Lupron Depot (4-Month) Intramuscular
30 MG — Kit
Gonadotropin Releasing Hormone Receptor Agonist
Also known as:
Lupron Depot (4-Month) Intramuscular Kit
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Coverage by Insurer
Informational only — Coverage rules change frequently; verify tier placement and restrictions with your plan or pharmacy before acting.
AmeriHealth Caritas NC
10 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| AmeriHealth Caritas Next Gold Premier + No Referrals | Tier 5 - Specialty | ✓ | — | — | PA |
| AmeriHealth Caritas Next Bronze Essential + No Referrals | Tier 5 - Specialty | ✓ | — | — | PA |
| AmeriHealth Caritas Next Gold Signature + No Referrals | Tier 5 - Specialty | ✓ | — | — | PA |
| AmeriHealth Caritas Next Silver Premier + No Referrals | Tier 5 - Specialty | ✓ | — | — | PA |
| AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals | Tier 5 - Specialty | ✓ | — | — | PA |
| AmeriHealth Caritas Next Silver Signature + No Referrals | Tier 5 - Specialty | ✓ | — | — | PA |
| AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals | Tier 5 - Specialty | ✓ | — | — | PA |
| AmeriHealth Caritas Next Silver Essential + No Referrals | Tier 5 - Specialty | ✓ | — | — | PA |
| AmeriHealth Caritas Next Bronze Signature + No Referrals | Tier 5 - Specialty | ✓ | — | — | PA |
| AmeriHealth Caritas Next Bronze Premier + No Referrals | Tier 5 - Specialty | ✓ | — | — | PA |
Medicare Part D
56 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Provider Partners North Carolina Advantage Plan (HMO I-SNP) | Tier 1 - Preferred Generic | ✓ | — | ✓ 1 per 112 days | PA | QL |
| Provider Partners North Carolina Community Plan (HMO I-SNP) | Tier 1 - Preferred Generic | ✓ | — | ✓ 1 per 112 days | PA | QL |
| Provider Partners North Carolina Essential Plan (HMO I-SNP) | Tier 1 - Preferred Generic | ✓ | — | ✓ 1 per 112 days | PA | QL |
| HealthSpring Preferred (HMO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| HealthSpring Preferred Select (HMO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| HealthSpring True Choice (PPO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| HealthSpring Preferred Plus (HMO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| HealthSpring Preferred Savings (HMO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| HealthSpring TotalCare (HMO D-SNP) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| HealthSpring TotalCare Plus (HMO D-SNP) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| AARP Medicare Advantage from UHC NC-0015 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 1 per 112 days | PA | QL |
| UHC Dual Complete NC-S3 (HMO-POS D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 1 per 112 days | PA | QL |
| AARP Medicare Advantage from UHC NC-24 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 1 per 112 days | PA | QL |
| AARP Medicare Advantage from UHC NC-26 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 1 per 112 days | PA | QL |
| Erickson Advantage Signature (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 1 per 112 days | PA | QL |
| Erickson Advantage Guardian (HMO-POS I-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 1 per 112 days | PA | QL |
| Erickson Advantage Freedom (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 1 per 112 days | PA | QL |
| Erickson Advantage Liberty (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 1 per 112 days | PA | QL |
| UHC Complete Care NC-25 (HMO-POS C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 1 per 112 days | PA | QL |
| UHC Complete Care NC-27 (HMO-POS C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 1 per 112 days | PA | QL |
| UHC Complete Care NC-28 (HMO-POS C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 1 per 112 days | PA | QL |
| Erickson Advantage Champion (HMO-POS C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 1 per 112 days | PA | QL |
| Alignment Health Platinum (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 1 per 112 days | PA | QL |
| Alignment Health NC Duals (HMO-POS D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 1 per 112 days | PA | QL |
| UHC Nursing Home Plan NC-F001 (PPO I-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 1 per 112 days | PA | QL |
| Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 1 per 112 days | PA | QL |
| Alignment Health Platinum Select (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 1 per 112 days | PA | QL |
| Alignment Health Heart & Diabetes Care (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 1 per 112 days | PA | QL |
| Alignment Health AVA (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 1 per 112 days | PA | QL |
| HealthTeam Advantage Plan I (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 1 per 112 days | PA | QL |
| HealthTeam Advantage Plan II (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 1 per 112 days | PA | QL |
| HealthTeam Advantage Vitality Plan (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 1 per 112 days | PA | QL |
| HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 1 per 112 days | PA | QL |
| Troy Medicare (HMO) | Tier 5 - Specialty | ✓ | — | — | PA |
| Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | — | PA |
| AmeriHealth Caritas VIP Care (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | — | PA |
| Alignment Health smartHMO (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 1 per 112 days | PA | QL |
| UHC Dual Complete NC-S001 (PPO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 1 per 112 days | PA | QL |
| UHC Dual Complete NC-S2 (PPO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 1 per 112 days | PA | QL |
| AARP Medicare Advantage Access from UHC NC-23 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 1 per 112 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0001 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 1 per 112 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0004 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 1 per 112 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0016 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 1 per 112 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0017 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 1 per 112 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0019 (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 1 per 112 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0021 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 1 per 112 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0022 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 1 per 112 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0007 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 1 per 112 days | PA | QL |
| UHC Dual Complete NC-D001 (HMO-POS D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 1 per 112 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0008 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 1 per 112 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0009 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 1 per 112 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0011 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 1 per 112 days | PA | QL |
| AARP Medicare Advantage from UHC NC-0012 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 1 per 112 days | PA | QL |
| AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 1 per 112 days | PA | QL |
| AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) | Tier 5 - Specialty | ✓ | — | ✓ 1 per 112 days | PA | QL |
| UHC Dual Complete NC-V001 (HMO-POS D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 1 per 112 days | PA | QL |