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.
| NDC | Brand Name | Generic Name | Form | Strength | PDL Status |
Rebate | Carveout ‐ Bill FFS |
Current Drug Use Criteria |
|---|---|---|---|---|---|---|---|---|
| 00054110058 | AMINOCAPROIC ACID | aminocaproic acid | SOLUTION | 250 mg/mL | Y | N | ||
| 31722003523 | AMINOCAPROIC ACID | aminocaproic acid | SOLUTION | 250 mg/mL | Y | N | ||
| 52817081508 | AMINOCAPROIC ACID | aminocaproic acid | SOLUTION | 250 mg/mL | Y | N | ||
| 59651057308 | AMINOCAPROIC ACID | aminocaproic acid | SOLUTION | 250 mg/mL | Y | N | ||
| 69238159608 | AMINOCAPROIC ACID | aminocaproic acid | SOLUTION | 250 mg/mL | Y | N | ||
| 69680011408 | AMINOCAPROIC ACID | aminocaproic acid | SOLUTION | 250 mg/mL | Y | N | ||
| 70377010411 | AMINOCAPROIC ACID | aminocaproic acid | SOLUTION | 250 mg/mL | Y | N | ||
| 80005013022 | AMINOCAPROIC ACID | aminocaproic acid | SOLUTION | 250 mg/mL | Y | N | ||
| 00054111013 | AMINOCAPROIC ACID | aminocaproic acid | TABLET | 1,000 mg | Y | N | ||
| 24658079930 | AMINOCAPROIC ACID | aminocaproic acid | TABLET | 1,000 mg | Y | N | ||
| 69680011630 | AMINOCAPROIC ACID | aminocaproic acid | TABLET | 1,000 mg | Y | N | ||
| 70377010311 | AMINOCAPROIC ACID | aminocaproic acid | TABLET | 1,000 mg | Y | N | ||
| 00904716507 | AMINOCAPROIC ACID | aminocaproic acid | TABLET | 500 mg | Y | N | ||
| 24658079830 | AMINOCAPROIC ACID | aminocaproic acid | TABLET | 500 mg | Y | N | ||
| 60687073925 | AMINOCAPROIC ACID | aminocaproic acid | TABLET | 500 mg | Y | N | ||
| 60687073995 | AMINOCAPROIC ACID | aminocaproic acid | TABLET | 500 mg | Y | N | ||
| 62559022530 | AMINOCAPROIC ACID | aminocaproic acid | TABLET | 500 mg | Y | N | ||
| 69238163703 | AMINOCAPROIC ACID | aminocaproic acid | TABLET | 500 mg | Y | N | ||
| 69680011530 | AMINOCAPROIC ACID | aminocaproic acid | TABLET | 500 mg | Y | N | ||
| 70377010211 | AMINOCAPROIC ACID | aminocaproic acid | TABLET | 500 mg | Y | N | ||
| 72205004930 | AMINOCAPROIC ACID | aminocaproic acid | TABLET | 500 mg | Y | N | ||
| 00409434616 | AMINOCAPROIC ACID | aminocaproic acid | VIAL | 250 mg/mL | Y | N | ||
| 00409434673 | AMINOCAPROIC ACID | aminocaproic acid | VIAL | 250 mg/mL | Y | N | ||
| 00517912001 | AMINOCAPROIC ACID | aminocaproic acid | VIAL | 250 mg/mL | Y | N | ||
| 00517912025 | AMINOCAPROIC ACID | aminocaproic acid | VIAL | 250 mg/mL | Y | N | ||
| 00517919101 | AMINOCAPROIC ACID | aminocaproic acid | VIAL | 250 mg/mL | Y | N | ||
| 00517919125 | AMINOCAPROIC ACID | aminocaproic acid | VIAL | 250 mg/mL | Y | N | ||
