Bowel Preparation Agents
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.
| NDC | Brand Name | Generic Name | Form | Strength | PDL Status |
Rebate | Current Drug Use Criteria |
|---|---|---|---|---|---|---|---|
| 00132000046 | MINERAL OIL | mineral oil | EMULSION | 50 % | Y | ||
| 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 | |
| 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 | |
| 65649020175 | MOVIPREP | 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 | |
| 65649020176 | MOVIPREP | 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 | |
| 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 | |
| 68682020175 | 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 | |
| 65649040001 | PLENVU | peg3350/sod sul/NaCl/KCl/asb/C | POWD PK SQ | 140 gram-9 gram-5.2 gram-2.2 gram-48.11 gram-7.54 gram | Y | Y | |
| 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 | |
| 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 | |
| 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 | |
| 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 | |
| 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 | |
| 55566670002 | CLENPIQ | sod picosulf/mag ox/citric ac | SOLUTION | 10 mg-3.5 gram-12 gram/160 mL | N | Y | |
| 55566680000 | CLENPIQ | sod picosulf/mag ox/citric ac | SOLUTION | 10 mg-3.5 gram-12 gram/175 mL | N | Y | |
| 55566680001 | CLENPIQ | sod picosulf/mag ox/citric ac | SOLUTION | 10 mg-3.5 gram-12 gram/175 mL | N | Y | |
| 52268020001 | SUTAB | sod sulf/pot chloride/mag sulf | TABLET | 1.479 gram-0.188 gram-0.225 gram | N | Y | |
| 52268020101 | SUTAB | sod sulf/pot chloride/mag sulf | TABLET | 1.479 gram-0.188 gram-0.225 gram | N | Y | |
| 43386005019 | GAVILYTE-N | sodium chloride/NaHCO3/KCl/peg | SOLN RECON | 420 gram | Y | Y | |
| 10572030201 | PEG 3350-ELECTROLYTE | sodium chloride/NaHCO3/KCl/peg | SOLN RECON | 420 gram | Y | Y | |
| 64380076921 | PEG 3350-ELECTROLYTE | sodium chloride/NaHCO3/KCl/peg | SOLN RECON | 420 gram | Y | Y | |
| 00363012612 | ORAL SALINE LAXATIVE | sodium phosphate,mono-dibasic | LIQUID | 7.2 gram-2.7 gram/15 mL | Y | N | |
| 10939024244 | ORAL SALINE LAXATIVE | sodium phosphate,mono-dibasic | LIQUID | 7.2 gram-2.7 gram/15 mL | Y | N | |
| 11917015096 | ORAL SALINE LAXATIVE | sodium phosphate,mono-dibasic | LIQUID | 7.2 gram-2.7 gram/15 mL | Y | N | |
| 96295011444 | ORAL SALINE LAXATIVE KIT | sodium phosphate,mono-dibasic | LIQUID | 7.2 gram-2.7 gram/15 mL | Y | N | |
| 11917010653 | PHOSPHATE LAXATIVE | sodium phosphate,mono-dibasic | LIQUID | 7.2 gram-2.7 gram/15 mL | Y | N | |
| 96295011504 | PREPARATION CLEANSING | sodium phosphate,mono-dibasic | LIQUID | 7.2 gram-2.7 gram/15 mL | Y | N | |
| 37205099603 | PREPARATION CLEANSING | sodium phosphate,mono-dibasic | LIQUID | 7.2 gram-2.7 gram/15 mL | Y | Y | |
| 96295011129 | ORAL SALINE LAXATIVE | sodium phosphate,mono-dibasic | SOLUTION | Y | 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 | |
| 10572001201 | SOD SULF-POTASS SULF-MAG SULF | sodium, potassium,mag sulfates | SOLN RECON | 17.5 gram-3.13 gram-1.6 gram | Y | Y | |
| 31722009817 | SOD SULF-POTASS SULF-MAG SULF | sodium, potassium,mag sulfates | SOLN RECON | 17.5 gram-3.13 gram-1.6 gram | Y | Y | |
| 31722009831 | SOD SULF-POTASS SULF-MAG SULF | sodium, potassium,mag sulfates | SOLN RECON | 17.5 gram-3.13 gram-1.6 gram | Y | Y | |
| 43386070002 | SOD SULF-POTASS SULF-MAG SULF | sodium, potassium,mag sulfates | SOLN RECON | 17.5 gram-3.13 gram-1.6 gram | Y | Y | |
| 43386070083 | SOD SULF-POTASS SULF-MAG SULF | sodium, potassium,mag sulfates | SOLN RECON | 17.5 gram-3.13 gram-1.6 gram | Y | Y | |
| 51672417005 | SOD SULF-POTASS SULF-MAG SULF | sodium, potassium,mag sulfates | SOLN RECON | 17.5 gram-3.13 gram-1.6 gram | Y | Y | |
| 64380011601 | SOD SULF-POTASS SULF-MAG SULF | sodium, potassium,mag sulfates | SOLN RECON | 17.5 gram-3.13 gram-1.6 gram | Y | Y | |
| 64380011602 | SOD SULF-POTASS SULF-MAG SULF | sodium, potassium,mag sulfates | SOLN RECON | 17.5 gram-3.13 gram-1.6 gram | Y | Y | |
| 67877072582 | SOD SULF-POTASS SULF-MAG SULF | sodium, potassium,mag sulfates | SOLN RECON | 17.5 gram-3.13 gram-1.6 gram | Y | Y | |
| 67877072592 | SOD SULF-POTASS SULF-MAG SULF | sodium, potassium,mag sulfates | SOLN RECON | 17.5 gram-3.13 gram-1.6 gram | Y | Y | |
| 69452042862 | SOD SULF-POTASS SULF-MAG SULF | sodium, potassium,mag sulfates | SOLN RECON | 17.5 gram-3.13 gram-1.6 gram | Y | Y | |
| 69452042897 | SOD SULF-POTASS SULF-MAG SULF | sodium, potassium,mag sulfates | SOLN RECON | 17.5 gram-3.13 gram-1.6 gram | Y | Y | |
| 72603027801 | SOD SULF-POTASS SULF-MAG SULF | sodium, potassium,mag sulfates | SOLN RECON | 17.5 gram-3.13 gram-1.6 gram | Y | Y | |
| 72603027802 | SOD SULF-POTASS SULF-MAG SULF | sodium, potassium,mag sulfates | SOLN RECON | 17.5 gram-3.13 gram-1.6 gram | Y | Y | |
| 52268001101 | SUPREP | sodium, potassium,mag sulfates | SOLN RECON | 17.5 gram-3.13 gram-1.6 gram | Y | Y | |
| 52268001201 | SUPREP | sodium, potassium,mag sulfates | SOLN RECON | 17.5 gram-3.13 gram-1.6 gram | Y | Y |