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Bowel Preps – NC Standard

Commercial Policy
Version Date: July 2023

Restricted Product(s):

  • Clenpiq® (Sodium picosulfate, magnesium oxide, and anhydrous citric acid) 
  • OsmoPrep® (Sod phos monosod phos di tabs 1.102-0.398 gm (1.5gm Na phos)) 
  • Suflave TM (polyethylene glycol 3350, sodium sulfate, potassium chloride, magnesium sulfate, and sodium chloride)

FDA Approved Use:

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

Criteria for Approval of Restricted Product(s):

  1. The patient has had a history of insufficient bowel preparation with generic polyethylene glycol with balanced electrolytes (e.g. Trilyte, Gavilyte-N, Gavilyte-C, Gavilyte-H, Gavilyte-G); OR
  2. The patient has had a history of insufficient bowel preparation with brand or generic Suprep; OR 
  3. The patient runs the risk of forgoing colonoscopy due to adverse tolerability of unrestricted bowel preparations; AND
  4. For formularies that exclude (non-formulary) the requested medication, Non-formulary Exception Criteria applies.

Duration of Approval: 365 days (1 year) 

References:

All information referenced is from FDA package insert unless otherwise noted below. 

Policy Implementation/Update Information:

Criteria and treatment protocols are reviewed annually by the Blue Cross NC P&T Committee, regardless of change. This policy is reviewed in Q2 annually.

July 2023: Criteria update: Added Suflave to the policy.

September 2022: Criteria update: Removed authorized generic Suprep from the policy.

July 2022: Criteria update: Added authorized generic Suprep to the policy.

July 2022: Criteria update: Removed Prepopik from policy (obsolete). Duration of approval changed to 365 days.

April 2021: Criteria update: Removed Golytely from policy.

Sept 2020: Criteria update: Removed Moviprep from policy.

July 2019: Original utilization management criteria issued.

Blue Cross and Blue Shield of North Carolina does not discriminate on the basis of race, color, national origin, sex, age or disability in its health programs and activities. Learn more about our non-discrimination policy and no-cost services available to you.

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