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 Maine and New Hampshire (CMS PDP Region 01).
Not on any stand-alone Part D formulary in Maine and New Hampshire
None of the 9 stand-alone Part D (PDP) plans in CMS PDP Region 01 list this drug. On one of those plans the patient would pay the full retail price, or you would need a formulary exception.