CurrentCentenePolicy N/A

Colonoscopy Preparation Products

This clinical policy governs coverage and product information for oral and tablet colonoscopy bowel preparation products for members of the Health Plan (Centene). It affects providers who prescribe, dispense, or seek coverage for these products.

Policy Summary

PayerCentene

PolicyColonoscopy Preparation Products

Policy CodePolicy N/A

Change TypeProduct additions, removals, and formulary redirects

Effective DateN/A

Next Review DateN/A

Key ActionSubmit documentation (office notes, labs, or clinical information) supporting that the member meets approval criteria when requesting coverage.

SourceLink

POLICY UPDATE CHANGES

Added newly approved combination product Suflave to policy.

Removed discontinued products Prepopik and Colyte from policy.

Added GaviLyte-C to policy.

Added generic Suprep as a redirect for members 12 years and older.

≈13listed bowel preparation products/formulations in this section

2024-07-30most recent references review date

11.24most recent P&T approval quarter/year listed

Coverage Criteria

Note: the policy record was updated to remove discontinued bowel preparation products. Prepopik and Colyte have been removed from the policy and are no longer listed as covered products; providers should not rely on this policy for coverage of those specific products.

Provider Actions and Responsibilities

Note

Formulary / Redirect Updates

Formulary/redirect updates: The Health Plan updates formulary and product redirects periodically. Recent updates include adding generic Suprep as a formulary redirect for members ≥ 12 years of age and the addition of GaviLyte‑C and Suflave (with discontinued products Prepopik and Colyte removed). These changes may affect prior authorization and coverage routing; providers should verify the member’s current formulary and any applicable redirects before prescribing or dispensing.

Generic Suprep added as redirect for members ≥ 12 years (per March SDC, 03.12.24).
Policy history: removal of discontinued Prepopik and Colyte; addition of GaviLyte‑C and Suflave (4Q 2023).

Step Therapy

Policy Summary

PayerCentene

PolicyColonoscopy Preparation Products

Policy CodePolicy N/A

Change TypeProduct additions, removals, and formulary redirects

Effective DateN/A

Next Review DateN/A

Key ActionSubmit documentation (office notes, labs, or clinical information) supporting that the member meets approval criteria when requesting coverage.

SourceLink

On This Page

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Documentation Required

Provider Documentation and Responsibility

Provider documentation and responsibility: Providers are expected to follow contract terms, exercise independent medical judgment, and document the medical necessity of prescribed colonoscopy preparation products in the medical record. Coverage decisions and benefit administration remain subject to the member’s plan terms, limitations, and exclusions. Providers must submit claims consistent with coverage documents and retain required clinical documentation to support medical necessity if audited or if a prior authorization or claim denial is reviewed.

Document indication, relevant clinical findings, and rationale for product selection in the patient chart.
Submit claims consistent with the member’s evidence of coverage and contract terms.
Maintain documentation supporting medical necessity for prior authorization or claim review.

Product Availability and Formulations

Product availability / formulation

ClenpiqOral solution: each bottle contains 10 mg sodium picosulfate; 3.5 g magnesium oxide; 12 g anhydrous citric acid in 160 mL

GaviLyte-CPowder for oral solution (4 L): PEG 3350 240 g; sodium chloride 5.84 g; potassium chloride 2.98 g; sodium bicarbonate 6.72 g; sodium sulfate (anhydrous) 22.72 g

GoLYTELY / NulytelyPowder for oral solution (4 L): PEG 3350 ~236–420 g depending on product; electrolytes include sodium sulfate ~22.7 g, sodium bicarbonate ~5.7–6.74 g, sodium chloride ~5.86–11.2 g, potassium chloride ~1.48–2.97 g

MoviPrepOral solution (two-pouch system): Pouch A—100 g PEG 3350; 7.5 g sodium sulfate; 2.691 g sodium chloride; 1.015 g potassium chloride. Pouch B—4.7 g ascorbic acid; 5.9 g sodium ascorbate

PlenvuOral solution (dose pouches): Dose pouch 1—100 g PEG 3350; 9 g sodium sulfate; 2 g sodium chloride; 1 g potassium chloride. Dose pouch 2A—40 g PEG 3350; 3.2 g sodium chloride; 1.2 g potassium chloride. Dose pouch 2B—48.11 g sodium ascorbate; 7.54 g ascorbic acid

SuflaveOral solution: two bottles plus two flavor packets; each bottle contains 178.7 g PEG 3350; 7.3 g sodium sulfate; 1.12 g potassium chloride; 0.9 g magnesium sulfate; 0.5 g sodium chloride

Suprep (adult and pediatric >=12 yrs)Oral solution bottles (Adults): two 6‑oz bottles each containing 17.5 g sodium sulfate; 3.13 g potassium sulfate; 1.6 g magnesium sulfate. Pediatric (≥12 yrs): two 4.5‑oz bottles each containing 13.13 g sodium sulfate; 2.35 g potassium sulfate; 1.2 g magnesium sulfate

OsmoPrep and Sutab (tablet formulations)OsmoPrep: tablet form—15 g sodium phosphate per tablet. Sutab: tablet formulation—per tablet 1.479 g sodium sulfate; 0.225 g magnesium sulfate; 0.188 g potassium chloride

OpenPayer

Colonoscopy Preparation Products

Coverage Criteria

Provider Actions and Responsibilities

Background

Product Availability and Formulations