All *LAXATIVES*

Cascara Sagrada FLUID EXTRACT 1 GM/ML ORAL
Cascara Sagrada FLUID EXTRACT 1 GM/ML ORAL

Tier: 3
PA Type: No Prior Authorization
ST: N
Clenpiq SOLUTION 10-3.5-12 MG-GM -GM/160ML Oral
Clenpiq SOLUTION 10-3.5-12 MG-GM -GM/160ML Oral

Sod Picosulfate-Mag Ox-Cit Acd

Tier: 2
PA Type: No Prior Authorization
ST: Y
Clenpiq SOLUTION 10-3.5-12 MG-GM -GM/160ML Oral
Clenpiq SOLUTION 10-3.5-12 MG-GM -GM/160ML Oral

Sod Picosulfate-Mag Ox-Cit Acd

Tier: 2
PA Type: No Prior Authorization
ST: Y
Colyte with Flavor Packs Solution Reconstituted 240 GM Oral
Colyte with Flavor Packs Solution Reconstituted 240 GM Oral

PEG 3350-KCl-NaBcb-NaCl-NaSulf

Tier: 3
PA Type: No Prior Authorization
ST: N
Constulose Solution 10 GM/15ML Oral
Constulose Solution 10 GM/15ML Oral

Tier: 1
PA Type: No Prior Authorization
ST: N
Constulose Solution 10 GM/15ML Oral
Constulose Solution 10 GM/15ML Oral

Tier: 1
PA Type: No Prior Authorization
ST: N
GaviLyte-C Solution Reconstituted 240 GM Oral
GaviLyte-C Solution Reconstituted 240 GM Oral

PEG 3350-KCl-NaBcb-NaCl-NaSulf

Tier: 3
PA Type: No Prior Authorization
ST: N
GaviLyte-G Solution Reconstituted 236 GM Oral
GaviLyte-G Solution Reconstituted 236 GM Oral

PEG 3350-KCl-NaBcb-NaCl-NaSulf

Tier: 1
PA Type: No Prior Authorization
ST: N
GaviLyte-H KIT 5-210 MG-GM ORAL
GaviLyte-H KIT 5-210 MG-GM ORAL

Bisacodyl-PEG-KCl-NaBicar-NaCl

Tier: 1
PA Type: No Prior Authorization
ST: N
GaviLyte-N with Flavor Pack SOLUTION RECONSTITUTED 420 GM ORAL
GaviLyte-N with Flavor Pack SOLUTION RECONSTITUTED 420 GM ORAL

PEG 3350-KCl-Na Bicarb-NaCl

Tier: 1
PA Type: No Prior Authorization
ST: N
Gialax KIT ORAL
Gialax KIT ORAL

Polyethylene Glycol 3350

Tier: Non-Formulary
PA Type: No Prior Authorization
ST: N
Golytely Solution Reconstituted 227.1 GM Oral
Golytely Solution Reconstituted 227.1 GM Oral

PEG 3350-KCl-NaBcb-NaCl-NaSulf

Tier: 3
PA Type: No Prior Authorization
ST: N