Laxatives, Bowel Preparation
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 | BISACODYL | ENEMA | |||
bisacodyl | GENTLE LAXATIVE | SUPP.RECT | |||
bisacodyl | BISACODYL | SUPP.RECT | |||
bisacodyl/magnesium citrate | FLEET PREP KIT #6 | COMBO. PKG | |||
bisacodyl/magnesium citrate | FLEET PREP KIT #4 | COMBO. PKG | |||
bisacodyl/magnesium citrate | FLEET PREP KIT #5 | KIT | |||
docusate sodium | DOCUSOL | ENEMA | |||
docusate sodium | DOCUSOL KIDS | ENEMA | |||
docusate sodium | DOCUSATE SODIUM | ENEMA | |||
docusate sodium | COLACE | ENEMA | |||
docusate sodium | ENEMEEZ | ENEMA | |||
docusate sodium/benzocaine | ENEMEEZ PLUS | ENEMA | |||
docusate sodium/benzocaine | DOCUSOL PLUS | ENEMA | |||
glycerin | PEDIA-LAX | SOL/PF APP | |||
glycerin | GLYCERIN LAXATIVE | SOL/PF APP | |||
glycerin | INFANT SUPPOSITORY | SUPP.RECT | |||
glycerin | GLYCERIN | SUPP.RECT | |||
glycerin | ADULT SUPPOSITORY | SUPP.RECT | |||
glycerin | ADULT GLYCERIN | SUPP.RECT | |||
glycerin | PEDIA-LAX | SUPP.RECT | |||
magnesium sulfate | EPSOM SALT | GRANULES | |||
mineral oil | MINERAL OIL ENEMA | ENEMA | |||
mineral oil | READY TO USE ENEMA | ENEMA | |||
peg3350/sod sul/NaCl/KCl/asb/C | PEG3350-SOD SUL-NACL-KCL-ASB-C | POWD PACK | |||
peg3350/sod sul/NaCl/KCl/asb/C | MOVIPREP | POWD PACK | |||
peg3350/sod sul/NaCl/KCl/asb/C | PLENVU | POWD PK SQ | |||
peg3350/sod sulf,bicarb,Cl/KCl | PEG-3350 AND ELECTROLYTES | SOLN RECON | |||
peg3350/sod sulf,bicarb,Cl/KCl | GOLYTELY | SOLN RECON | |||
peg3350/sod sulf,bicarb,Cl/KCl | GAVILYTE-G | SOLN RECON | |||
peg3350/sod sulf,bicarb,Cl/KCl | GAVILYTE-C | SOLN RECON | |||
sod phosphate mbas/sod phos,di | OSMOPREP | TABLET | |||
sod picosulf/mag ox/citric ac | CLENPIQ | SOLUTION | |||
sodium chloride/NaHCO3/KCl/peg | NULYTELY | SOLN RECON | |||
sodium chloride/NaHCO3/KCl/peg | PEG 3350-ELECTROLYTE | SOLN RECON | |||
sodium chloride/NaHCO3/KCl/peg | GAVILYTE-N | SOLN RECON | |||
sodium phosphate,mono-dibasic | ENEMA | ENEMA | |||
sodium phosphate,mono-dibasic | ENEMA DISPOSABLE | ENEMA | |||
sodium phosphate,mono-dibasic | PEDIA-LAX ENEMA | ENEMA | |||
sodium phosphate,mono-dibasic | PREPARATION CLEANSING | LIQUID | |||
sodium, potassium,mag sulfates | SUPREP | SOLN RECON | |||
sodium, potassium,mag sulfates | SOD SULF-POTASS SULF-MAG SULF | SOLN RECON |