DEXTROAMPHETAMINE SULFATE 10 mg Capsule, Extended Release
Coverage in California (CMS PDP Region 32).
4 of 12 stand-alone Part D plans in California cover this drug on tier 4.
2 of 4 plans apply a prior authorization, step therapy or quantity limit.
222 Medicare Advantage plans in CA 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. CA: 222 plans.
Every plan that covers it
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible | 4Non-Preferred Drug | 29% | 29% | $1.3688 | — | None |
| Wellcare Value Script (PDP)$5.70/mo premium · $615.00 deductible | 4Non-Preferred Drug | 40% | 40% | $3.3008 | $39.6112 units |
|
| HealthSpring Extra Rx (PDP)$70.60/mo premium · $615.00 deductible | 4Non-Preferred Drug | 30% | 30% | $2.0046 | — | None |
| AARP Medicare Rx Preferred from UHC (PDP)$165.40/mo premium · $130.00 deductible | 4Non-Preferred Drug | 31% | — | $1.4600 | $26.2818 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.