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Dextrose, Sodium Acetate, Potassium Chloride, Magnesium Chloride, and Potassium Phosphate, Dibasic 5 g/100mL / .031 g/100mL / .13 g/100mL / .026 g/100mL / .32 g/100mL Medicare Part D Coverage

Brand name: Isolyte P in Dextrose
Dosage form
INJECTION, SOLUTION
Route
INTRAVENOUS
69%
of Medicare Part D plans
cover Dextrose, Sodium Acetate, Potassium Chloride, Magnesium Chloride, and Potassium Phosphate, Dibasic
3,790 of 5,530 plans
3.9
Avg. formulary tier
$0.00
Median 30-day copay
$0.00–$0.00
Copay range

Formulary Tier Distribution

How Medicare Part D plans classify Dextrose, Sodium Acetate, Potassium Chloride, Magnesium Chloride, and Potassium Phosphate, Dibasic. Lower tiers = lower copays.

Tier 1 - Preferred Generic 1%
50 plans • avg $0.00/mo
Tier 2 - Generic 1%
44 plans • avg $18.02/mo
Tier 3 - Preferred Brand 2%
69 plans • avg $11.09/mo
Tier 4 - Non-Preferred Drug 96%
3,620 plans • avg $1.53/mo
Tier 6 - Select Care 0%
7 plans • avg $0.00/mo

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Dextrose, Sodium Acetate, Potassium Chloride, Magnesium Chloride, and Potassium Phosphate, Dibasic Medicare Coverage by State

Coverage rates and average costs vary significantly by state. Click a state to see the specific plans available there.

Alabama 100% Arizona 100% Arkansas 100% California 100% Colorado 100% Connecticut 100% Delaware 100% District of Columbia 100% Florida 100% Georgia 100% Hawaii 100% Idaho 100% Illinois 100% Indiana 100% Iowa 100% Kansas 100% Kentucky 100% Louisiana 100% Maine 100% Maryland 100% Massachusetts 100% Michigan 100% Minnesota 100% Mississippi 100% Missouri 100% Montana 100% Nebraska 100% Nevada 100% New Hampshire 100% New Jersey 100% New Mexico 100% New York 100% North Carolina 100% North Dakota 100% Ohio 100% Oklahoma 100% Oregon 100% Pennsylvania 100% Puerto Rico 100% Rhode Island 100% South Carolina 100% South Dakota 100% Tennessee 100% Texas 100% Utah 100% Vermont 100% Virginia 100% Washington 100% West Virginia 100% Wisconsin 100% Wyoming 100%

Frequently Asked Questions about Dextrose, Sodium Acetate, Potassium Chloride, Magnesium Chloride, and Potassium Phosphate, Dibasic

69% of Medicare Part D plans cover Dextrose, Sodium Acetate, Potassium Chloride, Magnesium Chloride, and Potassium Phosphate, Dibasic. It is most commonly placed on Tier 4. Coverage varies by plan and geographic area.

The median 30-day copay for Dextrose, Sodium Acetate, Potassium Chloride, Magnesium Chloride, and Potassium Phosphate, Dibasic on Medicare Part D is $0.00 at a preferred pharmacy. Costs range from $0.00 to $0.00 depending on the plan.

Dextrose, Sodium Acetate, Potassium Chloride, Magnesium Chloride, and Potassium Phosphate, Dibasic is placed on Tier 4 by most Medicare Part D plans. Lower tier numbers generally mean lower copays.

0% of plans require prior authorization for Dextrose, Sodium Acetate, Potassium Chloride, Magnesium Chloride, and Potassium Phosphate, Dibasic. Prior authorization means your doctor must confirm the drug is medically necessary before the plan will cover it.

Coverage statistics based on CMS formulary data for plan year 2026. Data updated regularly. Methodology →