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.
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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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