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 ADULT ASPIRIN TAB CHEW Y    
ASPIRIN BAYER CHEWABLE ASPIRIN TAB CHEW Y    
ASPIRIN CHILDREN'S ASPIRIN TAB CHEW Y    
ASPIRIN CHILDREN'S CHEWABLE ASPIRIN TAB CHEW Y    
ASPIRIN ST. JOSEPH ASPIRIN TAB CHEW Y    
ASPIRIN ASPIRIN TAB CHEW Y    
ASPIRIN CHILDREN'S ASPIRIN TAB CHEW Y    
ASPIRIN LITE COAT ASPIRIN TABLET Y    
ASPIRIN ASPIRIN TABLET Y    
ASPIRIN ASPIRIN TABLET Y    
ASPIRIN BAYER ASPIRIN TABLET Y    
ASPIRIN ASPIRIN LITE COAT TABLET Y    
ASPIRIN ADULT LOW DOSE ASPIRIN EC TABLET DR Y    
ASPIRIN ENCOPRIN TABLET DR Y    
ASPIRIN ASPIRIN LOW STRENGTH TABLET DR Y    
ASPIRIN LO-DOSE ASPIRIN EC TABLET DR Y    
ASPIRIN LOW DOSE ASPIRIN TABLET DR Y    
ASPIRIN LOW DOSE ASPIRIN EC TABLET DR Y    
ASPIRIN REGRIPRIN TABLET DR Y    
ASPIRIN SUREPRIN 81 TABLET DR Y    
ASPIRIN ST. JOSEPH ASPIRIN TABLET DR Y    
ASPIRIN ECOTRIN TABLET DR Y    
ASPIRIN ASPIR 81 TABLET DR Y    
ASPIRIN ASPIRIN EC TABLET DR Y    
ASPIRIN ASPIR-LOW TABLET DR Y    
ASPIRIN ECPIRIN TABLET DR Y    
ASPIRIN ASPIRIN EC TABLET DR Y    
ASPIRIN ASPIRIN TABLET DR Y    
ASPIRIN ASPIR-TRIN TABLET DR Y    
ASPIRIN LOW DOSE ASPIRIN EC TABLET DR Y    
ASPIRIN/DIPYRIDAMOLE ASPIRIN-DIPYRIDAMOLE ER CPMP 12HR Y    
ASPIRIN/DIPYRIDAMOLE AGGRENOX CPMP 12HR Y    
CILOSTAZOL CILOSTAZOL TABLET Y    
CLOPIDOGREL BISULFATE CLOPIDOGREL TABLET Y    
CLOPIDOGREL BISULFATE PLAVIX TABLET Y    
DIPYRIDAMOLE DIPYRIDAMOLE TABLET Y    
ASPIRIN DURLAZA CAP ER 24H N PA Document  
ASPIRIN/OMEPRAZOLE YOSPRALA TAB IR DR N PA Document  
PRASUGREL HCL EFFIENT TABLET N PA Document Nov 17, 2011
TICAGRELOR BRILINTA TABLET N PA Document Nov 17, 2011
TICLOPIDINE HCL TICLOPIDINE HCL TABLET N PA Document  
VORAPAXAR SULFATE ZONTIVITY TABLET N PA Document