Platelet Inhibitors
PDL Reference Documents
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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.
| Generic Name | Brand Name | Form | PDL Status |
Current Drug Use Criteria | Carveout ‐ Bill FFS |
New Drug Evaluation & Updates |
|---|---|---|---|---|---|---|
| aspirin | ASPIRIN | TAB CHEW | Y | N | ||
| aspirin | ST. JOSEPH ASPIRIN | TAB CHEW | Y | N | ||
| aspirin | CHILDREN'S ASPIRIN | TAB CHEW | Y | N | ||
| aspirin | ADULT ASPIRIN | TAB CHEW | Y | N | ||
| aspirin | LITE COAT ASPIRIN | TABLET | Y | N | ||
| aspirin | LITE COAT ASPIRIN | TABLET | Y | N | ||
| aspirin | ASPIRIN | TABLET | Y | N | ||
| aspirin | BAYER ASPIRIN | TABLET | Y | N | ||
| aspirin | ASPIRIN EC | TABLET DR | Y | N | ||
| aspirin | ASPIRIN | TABLET DR | Y | N | ||
| aspirin | LOW DOSE ASPIRIN EC | TABLET DR | Y | N | ||
| aspirin | ECOTRIN | TABLET DR | Y | N | ||
| aspirin | ASPIRIN LOW STRENGTH | TABLET DR | Y | N | ||
| aspirin | ASPIRIN EC | TABLET DR | Y | N | ||
| aspirin | ADULT LOW DOSE ASPIRIN EC | TABLET DR | Y | N | ||
| aspirin/dipyridamole | ASPIRIN-DIPYRIDAMOLE ER | CPMP 12HR | Y | N | ||
| prasugrel HCl | EFFIENT | TABLET | Y | N | Nov 17, 2011 | |
| ticagrelor | TICAGRELOR | TABLET | Y | N | ||
| ticagrelor | BRILINTA | TABLET | Y | N | Nov 17, 2011 |