Pharmacy Prior Authorization Criteria

Bowel Prep Agents

Indications for Prior Authorization

Moviprep

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

Plenvu

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

Criteria

Brand Moviprep, Plenvu

For state-mandated plans in Illinois or other states where applicable: Step therapy requirements do NOT apply. Beginning January 1, 2026, step therapy requirements or use of the authorization of alternative covered medications in a manner that effectively creates a step therapy requirement will not be imposed.

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:
• Clenpiq
• Suprep
• Suflave

P & T Revisions

1970-01-01, 2025-12-18, 2025-09-08, 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

References

1. Moviprep prescribing information. Salix Pharmaceuticals, Inc. Bridgewater, NJ. June 2023.
2. Plenvu prescribing information. Salix Pharmaceuticals, Inc. Bridgewater, NJ. September 2023.
3. Suflave prescribing information. Sebela Pharmaceuticals, Inc. Holbrook, MA. June 2023.

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Revision History

• 1970-01-01: No criteria change, bulk copy oRX-EHB
• 2025-12-18: no criteria changes, added IL statute operational note
• 2025-09-08: 2025 Annual Review
• 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.

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