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,FULL LENGTH KOVALTRY VIAL    
ANTIHEMOPH.FVIII,FULL LENGTH ADVATE VIAL    
ANTIHEMOPH.FVIII,FULL LENGTH HELIXATE FS VIAL    
ANTIHEMOPH.FVIII,FULL LENGTH KOGENATE FS VIAL    
ANTIHEMOPH.FVIII,HEK B-DELETE NUWIQ VIAL    
ANTIHEMOPHILIC FACTOR, HUM REC RECOMBINATE VIAL    
ANTIHEMOPHILIC FACTOR, HUMAN HEMOFIL M VIAL    
ANTIHEMOPHILIC FACTOR, HUMAN MONOCLATE-P VIAL    
ANTIHEMOPHILIC FACTOR, HUMAN KOATE 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