polyethylene glycol 3350 240000 MG / potassium chloride 2980 MG / sodium bicarbonate 6720 MG / sodium chloride 5840 MG / sodium sulfate 22720 MG Powder for Oral Solution [GaviLyte-C]
polyethylene glycol
RxCUI: 967023
What the CMS Formulary Data Shows for polyethylene glycol 3350 240000 MG / potassium chloride 2980 MG / sodium bicarbonate 6720 MG / sodium chloride 5840 MG / sodium sulfate 22720 MG Powder for Oral Solution [GaviLyte-C]
Per the CMS 2026 Part D formulary file, polyethylene glycol 3350 240000 MG / potassium chloride 2980 MG / sodium bicarbonate 6720 MG / sodium chloride 5840 MG / sodium sulfate 22720 MG Powder for Oral Solution [GaviLyte-C] (RxNorm concept RXCUI 967023, generic name polyethylene glycol) appears on 327 distinct formulary files spanning 5,052 Medicare Part D plan offerings - 99.7% of enrollable Part D products, near-universal placement. Tier placement ranges from Tier 1 to Tier 4, with a cross-plan average of Tier 1.6.
Real-world access to polyethylene glycol 3350 240000 MG / potassium chloride 2980 MG / sodium bicarbonate 6720 MG / sodium chloride 5840 MG / sodium sulfate 22720 MG Powder for Oral Solution [GaviLyte-C] depends on utilization management as much as tier placement: 0% of covering formularies require prior authorization. 0% require step therapy. 0% apply quantity limits.
Historical spending context from the CMS Medicare Part D Drug Spending Dashboard shows 338,109 Part D beneficiaries filled polyethylene glycol 3350 240000 MG / potassium chloride 2980 MG / sodium bicarbonate 6720 MG / sodium chloride 5840 MG / sodium sulfate 22720 MG Powder for Oral Solution [GaviLyte-C] in 2023, with total plan-and-beneficiary spending of $7,010,222 and an average per-beneficiary annual cost of $20.73. The plan-by-plan detail below lists exactly which PDP and MA-PD contracts carry polyethylene glycol 3350 240000 MG / potassium chloride 2980 MG / sodium bicarbonate 6720 MG / sodium chloride 5840 MG / sodium sulfate 22720 MG Powder for Oral Solution [GaviLyte-C] today.
Coverage Details
- Formularies covering
- 327
- Plans covering
- 5,052
- Coverage rate
- 99.7%
- Tier range
- Tier 1 – Tier 4
- Average tier
- Tier 2, Generic
Restrictions
- Prior authorization required
- 0% of formularies
- Step therapy required
- 0% of formularies
- Quantity limits
- 0% of formularies
2023 Medicare Spending
- Beneficiaries
- 338,109
- Total spending
- $7,010,222
- Avg per beneficiary
- $20.73
Tier Distribution Across Plans
Medicare Advantage Plans (MA-PD) Covering polyethylene glycol 3350 240000 MG / potassium chloride 2980 MG / sodium bicarbonate 6720 MG / sodium chloride 5840 MG / sodium sulfate 22720 MG Powder for Oral Solution [GaviLyte-C]
