- Prior Authorization Required
- Step Therapy Applies
- Bowel Prep:
Duration: 1 plan year
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 1 plan year
A medical condition requires electrolyte combination that is not present in formulary products: No
Supporting Documentation Requirements: Chart Notes
Is the patient using for bowel cleansing prior to colonoscopy: Yes
Documented Diagnosis: Yes
Patient has experienced intolerance to the generic agents: No
Patient has experienced intolerance to the preferred brand: Yes
Trial with PEG product required: No
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