Laxatives, Bowel Preparation

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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 BISACODYL SUPP.RECT    
bisacodyl GENTLE LAXATIVE 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 COLACE ENEMA    
docusate sodium DOCUSATE SODIUM ENEMA    
docusate sodium DOCUSOL ENEMA    
docusate sodium DOCUSOL KIDS 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 PEDIA-LAX SUPP.RECT    
glycerin INFANT SUPPOSITORY SUPP.RECT    
glycerin GLYCERIN SUPP.RECT    
glycerin ADULT SUPPOSITORY SUPP.RECT    
glycerin ADULT GLYCERIN SUPP.RECT    
magnesium sulfate EPSOM SALT GRANULES    
mineral oil READY TO USE ENEMA ENEMA    
mineral oil MINERAL OIL ENEMA ENEMA    
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 PEG-3350 AND ELECTROLYTES SOLN RECON    
peg3350/sod sulf,bicarb,Cl/KCl PEG 3350-ELECTROLYTE 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 GAVILYTE-N SOLN RECON    
sodium chloride/NaHCO3/KCl/peg NULYTELY SOLN RECON    
sodium chloride/NaHCO3/KCl/peg PEG 3350-ELECTROLYTE SOLN RECON    
sodium chloride/NaHCO3/KCl/peg NULYTELY WITH FLAVOR PACKS 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 SOD SULF-POTASS SULF-MAG SULF SOLN RECON    
sodium, potassium,mag sulfates SUPREP SOLN RECON