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 ANGIOMAX VIAL    
bivalirudin BIVALIRUDIN VIAL    
bivalirudin BIVALIRUDIN VIAL PORT    
bivalirudin/0.9 % sodium chlor BIVALIRUDIN-0.9% NACL FROZ.PIGGY    
citrate phosphate dextros soln CITRATE PHOSPHATE DEXTROSE SOLUTION    
desirudin IPRIVASK VIAL    
eptifibatide EPTIFIBATIDE VIAL    
eptifibatide INTEGRILIN VIAL    
heparin sod,porcine/0.9 % NaCl HEP-PAK KIT    
heparin sod,porcine/0.9 % NaCl HEP-PAK CVC KIT    
heparin sod,porcine/0.9 % NaCl HEP-PAK LKFL KIT    
heparin sod,pork in 0.45% NaCl HEPARIN SODIUM-0.45% NACL IV SOLN    
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 LOCK FLUSH SYRINGE    
heparin sodium,porcine HEPARIN SODIUM SYRINGE    
heparin sodium,porcine HEPARIN LOCK SYRINGE    
heparin sodium,porcine HEPARIN SODIUM VIAL    
heparin sodium,porcine HEPARIN LOCK VIAL    
heparin sodium,porcine/D5W HEPARIN SODIUM IN 5% DEXTROSE IV SOLN    
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 SYRINGE    
heparin sodium,porcine/PF HEPARIN FLUSH SYRINGE    
heparin sodium,porcine/PF HEPARIN IV FLUSH SYRINGE    
heparin sodium,porcine/PF HEPARIN LOCK FLUSH SYRINGE    
heparin sodium,porcine/PF HEPARIN FLUSH VIAL    
heparin sodium,porcine/PF HEPARIN SODIUM VIAL    
heparin sodium,porcine/PF HEPARIN LOCK VIAL    
tirofiban-0.9% sodium chloride AGGRASTAT PLAST. BAG