Hemostatics

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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.
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.

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NDC Brand Name Generic Name Form Strength PDL
Status		 Rebate Current Drug Use Criteria
00054110058 AMINOCAPROIC ACID aminocaproic acid SOLUTION 250 mg/mL Y  
31722003523 AMINOCAPROIC ACID aminocaproic acid SOLUTION 250 mg/mL Y  
52817081508 AMINOCAPROIC ACID aminocaproic acid SOLUTION 250 mg/mL Y  
59651057308 AMINOCAPROIC ACID aminocaproic acid SOLUTION 250 mg/mL Y  
69238159608 AMINOCAPROIC ACID aminocaproic acid SOLUTION 250 mg/mL Y  
69680011408 AMINOCAPROIC ACID aminocaproic acid SOLUTION 250 mg/mL Y  
70377010411 AMINOCAPROIC ACID aminocaproic acid SOLUTION 250 mg/mL Y  
00054111013 AMINOCAPROIC ACID aminocaproic acid TABLET 1,000 mg Y  
24658079930 AMINOCAPROIC ACID aminocaproic acid TABLET 1,000 mg Y  
69680011630 AMINOCAPROIC ACID aminocaproic acid TABLET 1,000 mg Y  
70377010311 AMINOCAPROIC ACID aminocaproic acid TABLET 1,000 mg Y  
00904716507 AMINOCAPROIC ACID aminocaproic acid TABLET 500 mg Y  
24658079830 AMINOCAPROIC ACID aminocaproic acid TABLET 500 mg Y  
60687073925 AMINOCAPROIC ACID aminocaproic acid TABLET 500 mg Y  
60687073995 AMINOCAPROIC ACID aminocaproic acid TABLET 500 mg Y  
62559022530 AMINOCAPROIC ACID aminocaproic acid TABLET 500 mg Y  
69238163703 AMINOCAPROIC ACID aminocaproic acid TABLET 500 mg Y  
69680011530 AMINOCAPROIC ACID aminocaproic acid TABLET 500 mg Y  
70377010211 AMINOCAPROIC ACID aminocaproic acid TABLET 500 mg Y  
72205004930 AMINOCAPROIC ACID aminocaproic acid TABLET 500 mg Y  
00409434616 AMINOCAPROIC ACID aminocaproic acid VIAL 250 mg/mL Y  
00409434673 AMINOCAPROIC ACID aminocaproic acid VIAL 250 mg/mL Y  
00517912001 AMINOCAPROIC ACID aminocaproic acid VIAL 250 mg/mL Y  
00517912025 AMINOCAPROIC ACID aminocaproic acid VIAL 250 mg/mL Y  
00517919101 AMINOCAPROIC ACID aminocaproic acid VIAL 250 mg/mL Y  
00517919125 AMINOCAPROIC ACID aminocaproic acid VIAL 250 mg/mL Y  
72572001501 AMINOCAPROIC ACID aminocaproic acid VIAL 250 mg/mL Y  
72572001525 AMINOCAPROIC ACID aminocaproic acid VIAL 250 mg/mL Y  
00310320001 ANDEXXA factor Xa,inactivated-zhzo VIAL 200 mg Y  
00310320004 ANDEXXA factor Xa,inactivated-zhzo VIAL 200 mg Y  
00310320005 ANDEXXA factor Xa,inactivated-zhzo VIAL 200 mg Y  
69853010201 ANDEXXA factor Xa,inactivated-zhzo VIAL 200 mg Y  
