Dyanavel XR

Generic: Amphetamine

2.5MG — Tablet

Antihyperkinesis / Adhd

Also known as: DYANAVEL XR SUER 2.5MG/ML; TBCR 5MG, 10MG, 15MG, 20MG DYANAVEL XR SUER 2.5MG/ML; TBCR 5MG,
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Coverage by Insurer

Informational only — Coverage rules change frequently; verify tier placement and restrictions with your plan or pharmacy before acting.
Source: CMS QHP JSON  ·  Checked: 17 hours, 29 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
AmeriHealth Caritas Next Bronze Essential + No Referrals
via Amphetamine 		Tier 2 - Generic — ✓ ✓ ST | QL
AmeriHealth Caritas Next Gold Premier + No Referrals
via Amphetamine 		Tier 2 - Generic — ✓ ✓ ST | QL
AmeriHealth Caritas Next Bronze Premier + No Referrals
via Amphetamine 		Tier 2 - Generic — ✓ ✓ ST | QL
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals
via Amphetamine 		Tier 2 - Generic — ✓ ✓ ST | QL
AmeriHealth Caritas Next Silver Premier + No Referrals
via Amphetamine 		Tier 2 - Generic — ✓ ✓ ST | QL
AmeriHealth Caritas Next Silver Essential + No Referrals
via Amphetamine 		Tier 2 - Generic — ✓ ✓ ST | QL
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals
via Amphetamine 		Tier 2 - Generic — ✓ ✓ ST | QL
AmeriHealth Caritas Next Silver Signature + No Referrals
via Amphetamine 		Tier 2 - Generic — ✓ ✓ ST | QL
AmeriHealth Caritas Next Bronze Signature + No Referrals
via Amphetamine 		Tier 2 - Generic — ✓ ✓ ST | QL
AmeriHealth Caritas Next Gold Signature + No Referrals
via Amphetamine 		Tier 2 - Generic — ✓ ✓ ST | QL
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals
via Adzenys Xr-Odt 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
AmeriHealth Caritas Next Silver Essential + No Referrals
via Adzenys 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
AmeriHealth Caritas Next Gold Premier + No Referrals
via Adzenys 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals
via Adzenys 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
AmeriHealth Caritas Next Bronze Signature + No Referrals
via Adzenys Xr-Odt 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
AmeriHealth Caritas Next Silver Signature + No Referrals
via Adzenys Xr-Odt 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals
via Adzenys Xr-Odt 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
AmeriHealth Caritas Next Silver Essential + No Referrals
via Adzenys Xr-Odt 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
AmeriHealth Caritas Next Bronze Premier + No Referrals
via Adzenys Xr-Odt 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
AmeriHealth Caritas Next Gold Premier + No Referrals
via Adzenys Xr-Odt 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
AmeriHealth Caritas Next Bronze Essential + No Referrals
via Adzenys Xr-Odt 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
AmeriHealth Caritas Next Gold Signature + No Referrals
via Adzenys Xr-Odt 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
AmeriHealth Caritas Next Silver Premier + No Referrals
via Adzenys Xr-Odt 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
AmeriHealth Caritas Next Bronze Essential + No Referrals
via Adzenys 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
AmeriHealth Caritas Next Bronze Signature + No Referrals
via Adzenys 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
AmeriHealth Caritas Next Silver Signature + No Referrals
via Adzenys 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
AmeriHealth Caritas Next Gold Signature + No Referrals
via Adzenys 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals
via Adzenys 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
AmeriHealth Caritas Next Bronze Premier + No Referrals
via Adzenys 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
AmeriHealth Caritas Next Silver Premier + No Referrals
via Adzenys 		Tier 4 - Non-Preferred — ✓ ✓ ST | QL
Source: CMS QHP JSON  ·  Formulary date: Jun 10, 2026  ·  Checked: 17 hours, 29 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Longevity Health Plan (HMO I-SNP)
via Amphetamine 		Tier 1 - Preferred Generic — — — None
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 17 hours, 29 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC Medicaid Preferred Drug List 2026 Non-Preferred — — — None
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 17 hours, 29 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC State Health Plan - HDHP 2026
via Amphetamine 		Tier 1 - Preferred Generic ✓ — ✓ PA | QL
NC State Health Plan - 70/30 Standard PPO 2026
via Amphetamine 		Tier 1 - Preferred Generic ✓ — ✓ PA | QL
NC State Health Plan - 80/20 Plus PPO 2026
via Amphetamine 		Tier 1 - Preferred Generic ✓ — ✓ PA | QL
NC State Health Plan - 70/30 Standard PPO 2026 Not Covered — — — None
NC State Health Plan - 80/20 Plus PPO 2026 Not Covered — — — None
NC State Health Plan - HDHP 2026
via Adzenys Xr-Odt 		Not Covered — — — None
NC State Health Plan - 70/30 Standard PPO 2026
via Adzenys Xr-Odt 		Not Covered — — — None
NC State Health Plan - 80/20 Plus PPO 2026
via Adzenys Xr-Odt 		Not Covered — — — None
NC State Health Plan - HDHP 2026 Not Covered — — — None
Source: Excel (XLSX)  ·  Formulary date: Jun 24, 2026  ·  Checked: 17 hours, 29 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
TRICARE Uniform Formulary 2026
via Amphetamine 		Tier 3 - Non-Formulary — — — None
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