Bowel Preparation Agents
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 |
|---|---|---|---|---|---|---|
| peg3350/sod sulf,bicarb,Cl/KCl | GAVILYTE-C | SOLN RECON | Y | N | ||
| sodium chloride/NaHCO3/KCl/peg | PEG 3350-ELECTROLYTE | SOLN RECON | Y | N | ||
| sodium chloride/NaHCO3/KCl/peg | GAVILYTE-N | SOLN RECON | Y | N | ||
| sodium phosphate,mono-dibasic | PREPARATION CLEANSING | LIQUID | Y | N | ||
| sodium phosphate,mono-dibasic | PHOSPHATE LAXATIVE | LIQUID | Y | N | ||
| sodium phosphate,mono-dibasic | ORAL SALINE LAXATIVE | SOLUTION | Y | N | ||
| sodium, potassium,mag sulfates | SOD SULF-POTASS SULF-MAG SULF | SOLN RECON | Y | N | ||
| sod picosulf/mag ox/citric ac | CLENPIQ | SOLUTION | N | N | ||
| sod sulf/pot chloride/mag sulf | SUTAB | TABLET | N | N |