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 & Updates |
|---|---|---|---|---|---|
| bisacodyl | BISACODYL | ENEMA | |||
| bisacodyl | GENTLE LAXATIVE | SUPP.RECT | |||
| bisacodyl | BISACODYL | SUPP.RECT | |||
| bisacodyl/magnesium citrate | FLEET PREP KIT #4 | COMBO. PKG | |||
| bisacodyl/magnesium citrate | FLEET PREP KIT #6 | COMBO. PKG | |||
| bisacodyl/magnesium citrate | FLEET PREP KIT #5 | KIT | |||
| docusate sodium | ENEMEEZ KIDS | ENEMA | |||
| docusate sodium | COLACE | ENEMA | |||
| docusate sodium | DOCUSATE SODIUM | ENEMA | |||
| docusate sodium | DOCUSOL | ENEMA | |||
| docusate sodium | DOCUSOL KIDS | ENEMA | |||
| docusate sodium | ENEMEEZ | ENEMA | |||
| docusate sodium/benzocaine | DOCUSOL PLUS | ENEMA | |||
| docusate sodium/benzocaine | ENEMEEZ 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 | |||
| mineral oil | READY TO USE ENEMA | ENEMA | |||
| mineral oil | MINERAL OIL ENEMA | ENEMA | |||
| sodium phosphate,mono-dibasic | ENEMA | ENEMA | |||
| sodium phosphate,mono-dibasic | PEDIA-LAX ENEMA | ENEMA | |||
| sodium phosphate,mono-dibasic | ENEMA DISPOSABLE | ENEMA |