peg 3350/sod sulf/sod bicarb/sod chloride/potassium chloride

236 gram-22.74 gram-6.74 gram-5.86 gram-2.97 gram, 240 gram-22.72 gram-6.72 gram-5.84 gram-2.98 gram — Solution

Also known as: GAVILYTE-G GAVILYTE-C PEG-3350 AND ELECTROLYTES

Informational only — Coverage rules change frequently; verify tier placement and restrictions with your plan or pharmacy before acting.

1 plan

Source: PDF · Formulary date: Jan 1, 2026 · Checked: 13 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Cigna Plus NC 4-Tier Formulary 2026 via Peg-3350 And Electrolytes	Tier 1 - Generic	—	—	—	None

1 plan

Source: Excel (XLSX) · Formulary date: Jan 5, 2026 · Checked: 13 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
TRICARE Uniform Formulary 2026	Tier 1 - Basic Core Formulary	—	—	—	None