59365606500 ASTRINGYN ferric subsulfate SOLN(GRAM) 259 mg/gram Y  
59365606501 ASTRINGYN ferric subsulfate SOLN(GRAM) 259 mg/gram Y  
68982034701 FIBRYGA fibrinogen VIAL 1 gram (700 mg-1,300 mg) Y  
68982034801 FIBRYGA fibrinogen VIAL 1 gram (700 mg-1,300 mg) Y  
68982034901 FIBRYGA fibrinogen VIAL 1 gram (700 mg-1,300 mg) Y  
68982034981 FIBRYGA fibrinogen VIAL 1 gram (700 mg-1,300 mg) Y  
63833089151 RIASTAP fibrinogen VIAL 1 gram (900 mg-1,300 mg) Y  
63833089190 RIASTAP fibrinogen VIAL 1 gram (900 mg-1,300 mg) Y  
00009043304 GELFOAM gelatin sponge,absorb/porcine POWDER Y  
00009104001 GEL-FLOW NT gelatin sponge,absorbable SYRINGE Y  
00009104006 GEL-FLOW NT gelatin sponge,absorbable SYRINGE Y  
00597019705 PRAXBIND idarucizumab VIAL 2.5 gram/50 mL Y  
63323022901 PROTAMINE SULFATE protamine sulfate VIAL 10 mg/mL Y  
63323022905 PROTAMINE SULFATE protamine sulfate VIAL 10 mg/mL Y  
63323022915 PROTAMINE SULFATE protamine sulfate VIAL 10 mg/mL Y  
63323022921 PROTAMINE SULFATE protamine sulfate VIAL 10 mg/mL Y  
63323022930 PROTAMINE SULFATE protamine sulfate VIAL 10 mg/mL Y  
63323022935 PROTAMINE SULFATE protamine sulfate VIAL 10 mg/mL Y  
63323022941 PROTAMINE SULFATE protamine sulfate VIAL 10 mg/mL Y  
63323022994 PROTAMINE SULFATE protamine sulfate VIAL 10 mg/mL Y  
63323022995 PROTAMINE SULFATE protamine sulfate VIAL 10 mg/mL Y  
60793020505 THROMBIN-JMI thrombin (bovine) NAS SP SYR 5,000 unit Y  
60793021721 THROMBIN-JMI thrombin (bovine) SPRAY 20,000 unit Y  
60793021722 THROMBIN-JMI thrombin (bovine) SPRAY SYRN 20,000 unit Y  
60793070505 THROMBIN-JMI thrombin (bovine) SPRAY SYRN 5,000 unit Y  
60793021720 THROMBIN-JMI thrombin (bovine) VIAL 20,000 unit Y  
60793031701 THROMBIN-JMI thrombin (bovine) VIAL 20,000 unit Y  
60793021505 THROMBIN-JMI thrombin (bovine) VIAL 5,000 unit Y  
60793031501 THROMBIN-JMI thrombin (bovine) VIAL 5,000 unit Y  
00338032601 RECOTHROM thrombin (recombinant) VIAL 20,000 unit Y  
00338032801 RECOTHROM thrombin (recombinant) VIAL 20,000 unit Y  
00338033001 RECOTHROM thrombin (recombinant) VIAL 20,000 unit Y  
00338032201 RECOTHROM thrombin (recombinant) VIAL 5,000 unit Y  
00338032401 RECOTHROM thrombin (recombinant) VIAL 5,000 unit Y  
00009225001 GEL-FLOW thrombin,bovine/gelatin sponge SYRINGEKIT 5,000 unit Y  
61953001401 VISTASEAL FIBRIN SEALANT thrombin,hu/fibrinogen/calcium SYRINGE 500 unit-80 mg/mL (10 mL) Y  
61953001101 VISTASEAL FIBRIN SEALANT thrombin,hu/fibrinogen/calcium SYRINGE 500 unit-80 mg/mL (2 mL) Y  
