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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 but eligible patients will encounter a co-pay at the pharmacy.
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
Current Drug Use Criteria New Drug Evaluation
aminocaproic acid AMICAR SOLUTION    
aminocaproic acid AMINOCAPROIC ACID TABLET    
aminocaproic acid AMICAR TABLET    
aminocaproic acid AMINOCAPROIC ACID VIAL    
factor Xa,inactivated-zhzo ANDEXXA VIAL    
ferric subsulfate ASTRINGYN SOLN(GRAM)    
fibrinogen RIASTAP EACH    
fibrinogen FIBRYGA VIAL    
fibrinogen/thrombin(human der) TACHOSIL ADH. PATCH    
gelatin sponge,absorb/porcine GELFOAM POWDER    
gelatin sponge,absorb/porcine GELFOAM COMPRESSED SPONGE    
gelatin sponge,absorb/porcine GELFOAM PACKS SPONGE    
gelatin sponge,absorb/porcine GELFOAM SPONGE    
gelatin sponge,absorbable GEL-FLOW NT SYRINGE    
idarucizumab PRAXBIND VIAL    
protamine sulfate PROTAMINE SULFATE VIAL    
thromb-cal-cell-dressing,hemos THROMBI-PAD MED. PAD    
thrombin (bovine) THROMBIN-JMI NAS SP SYR    
thrombin (bovine) THROMBIN-JMI SPRAY    
thrombin (bovine) THROMBIN-JMI SPRAY SYRN    
thrombin (bovine) THROMBIN-JMI VIAL    
thrombin,bovine/gelatin sponge GELFOAM JMI COMBO. PKG    
thrombin,bovine/gelatin sponge GELFOAM JMI KIT    
thrombin,bovine/gelatin sponge GEL-FLOW SYRINGEKIT    
thrombin/cal/cmc/gel/dress,hem THROMBI-GEL MED. PAD    
thrombin/fibrinogn/aprotin/cal TISSEEL VHSD SYRINGE    
tranexamic acid CYKLOKAPRON AMPUL    
tranexamic acid TRANEXAMIC ACID AMPUL    
tranexamic acid LYSTEDA TABLET    
tranexamic acid TRANEXAMIC ACID TABLET    
tranexamic acid CYKLOKAPRON VIAL    
tranexamic acid TRANEXAMIC ACID VIAL