LUPRON DEPOT-PED Kit

Also known as Leuprolide Acetate. Coverage in Pennsylvania and West Virginia (CMS PDP Region 06).

5 of 12 stand-alone Part D plans in Pennsylvania and West Virginia cover this drug on tier 4–5.

5 of 5 plans apply a prior authorization, step therapy or quantity limit.

166 Medicare Advantage plans in PA, WV 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. PA: 150 plans · WV: 16 plans.

Every plan that covers it

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Extra Rx (PDP)$62.60/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$26010.4953	—	Prior authorization
HealthSpring Assurance Rx (PDP)$74.00/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$26014.0084	—	Prior authorization
SilverScript Choice (PDP)$22.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$28393.1602	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$43.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$28397.8916	$5,111.620.18 units	Prior authorization Quantity limit 1 per 168 days
AARP Medicare Rx Preferred from UHC (PDP)$121.90/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$28397.8916	$5,111.620.18 units	Prior authorization Quantity limit 1 per 168 days

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.

See coverage in all 39 regions →