Medicare Part D coverage · polyethylene glycol · RxCUI 967012
polyethylene glycol 3350 236000 MG / potassium chloride 2970 MG / sodium bicarbonate 6740 MG / sodium chloride 5860 MG / sodium sulfate 22740 MG Powder for Oral Solution [Gavilyte-G]
Per the CMS 2026 Part D formulary file, polyethylene glycol 3350 236000 MG / potassium chloride 2970 MG / sodium bicarbonate 6740 MG / sodium chloride 5860 MG / sodium sulfate 22740 MG Powder for Oral Solution [Gavilyte-G] is covered by 4,785 Medicare Part D plans (94.7% of enrollable products), averaging Tier 1.6, with prior authorization required on 0% of covering formularies.
- 94.7%
- Plan coverage
- 4,785
- Plans covering
- T1.6
- Avg tier
- 0%
- Prior auth required
What the CMS Formulary Data Shows for polyethylene glycol 3350 236000 MG / potassium chloride 2970 MG / sodium bicarbonate 6740 MG / sodium chloride 5860 MG / sodium sulfate 22740 MG Powder for Oral Solution [Gavilyte-G]
Per the CMS 2026 Part D formulary file, polyethylene glycol 3350 236000 MG / potassium chloride 2970 MG / sodium bicarbonate 6740 MG / sodium chloride 5860 MG / sodium sulfate 22740 MG Powder for Oral Solution [Gavilyte-G] (RxNorm concept RXCUI 967012, generic name polyethylene glycol) appears on 316 distinct formulary files spanning 4,785 Medicare Part D plan offerings - 94.7% of enrollable Part D products, near-universal placement. Tier placement ranges from Tier 1 to Tier 3, with a cross-plan average of Tier 1.6.
Real-world access to polyethylene glycol 3350 236000 MG / potassium chloride 2970 MG / sodium bicarbonate 6740 MG / sodium chloride 5860 MG / sodium sulfate 22740 MG Powder for Oral Solution [Gavilyte-G] 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 766,658 Part D beneficiaries filled polyethylene glycol 3350 236000 MG / potassium chloride 2970 MG / sodium bicarbonate 6740 MG / sodium chloride 5860 MG / sodium sulfate 22740 MG Powder for Oral Solution [Gavilyte-G] in 2023, with total plan-and-beneficiary spending of $13,976,757 and an average per-beneficiary annual cost of $18.23. The plan-by-plan detail below lists exactly which PDP and MA-PD contracts carry polyethylene glycol 3350 236000 MG / potassium chloride 2970 MG / sodium bicarbonate 6740 MG / sodium chloride 5860 MG / sodium sulfate 22740 MG Powder for Oral Solution [Gavilyte-G] today.
Coverage Details
- Formularies covering
- 316
- Plans covering
- 4,785
- Coverage rate
- 94.7%
- Tier range
- Tier 1 – Tier 3
- 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
- 766,658
- Total spending
- $13,976,757
- Avg per beneficiary
- $18.23
Tier Distribution Across Plans
Medicare Advantage Plans (MA-PD) Covering polyethylene glycol 3350 236000 MG / potassium chloride 2970 MG / sodium bicarbonate 6740 MG / sodium chloride 5860 MG / sodium sulfate 22740 MG Powder for Oral Solution [Gavilyte-G]
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 |
Show the next 30 plans
| 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 |
| HealthSun HealthAdvantage Plan (HMO) | Healthsun Health Plans, Inc. | T1 | No | $0 | FL |
| HealthSun MediMax (HMO) | Healthsun Health Plans, Inc. | T1 | No | $0 | FL |
| HealthSun HealthAdvantage Plan (HMO) | Healthsun Health Plans, Inc. | T1 | No | $0 | FL |
| HealthSun HealthAdvantage Plan (HMO) | Healthsun Health Plans, Inc. | T1 | No | $0 | FL |
| HealthSun MediSun Plus (HMO D-SNP) | Healthsun Health Plans, Inc. | T1 | No | $0 | FL |
| HealthSun HealthAdvantage Plus (HMO) | Healthsun Health Plans, Inc. | T1 | No | $0 | FL |
| HealthSun HealthAdvantage Plus (HMO) | Healthsun Health Plans, Inc. | T1 | No | $0 | FL |
| HealthSun MediSun Extra (HMO D-SNP) | Healthsun Health Plans, Inc. | T1 | No | $0 | FL |
| HealthSun HealthAdvantage Plus (HMO) | Healthsun Health Plans, Inc. | T1 | No | $0 | FL |
