Lupron Depot-ped

11.25 MG, 15 MG, 30 MG, 45 MG, 7.5 MG — Kit

Informational only — Coverage rules change frequently; verify tier placement and restrictions with your plan or pharmacy before acting.

1 plan

Source: Excel (XLSX) · Formulary date: Sep 23, 2026 · Checked: 8 hours ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
TRICARE Uniform Formulary 2026	Tier 2 - Brand Formulary	✓	—	—	PA PA: LUPRON DEPOT-PED,FENSOLVI,LUPRON DEPOT, ELIGARD,LEUPROLIDE ACETATE FOR PT AGES 9 THRU 18 YRS REQ PA