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.
Osmoprep
-
For diagnosis of Colonoscopy
Indicated for cleansing of the colon as a preparation for colonoscopy in adults.
Criteria
Brand Moviprep, Plenvu, Osmoprep
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
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
- 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.
Revision History
- 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.
HEALTHY LIVING