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 Puerto Rico (CMS PDP Region 38).
Not on any stand-alone Part D formulary in Puerto Rico
None of the 3 stand-alone Part D (PDP) plans in CMS PDP Region 38 list this drug. On one of those plans the patient would pay the full retail price, or you would need a formulary exception.