Platelet Inhibitors

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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
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