Anticoagulants, Oral and SQ
PDL Reference Documents
Drug Use Review Documents
Newsletters
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.
| Generic Name | Brand Name | Form | PDL Status |
Current Drug Use Criteria | Carveout ‐ Bill FFS |
New Drug Evaluation & Updates |
|---|---|---|---|---|---|---|
| apixaban | ELIQUIS | TABLET | Y | N | ||
| enoxaparin sodium | LOVENOX | SYRINGE | Y | N | ||
| enoxaparin sodium | ENOXAPARIN SODIUM | SYRINGE | Y | N | ||
| enoxaparin sodium | LOVENOX | VIAL | Y | N | ||
| rivaroxaban | XARELTO | TAB DS PK | Y | N | ||
| rivaroxaban | RIVAROXABAN | TABLET | Y | N | ||
| warfarin sodium | WARFARIN SODIUM | TABLET | Y | N | ||
| apixaban | ELIQUIS SPRINKLE | CAP SPRINK | N | N | ||
| apixaban | ELIQUIS | TAB SUSP | N | N | ||
| dabigatran etexilate mesylate | PRADAXA | PELET PACK | N | N | ||
| dalteparin sodium,porcine | FRAGMIN | VIAL | N | N | ||
| fondaparinux sodium | FONDAPARINUX SODIUM | SYRINGE | N | N |