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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.
Disclosures:
BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. Blue Cross NC is an independent licensee of the Blue Cross and Blue Shield Association. All other marks are the property of their respective owners.
Blue Cross and Blue Shield of North Carolina does not discriminate on the basis of race, color, national origin, sex, age or disability in its health programs and activities. Learn more about our non-discrimination policy and no-cost services available to you.
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