GOLYTELY 236/22.74/6.74/5.86/2.97 g/4L Powder, For Solution
Also known as Polyethylene Glycol 3350, Sodium Sulfate Anhydrous, Sodium Bicarbonate, Sodium Chloride, Potassium Chloride. Coverage in Idaho and Utah (CMS PDP Region 31).
Not on any stand-alone Part D formulary in Idaho and Utah
None of the 10 stand-alone Part D (PDP) plans in CMS PDP Region 31 list this drug. On one of those plans the patient would pay the full retail price, or you would need a formulary exception.