Laxatives, Chronic Constipation
PDL Reference Documents
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 |
---|---|---|---|---|---|
bisacodyl | LAXATIVE | TABLET | Y | ||
bisacodyl | CORRECTOL | TABLET | Y | ||
bisacodyl | WOMAN'S LAXATIVE | TABLET | Y | ||
bisacodyl | WOMEN'S LAXATIVE | TABLET | Y | ||
bisacodyl | FEMITROL | TABLET | Y | ||
bisacodyl | GENTLE LAXATIVE | TABLET | Y | ||
bisacodyl | GENTLE LAXATIVE | TABLET DR | Y | ||
bisacodyl | LAXATIVE | TABLET DR | Y | ||
bisacodyl | MODANE | TABLET DR | Y | ||
bisacodyl | WOMEN'S GENTLE LAXATIVE | TABLET DR | Y | ||
bisacodyl | BISACODYL | TABLET DR | Y | ||
bisacodyl | LAXATIVE | TABLET DR | Y | ||
bisacodyl | ALOPHEN PILLS | TABLET DR | Y | ||
bisacodyl | BISACODYL | TABLET DR | Y | ||
bisacodyl | BISA-LAX | TABLET DR | Y | ||
bisacodyl | C-LAX LAXATIVE | TABLET DR | Y | ||
bisacodyl | DULCOLAX | TABLET DR | Y | ||
bisacodyl | DYLAXOL | TABLET DR | Y | ||
bisacodyl | GENTLE LAXATIVE | TABLET DR | Y | ||
bisacodyl | WOMEN'S GENTLE LAXATIVE | TABLET DR | Y | ||
bisacodyl | WOMEN'S LAXATIVE | TABLET DR | Y | ||
calcium polycarbophil | FIBER | TABLET | Y | ||
calcium polycarbophil | FIBER LAXATIVE | TABLET | Y | ||
calcium polycarbophil | FIBER TABS | TABLET | Y | ||
calcium polycarbophil | FIBER-LAX | TABLET | Y | ||
calcium polycarbophil | FIBER-LAX | TABLET | Y | ||
calcium polycarbophil | FIBER TABS | TABLET | Y | ||
calcium polycarbophil | FIBERCON | TABLET | Y | ||
calcium polycarbophil | FIBER THERAPY | TABLET | Y | ||
calcium polycarbophil | CALCIUM POLYCARBOPHIL | TABLET | Y | ||
calcium polycarbophil | FIBER | TABLET | Y | ||
calcium polycarbophil | FIBER LAX | TABLET | Y | ||
calcium polycarbophil | FIBER LAXATIVE | TABLET | Y | ||
cellulose | UNIFIBER | POWDER | Y | ||
docusate calcium | DOCUSATE CALCIUM | CAPSULE | Y | ||
docusate calcium | KAOPECTATE | CAPSULE | Y | ||
docusate calcium | STOOL SOFTENER | CAPSULE | Y | ||
docusate calcium | CALCIUM STOOL SOFTENER | CAPSULE | Y | ||
docusate calcium | DOCUSATE CALCIUM | CAPSULE | Y | ||
docusate calcium | STOOL SOFTENER | CAPSULE | Y | ||
docusate calcium | SURFAK | CAPSULE | Y | ||
docusate sodium | STOOL SOFTENER | CAPSULE | Y | ||
docusate sodium | DOK | CAPSULE | Y | ||
docusate sodium | DOCUSATE SODIUM | CAPSULE | Y | ||
docusate sodium | COLACE CLEAR | CAPSULE | Y | ||
docusate sodium | COLACE | CAPSULE | Y | ||
docusate sodium | COL-RITE | CAPSULE | Y | ||
docusate sodium | PHILLIPS' LAXATIVE | CAPSULE | Y | ||
docusate sodium | DOCUSATE SODIUM | CAPSULE | Y | ||
docusate sodium | DOK | CAPSULE | Y | ||
docusate sodium | DSS | CAPSULE | Y | ||
docusate sodium | DULCOLAX STOOL SOFTENER | CAPSULE | Y | ||
docusate sodium | DUOSOL | CAPSULE | Y | ||