61953001201 VISTASEAL FIBRIN SEALANT thrombin,hu/fibrinogen/calcium SYRINGE 500 unit-80 mg/mL (4 mL) Y  
00013111401 CYKLOKAPRON tranexamic acid AMPUL 1,000 mg/10 mL (100 mg/mL) Y  
00013111415 CYKLOKAPRON tranexamic acid AMPUL 1,000 mg/10 mL (100 mg/mL) Y  
23155090931 TRANEXAMIC ACID tranexamic acid AMPUL 1,000 mg/10 mL (100 mg/mL) Y  
23155090941 TRANEXAMIC ACID tranexamic acid AMPUL 1,000 mg/10 mL (100 mg/mL) Y  
00591372030 TRANEXAMIC ACID tranexamic acid TABLET 650 mg Y  
50268077211 TRANEXAMIC ACID tranexamic acid TABLET 650 mg Y  
50268077213 TRANEXAMIC ACID tranexamic acid TABLET 650 mg Y  
59651083930 TRANEXAMIC ACID tranexamic acid TABLET 650 mg Y  
60687075011 TRANEXAMIC ACID tranexamic acid TABLET 650 mg Y  
60687075021 TRANEXAMIC ACID tranexamic acid TABLET 650 mg Y  
62559026530 TRANEXAMIC ACID tranexamic acid TABLET 650 mg Y  
69918030130 TRANEXAMIC ACID tranexamic acid TABLET 650 mg Y  
72888017830 TRANEXAMIC ACID tranexamic acid TABLET 650 mg Y  
00013111420 CYKLOKAPRON tranexamic acid VIAL 1,000 mg/10 mL (100 mg/mL) Y  
00013111421 CYKLOKAPRON tranexamic acid VIAL 1,000 mg/10 mL (100 mg/mL) Y  
14789050010 TRANEXAMIC ACID tranexamic acid VIAL 1,000 mg/10 mL (100 mg/mL) Y  
23155016631 TRANEXAMIC ACID tranexamic acid VIAL 1,000 mg/10 mL (100 mg/mL) Y  
23155016641 TRANEXAMIC ACID tranexamic acid VIAL 1,000 mg/10 mL (100 mg/mL) Y  
23155052431 TRANEXAMIC ACID tranexamic acid VIAL 1,000 mg/10 mL (100 mg/mL) Y  
23155052441 TRANEXAMIC ACID tranexamic acid VIAL 1,000 mg/10 mL (100 mg/mL) Y  
23155091031 TRANEXAMIC ACID tranexamic acid VIAL 1,000 mg/10 mL (100 mg/mL) Y  
23155091041 TRANEXAMIC ACID tranexamic acid VIAL 1,000 mg/10 mL (100 mg/mL) Y  
25021041510 TRANEXAMIC ACID tranexamic acid VIAL 1,000 mg/10 mL (100 mg/mL) Y  
39822100001 TRANEXAMIC ACID tranexamic acid VIAL 1,000 mg/10 mL (100 mg/mL) Y  
43066000801 TRANEXAMIC ACID tranexamic acid VIAL 1,000 mg/10 mL (100 mg/mL) Y  
43066000810 TRANEXAMIC ACID tranexamic acid VIAL 1,000 mg/10 mL (100 mg/mL) Y  
55150018810 TRANEXAMIC ACID tranexamic acid VIAL 1,000 mg/10 mL (100 mg/mL) Y  
60505616900 TRANEXAMIC ACID tranexamic acid VIAL 1,000 mg/10 mL (100 mg/mL) Y  
60505616901 TRANEXAMIC ACID tranexamic acid VIAL 1,000 mg/10 mL (100 mg/mL) Y  
61990061100 TRANEXAMIC ACID tranexamic acid VIAL 1,000 mg/10 mL (100 mg/mL) Y  
61990061102 TRANEXAMIC ACID tranexamic acid VIAL 1,000 mg/10 mL (100 mg/mL) Y  
63323056301 TRANEXAMIC ACID tranexamic acid VIAL 1,000 mg/10 mL (100 mg/mL) Y  
63323056310 TRANEXAMIC ACID tranexamic acid VIAL 1,000 mg/10 mL (100 mg/mL) Y  
