Bowel Preparation Agents
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 |
|---|---|---|---|---|---|
| magnesium sulfate | EPSOM SALT | GRANULES | |||
| peg3350/sod sul/NaCl/KCl/asb/C | MOVIPREP | POWD PACK | |||
| peg3350/sod sul/NaCl/KCl/asb/C | PEG3350-SOD SUL-NACL-KCL-ASB-C | POWD PACK | |||
| peg3350/sod sul/NaCl/KCl/asb/C | PLENVU | POWD PK SQ | |||
| peg3350/sod sulf,bicarb,Cl/KCl | GAVILYTE-C | SOLN RECON | |||
| peg3350/sod sulf,bicarb,Cl/KCl | GAVILYTE-G | SOLN RECON | |||
| peg3350/sod sulf,bicarb,Cl/KCl | GOLYTELY | SOLN RECON | |||
| peg3350/sod sulf,bicarb,Cl/KCl | PEG-3350 AND ELECTROLYTES | SOLN RECON | |||
| sod picosulf/mag ox/citric ac | CLENPIQ | SOLUTION | |||
| sod sulf/pot chloride/mag sulf | SUTAB | TABLET | |||
| sodium chloride/NaHCO3/KCl/peg | PEG 3350-ELECTROLYTE | SOLN RECON | |||
| sodium chloride/NaHCO3/KCl/peg | GAVILYTE-N | SOLN RECON | |||
| sodium chloride/NaHCO3/KCl/peg | NULYTELY | SOLN RECON | |||
| sodium phosphate,mono-dibasic | PREPARATION CLEANSING | LIQUID | |||
| sodium, potassium,mag sulfates | SOD SULF-POTASS SULF-MAG SULF | SOLN RECON | |||
| sodium, potassium,mag sulfates | SUPREP | SOLN RECON |