docusate sodium | LAXA BASIC 100 | CAPSULE | Y | ||
docusate sodium | REGULAX SS | CAPSULE | Y | ||
docusate sodium | STOOL SOFTENER | CAPSULE | Y | ||
docusate sodium | SILACE | LIQUID | Y | ||
docusate sodium | DOCUSATE SODIUM | LIQUID | Y | ||
docusate sodium | DOCUSATE SODIUM | LIQUID | Y | ||
docusate sodium | DOCU LIQUID | LIQUID | Y | ||
docusate sodium | ONELAX DOCUSATE SODIUM | LIQUID | Y | ||
docusate sodium | STOOL SOFTENER | LIQUID | Y | ||
docusate sodium | SILACE | LIQUID | Y | ||
docusate sodium | SILACE | SYRUP | Y | ||
docusate sodium | PEDIA-LAX STOOL SOFTENER | SYRUP | Y | ||
docusate sodium | COLACE | SYRUP | Y | ||
docusate sodium | DOCUSATE SODIUM | SYRUP | Y | ||
docusate sodium | DIOCTO | SYRUP | Y | ||
docusate sodium | DOCUSATE SODIUM | SYRUP | Y | ||
docusate sodium | STOOL SOFTENER | SYRUP | Y | ||
docusate sodium | DOCUSATE SODIUM | TABLET | Y | ||
docusate sodium | DOK | TABLET | Y | ||
docusate sodium | STOOL SOFTENER | TABLET | Y | ||
docusate sodium | DOCUSATE SODIUM | TABLET | Y | ||
docusate sodium | MOVE IT ALONG | TABLET | Y | ||
docusate sodium | DOCUPRENE | TABLET | Y | ||
docusate sodium | PROMOLAXIN | TABLET | Y | ||
docusate sodium | STOOL SOFTENER | TABLET | Y | ||
fructooligosaccharides/polydex | FIBEREX F15 | LIQUID | Y | ||
glycerin/maltodextrin | LIQUAFIBER | LIQUID | Y | ||
guar gum | BENEFIBER | PACKET | Y | ||
guar gum | BENEFIBER | POWDER | Y | ||
inulin | CHILD'S FIBER SELECT GUMMIES | TAB CHEW | Y | ||
lactulose | GENERLAC | SOLUTION | Y | ||
lactulose | CONSTULOSE | SOLUTION | Y | ||
lactulose | ENULOSE | SOLUTION | Y | ||
lactulose | LACTULOSE | SOLUTION | Y | ||
magnesium citrate | MAGNESIUM CITRATE | SOLUTION | Y | ||
magnesium citrate | CITRATE OF MAGNESIA | SOLUTION | Y | ||
magnesium citrate | ONELAX MAGNESIUM CITRATE | SOLUTION | Y | ||
magnesium citrate | MAGNESIUM CITRATE | SOLUTION | Y | ||
magnesium citrate | CITROMA | SOLUTION | Y | ||
magnesium hydroxide | MILK OF MAGNESIA | ORAL SUSP | Y | ||
magnesium hydroxide | DULCOLAX | ORAL SUSP | Y | ||
magnesium hydroxide | MILK OF MAGNESIA | ORAL SUSP | Y | ||
magnesium hydroxide | PHILLIPS' MILK OF MAGNESIA | ORAL SUSP | Y | ||
magnesium hydroxide | PEDIA-LAX | TAB CHEW | Y | ||
magnesium hydroxide | DULCOLAX | TAB CHEW | Y | ||
methylcellulose | FIBER THERAPY | TABLET | Y | ||
methylcellulose | FIBER | TABLET | Y | ||
methylcellulose | FIBER LAXATIVE | TABLET | Y | ||
methylcellulose | SOLUBLE FIBER | TABLET | Y | ||
methylcellulose | FIBER THERAPY | TABLET | Y | ||
methylcellulose | CITRUCEL | TABLET | Y | ||
methylcellulose | FIBER LAXATIVE | TABLET | Y | ||
methylcellulose | FIBER | TABLET | Y | ||
methylcellulose (with sugar) | FIBER THERAPY | POWDER | Y | ||
