LISDEXAMFETAMINE DIMESYLATE 20 mg Tablet, Chewable
Coverage in Idaho and Utah (CMS PDP Region 31).
5 of 10 stand-alone Part D plans in Idaho and Utah cover this drug on tier 4.
4 of 5 plans apply a prior authorization, step therapy or quantity limit.
47 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: 21 plans · UT: 26 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 | 4Non-Preferred Drug | 40% | 40% | $5.9700 | $17.913 units |
|
| SilverScript Choice (PDP)$27.70/mo premium · $615.00 deductible | 4Non-Preferred Drug | 35% | 35% | $10.3871 | $31.163 units |
|
| HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible | 4Non-Preferred Drug | 31% | 31% | $5.9700 | $17.913 units |
|
| HealthSpring Assurance Rx (PDP)$128.60/mo premium · $615.00 deductible | 4Non-Preferred Drug | 30% | 30% | $5.9700 | $17.913 units |
|
| AARP Medicare Rx Preferred from UHC (PDP)$132.60/mo premium · $130.00 deductible | 4Non-Preferred Drug | 36% | — | $8.4527 | — | 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.