With the approval of Andexxa (Andexanet Alfa) came many headaches for those of us in the pharmacy world. The approval process was a bit odd and left us with many questions about safety, efficacy, cost, and post-administration anticoagulation. On top of that, it was made available to only select Level 1 Trauma Centers which needed to go through approval to bring it to formulary. Because it was approved so quickly, the FDA requires that PTLA continue to study the medication after marketing (ANNEXA-4 Phase 3b/4 study), and nobody really had any real standard processes to