polyethylene glycol 3350 | CLEARLAX | POWDER | Y | ||
polyethylene glycol 3350 | GAVILAX | POWDER | Y | ||
polyethylene glycol 3350 | POLYETHYLENE GLYCOL 3350 | POWDER | Y | ||
polyethylene glycol 3350 | SMOOTHLAX | POWDER | Y | ||
polyethylene glycol 3350 | CLEARLAX | POWDER | Y | ||
polyethylene glycol 3350 | GAVILAX | POWDER | Y | ||
polyethylene glycol 3350 | GENTLELAX | POWDER | Y | ||
polyethylene glycol 3350 | GLYCOLAX | POWDER | Y | ||
polyethylene glycol 3350 | LAXACLEAR | POWDER | Y | ||
polyethylene glycol 3350 | LAXATIVE PEG 3350 | POWDER | Y | ||
polyethylene glycol 3350 | MIRALAX | POWDER | Y | ||
polyethylene glycol 3350 | NATURA-LAX | POWDER | Y | ||
polyethylene glycol 3350 | POLYETHYLENE GLYCOL 3350 | POWDER | Y | ||
polyethylene glycol 3350 | PURELAX | POWDER | Y | ||
polyethylene glycol 3350 | POWDERLAX | POWDER | Y | ||
psyllium husk | NATURAL FIBER | CAPSULE | Y | ||
psyllium husk | WAL-MUCIL | CAPSULE | Y | ||
psyllium husk | FIBER | CAPSULE | Y | ||
psyllium husk | DAILY FIBER | CAPSULE | Y | ||
psyllium husk | FIBER THERAPY | CAPSULE | Y | ||
psyllium husk | NATURAL FIBER | CAPSULE | Y | ||
psyllium husk | PSYLLIUM FIBER | CAPSULE | Y | ||
psyllium husk | KONSYL | POWDER | Y | ||
psyllium husk | PSYLLIUM SEED | POWDER | Y | ||
psyllium husk | GERI-MUCIL | POWDER | Y | ||
psyllium husk | METAMUCIL | POWDER | Y | ||
psyllium husk | ONELAX DAILY FIBER | POWDER | Y | ||
psyllium husk | NATURAL FIBER SUPPLEMENT | POWDER | Y | ||
psyllium husk (with dextrose) | KONSYL FORMULA-D | POWDER | Y | ||
psyllium husk (with sugar) | ONELAX FIBER THERAPY | POWDER | Y | ||
psyllium husk (with sugar) | NATURAL VEGETABLE POWDER | POWDER | Y | ||
psyllium husk (with sugar) | DAILY FIBER | POWDER | Y | ||
psyllium husk (with sugar) | FIBER THERAPY | POWDER | Y | ||
psyllium husk (with sugar) | GERI-MUCIL | POWDER | Y | ||
psyllium husk (with sugar) | METAMUCIL | POWDER | Y | ||
psyllium husk (with sugar) | MULTIHEALTH FIBER | POWDER | Y | ||
psyllium husk (with sugar) | NATURAL DAILY FIBER | POWDER | Y | ||
psyllium husk (with sugar) | WAL-MUCIL | POWDER | Y | ||
psyllium husk (with sugar) | NATURAL FIBER LAXATIVE | POWDER | Y | ||
psyllium husk (with sugar) | PSYLLIUM FIBER POWDER | POWDER | Y | ||
psyllium husk (with sugar) | WAL-MUCIL NATURAL FIBER LAX | POWDER | Y | ||
psyllium husk (with sugar) | NATURAL FIBER | POWDER | Y | ||
psyllium husk/aspartame | MUCILIN SF | POWD PACK | Y | ||
psyllium husk/aspartame | WAL-MUCIL | POWDER | Y | ||
psyllium husk/aspartame | NATURAL DAILY FIBER | POWDER | Y | ||
psyllium husk/aspartame | MULTIHEALTH FIBER | POWDER | Y | ||
psyllium husk/aspartame | FIBER THERAPY | POWDER | Y | ||
psyllium husk/aspartame | GERI-MUCIL | POWDER | Y | ||
