MIXED SALTS OF A SINGLE ENTITY AMPHETAMINE PRODUCT XR 2.5/2.5/2.5/2.5 mg Capsule, Extended Release
Also known as Dextroamphetamine Saccharate, Amphetamine Aspartate Monohydrate, Dextroamphetamine Sulfate, Amphetamine Sulfate. Coverage in Missouri (CMS PDP Region 18).
8 of 10 stand-alone Part D plans in Missouri 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.
141 Medicare Advantage plans in MO 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. MO: 141 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)$16.50/mo premium · $615.00 deductible | 3Preferred Brand | 25% | 20% | $0.8704 | $2.613 units |
|
| Humana Value Rx Plan (PDP)$33.70/mo premium · $601.00 deductible | 3Preferred Brand | 20% | 15% | $0.8824 | $2.653 units |
|
| Humana Premier Rx Plan (PDP)$126.40/mo premium · $0.00 deductible | 3Preferred Brand | $45.00 | $125.00 | $0.8636 | $2.593 units |
|
| Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible | 4Non-Preferred Drug | 40% | 40% | $2.0108 | $6.033 units |
|
| HealthSpring Extra Rx (PDP)$70.70/mo premium · $615.00 deductible | 4Non-Preferred Drug | 30% | 30% | $1.5387 | $9.236 units |
|
| AARP Medicare Rx Saver from UHC (PDP)$71.90/mo premium · $615.00 deductible | 4Non-Preferred Drug | 39% | — | $0.7592 | $4.566 units |
|
| HealthSpring Assurance Rx (PDP)$74.30/mo premium · $615.00 deductible | 4Non-Preferred Drug | 30% | 30% | $1.0612 | $6.376 units |
|
| AARP Medicare Rx Preferred from UHC (PDP)$125.40/mo premium · $130.00 deductible | 4Non-Preferred Drug | 35% | — | $0.7644 | $4.596 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.