FillMapGold 22 Health · 13887-13887FL0010001-0About this plan

Does Gold 22 Health cover GaviLyte-N?

1 · Your plan

Gold 22 Health

13887-13887FL0010001-0 · ACA · ACA Marketplace

2 · Your medication

GaviLyte-N

GaviLyte-Nunder Gold 22 Health

Covered — just walk in

Nothing to clear first — take the prescription to an in-network pharmacy.

What you'd pay

$15per 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.

Your cost-sharing levelMarketplace plans publish a different amount for each level. Your eligibility notice says which applies. Nothing here is saved.

Covered forms and strengths (3)

polyethylene glycol 3350 420000 MG / potassium chloride 1480 MG / sodium bicarbonate 5720 MG / sodium chloride 11200 MG Powder for Oral SolutionAmount limit
polyethylene glycol 3350 420000 MG / potassium chloride 1480 MG / sodium bicarbonate 5720 MG / sodium chloride 11200 MG Powder for Oral Solution [GaviLyte-N]Amount limit
polyethylene glycol 3350 420000 MG / potassium chloride 1480 MG / sodium bicarbonate 5720 MG / sodium chloride 11200 MG Powder for Oral Solution [TriLyte]Amount limit

← All coverage for GaviLyte-N