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