Hemostatics
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 |
|---|---|---|---|---|---|
| aminocaproic acid | AMINOCAPROIC ACID | SOLUTION | |||
| aminocaproic acid | AMINOCAPROIC ACID | TABLET | |||
| aminocaproic acid | AMINOCAPROIC ACID | VIAL | |||
| factor Xa,inactivated-zhzo | ANDEXXA | VIAL | |||
| ferric subsulfate | ASTRINGYN | SOLN(GRAM) | |||
| fibrinogen | FIBRYGA | VIAL | |||
| fibrinogen | RIASTAP | VIAL | |||
| fibrinogen/thrombin(human der) | TACHOSIL | ADH. PATCH | |||
| gelatin sponge,absorb/porcine | GELFOAM | POWDER | |||
| gelatin sponge,absorbable | GEL-FLOW NT | SYRINGE | |||
| idarucizumab | PRAXBIND | VIAL | |||
| protamine sulfate | PROTAMINE SULFATE | VIAL | |||
| thrombin (bovine) | THROMBIN-JMI | NAS SP SYR | |||
| thrombin (bovine) | THROMBIN-JMI | SPRAY | |||
| thrombin (bovine) | THROMBIN-JMI | SPRAY SYRN | |||
| thrombin (bovine) | THROMBIN-JMI | VIAL | |||
| thrombin (recombinant) | RECOTHROM | VIAL | |||
| thrombin,bovine/gelatin sponge | GEL-FLOW | SYRINGEKIT | |||
| thrombin,hu/fibrinogen/calcium | VISTASEAL FIBRIN SEALANT | SYRINGE | |||
| tranexamic acid | CYKLOKAPRON | AMPUL | |||
| tranexamic acid | TRANEXAMIC ACID | TABLET | |||
| tranexamic acid | TRANEXAMIC ACID | VIAL | |||
| tranexamic acid | CYKLOKAPRON | VIAL | |||
| tranexamic acid in NaCl,iso-os | TRANEXAMIC ACID-NACL | PIGGYBACK |