LEUPROLIDE ACETATE DEPOT Kit
Also known as Leuprolide Acetate. Coverage in Pennsylvania and West Virginia (CMS PDP Region 06).
7 of 12 stand-alone Part D plans in Pennsylvania and West Virginia cover this drug on tier 4.
7 of 7 plans apply a prior authorization, step therapy or quantity limit.
217 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: 184 plans · WV: 33 plans.
Every plan that covers it
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Humana Basic Rx Plan (PDP)$6.60/mo premium · $615.00 deductible | 4Non-Preferred Drug | 33% | — | $1219.5630 | $402.460.33 units |
|
| Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible | 4Non-Preferred Drug | 33% | — | $1219.5630 | $402.460.33 units |
|
| HealthSpring Extra Rx (PDP)$62.60/mo premium · $615.00 deductible | 4Non-Preferred Drug | 31% | 31% | $1291.2989 | — |
|
| HealthSpring Assurance Rx (PDP)$74.00/mo premium · $615.00 deductible | 4Non-Preferred Drug | 31% | 31% | $1291.4732 | — |
|
| Humana Premier Rx Plan (PDP)$123.60/mo premium · $0.00 deductible | 4Non-Preferred Drug | 50% | 50% | $1219.5630 | $402.460.33 units |
|
| Blue Rx PDP Complete (PDP)$164.80/mo premium · $200.00 deductible | 4Non-Preferred Drug | 25% | 25% | $1289.6002 | $1,289.601 unit |
|
| Blue Rx PDP Plus (PDP)$193.20/mo premium · $615.00 deductible | 4Non-Preferred Drug | 25% | 25% | $1297.7798 | $1,297.781 unit |
|
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.