| Anthem Blue Cross (HMO, PPO, EPO) |
| Clenpiq (sod picosulf-mag ox-citric ac) |
| Drugs for the Stomach : Drugs to Prevent Constipation |
- Quantity Limit: limit maximum 320 mL PER 30 day(s)
- Bowel Prep:
Duration: 1 year(s)
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
A medical condition requires electrolyte combination that is not present in formulary products: No
Is the patient using for bowel cleansing prior to colonoscopy: No
Documented Diagnosis: Yes
Patient has experienced intolerance to the generic agents: Yes
Patient has experienced intolerance to the preferred brand: No
Trial with PEG product required: No
- Prior Authorization: Bowel Prep:
PA Applies
- Step Therapy: Bowel Prep:
Step Applies
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