FA/DHA ORAL 29-1-200MG CAPSULE
13811051410
VOL-NATE TABLET
PRENATAL VIT NO.73/IRON/FA ORAL 28 MG-1 MG TABLET
Preferred
13811051901
VOL-PLUS TABLET
PNV WITH CA,NO.71/IRON/FA ORAL 27 MG-1 MG TABLET
Preferred
13811051910
VOL-PLUS TABLET
PNV WITH CA,NO.71/IRON/FA ORAL 27 MG-1 MG TABLET
Preferred
13811051950
VOL-PLUS TABLET
PNV WITH CA,NO.71/IRON/FA ORAL 27 MG-1 MG TABLET
Preferred
13811051690
VOL-TAB RX TABLET
PRENATAL VIT #76/IRON,CARB/FA ORAL 29 MG-1 MG TABLET
76439027430
VP CH ULTRA SOFTGEL
PNV34/IRON,CARB&FUM/FA/DSS/DHA ORAL 27-1-50 MG CAPSULE
Non-Preferred
76439024230
VP-CH PLUS SOFTGEL
PNV59/IRON,CARBONYL/FA/DSS/DHA ORAL 29-1-50 MG CAPSULE
Preferred
76439022430
VP-CH-PNV PRENATAL SOFTGEL
PNV34/IRON,CARBONYL/FA/DSS/DHA ORAL 30-1-50 MG CAPSULE
Preferred
76439021690
VP-ERA OB PLUS TABLET
PNV #8/IRON PS & HEME POLYP/FA ORAL 22-6-1MG TABLET
Preferred
76439023860
VP-HEME OB + DHA COMBO PACK
PNV COMBO #22/IRON/FA/OM3/DHA ORAL 28-6-1-203 COMBO. PKG
Preferred
76439023790
VP-HEME OB TABLET
PNV#21/IRON PS& HEME POLYP/FA ORAL 28-6-1 MG TABLET
Preferred
76439024030
VP-HEME ONE SOFTGEL
PNV #19/IRON PS&HEME/FOLIC/DHA ORAL 22-6-1-200 CAPSULE
Preferred
76439022330
VP-PNV-DHA CAPSULE
PRENATAL NO.52/IRON/FA/DHA ORAL 28-1-200MG CAPSULE
Preferred
13811058330
ZATEAN-CH CAPSULE
PNV69/IRON,CARBONYL/FA/DSS/DHA ORAL 27-1-50 MG CAPSULE
Preferred
13811058030
ZATEAN-PN DHA CAPSULE
PNV COMBO#47/IRON/FA #1/DHA ORAL 27-1-300MG CAPSULE
Preferred
13811058230
ZATEAN-PN PLUS SOFTGEL
PNV WITH CA #68/IRON/FA#1/DHA ORAL 28-1-300MG CAPSULE
Preferred
13811058190
ZATEAN-PN TABLET
PNV W-CA #40/IRON FUM/FA CMB#1 ORAL 27 MG-1 MG TABLET
Preferred
5
Non-Preferred
Preferred
Effective 07/01/2015

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