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.
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.

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NDC Brand Name Generic Name Form Strength PDL
Status		 Rebate Carveout
‐ Bill FFS		 Current Drug Use Criteria
00132070336 BISACODYL bisacodyl ENEMA 10 mg/30 mL Y N  
00574705012 BISACODYL bisacodyl SUPP.RECT 10 mg Y N  
00574705050 BISACODYL bisacodyl SUPP.RECT 10 mg Y N  
00603046008 BISACODYL bisacodyl SUPP.RECT 10 mg Y N  
00904714212 BISACODYL bisacodyl SUPP.RECT 10 mg Y N  
45802071014 BISACODYL bisacodyl SUPP.RECT 10 mg Y N  
45802071034 BISACODYL bisacodyl SUPP.RECT 10 mg Y N  
57237032703 BISACODYL bisacodyl SUPP.RECT 10 mg Y N  
57237032721 BISACODYL bisacodyl SUPP.RECT 10 mg Y N  
46122060851 GENTLE LAXATIVE bisacodyl SUPP.RECT 10 mg Y N  
70000057301 GENTLE LAXATIVE bisacodyl SUPP.RECT 10 mg Y N  
70000057302 GENTLE LAXATIVE bisacodyl SUPP.RECT 10 mg Y N  
70677109101 GENTLE LAXATIVE bisacodyl SUPP.RECT 10 mg Y N  
57237033703 PROCTOZONE-B bisacodyl SUPP.RECT 10 mg Y N  
57237033704 PROCTOZONE-B bisacodyl SUPP.RECT 10 mg Y N  
57237033721 PROCTOZONE-B bisacodyl SUPP.RECT 10 mg Y N  
57237033751 PROCTOZONE-B bisacodyl SUPP.RECT 10 mg Y N  
00132021601 FLEET PREP KIT #4 bisacodyl/magnesium citrate COMBO. PKG Y N  
00132021801 FLEET PREP KIT #6 bisacodyl/magnesium citrate COMBO. PKG Y N  
00132021701 FLEET PREP KIT #5 bisacodyl/magnesium citrate KIT Y N  
17433988401 DOCUSOL KIDS docusate sodium ENEMA 100 mg/5 mL Y N  
17433988405 DOCUSOL KIDS docusate sodium ENEMA 100 mg/5 mL Y N  
17433000007 ENEMEEZ KIDS docusate sodium ENEMA 100 mg/5 mL Y N  
17433988600 ENEMEEZ KIDS docusate sodium ENEMA 100 mg/5 mL Y N  
17433988602 ENEMEEZ KIDS docusate sodium ENEMA 100 mg/5 mL Y N  
17433988605 ENEMEEZ KIDS docusate sodium ENEMA 100 mg/5 mL Y N  
54092049170 COLACE docusate sodium ENEMA 200 mg/5 mL Y N  
00904692093 DOCUSATE SODIUM docusate sodium ENEMA 283 mg/5 mL Y N  
17433987600 ENEMEEZ docusate sodium ENEMA 283 mg/5 mL Y N  
17433987602 ENEMEEZ docusate sodium ENEMA 283 mg/5 mL Y N  
17433987603 ENEMEEZ docusate sodium ENEMA 283 mg/5 mL Y N  
17433987605 ENEMEEZ docusate sodium ENEMA 283 mg/5 mL Y N  
17433000001 ENEMEEZ PLUS docusate sodium/benzocaine ENEMA 283 mg-20 mg/5 mL Y N  
17433987700 ENEMEEZ PLUS docusate sodium/benzocaine ENEMA 283 mg-20 mg/5 mL Y N  
17433987702 ENEMEEZ PLUS docusate sodium/benzocaine ENEMA 283 mg-20 mg/5 mL Y N  
17433987703 ENEMEEZ PLUS docusate sodium/benzocaine ENEMA 283 mg-20 mg/5 mL Y N  