100 Medicare Advantage plans with Part D drug coverage include this drug.
| Plan | Insurer | Tier | PA | Premium | States |
|---|---|---|---|---|---|
| Community Blue Medicare HMO Signature (HMO) | Highmark Western and Northeastern New York Inc. | T1 | No | $0 | NY |
| Community Blue Medicare HMO Merit (HMO) | Highmark Western and Northeastern New York Inc. | T1 | No | $0 | NY |
| Community Blue Medicare PPO Signature (PPO) | HIGHMARK SENIOR HEALTH COMPANY | T1 | No | $0 | PA |
| Complete Blue PPO Signature (PPO) | HIGHMARK SENIOR HEALTH COMPANY | T1 | No | $0 | PA |
| Community Blue Medicare Plus PPO Signature (PPO) | HIGHMARK SENIOR HEALTH COMPANY | T1 | No | $0 | PA |
| Complete Blue PPO Signature (PPO) | HIGHMARK SENIOR HEALTH COMPANY | T1 | No | $0 | PA |
| Complete Blue PPO Merit (PPO) | HIGHMARK SENIOR HEALTH COMPANY | T1 | No | $0 | PA |
| Complete Blue PPO Signature (PPO) | HIGHMARK SENIOR HEALTH COMPANY | T1 | No | $0 | PA |
| Complete Blue PPO Distinct (PPO) | HIGHMARK SENIOR HEALTH COMPANY | T1 | No | $0 | PA |
| Community Blue Medicare Plus PPO Signature (PPO) | HIGHMARK SENIOR HEALTH COMPANY | T1 | No | $0 | PA |
| Complete Blue Plus PPO Merit (PPO) | HIGHMARK SENIOR HEALTH COMPANY | T1 | No | $0 | PA |
| Community Blue Medicare PPO Signature (PPO) | HIGHMARK SENIOR HEALTH COMPANY | T1 | No | $0 | PA |
| Complete Blue PPO Merit (PPO) | HIGHMARK SENIOR HEALTH COMPANY | T1 | No | $0 | PA |
| Community Blue Medicare HMO Signature (HMO) | HIGHMARK CHOICE COMPANY | T1 | No | $0 | PA |
| Security Blue HMO-POS ValueRx (HMO-POS) | HIGHMARK CHOICE COMPANY | T1 | No | $0 | PA |
| Community Blue Medicare HMO Signature (HMO) | HIGHMARK CHOICE COMPANY | T1 | No | $0 | PA |
| Together Blue Medicare HMO Signature (HMO) | HIGHMARK CHOICE COMPANY | T1 | No | $0 | PA |
| Community Blue Medicare HMO Distinct (HMO) | HIGHMARK CHOICE COMPANY | T1 | No | $0 | PA |
| Complete Blue HMO Distinct (HMO) | HIGHMARK CHOICE COMPANY | T1 | No | $0 | PA |
| Complete Blue PPO Distinct (PPO) | HIGHMARK SENIOR SOLUTIONS COMPANY | T1 | No | $0 | WV |
| Complete Blue PPO Signature (PPO) | HIGHMARK SENIOR SOLUTIONS COMPANY | T1 | No | $0 | WV |
| Complete Blue PPO Signature (PPO) | HIGHMARK SENIOR SOLUTIONS COMPANY | T1 | No | $0 | WV |
| Complete Blue PPO Merit (PPO) | HIGHMARK SENIOR SOLUTIONS COMPANY | T1 | No | $0 | WV |
| Complete Blue PPO Signature (PPO) | HIGHMARK BCBSD INC. | T1 | No | $0 | DE |
| Sentara Community Complete Select (HMO D-SNP) | SENTARA HEALTH PLANS | T1 | No | $0 | VA |
| Sentara Community Complete (HMO D-SNP) | SENTARA HEALTH PLANS | T1 | No | $0 | VA |
| Freedom VIP Care (HMO C-SNP) | FREEDOM HEALTH, INC. | T1 | No | $0 | FL |
| Freedom VIP Savings (HMO C-SNP) | FREEDOM HEALTH, INC. | T1 | No | $0 | FL |
| Freedom VIP Savings (HMO C-SNP) | FREEDOM HEALTH, INC. | T1 | No | $0 | FL |
| Freedom VIP Rewards (HMO C-SNP) | FREEDOM HEALTH, INC. | T1 | No | $0 | FL |
| Freedom VIP Rewards (HMO C-SNP) | FREEDOM HEALTH, INC. | T1 | No | $0 | FL |
| Optimum Diamond Rewards (HMO C-SNP) | OPTIMUM HEALTHCARE, INC. | T1 | No | $0 | FL |
| Optimum Diamond Savings (HMO C-SNP) | OPTIMUM HEALTHCARE, INC. | T1 | No | $0 | FL |
| Optimum Diamond Rewards (HMO C-SNP) | OPTIMUM HEALTHCARE, INC. | T1 | No | $0 | FL |
| Optimum Diamond (HMO C-SNP) | OPTIMUM HEALTHCARE, INC. | T1 | No | $0 | FL |
