Antihemophilia Factors

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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
anti-inhibitor coagulant comp. FEIBA NF VIAL    
antihem.FVIII,sin-chn,B-dm tru AFSTYLA VIAL    
antihemo.FVIII,full length peg ADYNOVATE VIAL    
antihemoph.FVIII rec,Fc fusion ELOCTATE VIAL    
antihemoph.FVIII,B-dom truncat NOVOEIGHT VIAL    
antihemoph.FVIII,B-domain del XYNTHA SOLOFUSE SYRINGE    
antihemoph.FVIII,B-domain del XYNTHA VIAL    
antihemoph.FVIII,HEK B-delete NUWIQ VIAL    
antihemophil.FVIII,full length ADVATE VIAL    
antihemophil.FVIII,full length HELIXATE FS VIAL    
antihemophil.FVIII,full length KOVALTRY VIAL    
antihemophil.FVIII,full length KOGENATE FS VIAL    
antihemophilic factor, hum rec RECOMBINATE VIAL    
antihemophilic factor, human KOATE-DVI KIT    
antihemophilic factor, human HEMOFIL M VIAL    
antihemophilic factor, human KOATE VIAL    
antihemophilic factor, human KOATE-DVI VIAL    
antihemophilic factor, human MONOCLATE-P VIAL    
antihemophilic factor/VWF WILATE VIAL    
antihemophilic factor/VWF HUMATE-P VIAL    
antihemophilic factor/VWF ALPHANATE VIAL    
antihemophilic FVIII,rec porc OBIZUR VIAL    
coagulation factor VIIa,recomb NOVOSEVEN RT VIAL