Does Bronze 22 Health cover GaviLyte-C?
Bronze 22 Health
13887-13887FL0010003-0 · ACA · ACA Marketplace
GaviLyte-C
GaviLyte-Cunder Bronze 22 Health
Covered — just walk in
Nothing to clear first — take the prescription to an in-network pharmacy.
What you'd pay
$25per 30-day fill
From the first fill — no deductible on this drug.
This is the standard amount. If you qualified for a cost-sharing reduction when you enrolled, set your level above and this will follow it.
Amount limit applies — you can still fill it, but your plan caps how much you get at a time. This plan's drug list records the cap without stating the amount — your pharmacy can tell you when they fill it.
- Tier
- Generics
- Approval first
- Not needed
- Try another first
- No
- Amount limit
- Yes
Talk to your pharmacist or doctor before acting on anything here. They can see your full history and this page cannot. Never start, stop, or switch a medication based on it. Coverage rules change and plans make exceptions — your pharmacy can check your exact benefit in seconds.As of Sep 14, 2026 · CMS QHP machine-readable. Reference information, not medical advice and not a price.
Covered forms and strengths (4)
- polyethylene glycol 3350 236000 MG / potassium chloride 2970 MG / sodium bicarbonate 6740 MG / sodium chloride 5860 MG / sodium sulfate 22740 MG Powder for Oral SolutionAmount limit
- 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]Amount limit
- 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]Amount limit
- 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]Amount limit