Health Net
Prepopik (sod picosulf-mag ox-citric ac)
Drugs for the Stomach : Drugs to Prevent Constipation
  • 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