LUTRATE DEPOT Kit
Also known as Leuprolide Acetate. Coverage in Maine and New Hampshire (CMS PDP Region 01).
4 of 9 stand-alone Part D plans in Maine and New Hampshire cover this drug on tier 4.
4 of 4 plans apply a prior authorization, step therapy or quantity limit.
14 Medicare Advantage plans in ME, NH 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. ME: 10 plans · NH: 4 plans.
Every plan that covers it
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible | 4Non-Preferred Drug | 30% | 30% | $1906.1349 | — |
|
| Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible | 4Non-Preferred Drug | 33% | — | $2001.4375 | $660.470.33 units |
|
| Humana Value Rx Plan (PDP)$54.40/mo premium · $601.00 deductible | 4Non-Preferred Drug | 31% | — | $2001.4375 | $660.470.33 units |
|
| Humana Premier Rx Plan (PDP)$150.20/mo premium · $0.00 deductible | 4Non-Preferred Drug | 50% | 50% | $2001.4375 | $660.470.33 units |
|
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.