Gastrointestinal Drugs
Laxatives

Brand/Generic Name Dosage/Strength Status Restrictions Notes Relative Cost
Amitiza
lubiprostone		 8 mcg capsule; 24 mcg capsule   nonform.gif (625 bytes)

ql.gif st.gif mo.gif

Not Applicable
Cephulac generic.gif (400 bytes)
Lactulose Encephalopathy		   approved.gif (510 bytes)  

$
Colyte generic.gif (400 bytes)
peg 3350-electrolytes		 Recon Soln   approved.gif (510 bytes)  

$$
Colyte with Flavor Packs generic.gif (400 bytes)
peg 3350-electrolytes		 Recon Soln   approved.gif (510 bytes)  

$$
Golytely generic.gif (400 bytes)
peg 3350-electrolytes		 Recon Soln   approved.gif (510 bytes)  

$$
Halflytely-Bisacodyl w-Flav Pk
bisacodyl-peg-electrolyte soln		 5-210 mg-gram Kit   nonform.gif (625 bytes)  

Not Applicable
Kristalose generic.gif (400 bytes)
lactulose		 Packet   approved.gif (510 bytes)  

$
Miralax generic.gif (400 bytes)
polyethylene glycol 3350		 Powder in Packet   approved.gif (510 bytes)  

$$
MoviPrep
peg 3350-electrolytes-vit C		 100-7.5-2.691 gram Powder in Packet   nonform.gif (625 bytes)  

Not Applicable
NuLYTELY with Flavor Packs
peg-electrolyte soln		 420 g Recon Soln   approved.gif (510 bytes)  

$$
OsmoPrep
sod phos mono-sod phos dibasic		 tablet   nonform.gif (625 bytes)  

Not Applicable
Relistor
methylnaltrexone		 12 mg/0.6 mL Solution   nonform.gif (625 bytes)

priorauth.gif (377 bytes)

Not Applicable
TriLyte With Flavor Packets generic.gif (400 bytes)
peg-electrolyte soln		 420 g Recon Soln   approved.gif (510 bytes)  

Not Applicable
Visicol
Sod Phos Mono-Sod Phos Dibasic		   nonform.gif (625 bytes)  

Not Applicable

Key for Product(s) Listed Above
Formulary Prior Authorization (PA may not be required for some benefit plans) Non-Formulary
(Third tier coverage applies for selected plans)		 Not Reimbursed
Quantity Limit Not available through mail order as 90-day supply* Step Therapy Generic Available. Brand name medication may be covered at a higher member cost or may not be covered for certain plans.
Notes $Relative cost compared to others in category Specialty distribution for selected plans (Fourth or fifth tier coverage applied for selected plans)

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