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 | Carveout ‐ Bill FFS |
New Drug Evaluation & Updates |
|---|---|---|---|---|---|---|
| bisacodyl | BISACODYL | ENEMA | N | |||
| bisacodyl | BISACODYL | SUPP.RECT | N | |||
| bisacodyl/magnesium citrate | FLEET PREP KIT #4 | COMBO. PKG | N | |||
| bisacodyl/magnesium citrate | FLEET PREP KIT #6 | COMBO. PKG | N | |||
| docusate sodium | ENEMEEZ | ENEMA | N | |||
| docusate sodium | DOCUSATE SODIUM | ENEMA | N | |||
| docusate sodium/benzocaine | ENEMEEZ PLUS | ENEMA | N | |||
| glycerin | GLYCERIN LAXATIVE | SOL/PF APP | N | |||
| glycerin | PEDIA-LAX | SOL/PF APP | N | |||
| glycerin | ADULT SUPPOSITORY | SUPP.RECT | N | |||
| mineral oil | MINERAL OIL ENEMA | ENEMA | N | |||
| sodium phosphate,mono-dibasic | PEDIA-LAX ENEMA | ENEMA | N |