psyllium husk/aspartame | METAMUCIL | POWDER | Y | ||
psyllium husk/aspartame | METAMUCIL MULTIHEALTH FIBER | POWDER | Y | ||
psyllium husk/aspartame | METAMUCIL SUGAR-FREE | POWDER | Y | ||
psyllium husk/aspartame | MUCILIN SF | POWDER | Y | ||
psyllium seed | KONSYL | POWDER | Y | ||
psyllium seed | NATURAL VEGETABLE LAXATIVE | POWDER | Y | ||
psyllium seed | NVP | POWDER | Y | ||
psyllium seed | NATURAL VEGETABLE POWDER | POWDER | Y | ||
psyllium seed | WAL-MUCIL | POWDER | Y | ||
psyllium seed | NVP | POWDER | Y | ||
psyllium seed | NATURAL VEGETABLE SMOOTH | POWDER | Y | ||
psyllium seed | HYDROCIL INSTANT | POWDER | Y | ||
psyllium seed | NATURAL VEGETABLE POWDER | POWDER | Y | ||
psyllium seed (with dextrose) | KONSYL-D | PACKET | Y | ||
psyllium seed (with dextrose) | KONSYL-D | POWDER | Y | ||
psyllium seed (with dextrose) | MODANE BULK | POWDER | Y | ||
psyllium seed (with dextrose) | LAXATIVE | POWDER | Y | ||
psyllium seed (with dextrose) | FIBER | POWDER | Y | ||
psyllium seed (with dextrose) | NVP | POWDER | Y | ||
psyllium seed (with dextrose) | LAXATIVE VEGETABLE | POWDER | Y | ||
psyllium seed (with dextrose) | NATURAL FIBER | POWDER | Y | ||
psyllium seed (with dextrose) | NATURAL VEGETABLE POWDER | POWDER | Y | ||
psyllium seed (with dextrose) | SORBULAX | POWDER | Y | ||
psyllium seed (with dextrose) | NATURAL FIBER LAXATIVE | POWDER | Y | ||
psyllium seed (with sugar) | NATURAL PSYLLIUM LAXATIVE | POWDER | Y | ||
psyllium seed (with sugar) | NATURAL VEGETABLE LAXATIVE | POWDER | Y | ||
psyllium seed (with sugar) | NVP | POWDER | Y | ||
psyllium seed (with sugar) | LAXATIVE | POWDER | Y | ||
psyllium seed (with sugar) | FIBER | POWDER | Y | ||
psyllium seed (with sugar) | FIBER THERAPY | POWDER | Y | ||
psyllium seed (with sugar) | METAMUCIL | POWDER | Y | ||
psyllium seed (with sugar) | NATURAL FIBER LAXATIVE | POWDER | Y | ||
psyllium seed (with sugar) | NATURAL FIBER POWDER | POWDER | Y | ||
psyllium seed (with sugar) | NATURAL VEGETABLE | POWDER | Y | ||
psyllium seed (with sugar) | NATURAL VEGETABLE POWDER | POWDER | Y | ||
psyllium seed (with sugar) | NVP | POWDER | Y | ||
psyllium seed (with sugar) | NATURAL VEGETABLE LAXATIVE | POWDER | Y | ||
psyllium seed/aspartame | KONSYL | POWDER | Y | ||
psyllium seed/aspartame | NATURAL FIBER | POWDER | Y | ||
psyllium seed/sod bicarb | KONSYL EFFERVESCENT | PACKET | Y | ||
psyllium/sucr/sacchar/dextrose | MUCILIN | POWD PACK | Y | ||
senna leaf extract | SENNA | SYRUP | Y | ||
senna/psyllium seed | PERDIEM | GRANULES | Y | ||
sennosides | SENNA | CAPSULE | Y | ||
sennosides | SENNA | CAPSULE | Y | ||
sennosides | SENNA | SYRUP | Y | ||
sennosides | SENNALAX | SYRUP | Y | ||
sennosides | ONELAX SENNA | SYRUP | Y | ||
