
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
Sod Picosulfate-Mag Ox-Cit Acd
Tier: 2
PA Type: No Prior Authorization
ST: Y

Colyte with Flavor Packs Solution Reconstituted 240 GM Oral
PEG 3350-KCl-NaBcb-NaCl-NaSulf
Tier: 3
PA Type: No Prior Authorization
ST: N

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
PEG 3350-KCl-NaBcb-NaCl-NaSulf
Tier: 1
PA Type: No Prior Authorization
ST: N

GaviLyte-H KIT 5-210 MG-GM ORAL
Bisacodyl-PEG-KCl-NaBicar-NaCl
Tier: 1
PA Type: No Prior Authorization
ST: N
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