DEXTROAMPHETAMINE SACCHARATE, AMPHETAMINE ASPARTATE, DEXTROAMPHETAMINE SULFATE AND AMPHETAMINE SULFATE 1.25/1.25/1.25/1.25 mg Tablet

Coverage in Idaho and Utah (CMS PDP Region 31).

10 of 10 stand-alone Part D plans in Idaho and Utah cover this drug on tier 2–3.

Lowest 30-day cost $3.00 at a preferred pharmacy. 10 of 10 plans apply a prior authorization, step therapy or quantity limit.

82 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: 34 plans · UT: 48 plans.

Every plan that covers it

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	2Generic	$3.00	$9.00	$0.3145	$1.896 units	Quantity limit 6 per 30 days
Wellcare Classic (PDP)$23.70/mo premium · $615.00 deductible	2Generic	$10.00	$30.00	$0.4305	$2.586 units	Quantity limit 6 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.3790	$3.419 units	Quantity limit 9 per 30 days
Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.3829	$3.459 units	Quantity limit 9 per 30 days
SilverScript Choice (PDP)$27.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$0.2738	$1.646 units	Quantity limit 6 per 30 days
HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.7492	$26.9736 units	Quantity limit 36 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$56.50/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.3298	$1.986 units	Quantity limit 6 per 30 days
Humana Premier Rx Plan (PDP)$115.50/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.3768	$3.399 units	Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$128.60/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$0.6234	$22.4436 units	Quantity limit 36 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$132.60/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.3298	$1.986 units	Quantity limit 6 per 30 days

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.

See coverage in all 39 regions →