sennosides | SENNA | SYRUP | Y | ||
sennosides | CHOCOLATED LAXATIVE | TAB CHEW | Y | ||
sennosides | CHOCOLATED LAXATIVE | TAB CHEW | Y | ||
sennosides | EX-LAX | TAB CHEW | Y | ||
sennosides | SENNA LAXATIVE | TABLET | Y | ||
sennosides | LAXATIVE | TABLET | Y | ||
sennosides | SENNA LAX | TABLET | Y | ||
sennosides | SENOKOT | TABLET | Y | ||
sennosides | SENNA | TABLET | Y | ||
sennosides | SEN-O-TAB | TABLET | Y | ||
sennosides | SENNOSIDES | TABLET | Y | ||
sennosides | VEGETABLE LAXATIVE | TABLET | Y | ||
sennosides | SENNATURAL | TABLET | Y | ||
sennosides | SENNA LAX | TABLET | Y | ||
sennosides | LAXATIVE | TABLET | Y | ||
sennosides | EVAC-U-GEN | TABLET | Y | ||
sennosides | EX-LAX | TABLET | Y | ||
sennosides | GERI-KOT | TABLET | Y | ||
sennosides | SENNA LAXATIVE | TABLET | Y | ||
sennosides | LAXATIVE PILLS | TABLET | Y | ||
sennosides | NATURAL LAXATIVE | TABLET | Y | ||
sennosides | PERDIEM | TABLET | Y | ||
sennosides | SENALAX | TABLET | Y | ||
sennosides | SENNA | TABLET | Y | ||
sennosides | EX-LAX MAXIMUM STRENGTH | TABLET | Y | ||
sennosides/docusate sodium | STOOL SOFTENER-STIMULANT LAX | TABLET | Y | ||
sennosides/docusate sodium | COLACE 2-IN-1 | TABLET | Y | ||
sennosides/docusate sodium | STOOL SOFTENER-LAXATIVE | TABLET | Y | ||
sennosides/docusate sodium | SENEXON-S | TABLET | Y | ||
sennosides/docusate sodium | SENNA PLUS | TABLET | Y | ||
sennosides/docusate sodium | SENNA-S | TABLET | Y | ||
sennosides/docusate sodium | SENNA-TIME S | TABLET | Y | ||
sennosides/docusate sodium | SENNOSIDES-DOCUSATE SODIUM | TABLET | Y | ||
sennosides/docusate sodium | SENOKOT-S | TABLET | Y | ||
sennosides/docusate sodium | STIMULANT LAXATIVE PLUS | TABLET | Y | ||
sennosides/docusate sodium | SENNA-DOCUSATE SODIUM | TABLET | Y | ||
sennosides/docusate sodium | 2-IN-1 LAXATIVE | TABLET | Y | ||
sennosides/docusate sodium | DOCUSATE SODIUM-SENNOSIDES | TABLET | Y | ||
sennosides/docusate sodium | DOCUZEN | TABLET | Y | ||
sennosides/docusate sodium | LAX STOOL SOFTENER WITH SENNA | TABLET | Y | ||
sennosides/docusate sodium | LAXACIN | TABLET | Y | ||
sennosides/docusate sodium | P-COL RITE | TABLET | Y | ||
sennosides/docusate sodium | SENNA PLUS | TABLET | Y | ||
sennosides/docusate sodium | SENNA-S | TABLET | Y | ||
sennosides/docusate sodium | SENNOSIDES-DOCUSATE SODIUM | TABLET | Y | ||
sennosides/docusate sodium | STOOL SOFTENER | TABLET | Y | ||
sennosides/docusate sodium | STOOL SOFTENER-LAXATIVE | TABLET | Y | ||
sennosides/docusate sodium | STOOL SOFTENER-STIMULANT LAX | TABLET | Y | ||
sennosides/docusate sodium | VEGETABLE LAX-STOOL SOFTENER | TABLET | Y | ||
sennosides/docusate sodium | SENNA-S LAXATIVE | TABLET | Y | ||