| 72572001501 | AMINOCAPROIC ACID | aminocaproic acid | VIAL | 250 mg/mL | Y | N | ||
| 72572001525 | AMINOCAPROIC ACID | aminocaproic acid | VIAL | 250 mg/mL | Y | N | ||
| 00310320001 | ANDEXXA | factor Xa,inactivated-zhzo | VIAL | 200 mg | Y | N | ||
| 00310320004 | ANDEXXA | factor Xa,inactivated-zhzo | VIAL | 200 mg | Y | N | ||
| 00310320005 | ANDEXXA | factor Xa,inactivated-zhzo | VIAL | 200 mg | Y | N | ||
| 69853010201 | ANDEXXA | factor Xa,inactivated-zhzo | VIAL | 200 mg | Y | N | ||
| 59365606500 | ASTRINGYN | ferric subsulfate | SOLN(GRAM) | 259 mg/gram | Y | N | ||
| 59365606501 | ASTRINGYN | ferric subsulfate | SOLN(GRAM) | 259 mg/gram | Y | N | ||
| 68982034701 | FIBRYGA | fibrinogen | VIAL | 1 gram (700 mg-1,300 mg) | Y | N | ||
| 68982034801 | FIBRYGA | fibrinogen | VIAL | 1 gram (700 mg-1,300 mg) | Y | N | ||
| 68982034901 | FIBRYGA | fibrinogen | VIAL | 1 gram (700 mg-1,300 mg) | Y | N | ||
| 68982034981 | FIBRYGA | fibrinogen | VIAL | 1 gram (700 mg-1,300 mg) | Y | N | ||
| 63833089151 | RIASTAP | fibrinogen | VIAL | 1 gram (900 mg-1,300 mg) | Y | N | ||
| 63833089190 | RIASTAP | fibrinogen | VIAL | 1 gram (900 mg-1,300 mg) | Y | N | ||
| 68982035001 | FIBRYGA | fibrinogen | VIAL | 2 gram (1,400 mg-2,600 mg) | Y | N | ||
| 68982035081 | FIBRYGA | fibrinogen | VIAL | 2 gram (1,400 mg-2,600 mg) | Y | N | ||
| 00009043304 | GELFOAM | gelatin sponge,absorb/porcine | POWDER | Y | N | |||
| 00009104001 | GEL-FLOW NT | gelatin sponge,absorbable | SYRINGE | Y | N | |||
| 00009104006 | GEL-FLOW NT | gelatin sponge,absorbable | SYRINGE | Y | N | |||
| 00597019705 | PRAXBIND | idarucizumab | VIAL | 2.5 gram/50 mL | Y | N | ||
| 63323022901 | PROTAMINE SULFATE | protamine sulfate | VIAL | 10 mg/mL | Y | N | ||
| 63323022905 | PROTAMINE SULFATE | protamine sulfate | VIAL | 10 mg/mL | Y | N | ||
| 63323022915 | PROTAMINE SULFATE | protamine sulfate | VIAL | 10 mg/mL | Y | N | ||
| 63323022921 | PROTAMINE SULFATE | protamine sulfate | VIAL | 10 mg/mL | Y | N | ||
| 63323022930 | PROTAMINE SULFATE | protamine sulfate | VIAL | 10 mg/mL | Y | N | ||
| 63323022935 | PROTAMINE SULFATE | protamine sulfate | VIAL | 10 mg/mL | Y | N | ||
| 63323022941 | PROTAMINE SULFATE | protamine sulfate | VIAL | 10 mg/mL | Y | N | ||
| 63323022994 | PROTAMINE SULFATE | protamine sulfate | VIAL | 10 mg/mL | Y | N | ||
| 63323022995 | PROTAMINE SULFATE | protamine sulfate | VIAL | 10 mg/mL | Y | N | ||
| 60793020505 | THROMBIN-JMI | thrombin (bovine) | NAS SP SYR | 5,000 unit | Y | N | ||
| 60793021721 | THROMBIN-JMI | thrombin (bovine) | SPRAY | 20,000 unit | Y | N | ||
