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Bowel Preps – NC Standard
Commercial Utilization Management 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.
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