DEPO-SUBQ PROVERA 104 mg/.65mL Injection, Suspension
Also known as Medroxyprogesterone Acetate. Coverage in North Carolina (CMS PDP Region 08).
12 of 12 stand-alone Part D plans in North Carolina cover this drug on tier 3.
Lowest 30-day cost $45.00 at a preferred pharmacy. 3 of 12 plans apply a prior authorization, step therapy or quantity limit.
160 Medicare Advantage plans in NC 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. NC: 160 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)$3.60/mo premium · $615.00 deductible | 3Preferred Brand | 25% | 25% | $74.5350 | — | None |
| Wellcare Classic (PDP)$4.70/mo premium · $615.00 deductible | 3Preferred Brand | 25% | 25% | $74.5350 | — | None |
| Humana Basic Rx Plan (PDP)$6.80/mo premium · $615.00 deductible | 3Preferred Brand | 25% | 20% | $77.6022 | $17.070.22 units |
|
| Humana Value Rx Plan (PDP)$32.00/mo premium · $601.00 deductible | 3Preferred Brand | 20% | 15% | $77.6022 | $17.070.22 units |
|
| AARP Medicare Rx Saver from UHC (PDP)$56.90/mo premium · $615.00 deductible | 3Preferred Brand | 18% | 18% | $82.0272 | — | None |
| HealthSpring Extra Rx (PDP)$78.00/mo premium · $615.00 deductible | 3Preferred Brand | 17% | 17% | $75.8413 | — | None |
| Blue Medicare Rx Standard (PDP)$83.90/mo premium · $615.00 deductible | 3Preferred Brand | 20% | 20% | $85.2608 | — | None |
| SilverScript Choice (PDP)$90.20/mo premium · $615.00 deductible | 3Preferred Brand | 18% | 18% | $79.6788 | — | None |
| HealthSpring Assurance Rx (PDP)$110.40/mo premium · $615.00 deductible | 3Preferred Brand | 22% | 22% | $76.0163 | — | None |
| Humana Premier Rx Plan (PDP)$110.90/mo premium · $0.00 deductible | 3Preferred Brand | $45.00 | $125.00 | $77.6022 | $17.070.22 units |
|
| AARP Medicare Rx Preferred from UHC (PDP)$119.80/mo premium · $130.00 deductible | 3Preferred Brand | 17% | 17% | $82.0272 | — | None |
| Blue Medicare Rx Enhanced (PDP)$163.20/mo premium · $0.00 deductible | 3Preferred Brand | $45.00 | $135.00 | $85.2608 | — | 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.