| 60793021722 | THROMBIN-JMI | thrombin (bovine) | SPRAY SYRN | 20,000 unit | Y | N | ||
| 60793070505 | THROMBIN-JMI | thrombin (bovine) | SPRAY SYRN | 5,000 unit | Y | N | ||
| 60793021720 | THROMBIN-JMI | thrombin (bovine) | VIAL | 20,000 unit | Y | N | ||
| 60793031701 | THROMBIN-JMI | thrombin (bovine) | VIAL | 20,000 unit | Y | N | ||
| 60793021505 | THROMBIN-JMI | thrombin (bovine) | VIAL | 5,000 unit | Y | N | ||
| 60793031501 | THROMBIN-JMI | thrombin (bovine) | VIAL | 5,000 unit | Y | N | ||
| 00338032601 | RECOTHROM | thrombin (recombinant) | VIAL | 20,000 unit | Y | N | ||
| 00338032801 | RECOTHROM | thrombin (recombinant) | VIAL | 20,000 unit | Y | N | ||
| 00338033001 | RECOTHROM | thrombin (recombinant) | VIAL | 20,000 unit | Y | N | ||
| 00338032201 | RECOTHROM | thrombin (recombinant) | VIAL | 5,000 unit | Y | N | ||
| 00338032401 | RECOTHROM | thrombin (recombinant) | VIAL | 5,000 unit | Y | N | ||
| 00009225001 | GEL-FLOW | thrombin,bovine/gelatin sponge | SYRINGEKIT | 5,000 unit | Y | N | ||
| 61953001401 | VISTASEAL FIBRIN SEALANT | thrombin,hu/fibrinogen/calcium | SYRINGE | 500 unit-80 mg/mL (10 mL) | Y | N | ||
| 61953001101 | VISTASEAL FIBRIN SEALANT | thrombin,hu/fibrinogen/calcium | SYRINGE | 500 unit-80 mg/mL (2 mL) | Y | N | ||
| 61953001201 | VISTASEAL FIBRIN SEALANT | thrombin,hu/fibrinogen/calcium | SYRINGE | 500 unit-80 mg/mL (4 mL) | Y | N | ||
| 00013111401 | CYKLOKAPRON | tranexamic acid | AMPUL | 1,000 mg/10 mL (100 mg/mL) | Y | N | ||
| 00013111415 | CYKLOKAPRON | tranexamic acid | AMPUL | 1,000 mg/10 mL (100 mg/mL) | Y | N | ||
| 23155090931 | TRANEXAMIC ACID | tranexamic acid | AMPUL | 1,000 mg/10 mL (100 mg/mL) | Y | N | ||
| 23155090941 | TRANEXAMIC ACID | tranexamic acid | AMPUL | 1,000 mg/10 mL (100 mg/mL) | Y | N | ||
| 00591372030 | TRANEXAMIC ACID | tranexamic acid | TABLET | 650 mg | Y | N | ||
| 50268077211 | TRANEXAMIC ACID | tranexamic acid | TABLET | 650 mg | Y | N | ||
| 50268077213 | TRANEXAMIC ACID | tranexamic acid | TABLET | 650 mg | Y | N | ||
| 59651083930 | TRANEXAMIC ACID | tranexamic acid | TABLET | 650 mg | Y | N | ||
| 60687075011 | TRANEXAMIC ACID | tranexamic acid | TABLET | 650 mg | Y | N | ||
| 60687075021 | TRANEXAMIC ACID | tranexamic acid | TABLET | 650 mg | Y | N | ||
| 62559026530 | TRANEXAMIC ACID | tranexamic acid | TABLET | 650 mg | Y | N | ||
| 69918030130 | TRANEXAMIC ACID | tranexamic acid | TABLET | 650 mg | Y | N | ||
| 72888017830 | TRANEXAMIC ACID | tranexamic acid | TABLET | 650 mg | Y | N | ||
| 75907030930 | TRANEXAMIC ACID | tranexamic acid | TABLET | 650 mg | Y | N | ||
