Pharmacy Prior Authorization Criteria

Bowel Prep Agents

For diagnosis of Colonoscopy
Indicated for cleansing of the colon as a preparation for colonoscopy in adults.

For diagnosis of Colonoscopy
Indicated for cleansing of the colon in preparation for colonoscopy in adults.

For diagnosis of Colonoscopy
Indicated for cleansing of the colon as a preparation for colonoscopy in adults.

Step Therapy

Length of Approval: 12 Month(s)

Requested drug is being used for a Food and Drug Administration (FDA)-approved indication

AND

Trial and failure of a minimum 1 day supply within the last 180 days, contraindication, or intolerance to one of the following:

2024-11-13, 2023-11-01, 2023-09-01, 2022-10-24, 2022-09-27, 2021-10-07, 2021-04-06, 2021-01-20, 2020-09-30, 2020-06-30, 2019-11-07

Moviprep prescribing information. Salix Pharmaceuticals, Inc. Bridgewater, NJ. June 2023.
Plenvu prescribing information. Salix Pharmaceuticals, Inc. Bridgewater, NJ. September 2023.
Osmoprep prescribing information. Salix Pharmaceuticals, Inc. Bridgewater, NJ. March 2019.
Suflave prescribing information. Sebela Pharmaceuticals, Inc. Holbrook, MA. June 2023.

2024-11-13: Annual Review - no criteria changes.
2023-11-01: Program update to remove Suflave
2023-09-01: Annual Review - Addition of Suflave
2022-10-24: Guideline Update
2022-09-27: Annual Review - Addition of FDA diagnosis verification
2021-10-07: Annual Review - Prepopik removed as prerequisite
2021-04-06: Removed Sutab as target
2021-01-20: Program update: Sutab added as target.
2020-09-30: Program Update: Plenvu and Osmoprep added as targets in ST per Aug P&T; Added "Brand" to Moviprep in target list since generic came out for Oct P&T
2020-06-30: Program Update: length of look back period added to criteria
2019-11-07: New program.