DEXTROAMPHETAMINE SACCHARATE, AMPHETAMINE ASPARTATE MONOHYDRATE, DEXTROAMPHETAMINE SULFATE, AMPHETAMINE SULFATE 3.75/3.75/3.75/3.75 mg Capsule, Extended Release
Coverage in Oregon and Washington (CMS PDP Region 30).
8 of 10 stand-alone Part D plans in Oregon and Washington cover this drug on tier 3–4.
Lowest 30-day cost $45.00 at a preferred pharmacy. 8 of 8 plans apply a prior authorization, step therapy or quantity limit.
200 Medicare Advantage plans in OR, WA 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. OR: 87 plans · WA: 113 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% | $0.8831 | $2.653 units |
|
| Humana Value Rx Plan (PDP)$22.10/mo premium · $601.00 deductible | 3Preferred Brand | 20% | 15% | $0.8900 | $2.673 units |
|
| Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible | 3Preferred Brand | $45.00 | $125.00 | $0.8793 | $2.643 units |
|
| Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible | 4Non-Preferred Drug | 40% | 40% | $2.1545 | $6.463 units |
|
| HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible | 4Non-Preferred Drug | 30% | 30% | $1.1415 | $6.856 units |
|
| AARP Medicare Rx Saver from UHC (PDP)$38.40/mo premium · $615.00 deductible | 4Non-Preferred Drug | 36% | — | $0.8543 | $5.136 units |
|
| HealthSpring Extra Rx (PDP)$50.00/mo premium · $615.00 deductible | 4Non-Preferred Drug | 30% | 30% | $1.6700 | $10.026 units |
|
| AARP Medicare Rx Preferred from UHC (PDP)$110.00/mo premium · $130.00 deductible | 4Non-Preferred Drug | 37% | — | $0.8545 | $5.136 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.