| Freedom Medi-Medi Partial (HMO D-SNP) | FREEDOM HEALTH, INC. | T1 | No | $0 | FL |
| Freedom Medi-Medi Full (HMO D-SNP) | FREEDOM HEALTH, INC. | T1 | No | $0 | FL |
| Optimum Emerald Partial (HMO D-SNP) | OPTIMUM HEALTHCARE, INC. | T1 | No | $0 | FL |
| Optimum Emerald Full (HMO D-SNP) | OPTIMUM HEALTHCARE, INC. | T1 | No | $0 | FL |
| Freedom Medicare Plan Rx (HMO) | FREEDOM HEALTH, INC. | T1 | No | $0 | FL |
| Freedom Medicare Plan Rx (HMO) | FREEDOM HEALTH, INC. | T1 | No | $0 | FL |
| Freedom VIP Savings COPD (HMO C-SNP) | FREEDOM HEALTH, INC. | T1 | No | $0 | FL |
| Freedom VIP Savings COPD (HMO C-SNP) | FREEDOM HEALTH, INC. | T1 | No | $0 | FL |
| Freedom Platinum Plan Rx (HMO) | FREEDOM HEALTH, INC. | T1 | No | $0 | FL |
| Freedom Platinum Plan Rx (HMO) | FREEDOM HEALTH, INC. | T1 | No | $0 | FL |
| Freedom Platinum Plan Rx (HMO) | FREEDOM HEALTH, INC. | T1 | No | $0 | FL |
| Freedom Platinum Plan Rx (HMO) | FREEDOM HEALTH, INC. | T1 | No | $0 | FL |
| Freedom Platinum Plan Rx (HMO) | FREEDOM HEALTH, INC. | T1 | No | $0 | FL |
| Freedom Platinum Rewards Plan Rx (HMO) | FREEDOM HEALTH, INC. | T1 | No | $0 | FL |
| Freedom Platinum Rewards Plan Rx (HMO) | FREEDOM HEALTH, INC. | T1 | No | $0 | FL |
Frequently Asked Questions
Is polyethylene glycol 3350 240000 MG / potassium chloride 2980 MG / sodium bicarbonate 6720 MG / sodium chloride 5840 MG / sodium sulfate 22720 MG Powder for Oral Solution [GaviLyte-C] covered by Medicare Part D?
Yes, polyethylene glycol 3350 240000 MG / potassium chloride 2980 MG / sodium bicarbonate 6720 MG / sodium chloride 5840 MG / sodium sulfate 22720 MG Powder for Oral Solution [GaviLyte-C] is covered by 5,052 Medicare Part D plans (99.7% of all Part D formularies).
What tier is polyethylene glycol 3350 240000 MG / potassium chloride 2980 MG / sodium bicarbonate 6720 MG / sodium chloride 5840 MG / sodium sulfate 22720 MG Powder for Oral Solution [GaviLyte-C] on Medicare Part D plans?
polyethylene glycol 3350 240000 MG / potassium chloride 2980 MG / sodium bicarbonate 6720 MG / sodium chloride 5840 MG / sodium sulfate 22720 MG Powder for Oral Solution [GaviLyte-C] averages Tier 1.6 across Part D plans, ranging from Tier 1 to Tier 4.
Does polyethylene glycol 3350 240000 MG / potassium chloride 2980 MG / sodium bicarbonate 6720 MG / sodium chloride 5840 MG / sodium sulfate 22720 MG Powder for Oral Solution [GaviLyte-C] require prior authorization?
0% of Part D formularies require prior authorization for polyethylene glycol 3350 240000 MG / potassium chloride 2980 MG / sodium bicarbonate 6720 MG / sodium chloride 5840 MG / sodium sulfate 22720 MG Powder for Oral Solution [GaviLyte-C]. Step therapy: 0%. Quantity limits: 0%.
How much does Medicare spend on polyethylene glycol 3350 240000 MG / potassium chloride 2980 MG / sodium bicarbonate 6720 MG / sodium chloride 5840 MG / sodium sulfate 22720 MG Powder for Oral Solution [GaviLyte-C]?
In 2023, total Medicare Part D spending on polyethylene glycol 3350 240000 MG / potassium chloride 2980 MG / sodium bicarbonate 6720 MG / sodium chloride 5840 MG / sodium sulfate 22720 MG Powder for Oral Solution [GaviLyte-C] was $7,010,222, covering 338,109 beneficiaries. The average spend per beneficiary was $20.73.
Read our methodology - how this data is sourced, computed, and verified.