Brand/Generic Name

Dosage/Strength

Status

Restrictions

Notes

Relative Cost

Arixtra fondaparinux 2.5 mg/0.5 mL Syringe; 5 mg/0.4 mL Syringe; 7.5 mg/0.6 mL Syringe; 10 mg/0.8 mL Syringe   $$$$$+ Coumadin warfarin 5 mg Recon Soln   $$$ Coumadin warfarin 7.5 mg tablet; 2.5 mg tablet; 3 mg tablet; 4 mg tablet; 6 mg tablet; 2 mg tablet; 5 mg tablet; 10 mg tablet; 1 mg tablet   $$$ Eliquis apixaban 2.5 mg tablet; 5 mg tablet   Not Applicable Fragmin dalteparin (porcine) 2,500 unit/0.2 mL Syringe; 5,000 unit/0.2 mL Syringe; 7,500 unit/0.3 mL Syringe; 10,000 unit/mL Syringe; 12,500 unit/0.5 mL Syringe; 15,000 unit/0.6 mL Syringe; 18,000 unit/0.72 mL Syringe   $$$$$+ Fragmin dalteparin (porcine) 25,000 unit/mL Solution   $$$$$+ heparin (porcine) heparin (porcine) 1,000 unit/mL Solution; 20,000 unit/mL Solution; 10,000 unit/mL Solution; 5,000 unit/mL Solution   $ heparin (porcine) heparin (porcine) 5,000 unit/mL Cartridge   $ Innohep tinzaparin (porcine) 20,000 anti-Xa unit/mL Solution   $$$$$+ Iprivask desirudin 15 mg Recon Soln   Not Applicable Lovenox enoxaparin 100 mg/mL Syringe; 60 mg/0.6 mL Syringe; 150 mg/mL Syringe; 80 mg/0.8 mL Syringe; 40 mg/0.4 mL Syringe; 120 mg/0.8 mL Syringe; 30 mg/0.3 mL Syringe   $$$$$+ Lovenox enoxaparin 300 mg/3 mL Solution   $$$$$+ Pradaxa dabigatran etexilate 150 mg capsule; 75 mg capsule   Not Applicable Xarelto rivaroxaban 15 mg tablet   Not Applicable Xarelto rivaroxaban 20 mg tablet; 10 mg tablet   Not Applicable

Key for Product(s) Listed Above

Formulary Prior Authorization (PA may not be required for some benefit plans) Non-Formulary (Third tier coverage applies for selected plans) Not Reimbursed Quantity Limit Not available through mail order as 90-day supply* Step Therapy Generic Available. Brand name medication may be covered at a higher member cost or may not be covered for certain plans. Notes $Relative cost compared to others in category Specialty distribution for selected plans (Fourth or fifth tier coverage applied for selected plans)

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