Anticoagulants, Intravenous

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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
CANGRELOR TETRASODIUM KENGREAL VIAL N    
TIROFIBAN HCL MONOHYDRATE AGGRASTAT VIAL N    
TIROFIBAN-0.9% SODIUM CHLORIDE AGGRASTAT VIAL N    
ABCIXIMAB REOPRO VIAL    
ARGATROBAN ARGATROBAN VIAL    
ARGATROBAN IN 0.9 % SOD CHLOR ARGATROBAN-0.9% NACL IV SOLN    
ARGATROBAN IN 0.9 % SOD CHLOR ARGATROBAN-0.9% NACL VIAL    
ARGATROBAN IN NACL,ISO-OSMOTIC ARGATROBAN-SODIUM CHLORIDE VIAL    
BIVALIRUDIN BIVALIRUDIN VIAL    
BIVALIRUDIN ANGIOMAX VIAL    
BIVALIRUDIN BIVALIRUDIN VIAL PORT    
DESIRUDIN IPRIVASK VIAL    
EPTIFIBATIDE EPTIFIBATIDE VIAL    
EPTIFIBATIDE INTEGRILIN VIAL    
HEPARIN SOD,PORK IN 0.45% NACL HEPARIN SODIUM IN 0.45% NACL IV SOLN    
HEPARIN SODIUM,PORCINE HEPARIN SODIUM CARTRIDGE    
HEPARIN SODIUM,PORCINE HEPARIN SODIUM SYRINGE    
HEPARIN SODIUM,PORCINE HEPARIN SODIUM VIAL    
HEPARIN SODIUM,PORCINE/D5W HEPARIN SODIUM-D5W IV SOLN    
HEPARIN SODIUM,PORCINE/NS/PF HEPARIN SODIUM-0.9% NACL IV SOLN    
HEPARIN SODIUM,PORCINE/PF HEPARIN SODIUM VIAL    
TIROFIBAN-0.9% SODIUM CHLORIDE AGGRASTAT PLAST. BAG