67457019700 TRANEXAMIC ACID tranexamic acid VIAL 1,000 mg/10 mL (100 mg/mL) Y  
67457019710 TRANEXAMIC ACID tranexamic acid VIAL 1,000 mg/10 mL (100 mg/mL) Y  
69543037613 TRANEXAMIC ACID tranexamic acid VIAL 1,000 mg/10 mL (100 mg/mL) Y  
70860040710 TRANEXAMIC ACID tranexamic acid VIAL 1,000 mg/10 mL (100 mg/mL) Y  
70860040741 TRANEXAMIC ACID tranexamic acid VIAL 1,000 mg/10 mL (100 mg/mL) Y  
72485010701 TRANEXAMIC ACID tranexamic acid VIAL 1,000 mg/10 mL (100 mg/mL) Y  
72485010710 TRANEXAMIC ACID tranexamic acid VIAL 1,000 mg/10 mL (100 mg/mL) Y  
72485051001 TRANEXAMIC ACID tranexamic acid VIAL 1,000 mg/10 mL (100 mg/mL) Y  
72485051010 TRANEXAMIC ACID tranexamic acid VIAL 1,000 mg/10 mL (100 mg/mL) Y  
72603038701 TRANEXAMIC ACID tranexamic acid VIAL 1,000 mg/10 mL (100 mg/mL) Y  
72603038710 TRANEXAMIC ACID tranexamic acid VIAL 1,000 mg/10 mL (100 mg/mL) Y  
81284061100 TRANEXAMIC ACID tranexamic acid VIAL 1,000 mg/10 mL (100 mg/mL) Y  
81284061110 TRANEXAMIC ACID tranexamic acid VIAL 1,000 mg/10 mL (100 mg/mL) Y  
81284061200 TRANEXAMIC ACID tranexamic acid VIAL 1,000 mg/10 mL (100 mg/mL) Y  
81284061210 TRANEXAMIC ACID tranexamic acid VIAL 1,000 mg/10 mL (100 mg/mL) Y  
83634040110 TRANEXAMIC ACID tranexamic acid VIAL 1,000 mg/10 mL (100 mg/mL) Y  
83634040141 TRANEXAMIC ACID tranexamic acid VIAL 1,000 mg/10 mL (100 mg/mL) Y  
14789011505 TRANEXAMIC ACID-NACL tranexamic acid in NaCl,iso-os PIGGYBACK 1,000 mg/100 mL (10 mg/mL) Y  
14789011508 TRANEXAMIC ACID-NACL tranexamic acid in NaCl,iso-os PIGGYBACK 1,000 mg/100 mL (10 mg/mL) Y  
25021041882 TRANEXAMIC ACID-NACL tranexamic acid in NaCl,iso-os PIGGYBACK 1,000 mg/100 mL (10 mg/mL) Y  
51754010801 TRANEXAMIC ACID-NACL tranexamic acid in NaCl,iso-os PIGGYBACK 1,000 mg/100 mL (10 mg/mL) Y  
51754010803 TRANEXAMIC ACID-NACL tranexamic acid in NaCl,iso-os PIGGYBACK 1,000 mg/100 mL (10 mg/mL) Y  
65219053401 TRANEXAMIC ACID-NACL tranexamic acid in NaCl,iso-os PIGGYBACK 1,000 mg/100 mL (10 mg/mL) Y  
65219053410 TRANEXAMIC ACID-NACL tranexamic acid in NaCl,iso-os PIGGYBACK 1,000 mg/100 mL (10 mg/mL) Y  
80830232901 TRANEXAMIC ACID-NACL tranexamic acid in NaCl,iso-os PIGGYBACK 1,000 mg/100 mL (10 mg/mL) Y  
80830232902 TRANEXAMIC ACID-NACL tranexamic acid in NaCl,iso-os PIGGYBACK 1,000 mg/100 mL (10 mg/mL) Y  
80830232903 TRANEXAMIC ACID-NACL tranexamic acid in NaCl,iso-os PIGGYBACK 1,000 mg/100 mL (10 mg/mL) Y  
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