LUPRON DEPOT Kit

Also known as Leuprolide Acetate. Coverage in Idaho and Utah (CMS PDP Region 31).

8 of 10 stand-alone Part D plans in Idaho and Utah cover this drug on tier 4–5.

8 of 8 plans apply a prior authorization, step therapy or quantity limit.

82 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: 34 plans · UT: 48 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)$56.30/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$5166.1100	—	Prior authorization
HealthSpring Assurance Rx (PDP)$128.60/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$5165.0200	—	Prior authorization
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$5408.7748	$1,784.900.33 units	Prior authorization Quantity limit 1 per 90 days
Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$5408.7748	$1,784.900.33 units	Prior authorization Quantity limit 1 per 90 days
SilverScript Choice (PDP)$27.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$5582.7650	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$56.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$5741.6244	$2,066.980.36 units	Prior authorization Quantity limit 1 per 84 days
Humana Premier Rx Plan (PDP)$115.50/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$5408.7748	$1,784.900.33 units	Prior authorization Quantity limit 1 per 90 days
AARP Medicare Rx Preferred from UHC (PDP)$132.60/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$5741.6244	$2,066.980.36 units	Prior authorization Quantity limit 1 per 84 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 →