DEPO-SUBQ PROVERA 104 mg/.65mL Injection, Suspension
Also known as Medroxyprogesterone Acetate. Coverage in Maine and New Hampshire (CMS PDP Region 01).
9 of 9 stand-alone Part D plans in Maine and New Hampshire cover this drug on tier 3.
Lowest 30-day cost $45.00 at a preferred pharmacy. 3 of 9 plans apply a prior authorization, step therapy or quantity limit.
61 Medicare Advantage plans in ME, NH 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. ME: 45 plans · NH: 16 plans.
Every plan that covers it
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible | 3Preferred Brand | 25% | 25% | $75.2995 | — | None |
| Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible | 3Preferred Brand | 25% | 25% | $75.2995 | — | None |
| HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible | 3Preferred Brand | 25% | 25% | $77.7291 | — | None |
| Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible | 3Preferred Brand | 25% | 20% | $78.2466 | $17.210.22 units |
|
| Humana Value Rx Plan (PDP)$54.40/mo premium · $601.00 deductible | 3Preferred Brand | 20% | 15% | $78.2466 | $17.210.22 units |
|
| AARP Medicare Rx Saver from UHC (PDP)$82.40/mo premium · $615.00 deductible | 3Preferred Brand | 17% | 17% | $83.9756 | — | None |
| SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible | 3Preferred Brand | 18% | 18% | $79.6788 | — | None |
| AARP Medicare Rx Preferred from UHC (PDP)$104.30/mo premium · $130.00 deductible | 3Preferred Brand | 15% | 15% | $83.9756 | — | None |
| Humana Premier Rx Plan (PDP)$150.20/mo premium · $0.00 deductible | 3Preferred Brand | $45.00 | $125.00 | $78.2466 | $17.210.22 units |
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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.