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.
| NDC | Brand Name | Generic Name | Form | Strength | PDL Status |
Rebate | Current Drug Use Criteria |
|---|---|---|---|---|---|---|---|
| 00132070336 | BISACODYL | bisacodyl | ENEMA | 10 mg/30 mL | Y | ||
| 00574705012 | BISACODYL | bisacodyl | SUPP.RECT | 10 mg | Y | ||
| 00574705050 | BISACODYL | bisacodyl | SUPP.RECT | 10 mg | Y | ||
| 00603046008 | BISACODYL | bisacodyl | SUPP.RECT | 10 mg | Y | ||
| 00904714212 | BISACODYL | bisacodyl | SUPP.RECT | 10 mg | Y | ||
| 45802071014 | BISACODYL | bisacodyl | SUPP.RECT | 10 mg | Y | ||
| 45802071034 | BISACODYL | bisacodyl | SUPP.RECT | 10 mg | Y | ||
| 57237032703 | BISACODYL | bisacodyl | SUPP.RECT | 10 mg | Y | ||
| 57237032721 | BISACODYL | bisacodyl | SUPP.RECT | 10 mg | Y | ||
| 46122060851 | GENTLE LAXATIVE | bisacodyl | SUPP.RECT | 10 mg | Y | ||
| 70000057301 | GENTLE LAXATIVE | bisacodyl | SUPP.RECT | 10 mg | Y | ||
| 70000057302 | GENTLE LAXATIVE | bisacodyl | SUPP.RECT | 10 mg | Y | ||
| 70677109101 | GENTLE LAXATIVE | bisacodyl | SUPP.RECT | 10 mg | Y | ||
| 57237033703 | PROCTOZONE-B | bisacodyl | SUPP.RECT | 10 mg | Y | ||
| 57237033751 | PROCTOZONE-B | bisacodyl | SUPP.RECT | 10 mg | Y | ||
| 00132021601 | FLEET PREP KIT #4 | bisacodyl/magnesium citrate | COMBO. PKG | Y | |||
| 00132021801 | FLEET PREP KIT #6 | bisacodyl/magnesium citrate | COMBO. PKG | Y | |||
| 00132021701 | FLEET PREP KIT #5 | bisacodyl/magnesium citrate | KIT | Y | |||
| 17433988401 | DOCUSOL KIDS | docusate sodium | ENEMA | 100 mg/5 mL | Y | ||
| 17433988405 | DOCUSOL KIDS | docusate sodium | ENEMA | 100 mg/5 mL | Y | ||
| 17433000007 | ENEMEEZ KIDS | docusate sodium | ENEMA | 100 mg/5 mL | Y | ||
| 17433988602 | ENEMEEZ KIDS | docusate sodium | ENEMA | 100 mg/5 mL | Y | ||
| 17433988605 | ENEMEEZ KIDS | docusate sodium | ENEMA | 100 mg/5 mL | Y | ||
| 54092049170 | COLACE | docusate sodium | ENEMA | 200 mg/5 mL | Y | ||
| 00904692093 | DOCUSATE SODIUM | docusate sodium | ENEMA | 283 mg/5 mL | Y | ||
| 17433987600 | ENEMEEZ | docusate sodium | ENEMA | 283 mg/5 mL | Y | ||
| 17433987603 | ENEMEEZ | docusate sodium | ENEMA | 283 mg/5 mL | Y | ||
| 17433987605 | ENEMEEZ | docusate sodium | ENEMA | 283 mg/5 mL | Y | ||
| 17433000001 | ENEMEEZ PLUS | docusate sodium/benzocaine | ENEMA | 283 mg-20 mg/5 mL | Y | ||
| 17433987700 | ENEMEEZ PLUS | docusate sodium/benzocaine | ENEMA | 283 mg-20 mg/5 mL | Y | ||
| 17433987703 | ENEMEEZ PLUS | docusate sodium/benzocaine | ENEMA | 283 mg-20 mg/5 mL | Y | ||
| 17433987705 | ENEMEEZ PLUS | docusate sodium/benzocaine | ENEMA | 283 mg-20 mg/5 mL | Y | ||
| 00132019012 | PEDIA-LAX | glycerin | SOL/PF APP | 2.8 gram/2.7 mL | Y | ||
| 00132018582 | GLYCERIN LAXATIVE | glycerin | SOL/PF APP | 5.4 gram/5.4 mL | Y | ||
| 00132007900 | ADULT GLYCERIN | glycerin | SUPP.RECT | Adult | Y | ||
