Bowel Prep Agents (Brand Moviprep, Plenvu, Osmoprep)

Bowel Prep Agents (Brand Moviprep, Plenvu, Osmoprep)

Self-Administration – Oral

Diagnosis considered for coverage:

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

Coverage Criteria:

• 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

Coverage Duration:

• 12 months

Authorization is not covered for the following:

The use of this drug for indications not listed in this policy does not meet the coverage criteria established by the Western Health Advantage (WHA) Pharmacy and Therapeutics (P&T) Committee.

Policy Updates:

• 02/20/2023 – New policy approved by P&T.

References:

1. Moviprep prescribing information. Salix Pharmaceuticals, Inc. Bridgewater, NJ. May 2021.
2. Plenvu prescribing information. Salix Pharmaceuticals, Inc. Bridgewater, NJ. May 2021.
3. Osmoprep prescribing information. Salix Pharmaceuticals, Inc. Bridgewater, NJ. March 2019.
4. Suflave prescribing information. Sebela Pharmaceuticals, Inc. Holbrook, MA. June 2023.