Laxatives, Bowel Preparation

← Back to Class List

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.

Alternate detailed view >

Generic Name Brand Name Form PDL
Status
Current Drug Use Criteria Carveout
‐ Bill FFS
New Drug Evaluation & Updates
bisacodyl BISACODYL ENEMA    
bisacodyl FLEET MINI ENEMA    
bisacodyl BISACODYL SUPP.RECT    
bisacodyl PROCTOZONE-B 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 KIDS ENEMA    
docusate sodium ENEMEEZ KIDS ENEMA    
docusate sodium ENEMEEZ ENEMA    
docusate sodium/benzocaine ENEMEEZ PLUS ENEMA    
glycerin GLYCERIN LAXATIVE SOL/PF APP    
glycerin PEDIA-LAX SOL/PF APP    
glycerin ADULT GLYCERIN SUPP.RECT    
glycerin ADULT SUPPOSITORY SUPP.RECT    
glycerin CHILDREN'S PROCTOZONE-G SUPP.RECT    
glycerin GLYCERIN SUPP.RECT    
glycerin INFANT SUPPOSITORY SUPP.RECT    
glycerin PROCTOZONE-GMAX SUPP.RECT    
mineral oil MINERAL OIL ENEMA ENEMA    
mineral oil READY TO USE ENEMA ENEMA    
sodium phosphate,mono-dibasic PEDIA-LAX ENEMA ENEMA    
sodium phosphate,mono-dibasic ENEMA ENEMA