DEXTROAMPHETAMINE SULFATE 5 mg Tablet
Coverage in South Carolina (CMS PDP Region 09).
8 of 11 stand-alone Part D plans in South Carolina cover this drug on tier 4.
6 of 8 plans apply a prior authorization, step therapy or quantity limit.
66 Medicare Advantage plans in SC 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. SC: 66 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)$10.10/mo premium · $615.00 deductible | 4Non-Preferred Drug | 30% | — | $0.9471 | $14.2115 units |
|
| Humana Value Rx Plan (PDP)$65.60/mo premium · $601.00 deductible | 4Non-Preferred Drug | 34% | — | $0.9475 | $14.2115 units |
|
| HealthSpring Extra Rx (PDP)$71.20/mo premium · $615.00 deductible | 4Non-Preferred Drug | 30% | 30% | $0.8661 | — | None |
| SilverScript Choice (PDP)$98.40/mo premium · $615.00 deductible | 4Non-Preferred Drug | 33% | 33% | $1.2104 | $21.7918 units |
|
| AARP Medicare Rx Preferred from UHC (PDP)$139.20/mo premium · $130.00 deductible | 4Non-Preferred Drug | 35% | — | $0.7306 | $13.1518 units |
|
| BlueCross Rx Value (PDP)$139.70/mo premium · $615.00 deductible | 4Non-Preferred Drug | 50% | 50% | $0.6371 | $5.739 units |
|
| Humana Premier Rx Plan (PDP)$145.60/mo premium · $0.00 deductible | 4Non-Preferred Drug | 50% | 50% | $0.9469 | $14.2015 units |
|
| HealthSpring Assurance Rx (PDP)$152.50/mo premium · $615.00 deductible | 4Non-Preferred Drug | 31% | 31% | $0.5845 | — | None |
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.