| HealthSun VitalCare (HMO C-SNP) | Healthsun Health Plans, Inc. | T1 | No | $0 | FL |
| HealthSun VitalCare (HMO C-SNP) | Healthsun Health Plans, Inc. | T1 | No | $0 | FL |
| HealthSun MediSun Full Dual Plus (HMO D-SNP) | Healthsun Health Plans, Inc. | T1 | No | $0 | FL |
| HealthSun MediSun Full Dual Extra (HMO D-SNP) | Healthsun Health Plans, Inc. | T1 | No | $0 | FL |
| Simply Complete (HMO D-SNP) | Simply Healthcare Plans, Inc. | T1 | No | $0 | FL |
| Simply More (HMO) | Simply Healthcare Plans, Inc. | T1 | No | $0 | FL |
| Simply Complete (HMO D-SNP) | Simply Healthcare Plans, Inc. | T1 | No | $0 | FL |
| Simply Level (HMO C-SNP) | Simply Healthcare Plans, Inc. | T1 | No | $0 | FL |
| Simply Level (HMO C-SNP) | Simply Healthcare Plans, Inc. | T1 | No | $0 | FL |
| Simply More (HMO) | Simply Healthcare Plans, Inc. | T1 | No | $0 | FL |
| Simply Level (HMO C-SNP) | Simply Healthcare Plans, Inc. | T1 | No | $0 | FL |
| Simply More (HMO) | Simply Healthcare Plans, Inc. | T1 | No | $0 | FL |
| Simply Level (HMO C-SNP) | Simply Healthcare Plans, Inc. | T1 | No | $0 | FL |
| Simply Complete (HMO D-SNP) | Simply Healthcare Plans, Inc. | T1 | No | $0 | FL |
| Simply More (HMO) | Simply Healthcare Plans, Inc. | T1 | No | $0 | FL |
Showing top 50 of 100 plans.
Frequently Asked Questions
Is polyethylene glycol 3350 236000 MG / potassium chloride 2970 MG / sodium bicarbonate 6740 MG / sodium chloride 5860 MG / sodium sulfate 22740 MG Powder for Oral Solution [Gavilyte-G] covered by Medicare Part D?
Yes, polyethylene glycol 3350 236000 MG / potassium chloride 2970 MG / sodium bicarbonate 6740 MG / sodium chloride 5860 MG / sodium sulfate 22740 MG Powder for Oral Solution [Gavilyte-G] is covered by 4,785 Medicare Part D plans (94.7% of all Part D formularies).
What tier is polyethylene glycol 3350 236000 MG / potassium chloride 2970 MG / sodium bicarbonate 6740 MG / sodium chloride 5860 MG / sodium sulfate 22740 MG Powder for Oral Solution [Gavilyte-G] on Medicare Part D plans?
polyethylene glycol 3350 236000 MG / potassium chloride 2970 MG / sodium bicarbonate 6740 MG / sodium chloride 5860 MG / sodium sulfate 22740 MG Powder for Oral Solution [Gavilyte-G] averages Tier 1.6 across Part D plans, ranging from Tier 1 to Tier 3.
Does polyethylene glycol 3350 236000 MG / potassium chloride 2970 MG / sodium bicarbonate 6740 MG / sodium chloride 5860 MG / sodium sulfate 22740 MG Powder for Oral Solution [Gavilyte-G] require prior authorization?
0% of Part D formularies require prior authorization for polyethylene glycol 3350 236000 MG / potassium chloride 2970 MG / sodium bicarbonate 6740 MG / sodium chloride 5860 MG / sodium sulfate 22740 MG Powder for Oral Solution [Gavilyte-G]. Step therapy: 0%. Quantity limits: 0%.
How much does Medicare spend on polyethylene glycol 3350 236000 MG / potassium chloride 2970 MG / sodium bicarbonate 6740 MG / sodium chloride 5860 MG / sodium sulfate 22740 MG Powder for Oral Solution [Gavilyte-G]?
In 2023, total Medicare Part D spending on polyethylene glycol 3350 236000 MG / potassium chloride 2970 MG / sodium bicarbonate 6740 MG / sodium chloride 5860 MG / sodium sulfate 22740 MG Powder for Oral Solution [Gavilyte-G] was $13,976,757, covering 766,658 beneficiaries. The average spend per beneficiary was $18.23.
Read our methodology - how this data is sourced, computed, and verified.
Nationwide similar Part D drugs
Data-derived peers across the CMS Part D formulary extract: nearest average tier placement and nearest prior-authorization rate. Not therapeutic alternatives or same-generic strengths.
Closest average formulary tier
Similar prior-authorization rate
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