MIXED SALTS OF A SINGLE ENTITY AMPHETAMINE PRODUCT XR 5/5/5/5 mg Capsule, Extended Release
Also known as Dextroamphetamine Saccharate, Amphetamine Aspartate Monohydrate, Dextroamphetamine Sulfate, Amphetamine Sulfate. Coverage in Idaho and Utah (CMS PDP Region 31).
9 of 10 stand-alone Part D plans in Idaho and Utah cover this drug on tier 3–4.
Lowest 30-day cost $45.00 at a preferred pharmacy. 9 of 9 plans apply a prior authorization, step therapy or quantity limit.
88 Medicare Advantage plans in ID, UT 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. ID: 40 plans · UT: 48 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% | $0.8487 | $5.096 units |
|
| Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible | 3Preferred Brand | 20% | 15% | $0.8598 | $5.166 units |
|
| Humana Premier Rx Plan (PDP)$115.50/mo premium · $0.00 deductible | 3Preferred Brand | $45.00 | $125.00 | $0.8424 | $5.056 units |
|
| Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible | 4Non-Preferred Drug | 40% | 40% | $1.9290 | $5.793 units |
|
| SilverScript Choice (PDP)$27.70/mo premium · $615.00 deductible | 4Non-Preferred Drug | 35% | 35% | $0.8969 | $2.693 units |
|
| HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible | 4Non-Preferred Drug | 31% | 31% | $1.5752 | $9.456 units |
|
| AARP Medicare Rx Saver from UHC (PDP)$56.50/mo premium · $615.00 deductible | 4Non-Preferred Drug | 35% | — | $0.8047 | $4.836 units |
|
| HealthSpring Assurance Rx (PDP)$128.60/mo premium · $615.00 deductible | 4Non-Preferred Drug | 30% | 30% | $1.2496 | $7.506 units |
|
| AARP Medicare Rx Preferred from UHC (PDP)$132.60/mo premium · $130.00 deductible | 4Non-Preferred Drug | 36% | — | $0.8047 | $4.836 units |
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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.