| 00013111420 | CYKLOKAPRON | tranexamic acid | VIAL | 1,000 mg/10 mL (100 mg/mL) | Y | N | ||
| 00013111421 | CYKLOKAPRON | tranexamic acid | VIAL | 1,000 mg/10 mL (100 mg/mL) | Y | N | ||
| 14789050010 | TRANEXAMIC ACID | tranexamic acid | VIAL | 1,000 mg/10 mL (100 mg/mL) | Y | N | ||
| 23155016631 | TRANEXAMIC ACID | tranexamic acid | VIAL | 1,000 mg/10 mL (100 mg/mL) | Y | N | ||
| 23155016641 | TRANEXAMIC ACID | tranexamic acid | VIAL | 1,000 mg/10 mL (100 mg/mL) | Y | N | ||
| 23155052431 | TRANEXAMIC ACID | tranexamic acid | VIAL | 1,000 mg/10 mL (100 mg/mL) | Y | N | ||
| 23155052441 | TRANEXAMIC ACID | tranexamic acid | VIAL | 1,000 mg/10 mL (100 mg/mL) | Y | N | ||
| 23155091031 | TRANEXAMIC ACID | tranexamic acid | VIAL | 1,000 mg/10 mL (100 mg/mL) | Y | N | ||
| 23155091041 | TRANEXAMIC ACID | tranexamic acid | VIAL | 1,000 mg/10 mL (100 mg/mL) | Y | N | ||
| 25021041510 | TRANEXAMIC ACID | tranexamic acid | VIAL | 1,000 mg/10 mL (100 mg/mL) | Y | N | ||
| 25021041566 | TRANEXAMIC ACID | tranexamic acid | VIAL | 1,000 mg/10 mL (100 mg/mL) | Y | N | ||
| 39822100001 | TRANEXAMIC ACID | tranexamic acid | VIAL | 1,000 mg/10 mL (100 mg/mL) | Y | N | ||
| 43066000801 | TRANEXAMIC ACID | tranexamic acid | VIAL | 1,000 mg/10 mL (100 mg/mL) | Y | N | ||
| 43066000810 | TRANEXAMIC ACID | tranexamic acid | VIAL | 1,000 mg/10 mL (100 mg/mL) | Y | N | ||
| 55150018810 | TRANEXAMIC ACID | tranexamic acid | VIAL | 1,000 mg/10 mL (100 mg/mL) | Y | N | ||
| 60505616900 | TRANEXAMIC ACID | tranexamic acid | VIAL | 1,000 mg/10 mL (100 mg/mL) | Y | N | ||
| 60505616901 | TRANEXAMIC ACID | tranexamic acid | VIAL | 1,000 mg/10 mL (100 mg/mL) | Y | N | ||
| 61990061100 | TRANEXAMIC ACID | tranexamic acid | VIAL | 1,000 mg/10 mL (100 mg/mL) | Y | N | ||
| 61990061102 | TRANEXAMIC ACID | tranexamic acid | VIAL | 1,000 mg/10 mL (100 mg/mL) | Y | N | ||
| 63323056301 | TRANEXAMIC ACID | tranexamic acid | VIAL | 1,000 mg/10 mL (100 mg/mL) | Y | N | ||
| 63323056310 | TRANEXAMIC ACID | tranexamic acid | VIAL | 1,000 mg/10 mL (100 mg/mL) | Y | N | ||
| 65145010601 | TRANEXAMIC ACID | tranexamic acid | VIAL | 1,000 mg/10 mL (100 mg/mL) | Y | N | ||
| 65145010610 | TRANEXAMIC ACID | tranexamic acid | VIAL | 1,000 mg/10 mL (100 mg/mL) | Y | N | ||
| 67457019700 | TRANEXAMIC ACID | tranexamic acid | VIAL | 1,000 mg/10 mL (100 mg/mL) | Y | N | ||
| 67457019710 | TRANEXAMIC ACID | tranexamic acid | VIAL | 1,000 mg/10 mL (100 mg/mL) | Y | N | ||
| 69543037613 | TRANEXAMIC ACID | tranexamic acid | VIAL | 1,000 mg/10 mL (100 mg/mL) | Y | N | ||
