DEXTROAMPHETAMINE SACCHARATE, AMPHETAMINE ASPARTATE, DEXTROAMPHETAMINE SULFATE AND AMPHETAMINE SULFATE 5/5/5/5 mg Tablet
Coverage in New Jersey (CMS PDP Region 04).
12 of 12 stand-alone Part D plans in New Jersey cover this drug on tier 2–3.
Lowest 30-day cost $3.00 at a preferred pharmacy. 12 of 12 plans apply a prior authorization, step therapy or quantity limit.
72 Medicare Advantage plans in NJ 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. NJ: 72 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)$22.80/mo premium · $615.00 deductible | 2Generic | $3.00 | $9.00 | $0.1833 | $1.659 units |
|
| Wellcare Classic (PDP)$28.20/mo premium · $615.00 deductible | 2Generic | $10.00 | $30.00 | $0.2539 | $2.299 units |
|
| Humana Basic Rx Plan (PDP)$4.40/mo premium · $615.00 deductible | 3Preferred Brand | 25% | 20% | $0.4946 | $4.459 units |
|
| Humana Value Rx Plan (PDP)$35.60/mo premium · $601.00 deductible | 3Preferred Brand | 19% | 14% | $0.4956 | $4.469 units |
|
| HealthSpring Extra Rx (PDP)$59.90/mo premium · $615.00 deductible | 3Preferred Brand | 16% | 16% | $0.7021 | $6.329 units |
|
| Horizon Medicare Blue Rx Standard (PDP)$72.30/mo premium · $615.00 deductible | 3Preferred Brand | 18% | 18% | $0.7234 | $6.519 units |
|
| AARP Medicare Rx Saver from UHC (PDP)$77.40/mo premium · $615.00 deductible | 3Preferred Brand | 17% | 17% | $0.4046 | $3.649 units |
|
| SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible | 3Preferred Brand | 18% | 18% | $0.3001 | $2.709 units |
|
| HealthSpring Assurance Rx (PDP)$109.30/mo premium · $615.00 deductible | 3Preferred Brand | 20% | 20% | $0.5959 | $5.369 units |
|
| Humana Premier Rx Plan (PDP)$111.90/mo premium · $0.00 deductible | 3Preferred Brand | $45.00 | $125.00 | $0.4940 | $4.459 units |
|
| AARP Medicare Rx Preferred from UHC (PDP)$118.90/mo premium · $130.00 deductible | 3Preferred Brand | 15% | 15% | $0.4046 | $3.649 units |
|
| Horizon Medicare Blue Rx Enhanced (PDP)$139.10/mo premium · $200.00 deductible | 3Preferred Brand | 20% | 20% | $0.7234 | $6.519 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.