sennosides/docusate sodium | SENALAX SS | TABLET | Y | ||
sennosides/docusate sodium | STIMULANT LAXATIVE PLUS | TABLET | Y | ||
soluble corn fiber | FIBERCEL | POWDER | Y | ||
alvimopan | ALVIMOPAN | CAPSULE | N | PA Document | |
alvimopan | ENTEREG | CAPSULE | N | PA Document | |
bran | OAT BRAN FIBER | TABLET | N | PA Document | |
bran | BRAN | TABLET | N | PA Document | |
casanthranol/docusate sodium | STOOL SOFTENER W/LAXATIVE | CAPSULE | N | PA Document | |
casanthranol/docusate sodium | PERI-COLACE | CAPSULE | N | PA Document | |
casanthranol/docusate sodium | DOCUSATE SODIUM W/CASANTHRANOL | CAPSULE | N | PA Document | |
casanthranol/docusate sodium | DOCUSATE SODIUM-CASANTHRANOL | CAPSULE | N | PA Document | |
cascara sagrada/mag hydrox | MILK OF MAGNESIA W/CASCARA | ORAL SUSP | N | PA Document | |
castor oil | CASTOR OIL | OIL | N | PA Document | |
lactulose | KRISTALOSE | PACKET | N | PA Document | |
linaclotide | LINZESS | CAPSULE | N | PA Document | Mar 28, 2013 |
lubiprostone | AMITIZA | CAPSULE | N | PA Document | |
lubiprostone | LUBIPROSTONE | CAPSULE | N | PA Document | |
methylcellulose | FIBER THERAPY | POWDER | N | PA Document | |
methylcellulose | CITRUCEL | POWDER | N | PA Document | |
methylcellulose (with sugar) | FIBER THERAPY | POWDER | N | PA Document | |
methylnaltrexone bromide | RELISTOR | SYRINGE | N | PA Document | |
methylnaltrexone bromide | RELISTOR | TABLET | N | PA Document | |
methylnaltrexone bromide | RELISTOR | VIAL | N | PA Document | |
mineral oil | MINERAL OIL | OIL | N | PA Document | |
naldemedine tosylate | SYMPROIC | TABLET | N | PA Document | Jul 27, 2017 |
naloxegol oxalate | MOVANTIK | TABLET | N | PA Document | |
peg 3350/sod sulf,chlr/pot/mag | SUFLAVE | SOLN RECON | N | PA Document | |
plecanatide | TRULANCE | TABLET | N | PA Document | Jul 27, 2017 |
polyethylene glycol 3350 | CLEARLAX | POWD PACK | N | PA Document | |
polyethylene glycol 3350 | HEALTHYLAX | POWD PACK | N | PA Document | |
polyethylene glycol 3350 | POLYETHYLENE GLYCOL 3350 | POWD PACK | N | PA Document | |
polyethylene glycol 3350 | SMOOTHLAX | POWD PACK | N | PA Document | |
prucalopride succinate | MOTEGRITY | TABLET | N | PA Document | |
psyllium husk | KONSYL | POWD PACK | N | PA Document | |
psyllium husk/sweetleaf | KONSYL DAILY FIBER | POWD PACK | N | PA Document | |
senna leaf extract | SENOKOT KIDS | TAB CHEW | N | PA Document | |
senna leaf extract | SENOKOT | TAB CHEW | N | PA Document | |
sennosides/docusate sodium | STOOL SOFTENER-STIMULANT LAX | CAPSULE | N | PA Document | |
sennosides/docusate sodium | SENNA PLUS | CAPSULE | N | PA Document | |
tenapanor HCl | IBSRELA | TABLET | N | PA Document | |
senna leaf/herbal no.324 | SENOKOT-CHAMOMILE | TEA (EA) |