| 70860040710 | TRANEXAMIC ACID | tranexamic acid | VIAL | 1,000 mg/10 mL (100 mg/mL) | Y | N | ||
| 70860040741 | TRANEXAMIC ACID | tranexamic acid | VIAL | 1,000 mg/10 mL (100 mg/mL) | Y | N | ||
| 72485010701 | TRANEXAMIC ACID | tranexamic acid | VIAL | 1,000 mg/10 mL (100 mg/mL) | Y | N | ||
| 72485010710 | TRANEXAMIC ACID | tranexamic acid | VIAL | 1,000 mg/10 mL (100 mg/mL) | Y | N | ||
| 72485051001 | TRANEXAMIC ACID | tranexamic acid | VIAL | 1,000 mg/10 mL (100 mg/mL) | Y | N | ||
| 72485051010 | TRANEXAMIC ACID | tranexamic acid | VIAL | 1,000 mg/10 mL (100 mg/mL) | Y | N | ||
| 72603038701 | TRANEXAMIC ACID | tranexamic acid | VIAL | 1,000 mg/10 mL (100 mg/mL) | Y | N | ||
| 72603038710 | TRANEXAMIC ACID | tranexamic acid | VIAL | 1,000 mg/10 mL (100 mg/mL) | Y | N | ||
| 81284061100 | TRANEXAMIC ACID | tranexamic acid | VIAL | 1,000 mg/10 mL (100 mg/mL) | Y | N | ||
| 81284061110 | TRANEXAMIC ACID | tranexamic acid | VIAL | 1,000 mg/10 mL (100 mg/mL) | Y | N | ||
| 81284061200 | TRANEXAMIC ACID | tranexamic acid | VIAL | 1,000 mg/10 mL (100 mg/mL) | Y | N | ||
| 81284061210 | TRANEXAMIC ACID | tranexamic acid | VIAL | 1,000 mg/10 mL (100 mg/mL) | Y | N | ||
| 83634040110 | TRANEXAMIC ACID | tranexamic acid | VIAL | 1,000 mg/10 mL (100 mg/mL) | Y | N | ||
| 83634040141 | TRANEXAMIC ACID | tranexamic acid | VIAL | 1,000 mg/10 mL (100 mg/mL) | Y | N | ||
| 14789011505 | TRANEXAMIC ACID-NACL | tranexamic acid in NaCl,iso-os | PIGGYBACK | 1,000 mg/100 mL (10 mg/mL) | Y | N | ||
| 14789011508 | TRANEXAMIC ACID-NACL | tranexamic acid in NaCl,iso-os | PIGGYBACK | 1,000 mg/100 mL (10 mg/mL) | Y | N | ||
| 25021041882 | TRANEXAMIC ACID-NACL | tranexamic acid in NaCl,iso-os | PIGGYBACK | 1,000 mg/100 mL (10 mg/mL) | Y | N | ||
| 51754010801 | TRANEXAMIC ACID-NACL | tranexamic acid in NaCl,iso-os | PIGGYBACK | 1,000 mg/100 mL (10 mg/mL) | Y | N | ||
| 51754010803 | TRANEXAMIC ACID-NACL | tranexamic acid in NaCl,iso-os | PIGGYBACK | 1,000 mg/100 mL (10 mg/mL) | Y | N | ||
| 65219053401 | TRANEXAMIC ACID-NACL | tranexamic acid in NaCl,iso-os | PIGGYBACK | 1,000 mg/100 mL (10 mg/mL) | Y | N | ||
| 65219053410 | TRANEXAMIC ACID-NACL | tranexamic acid in NaCl,iso-os | PIGGYBACK | 1,000 mg/100 mL (10 mg/mL) | Y | N | ||
| 80830232901 | TRANEXAMIC ACID-NACL | tranexamic acid in NaCl,iso-os | PIGGYBACK | 1,000 mg/100 mL (10 mg/mL) | Y | N | ||
| 80830232902 | TRANEXAMIC ACID-NACL | tranexamic acid in NaCl,iso-os | PIGGYBACK | 1,000 mg/100 mL (10 mg/mL) | Y | N | ||
| 80830232903 | TRANEXAMIC ACID-NACL | tranexamic acid in NaCl,iso-os | PIGGYBACK | 1,000 mg/100 mL (10 mg/mL) | Y | N |