Bowel Preparation Agents

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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
peg3350/sod sul/NaCl/KCl/asb/C PLENVU POWD PK SQ Y    
peg3350/sod sulf,bicarb,Cl/KCl GOLYTELY SOLN RECON Y    
peg3350/sod sulf,bicarb,Cl/KCl PEG-3350 AND ELECTROLYTES SOLN RECON Y    
peg3350/sod sulf,bicarb,Cl/KCl GAVILYTE-G SOLN RECON Y    
peg3350/sod sulf,bicarb,Cl/KCl GAVILYTE-C SOLN RECON Y    
sodium chloride/NaHCO3/KCl/peg PEG 3350-ELECTROLYTE SOLN RECON Y    
sodium chloride/NaHCO3/KCl/peg GAVILYTE-N SOLN RECON Y    
sodium phosphate,mono-dibasic PREPARATION CLEANSING LIQUID Y    
sodium phosphate,mono-dibasic PREPARATION CLEANSING LIQUID Y    
sodium phosphate,mono-dibasic PHOSPHATE LAXATIVE LIQUID Y    
sodium phosphate,mono-dibasic ORAL SALINE LAXATIVE KIT LIQUID Y    
sodium phosphate,mono-dibasic ORAL SALINE LAXATIVE LIQUID Y    
sodium phosphate,mono-dibasic ORAL SALINE LAXATIVE SOLUTION Y    
sodium, potassium,mag sulfates SUPREP SOLN RECON Y    
sodium, potassium,mag sulfates SOD SULF-POTASS SULF-MAG SULF SOLN RECON Y    
peg 3350/sod sulf,chlr/pot/mag SUFLAVE SOLN RECON N    
peg3350/sod sul/NaCl/KCl/asb/C MOVIPREP POWD PACK N    
peg3350/sod sul/NaCl/KCl/asb/C PEG3350-SOD SUL-NACL-KCL-ASB-C POWD PACK N    
sod picosulf/mag ox/citric ac CLENPIQ SOLUTION N    
sod sulf/pot chloride/mag sulf SUTAB TABLET N    
mineral oil MINERAL OIL EMULSION