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Utilization Management Policy Name: Prenatal Vitamin Benefit Limitation – NC Standard
Utilization Management Policy Name: Prenatal Vitamin Benefit Limitation – NC Standard
Benefit limitation:
Prenatal vitamins are limited to those planning pregnancy, currently pregnant or breastfeeding.
Criteria for Approval of Restricted Product(s):
- The patient is planning pregnancy, currently pregnant or breastfeeding; AND
- For formularies that exclude (non-formulary) the requested medication, Non-formulary Exception Criteria applies.
Duration of Approval:
365 days (1 year)
References:
All information referenced is from FDA package insert unless otherwise noted below.
Policy Implementation/Update Information:
January 2021: Original utilization management criteria issued.
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