Bowel Preparation Agents

← Back to Class List

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.

< Return to summary view

NDC Brand Name Generic Name Form Strength PDL
Status		 Rebate Carveout
‐ Bill FFS		 Current Drug Use Criteria
00132000046 MINERAL OIL mineral oil EMULSION 50 % Y N  
52268055001 SUFLAVE peg 3350/sod sulf,chlr/pot/mag SOLN RECON 178.7 gram-7.3 gram-0.5 gram-1.12 gram-0.9 gram N Y N  
52268055101 SUFLAVE peg 3350/sod sulf,chlr/pot/mag SOLN RECON 178.7 gram-7.3 gram-0.5 gram-1.12 gram-0.9 gram N Y N  
00093356026 PEG3350-SOD SUL-NACL-KCL-ASB-C peg3350/sod sul/NaCl/KCl/asb/C POWD PACK 100 gram-7.5 gram-2.691 gram-1.015 gram-5.9 gram-4.7 gram N Y N  
43386009019 GAVILYTE-G peg3350/sod sulf,bicarb,Cl/KCl SOLN RECON 236 gram-22.74 gram-6.74 gram-5.86 gram-2.97 gram Y Y N  
52268010001 GOLYTELY peg3350/sod sulf,bicarb,Cl/KCl SOLN RECON 236 gram-22.74 gram-6.74 gram-5.86 gram-2.97 gram Y Y N  
10572010001 PEG-3350 AND ELECTROLYTES peg3350/sod sulf,bicarb,Cl/KCl SOLN RECON 236 gram-22.74 gram-6.74 gram-5.86 gram-2.97 gram Y Y N  
64380076621 PEG-3350 AND ELECTROLYTES peg3350/sod sulf,bicarb,Cl/KCl SOLN RECON 236 gram-22.74 gram-6.74 gram-5.86 gram-2.97 gram Y Y N  
43386006019 GAVILYTE-C peg3350/sod sulf,bicarb,Cl/KCl SOLN RECON 240 gram-22.72 gram-6.72 gram-5.84 gram-2.98 gram Y Y N  
55566670002 CLENPIQ sod picosulf/mag ox/citric ac SOLUTION 10 mg-3.5 gram-12 gram/160 mL N Y N  
55566680000 CLENPIQ sod picosulf/mag ox/citric ac SOLUTION 10 mg-3.5 gram-12 gram/175 mL N Y N  
55566680001 CLENPIQ sod picosulf/mag ox/citric ac SOLUTION 10 mg-3.5 gram-12 gram/175 mL N Y N  
52268020001 SUTAB sod sulf/pot chloride/mag sulf TABLET 1.479 gram-0.188 gram-0.225 gram N Y N  
52268020101 SUTAB sod sulf/pot chloride/mag sulf TABLET 1.479 gram-0.188 gram-0.225 gram N Y N  
43386005019 GAVILYTE-N sodium chloride/NaHCO3/KCl/peg SOLN RECON 420 gram Y Y N  
10572030201 PEG 3350-ELECTROLYTE sodium chloride/NaHCO3/KCl/peg SOLN RECON 420 gram Y Y N  
64380076921 PEG 3350-ELECTROLYTE sodium chloride/NaHCO3/KCl/peg SOLN RECON 420 gram Y Y N  
00363012612 ORAL SALINE LAXATIVE sodium phosphate,mono-dibasic LIQUID 7.2 gram-2.7 gram/15 mL Y N N  
10939024244 ORAL SALINE LAXATIVE sodium phosphate,mono-dibasic LIQUID 7.2 gram-2.7 gram/15 mL Y N N  
11917015096 ORAL SALINE LAXATIVE sodium phosphate,mono-dibasic LIQUID 7.2 gram-2.7 gram/15 mL Y N N  
96295011444 ORAL SALINE LAXATIVE KIT sodium phosphate,mono-dibasic LIQUID 7.2 gram-2.7 gram/15 mL Y N N  
11917010653 PHOSPHATE LAXATIVE sodium phosphate,mono-dibasic LIQUID 7.2 gram-2.7 gram/15 mL Y N N  
37205099603 PREPARATION CLEANSING sodium phosphate,mono-dibasic LIQUID 7.2 gram-2.7 gram/15 mL Y N N  
96295011504 PREPARATION CLEANSING sodium phosphate,mono-dibasic LIQUID 7.2 gram-2.7 gram/15 mL Y N N  
96295011129 ORAL SALINE LAXATIVE sodium phosphate,mono-dibasic SOLUTION Y N N  
10572001101 SOD SULF-POTASS SULF-MAG SULF sodium, potassium,mag sulfates SOLN RECON 17.5 gram-3.13 gram-1.6 gram Y Y N  
10572001201 SOD SULF-POTASS SULF-MAG SULF sodium, potassium,mag sulfates SOLN RECON 17.5 gram-3.13 gram-1.6 gram Y Y N  
31722009817 SOD SULF-POTASS SULF-MAG SULF sodium, potassium,mag sulfates SOLN RECON 17.5 gram-3.13 gram-1.6 gram Y Y N  
31722009831 SOD SULF-POTASS SULF-MAG SULF sodium, potassium,mag sulfates SOLN RECON 17.5 gram-3.13 gram-1.6 gram Y Y N  
43386070002 SOD SULF-POTASS SULF-MAG SULF sodium, potassium,mag sulfates SOLN RECON 17.5 gram-3.13 gram-1.6 gram Y Y N  
43386070083 SOD SULF-POTASS SULF-MAG SULF sodium, potassium,mag sulfates SOLN RECON 17.5 gram-3.13 gram-1.6 gram Y Y N  
51672417005 SOD SULF-POTASS SULF-MAG SULF sodium, potassium,mag sulfates SOLN RECON 17.5 gram-3.13 gram-1.6 gram Y Y N  
64380011601 SOD SULF-POTASS SULF-MAG SULF sodium, potassium,mag sulfates SOLN RECON 17.5 gram-3.13 gram-1.6 gram Y Y N  
64380011602 SOD SULF-POTASS SULF-MAG SULF sodium, potassium,mag sulfates SOLN RECON 17.5 gram-3.13 gram-1.6 gram Y Y N  
67877072582 SOD SULF-POTASS SULF-MAG SULF sodium, potassium,mag sulfates SOLN RECON 17.5 gram-3.13 gram-1.6 gram Y Y N  
67877072592 SOD SULF-POTASS SULF-MAG SULF sodium, potassium,mag sulfates SOLN RECON 17.5 gram-3.13 gram-1.6 gram Y Y N  
69452042862 SOD SULF-POTASS SULF-MAG SULF sodium, potassium,mag sulfates SOLN RECON 17.5 gram-3.13 gram-1.6 gram Y Y N  
69452042897 SOD SULF-POTASS SULF-MAG SULF sodium, potassium,mag sulfates SOLN RECON 17.5 gram-3.13 gram-1.6 gram Y Y N  
72603027801 SOD SULF-POTASS SULF-MAG SULF sodium, potassium,mag sulfates SOLN RECON 17.5 gram-3.13 gram-1.6 gram Y Y N  
72603027802 SOD SULF-POTASS SULF-MAG SULF sodium, potassium,mag sulfates SOLN RECON 17.5 gram-3.13 gram-1.6 gram Y Y N  
52268001101 SUPREP sodium, potassium,mag sulfates SOLN RECON 17.5 gram-3.13 gram-1.6 gram Y Y N  
52268001201 SUPREP sodium, potassium,mag sulfates SOLN RECON 17.5 gram-3.13 gram-1.6 gram Y Y N  
Back to Top ↑