Anticoagulants, Intravenous
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 | New Drug Evaluation |
|---|---|---|---|---|---|
| cangrelor tetrasodium | KENGREAL | VIAL | N | ||
| eptifibatide | EPTIFIBATIDE | PLAST. BAG | N | ||
| tirofiban HCl monohydrate | AGGRASTAT | VIAL | N | ||
| tirofiban-0.9% sodium chloride | AGGRASTAT | VIAL | N | ||
| argatroban | ARGATROBAN | VIAL | |||
| argatroban in 0.9 % sod chlor | ARGATROBAN-0.9% NACL | VIAL | |||
| bivalirudin | BIVALIRUDIN | VIAL | |||
| citrate phosphate dextros soln | CITRATE PHOSPHATE DEXTROSE | SOLUTION | |||
| eptifibatide | EPTIFIBATIDE | VIAL | |||
| heparin sod,porcine/0.9 % NaCl | HEP-PAK | KIT | |||
| heparin sod,porcine/0.9 % NaCl | HEP-PAK CVC | KIT | |||
| heparin sod,porcine/0.9 % NaCl | HEP-PAK LKFL | KIT | |||
| heparin sod,pork in 0.45% NaCl | HEPARIN SODIUM IN 0.45% NACL | IV SOLN | |||
| heparin sod,pork in 0.45% NaCl | HEPARIN SODIUM-0.45% NACL | IV SOLN | |||
| heparin sodium,porcine | HEPARIN SODIUM | CARTRIDGE | |||
| heparin sodium,porcine | HEPARIN LOCK | SYRINGE | |||
| heparin sodium,porcine | HEPARIN LOCK FLUSH | SYRINGE | |||
| heparin sodium,porcine | HEPARIN SODIUM | SYRINGE | |||
| heparin sodium,porcine | HEPARIN SODIUM | VIAL | |||
| heparin sodium,porcine | HEPARIN LOCK | VIAL | |||
| heparin sodium,porcine/D5W | HEPARIN SODIUM IN 5% DEXTROSE | IV SOLN | |||
| heparin sodium,porcine/D5W | HEPARIN SODIUM-D5W | IV SOLN | |||
| heparin sodium,porcine/NS/PF | HEPARIN SODIUM-0.9% NACL | IV SOLN | |||
| heparin sodium,porcine/PF | HEPARIN SODIUM | CARTRIDGE | |||
| heparin sodium,porcine/PF | HEPARIN SODIUM | SYRINGE | |||
| heparin sodium,porcine/PF | HEPARIN SODIUM | VIAL | |||
| sodium citrate | ANTICOAGULANT SODIUM CITRATE | SOLUTION | |||
| tirofiban-0.9% sodium chloride | TIROFIBAN HCL | PLAST. BAG | |||
| tirofiban-0.9% sodium chloride | AGGRASTAT | PLAST. BAG |