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 [Golytely]
polyethylene glycol
RxCUI: 966922
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 [Golytely]
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 [Golytely] (RxNorm concept RXCUI 966922, generic name polyethylene glycol) appears on 4 distinct formulary files spanning 11 Medicare Part D plan offerings - 0.2% of enrollable Part D products, selective placement; verify formulary inclusion before enrolling. Tier placement ranges from Tier 1 to Tier 2, with a cross-plan average of Tier 1.3.
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 [Golytely] 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 10,172 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 [Golytely] in 2023, with total plan-and-beneficiary spending of $261,461 and an average per-beneficiary annual cost of $25.70. 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 [Golytely] today.
Coverage Details
- Formularies covering
- 4
- Plans covering
- 11
- Coverage rate
- 0.2%
- Tier range
- Tier 1 – Tier 2
- Average tier
- Tier 1, Preferred Generic
Restrictions
- Prior authorization required
- 0% of formularies
- Step therapy required
- 0% of formularies
- Quantity limits
- 0% of formularies
2023 Medicare Spending
- Beneficiaries
- 10,172
- Total spending
- $261,461
- Avg per beneficiary
- $25.70
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 [Golytely]
11 Medicare Advantage plans with Part D drug coverage include this drug.
| Plan | Insurer | Tier | PA | Premium | States |
|---|---|---|---|---|---|
| Hamaspik Medicare Choice (HMO D-SNP) | HAMASPIK, INC. | T1 | No | $0 | NY |
| CalOptima Health OneCare Complete (HMO D-SNP) | ORANGE COUNTY HEALTH AUTHORITY | T1 | No | $0 | CA |
| Highmark Wholecare Medicare Assured Diamond (HMO D-SNP) | GATEWAY HEALTH PLAN, INC. | T1 | No | $0 | PA |
| Highmark Wholecare Medicare Assured Diamond (HMO D-SNP) | GATEWAY HEALTH PLAN, INC. | T1 | No | $0 | PA |
| Highmark Health Options Duals (HMO D-SNP) | HIGHMARK HEALTH OPTIONS WEST VIRGINIA INC. | T1 | No | $0 | WV |
| Highmark Health Options Duals (HMO D-SNP) | HIGHMARK BCBSD, INC. | T1 | No | $0 | DE |
| Highmark Wholecare Medicare Assured Ruby (HMO D-SNP) | GATEWAY HEALTH PLAN, INC. | T1 | No | $13.10 | PA |
| Highmark Wholecare Medicare Assured Ruby (HMO D-SNP) | GATEWAY HEALTH PLAN, INC. | T1 | No | $17.60 | PA |
| Highmark Health Options Duals Select (HMO D-SNP) | HIGHMARK BCBSD, INC. | T1 | No | $31.20 | DE |
| Hamaspik Medicare Select (HMO D-SNP) | HAMASPIK, INC. | T1 | No | $34.50 | NY |
| CareAdvantage (HMO D-SNP) | SAN MATEO HEALTH COMMISSION | T2 | No | $0 | CA |
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 [Golytely] 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 [Golytely] is covered by 11 Medicare Part D plans (0.2% 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 [Golytely] 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 [Golytely] averages Tier 1.3 across Part D plans, ranging from Tier 1 to Tier 2.
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 [Golytely] 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 [Golytely]. 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 [Golytely]?
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 [Golytely] was $261,461, covering 10,172 beneficiaries. The average spend per beneficiary was $25.70.
Read our methodology - how this data is sourced, computed, and verified.