Anticoagulants, Oral and SQ

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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
Current Drug Use Criteria New Drug Evaluation
apixaban ELIQUIS TAB DS PK Y    
apixaban ELIQUIS TABLET Y    
dabigatran etexilate mesylate PRADAXA CAPSULE Y   Jan 26, 2012
dalteparin sodium,porcine FRAGMIN SYRINGE Y    
edoxaban tosylate SAVAYSA TABLET Y    
enoxaparin sodium ENOXAPARIN SODIUM SYRINGE Y    
enoxaparin sodium LOVENOX SYRINGE Y    
enoxaparin sodium LOVENOX VIAL Y    
enoxaparin sodium ENOXAPARIN SODIUM VIAL Y    
rivaroxaban XARELTO TAB DS PK Y    
rivaroxaban XARELTO TABLET Y   Jan 26, 2012
warfarin sodium COUMADIN TABLET Y    
warfarin sodium JANTOVEN TABLET Y    
warfarin sodium WARFARIN SODIUM TABLET Y    
betrixaban maleate BEVYXXA CAPSULE N   Nov 30, 2017
dalteparin sodium,porcine FRAGMIN VIAL N    
enoxaparin sodium LOVENOX AMPUL N    
fondaparinux sodium ARIXTRA SYRINGE N