| 00132007912 | ADULT GLYCERIN | glycerin | SUPP.RECT | Adult | Y | ||
| 00132007924 | ADULT GLYCERIN | glycerin | SUPP.RECT | Adult | Y | ||
| 00132007950 | ADULT GLYCERIN | glycerin | SUPP.RECT | Adult | Y | ||
| 00904733301 | ADULT GLYCERIN | glycerin | SUPP.RECT | Adult | Y | ||
| 00904733317 | ADULT GLYCERIN | glycerin | SUPP.RECT | Adult | Y | ||
| 70000057201 | ADULT GLYCERIN | glycerin | SUPP.RECT | Adult | Y | ||
| 00113032053 | ADULT SUPPOSITORY | glycerin | SUPP.RECT | Adult | Y | ||
| 00113032063 | ADULT SUPPOSITORY | glycerin | SUPP.RECT | Adult | Y | ||
| 00113032071 | ADULT SUPPOSITORY | glycerin | SUPP.RECT | Adult | Y | ||
| 00113032078 | ADULT SUPPOSITORY | glycerin | SUPP.RECT | Adult | Y | ||
| 45802071514 | GLYCERIN | glycerin | SUPP.RECT | Adult | Y | ||
| 57237032521 | GLYCERIN | glycerin | SUPP.RECT | Adult | Y | ||
| 57237032552 | GLYCERIN | glycerin | SUPP.RECT | Adult | Y | ||
| 45802071614 | GLYCERIN | glycerin | SUPP.RECT | PEDIATRIC | Y | ||
| 45802071633 | GLYCERIN | glycerin | SUPP.RECT | PEDIATRIC | Y | ||
| 57237032621 | GLYCERIN | glycerin | SUPP.RECT | PEDIATRIC | Y | ||
| 57237032652 | GLYCERIN | glycerin | SUPP.RECT | PEDIATRIC | Y | ||
| 70000042901 | GLYCERIN | glycerin | SUPP.RECT | PEDIATRIC | Y | ||
| 00113031763 | INFANT SUPPOSITORY | glycerin | SUPP.RECT | PEDIATRIC | Y | ||
| 00132030140 | MINERAL OIL ENEMA | mineral oil | ENEMA | Y | |||
| 49348018520 | READY TO USE ENEMA | mineral oil | ENEMA | Y | |||
| 70677109001 | READY TO USE ENEMA | mineral oil | ENEMA | Y | |||
| 00132020140 | ENEMA | sodium phosphate,mono-dibasic | ENEMA | 19 gram-7 gram/118 mL | Y | ||
| 00132020142 | ENEMA | sodium phosphate,mono-dibasic | ENEMA | 19 gram-7 gram/118 mL | Y | ||
| 00132020145 | ENEMA | sodium phosphate,mono-dibasic | ENEMA | 19 gram-7 gram/118 mL | Y | ||
| 00904632078 | ENEMA | sodium phosphate,mono-dibasic | ENEMA | 19 gram-7 gram/118 mL | Y | ||
| 49348018620 | ENEMA | sodium phosphate,mono-dibasic | ENEMA | 19 gram-7 gram/118 mL | Y | ||
| 70000010802 | ENEMA | sodium phosphate,mono-dibasic | ENEMA | 19 gram-7 gram/118 mL | Y | ||
| 70677108901 | ENEMA | sodium phosphate,mono-dibasic | ENEMA | 19 gram-7 gram/118 mL | Y | ||
| 70677108902 | ENEMA | sodium phosphate,mono-dibasic | ENEMA | 19 gram-7 gram/118 mL | Y | ||
| 83324029245 | ENEMA | sodium phosphate,mono-dibasic | ENEMA | 19 gram-7 gram/118 mL | Y | ||
| 83324029390 | ENEMA | sodium phosphate,mono-dibasic | ENEMA | 19 gram-7 gram/118 mL | Y | ||
| 00536741551 | ENEMA DISPOSABLE | sodium phosphate,mono-dibasic | ENEMA | 19 gram-7 gram/118 mL | Y | ||
| 00132002011 | ENEMA | sodium phosphate,mono-dibasic | ENEMA | 19 gram-7 gram/197 mL | Y | ||
| 00132020220 | PEDIA-LAX ENEMA | sodium phosphate,mono-dibasic | ENEMA | 9.5 gram-3.5 gram/59 mL | Y |