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 but eligible patients will encounter a co-pay at the pharmacy.
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 BISCOLAX SUPP.RECT    
BISACODYL BISACODYL SUPP.RECT    
BISACODYL BISAC-EVAC SUPP.RECT    
DOCUSATE SODIUM DOCUSOL KIDS ENEMA    
DOCUSATE SODIUM ENEMEEZ ENEMA    
DOCUSATE SODIUM DOCUSOL ENEMA    
DOCUSATE SODIUM/BENZOCAINE ENEMEEZ 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 ADULT GLYCERIN SUPP.RECT    
GLYCERIN SANI-SUPP SUPP.RECT    
MAGNESIUM SULFATE EPSOM SALT GRANULES    
MINERAL OIL MINERAL OIL ENEMA ENEMA    
MINERAL OIL READY TO USE ENEMA ENEMA    
PEG3350/SOD SUL/NACL/ASB/C/KCL MOVIPREP POWD PACK    
PEG3350/SOD SULF,BICARB,CL/KCL GOLYTELY POWD PACK    
PEG3350/SOD SULF,BICARB,CL/KCL PEG 3350-ELECTROLYTE SOLN RECON    
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    
PEG3350/SOD SULF,BICARB,CL/KCL COLYTE WITH FLAVOR PACKETS SOLN RECON    
SOD PHOSPHATE MBAS/SOD PHOS,DI OSMOPREP TABLET    
SOD PICOSULF/MAG OX/CITRIC AC PREPOPIK POWD PACK    
SODIUM CHLORIDE/NAHCO3/KCL/PEG GAVILYTE-N SOLN RECON    
SODIUM CHLORIDE/NAHCO3/KCL/PEG TRILYTE WITH FLAVOR PACKETS 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 PEDIA-LAX ENEMA ENEMA    
SODIUM PHOSPHATE,MONO-DIBASIC ENEMA DISPOSABLE ENEMA    
SODIUM PHOSPHATE,MONO-DIBASIC ENEMA ENEMA    
SODIUM, POTASSIUM,MAG SULFATES SUPREP SOLN RECON