DEXTROAMPHETAMINE SACCHARATE, AMPHETAMINE ASPARTATE MONOHYDRATE, DEXTROAMPHETAMINE SULFATE, AMPHETAMINE SULFATE 1.25/1.25/1.25/1.25 mg Capsule, Extended Release
Coverage in Puerto Rico (CMS PDP Region 38).
3 of 3 stand-alone Part D plans in Puerto Rico cover this drug on tier 4.
3 of 3 plans apply a prior authorization, step therapy or quantity limit.
42 Medicare Advantage plans in PR do cover it
Medicare Advantage plans carry their own formularies, separate from stand-alone Part D. A patient on an MA-PD plan may have coverage even where no PDP lists the drug. PR: 42 plans.
Every plan that covers it
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| HealthSpring Extra Rx (PDP)$50.00/mo premium · $615.00 deductible | 4Non-Preferred Drug | 31% | 31% | $2.8400 | $17.046 units |
|
| HealthSpring Assurance Rx (PDP)$65.70/mo premium · $615.00 deductible | 4Non-Preferred Drug | 34% | 34% | $1.3100 | $7.866 units |
|
| AARP Medicare Rx Preferred from UHC (PDP)$145.10/mo premium · $615.00 deductible | 4Non-Preferred Drug | 25% | 25% | $3.0658 | $18.396 units |
|
Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity.