LUPRON DEPOT Kit

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

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

10 of 10 plans apply a prior authorization, step therapy or quantity limit.

350 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: 298 plans · WV: 52 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%	$5208.8024	—	Prior authorization
HealthSpring Assurance Rx (PDP)$74.00/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$5205.6776	—	Prior authorization
Humana Basic Rx Plan (PDP)$6.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$5399.1600	$1,781.720.33 units	Prior authorization Quantity limit 1 per 90 days
Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$5399.1600	$1,781.720.33 units	Prior authorization Quantity limit 1 per 90 days
SilverScript Choice (PDP)$22.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$5582.7650	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$43.50/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$5688.8168	$2,047.970.36 units	Prior authorization Quantity limit 1 per 84 days
AARP Medicare Rx Preferred from UHC (PDP)$121.90/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$5688.8168	$2,047.970.36 units	Prior authorization Quantity limit 1 per 84 days
Humana Premier Rx Plan (PDP)$123.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$5399.1600	$1,781.720.33 units	Prior authorization Quantity limit 1 per 90 days
Blue Rx PDP Complete (PDP)$164.80/mo premium · $200.00 deductible	5Specialty Tier	25%	—	$5251.7741	$1,733.090.33 units	Quantity limit 1 per 90 days
Blue Rx PDP Plus (PDP)$193.20/mo premium · $615.00 deductible	5Specialty Tier	25%	25%	$5184.4147	$1,710.860.33 units	Quantity limit 1 per 90 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 →