Pediatric 1.5 ML leuprolide acetate 30 MG/ML Prefilled Syringe [Lupron]
Pediatric
RxCUI: 2639669
Important: Drug coverage and costs vary by plan and location. Verify coverage directly with your Medicare plan before filling a prescription. This is informational data only and should not replace advice from your healthcare provider or pharmacist.
59.8%
Plan Coverage
3,028
Plans Covering
T4.3
Avg Tier
93.7%
Prior Auth Required
What the CMS Formulary Data Shows for Pediatric 1.5 ML leuprolide acetate 30 MG/ML Prefilled Syringe [Lupron]
Per the CMS 2026 Part D formulary file, Pediatric 1.5 ML leuprolide acetate 30 MG/ML Prefilled Syringe [Lupron] (RxNorm concept RXCUI 2639669, generic name Pediatric) appears on 189 distinct formulary files spanning 3,028 Medicare Part D plan offerings - 59.8% of enrollable Part D products, mid-range placement; shopping across contracts changes access. Tier placement ranges from Tier 1 to Tier 5, with a cross-plan average of Tier 4.3.
Real-world access to Pediatric 1.5 ML leuprolide acetate 30 MG/ML Prefilled Syringe [Lupron] depends on utilization management as much as tier placement: 93.7% of covering formularies require prior authorization. 0% require step therapy. 30.7% apply quantity limits.
Medicare Part D spending dashboard figures are not published for this drug. The plan-by-plan detail below lists exactly which PDP and MA-PD contracts carry Pediatric 1.5 ML leuprolide acetate 30 MG/ML Prefilled Syringe [Lupron] today.
Coverage Details
- Formularies covering
- 189
- Plans covering
- 3,028
- Coverage rate
- 59.8%
- Tier range
- Tier 1 – Tier 5
- Average tier
- Tier 4, Non-Preferred
Restrictions
- Prior authorization required
- 93.7% of formularies
- Step therapy required
- 0% of formularies
- Quantity limits
- 30.7% of formularies
Tier Distribution Across Plans
63 plans
Tier 1, Preferred Generic
2 plans
Tier 2, Generic
35 plans
Tier 4, Non-Preferred
Standalone Drug Plans (PDP) Covering Pediatric 1.5 ML leuprolide acetate 30 MG/ML Prefilled Syringe [Lupron]
25 standalone prescription drug plans include this drug.
| Plan | Insurer | Tier | PA | ST | Premium | States |
|---|---|---|---|---|---|---|
| HealthSpring Assurance Rx (PDP) | MEDCO CONTAINMENT LIFE AND MEDCO CONTAINMENT NY | T4 | Yes | No | $0 | - |
| HealthSpring Assurance Rx (PDP) | MEDCO CONTAINMENT LIFE AND MEDCO CONTAINMENT NY | T4 | Yes | No | $0 | - |
| HealthSpring Assurance Rx (PDP) | MEDCO CONTAINMENT LIFE AND MEDCO CONTAINMENT NY | T4 | Yes | No | $0 | - |
| HealthSpring Assurance Rx (PDP) | MEDCO CONTAINMENT LIFE AND MEDCO CONTAINMENT NY | T4 | Yes | No | $0 | - |
| HealthSpring Assurance Rx (PDP) | MEDCO CONTAINMENT LIFE AND MEDCO CONTAINMENT NY | T4 | Yes | No | $0 | - |
| HealthSpring Assurance Rx (PDP) | MEDCO CONTAINMENT LIFE AND MEDCO CONTAINMENT NY | T4 | Yes | No | $0 | - |
| HealthSpring Assurance Rx (PDP) | MEDCO CONTAINMENT LIFE AND MEDCO CONTAINMENT NY | T4 | Yes | No | $0 | - |
| HealthSpring Assurance Rx (PDP) | MEDCO CONTAINMENT LIFE AND MEDCO CONTAINMENT NY | T4 | Yes | No | $0 | - |
| HealthSpring Assurance Rx (PDP) | MEDCO CONTAINMENT LIFE AND MEDCO CONTAINMENT NY | T4 | Yes | No | $0 | - |
| HealthSpring Assurance Rx (PDP) | MEDCO CONTAINMENT LIFE AND MEDCO CONTAINMENT NY | T4 | Yes | No | $6.70 | - |
| HealthSpring Assurance Rx (PDP) | MEDCO CONTAINMENT LIFE AND MEDCO CONTAINMENT NY | T4 | Yes | No | $32.60 | - |
| HealthSpring Assurance Rx (PDP) | MEDCO CONTAINMENT LIFE AND MEDCO CONTAINMENT NY | T4 | Yes | No | $35.70 | - |
| HealthSpring Assurance Rx (PDP) | MEDCO CONTAINMENT LIFE AND MEDCO CONTAINMENT NY | T4 | Yes | No | $48.40 | - |
| HealthSpring Extra Rx (PDP) | MEDCO CONTAINMENT LIFE AND MEDCO CONTAINMENT NY | T4 | Yes | No | $50.00 | - |