17433987705 ENEMEEZ PLUS docusate sodium/benzocaine ENEMA 283 mg-20 mg/5 mL Y N  
00132019012 PEDIA-LAX glycerin SOL/PF APP 2.8 gram/2.7 mL Y N  
00132018582 GLYCERIN LAXATIVE glycerin SOL/PF APP 5.4 gram/5.4 mL Y N  
00132007900 ADULT GLYCERIN glycerin SUPP.RECT Adult Y N  
00132007912 ADULT GLYCERIN glycerin SUPP.RECT Adult Y N  
00132007924 ADULT GLYCERIN glycerin SUPP.RECT Adult Y N  
00132007950 ADULT GLYCERIN glycerin SUPP.RECT Adult Y N  
00904733301 ADULT GLYCERIN glycerin SUPP.RECT Adult Y N  
00904733317 ADULT GLYCERIN glycerin SUPP.RECT Adult Y N  
70000057201 ADULT GLYCERIN glycerin SUPP.RECT Adult Y N  
00113032053 ADULT SUPPOSITORY glycerin SUPP.RECT Adult Y N  
00113032063 ADULT SUPPOSITORY glycerin SUPP.RECT Adult Y N  
00113032071 ADULT SUPPOSITORY glycerin SUPP.RECT Adult Y N  
00113032078 ADULT SUPPOSITORY glycerin SUPP.RECT Adult Y N  
45802071514 GLYCERIN glycerin SUPP.RECT Adult Y N  
57237032521 GLYCERIN glycerin SUPP.RECT Adult Y N  
57237032552 GLYCERIN glycerin SUPP.RECT Adult Y N  
45802071614 GLYCERIN glycerin SUPP.RECT PEDIATRIC Y N  
45802071633 GLYCERIN glycerin SUPP.RECT PEDIATRIC Y N  
57237032621 GLYCERIN glycerin SUPP.RECT PEDIATRIC Y N  
57237032652 GLYCERIN glycerin SUPP.RECT PEDIATRIC Y N  
70000042901 GLYCERIN glycerin SUPP.RECT PEDIATRIC Y N  
00113031763 INFANT SUPPOSITORY glycerin SUPP.RECT PEDIATRIC Y N  
00132030140 MINERAL OIL ENEMA mineral oil ENEMA Y N  
49348018520 READY TO USE ENEMA mineral oil ENEMA Y N  
70677109001 READY TO USE ENEMA mineral oil ENEMA Y N  
00132020140 ENEMA sodium phosphate,mono-dibasic ENEMA 19 gram-7 gram/118 mL Y N  
00132020142 ENEMA sodium phosphate,mono-dibasic ENEMA 19 gram-7 gram/118 mL Y N  
00132020145 ENEMA sodium phosphate,mono-dibasic ENEMA 19 gram-7 gram/118 mL Y N  
00904632078 ENEMA sodium phosphate,mono-dibasic ENEMA 19 gram-7 gram/118 mL Y N  
49348018620 ENEMA sodium phosphate,mono-dibasic ENEMA 19 gram-7 gram/118 mL Y N  
70677108901 ENEMA sodium phosphate,mono-dibasic ENEMA 19 gram-7 gram/118 mL Y N  
70677108902 ENEMA sodium phosphate,mono-dibasic ENEMA 19 gram-7 gram/118 mL Y N  
83324029245 ENEMA sodium phosphate,mono-dibasic ENEMA 19 gram-7 gram/118 mL Y N  
83324029390 ENEMA sodium phosphate,mono-dibasic ENEMA 19 gram-7 gram/118 mL Y N  
00536741551 ENEMA DISPOSABLE sodium phosphate,mono-dibasic ENEMA 19 gram-7 gram/118 mL Y N  
00132002011 ENEMA sodium phosphate,mono-dibasic ENEMA 19 gram-7 gram/197 mL Y N  
00132020220 PEDIA-LAX ENEMA sodium phosphate,mono-dibasic ENEMA 9.5 gram-3.5 gram/59 mL Y N  
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