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 Indiana and Kentucky (CMS PDP Region 15).
Not on any stand-alone Part D formulary in Indiana and Kentucky
None of the 10 stand-alone Part D (PDP) plans in CMS PDP Region 15 list this drug. On one of those plans the patient would pay the full retail price, or you would need a formulary exception.