LEUPROLIDE ACETATE DEPOT Kit

Also known as Leuprolide Acetate. Coverage in Texas (CMS PDP Region 22).

7 of 12 stand-alone Part D plans in Texas cover this drug on tier 4.

7 of 7 plans apply a prior authorization, step therapy or quantity limit.

175 Medicare Advantage plans in TX 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. TX: 175 plans.

Every plan that covers it

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Value Rx Plan (PDP)$22.90/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$1287.3165	$424.810.33 units	Prior authorization Quantity limit 1 per 90 days
Humana Basic Rx Plan (PDP)$41.70/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$1287.3165	$424.810.33 units	Prior authorization Quantity limit 1 per 90 days
HealthSpring Extra Rx (PDP)$70.00/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$1241.1200	—	Prior authorization
Blue Cross MedicareRx Basic (PDP)$104.70/mo premium · $615.00 deductible	4Non-Preferred Drug	42%	42%	$1286.3550	$463.090.36 units	Prior authorization Quantity limit 1 per 84 days
HealthSpring Assurance Rx (PDP)$111.40/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$1240.4650	—	Prior authorization
Humana Premier Rx Plan (PDP)$118.20/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$1287.3165	$424.810.33 units	Prior authorization Quantity limit 1 per 90 days
Blue Cross MedicareRx Value (PDP)$167.40/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$1286.3550	$463.090.36 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 →