Antihemophilia Factors
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 |
|---|---|---|---|---|---|---|
| anti-inhibitor coagulant comp. | FEIBA | VIAL | N | |||
| antihem.FVIII,sin-chn,B-dm tru | AFSTYLA | VIAL | N | |||
| antihemo.FVIII,full length peg | ADYNOVATE | VIAL | N | |||
| antihemoph.FVIII rec,Fc fusion | ELOCTATE | VIAL | N | |||
| antihemoph.FVIII,B-dom truncat | NOVOEIGHT | VIAL | N | |||
| antihemoph.FVIII,B-domain del | XYNTHA SOLOFUSE | SYRINGE | N | |||
| antihemoph.FVIII,B-domain del | XYNTHA | VIAL | N | |||
| antihemoph.FVIII,HEK B-delete | NUWIQ | VIAL | N | |||
| antihemophil.FVIII,full length | ADVATE | VIAL | N | |||
| antihemophil.FVIII,full length | KOVALTRY | VIAL | N | |||
| antihemophilic factor, hum rec | KOGENATE | KIT | N | |||
| antihemophilic factor, hum rec | BIOCLATE | VIAL | N | |||
| antihemophilic factor, hum rec | RECOMBINATE | VIAL | N | |||
| antihemophilic factor, human | MONOCLATE-P | KIT | N | |||
| antihemophilic factor, human | KOATE | VIAL | N | |||
| antihemophilic factor, human | HEMOFIL M | VIAL | N | |||
| antihemophilic factor/VWF | ALPHANATE | VIAL | N | |||
| antihemophilic factor/VWF | HUMATE-P | VIAL | N | |||
| antihemophilic factor/VWF | WILATE | VIAL | N | |||
| antihemophilic FVIII,rec porc | OBIZUR | VIAL | N | |||
| coagulation factor VIIa,recomb | NOVOSEVEN RT | VIAL | N | |||
| coagulation VIIa,recomb-jncw | SEVENFACT | VIAL | N | |||
| FVIII rec,B-dom delet peg-aucl | JIVI | VIAL | N | |||
| FVIII rec,B-dom trunc peg-exei | ESPEROCT | VIAL | N | |||
| FVIII rec,Fc-VWF-XTEN,BDD-ehtl | ALTUVIIIO | VIAL | N |