Platelet Inhibitors

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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
aspirin ASPIRIN TAB CHEW Y    
aspirin CHILDREN'S ASPIRIN TAB CHEW Y    
aspirin ADULT ASPIRIN TAB CHEW Y    
aspirin CHILD ASPIRIN TAB CHEW Y    
aspirin BAYER CHILDREN'S ASPIRIN TAB CHEW Y    
aspirin BAYER CHEWABLE ASPIRIN TAB CHEW Y    
aspirin BABY ASPIRIN TAB CHEW Y    
aspirin CHILDREN'S CHEWABLE ASPIRIN TAB CHEW Y    
aspirin ASPIRIN TAB CHEW Y    
aspirin ASPIRIN FOR CHILDREN TAB CHEW Y    
aspirin ST. JOSEPH ASPIRIN CHILDREN TAB CHEW Y    
aspirin ST. JOSEPH ASPIRIN TAB CHEW Y    
aspirin ST JOSEPH ASPIRIN TAB CHEW Y    
aspirin CHILDRENS ASPIRIN TAB CHEW Y    
aspirin CHILDREN'S ASPIRIN TAB CHEW Y    
aspirin ASPIRIN TABLET Y    
aspirin BAYER ASPIRIN TABLET Y    
aspirin ASPIRIN LITE-COAT TABLET Y    
aspirin ASPIRIN TABLET Y    
aspirin ANALGESIC TABLET Y    
aspirin ADULT ASPIRIN TABLET Y    
aspirin ASPIRIN LITE COAT TABLET Y    
aspirin ST. JOSEPH ASPIRIN TABLET Y    
aspirin QUALITY ASPIRIN TABLET Y    
aspirin NORWICH ASPIRIN TABLET Y    
aspirin LOW-DOSE ASPIRIN TABLET Y    
aspirin LITE COAT ASPIRIN TABLET Y    
aspirin GENPRIN TABLET Y    
aspirin EMPIRIN TABLET Y    
aspirin COATED ASPIRIN TABLET Y    
aspirin ASPIRIN EC TABLET DR Y    
aspirin LOW DOSE ASPIRIN EC TABLET DR Y    
aspirin ECPIRIN TABLET DR Y    
aspirin ASPIR-LOW TABLET DR Y    
aspirin ASPIRIN TABLET DR Y    
aspirin ASPIR 81 TABLET DR Y    
aspirin ADULT ASPIRIN REGIMEN TABLET DR Y    
aspirin ASPIRIN EC TABLET DR Y    
aspirin ASPIRIN E.C. TABLET DR Y    
aspirin BAYER THERAPY TABLET DR Y    
aspirin ASPIR-TRIN TABLET DR Y    
aspirin ASPIR-LOW TABLET DR Y    
aspirin ASPIRIN LOW STRENGTH TABLET DR Y    
aspirin ASPIRIN LOW DOSE TABLET DR Y    
aspirin ASPIRIN ENTERIC COATED TABLET DR Y    
aspirin COPRIN TABLET DR Y    
aspirin ASPIRIN TABLET DR Y    
aspirin ARTHRITIS PAIN RELIEF TABLET DR Y    
aspirin ADULT LOW STRENGTH ASPIRIN TABLET DR Y    
aspirin ADULT LOW STRENGTH TABLET DR Y    
aspirin ADULT LOW DOSE ASPIRIN EC TABLET DR Y    
aspirin ADULT LOW DOSE ASPIRIN TABLET DR Y    
aspirin ADULT ASPIRIN REGIMEN TABLET DR Y    
aspirin ADULT ASPIRIN TABLET DR Y    
aspirin LOW DOSE ASPIRIN EC TABLET DR Y    
aspirin TASPRIN TABLET DR Y    
aspirin SUREPRIN 81 TABLET DR Y    
aspirin ST. JOSEPH ASPIRIN TABLET DR Y    
aspirin ST JOSEPH ASPIRIN TABLET DR Y    
aspirin REGRIPRIN TABLET DR Y    
aspirin LOW DOSE ASPIRIN TABLET DR Y    
aspirin LO-DOSE ASPIRIN EC TABLET DR Y    
aspirin HALFPRIN TABLET DR Y    
aspirin GENACOTE TABLET DR Y    
aspirin ENTERCOTE TABLET DR Y    
aspirin ENCOPRIN TABLET DR Y    
aspirin ECOTRIN TABLET DR Y    
aspirin ECO-5 TABLET DR Y    
aspirin ECASPIRIN TABLET DR Y    
aspirin NINOPRIN TABLET DR Y    
aspirin/dipyridamole ASPIRIN-DIPYRIDAMOLE ER CPMP 12HR Y    
aspirin/dipyridamole AGGRENOX CPMP 12HR Y    
cilostazol CILOSTAZOL TABLET Y    
clopidogrel bisulfate PLAVIX TABLET Y    
clopidogrel bisulfate CLOPIDOGREL TABLET Y    
clopidogrel bisulfate CLOPIDOGREL BISULFATE TABLET Y    
dipyridamole DIPYRIDAMOLE TABLET Y    
aspirin/omeprazole YOSPRALA TAB IR DR N PA Document  
prasugrel HCl EFFIENT TABLET N PA Document Nov 17, 2011
prasugrel HCl PRASUGREL HCL TABLET N PA Document  
ticagrelor BRILINTA TABLET N PA Document Nov 17, 2011
ticlopidine HCl TICLOPIDINE HCL TABLET N PA Document  
vorapaxar sulfate ZONTIVITY TABLET N PA Document