Anticoagulants, Oral and SQ

← Back to Class List

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 but eligible patients will encounter a co-pay at the pharmacy.
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.

Generic Name Brand Name Form PDL
Status
Current Drug Use Criteria New Drug Evaluation
APIXABAN ELIQUIS TABLET Y    
DABIGATRAN ETEXILATE MESYLATE PRADAXA CAPSULE Y   Jan 26, 2012
DALTEPARIN SODIUM,PORCINE FRAGMIN SYRINGE Y    
EDOXABAN TOSYLATE SAVAYSA TABLET Y    
ENOXAPARIN SODIUM LOVENOX SYRINGE Y    
ENOXAPARIN SODIUM ENOXAPARIN SODIUM SYRINGE Y    
ENOXAPARIN SODIUM LOVENOX VIAL Y    
ENOXAPARIN SODIUM ENOXAPARIN SODIUM VIAL Y    
RIVAROXABAN XARELTO TAB DS PK Y    
RIVAROXABAN XARELTO TABLET Y   Jan 26, 2012
WARFARIN SODIUM WARFARIN SODIUM TABLET Y    
WARFARIN SODIUM JANTOVEN TABLET Y    
WARFARIN SODIUM COUMADIN TABLET Y    
DALTEPARIN SODIUM,PORCINE FRAGMIN VIAL N    
FONDAPARINUX SODIUM ARIXTRA SYRINGE N    
FONDAPARINUX SODIUM FONDAPARINUX SODIUM SYRINGE N