DEXTROAMPHETAMINE SACCHARATE, AMPHETAMINE ASPARTATE MONOHYDRATE, DEXTROAMPHETAMINE SULFATE, AMPHETAMINE SULFATE 3.75/3.75/3.75/3.75 mg Capsule, Extended Release
Coverage in Illinois (CMS PDP Region 17).
10 of 12 stand-alone Part D plans in Illinois cover this drug on tier 3–4.
Lowest 30-day cost $45.00 at a preferred pharmacy. 10 of 10 plans apply a prior authorization, step therapy or quantity limit.
137 Medicare Advantage plans in IL 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. IL: 137 plans.
Every plan that covers it
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible | 3Preferred Brand | 25% | 20% | $1.0574 | $3.173 units |
|
| Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible | 3Preferred Brand | 20% | 15% | $1.0624 | $3.193 units |
|
| Humana Premier Rx Plan (PDP)$119.40/mo premium · $0.00 deductible | 3Preferred Brand | $45.00 | $125.00 | $1.0546 | $3.163 units |
|
| Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible | 4Non-Preferred Drug | 40% | 40% | $2.5167 | $7.553 units |
|
| AARP Medicare Rx Saver from UHC (PDP)$40.20/mo premium · $615.00 deductible | 4Non-Preferred Drug | 39% | — | $0.8392 | $5.046 units |
|
| HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible | 4Non-Preferred Drug | 30% | 30% | $2.1367 | $12.826 units |
|
| Blue Cross MedicareRx Basic (PDP)$89.70/mo premium · $615.00 deductible | 4Non-Preferred Drug | 43% | 43% | $2.0881 | $6.263 units |
|
| AARP Medicare Rx Preferred from UHC (PDP)$103.90/mo premium · $130.00 deductible | 4Non-Preferred Drug | 38% | — | $0.8392 | $5.046 units |
|
| HealthSpring Assurance Rx (PDP)$104.20/mo premium · $615.00 deductible | 4Non-Preferred Drug | 32% | 32% | $1.2127 | $7.286 units |
|
| Blue Cross MedicareRx Value (PDP)$119.70/mo premium · $615.00 deductible | 4Non-Preferred Drug | 32% | 32% | $1.9354 | $5.813 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.