GoLYTELY NDC 52268-100

NDC codes

FDA NDC Directory

Product NDC (as listed)52268-100Labeler and product segments. Claims need a package NDC.

Product NDC at billing width52268-0100Add the package segment from the table below.

Package NDCs as listed with the FDA, and the 11-digit 5-4-2 form used on claims. The highlighted digit is the added leading zero.
Package NDC	11-digit (billing)	Package	Copy
52268-100-01	52268010001	4 L in 1 BOTTLE, PLASTIC (52268-100-01)Marketed from Jul 13, 1984

How the 11-digit form is made: The product segment has 3 digits, so one leading zero is added to it (5-3-2 → 5-4-2). Formatting the NDC does not by itself make it billable — the product, package and quantity must match what was dispensed or administered, and payer rules apply. Conversion rules

Product information

Brand name (proprietary): GoLYTELY
Generic name (nonproprietary): polyethylene glycol 3350, sodium sulfate anhydrous, sodium bicarbonate, sodium chloride, potassium chloride
Active ingredients: Polyethylene glycol 3350 — 236 g/4LSodium sulfate anhydrous — 22.74 g/4LSodium bicarbonate — 6.74 g/4LSodium chloride — 5.86 g/4LPotassium chloride — 2.97 g/4L
Dosage form: Powder, For solution
Route: Oral
Labeler: Braintree Laboratories, Inc.
Product type: Prescription drug
Marketing category: NDA — New Drug ApplicationApplication NDA 019011
Marketing start: Jul 13, 1984
Listing expires: Dec 31, 2026
Other FDA classes: Increased Large Intestinal Motility (Physiologic effect)Increased Large Intestinal Motility (Physiologic effect)Increased Large Intestinal Motility (Physiologic effect)Increased Large Intestinal Motility (Physiologic effect)Inhibition Large Intestine Fluid/Electrolyte Absorption (Physiologic effect)Inhibition Large Intestine Fluid/Electrolyte Absorption (Physiologic effect)Inhibition Large Intestine Fluid/Electrolyte Absorption (Physiologic effect)Inhibition Large Intestine Fluid/Electrolyte Absorption (Physiologic effect)Osmotic Activity (Mechanism)Osmotic Activity (Mechanism)Osmotic Activity (Mechanism)Osmotic Activity (Mechanism)Osmotic Activity (Mechanism)Potassium Compounds (Chemical structure)Stimulation Large Intestine Fluid/Electrolyte Secretion (Physiologic effect)
Identifiers: Product ID 52268-100_c3649858-77b7-2295-e053-2995a90a048fSPL ID c3649858-77b7-2295-e053-2995a90a048fSPL set ID 57d22b0b-1ae0-4203-babc-f3bac17bd1c9RxCUI 966916, 966920, 966922, 1870431UNII G2M7P15E5P, 36KCS0R750, 8MDF5V39QO, 451W47IQ8X, 660YQ98I10
Pharmacologic class: Osmotic Laxative; Potassium Salt

Billing references

What Med-Code can say about coding this product, and where each statement comes from. Nothing here is inferred from the name alone.

HCPCS codeNo match

No HCPCS code in Med-Code's directory. Oral products like this are usually dispensed by a pharmacy and billed by NDC.

NDC on a medical claim

N452268010001 followed by a unit qualifier and the quantity

Package 52268-0100-01. Unit qualifiers: F2 (international unit), GR (gram), ME (milligram), ML (milliliter), UN (unit (each)). The qualifier and quantity depend on what was given. About the N4 qualifier

Product label

Current FDA label (SPL), effective May 28, 2021.

Indications (excerpt from the label)

GoLYTELY is indicated for bowel cleansing prior to colonoscopy and barium enema X-ray examination in adults. GoLYTELY is a combination of PEG 3350, an osmotic laxative, and electrolytes indicated for cleansing of the colon in preparation for colonoscopy and barium enema X-ray examination in adults ( 1 )

Excerpt only. Read the full label for complete information.

Full label on DailyMed (opens in a new tab)

Other NDCs under NDA 019011

Products listed under the same FDA application: other strengths and forms, and repackagers who relabel the same product.

FDA NDC Directory listings under NDA 019011
Product	Strength	Form · route	Labeler	Product NDC
PEG 3350 and Electrolytespolyethylene glycol 3350, sodium sulfate anhydrous, sodium bicarbonate, sodium chloride, potassium chloride	Polyethylene glycol 3350 236 g/4L + 4 more ingredients	Powder, For solutionOral	Wilshire Pharmaceuticals, Inc.	52536-236
PEG 3350 and Electrolytespolyethylene glycol 3350, sodium sulfate anhydrous, sodium bicarbonate, sodium chloride, potassium chloride	Polyethylene glycol 3350 236 g/4L + 4 more ingredients	Powder, For solutionOral	A-S Medication Solutions	50090-8020
PEG-3350 and Electrolytespolyethylene glycol 3350, sodium sulfate anhydrous, sodium bicarbonate, sodium chloride, potassium chloride	Polyethylene glycol 3350 236 g/4L + 4 more ingredients	Powder, For solutionOral	Affordable Pharmaceuticals, LLC	10572-100
PEG-3350 and Electrolytespolyethylene glycol 3350, sodium sulfate anhydrous, sodium bicarbonate, sodium chloride, potassium chloride	Polyethylene glycol 3350 236 g/4L + 4 more ingredients	Powder, For solutionOral	A-S Medication Solutions	50090-6521
GoLYTELYpolyethylene glycol 3350, sodium sulfate anhydrous, sodium bicarbonate, sodium chloride, potassium chloride	Polyethylene glycol 3350 236 g/4L + 4 more ingredients	Powder, For solutionOral	Azurity Pharmaceuticals, Inc.	24338-236