| HealthSpring Extra Rx (PDP) | MEDCO CONTAINMENT LIFE AND MEDCO CONTAINMENT NY | T4 | Yes | No | $50.00 | - |
| HealthSpring Extra Rx (PDP) | MEDCO CONTAINMENT LIFE AND MEDCO CONTAINMENT NY | T4 | Yes | No | $50.40 | - |
| HealthSpring Extra Rx (PDP) | MEDCO CONTAINMENT LIFE AND MEDCO CONTAINMENT NY | T4 | Yes | No | $52.60 | - |
| HealthSpring Extra Rx (PDP) | MEDCO CONTAINMENT LIFE AND MEDCO CONTAINMENT NY | T4 | Yes | No | $54.50 | - |
| HealthSpring Extra Rx (PDP) | MEDCO CONTAINMENT LIFE AND MEDCO CONTAINMENT NY | T4 | Yes | No | $56.30 | - |
| HealthSpring Extra Rx (PDP) | MEDCO CONTAINMENT LIFE AND MEDCO CONTAINMENT NY | T4 | Yes | No | $56.30 | - |
| HealthSpring Assurance Rx (PDP) | MEDCO CONTAINMENT LIFE AND MEDCO CONTAINMENT NY | T4 | Yes | No | $59.70 | - |
| HealthSpring Extra Rx (PDP) | MEDCO CONTAINMENT LIFE AND MEDCO CONTAINMENT NY | T4 | Yes | No | $59.90 | - |
| HealthSpring Extra Rx (PDP) | MEDCO CONTAINMENT LIFE AND MEDCO CONTAINMENT NY | T4 | Yes | No | $60.60 | - |
| HealthSpring Assurance Rx (PDP) | MEDCO CONTAINMENT LIFE AND MEDCO CONTAINMENT NY | T4 | Yes | No | $61.70 | - |
| HealthSpring Extra Rx (PDP) | MEDCO CONTAINMENT LIFE AND MEDCO CONTAINMENT NY | T4 | Yes | No | $62.60 | - |
Medicare Advantage Plans (MA-PD) Covering Pediatric 1.5 ML leuprolide acetate 30 MG/ML Prefilled Syringe [Lupron]
75 Medicare Advantage plans with Part D drug coverage include this drug.
| Plan | Insurer | Tier | PA | Premium | States |
|---|---|---|---|---|---|
| Florida Complete Care-Duals VIP (HMO-POS D-SNP) | HPMP OF FLORIDA, INC. | T1 | Yes | $0 | FL |
| Mercy Care Advantage (HMO D-SNP) | MERCY CARE | T1 | Yes | $0 | AZ |
| Mercy Care Advantage (HMO D-SNP) | MERCY CARE | T1 | Yes | $0 | AZ |
| Mercy Care Advantage (HMO D-SNP) | MERCY CARE | T1 | Yes | $0 | AZ |
| Elderplan Plus Long-Term Care (HMO-POS D-SNP) | ELDERPLAN, INC. | T1 | Yes | $0 | NY |
| Health Choice Pathway (HMO D-SNP) | HEALTH CHOICE ARIZONA, INC. | T1 | Yes | $0 | AZ |
| Healthfirst CompleteCare (HMO D-SNP) | HEALTHFIRST HEALTH PLAN, INC. | T1 | Yes | $0 | NY |
| IMCare Classic (HMO D-SNP) | ITASCA MEDICAL CARE | T1 | Yes | $0 | MN |
| Johns Hopkins Advantage MD D-SNP (HMO D-SNP) | HOPKINS HEALTH ADVANTAGE, INC. | T1 | Yes | $0 | MD |
| MetroPlus UltraCare (HMO D-SNP) | METROPLUS HEALTH PLAN, INC. | T1 | Yes | $0 | NY |
| Senior Whole Health SCO (HMO D-SNP) | SENIOR WHOLE HEALTH, LLC | T1 | Yes | $0 | MA |
| Senior Whole Health SCO NHC (HMO D-SNP) | SENIOR WHOLE HEALTH, LLC | T1 | Yes | $0 | MA |
| Molina One Care (HMO D-SNP) | SENIOR WHOLE HEALTH, LLC | T1 | Yes | $0 | MA |
| Gold Coast Health Plan Total Care Advantage (HMO D-SNP) | Ventura County Medi-Cal Managed Care Commission | T1 | Yes | $0 | CA |
| Blue Cross Medicare Advantage Dual Care Plus (HMO D-SNP) | Health Care Service Corporation | T1 | Yes | $0 | NM |
| Blue Cross MA Dual Care Plus Preferred (PPO D-SNP) | Health Care Service Corporation | T1 | Yes | $0 | NM |
| Horizon NJ TotalCare (HMO D-SNP) | HORIZON HEALTHCARE OF NEW JERSEY, INC. | T1 | Yes | $0 | NJ |
| SecureBlue (HMO D-SNP) | HMO Minnesota | T1 | Yes | $0 | MN |
| Hamaspik Medicare Choice (HMO D-SNP) | HAMASPIK, INC. | T1 | Yes | $0 | NY |
| CCA One Care (HMO D-SNP) | COMMONWEALTH CARE ALLIANCE, INC. | T1 | Yes | $0 | MA |
| CCA Senior Care Options (HMO D-SNP) | COMMONWEALTH CARE ALLIANCE, INC. | T1 | Yes | $0 | MA |
| Elevate Medicare Choice (HMO D-SNP) | DENVER HEALTH MEDICAL PLAN, INC. | T1 | Yes | $0 | CO |
| AllCare Advantage Redwood Rx (HMO D-SNP) | ALLCARE HEALTH PLAN, INC. | T1 | Yes | $0 | OR |
| PrimeWest Senior Health Complete (HMO D-SNP) | PRIMEWEST RURAL MN HEALTH CARE ACCESS INITIATIVE | T1 | Yes | $0 | MN |
| Prime Health Complete (HMO D-SNP) | PRIMEWEST RURAL MN HEALTH CARE ACCESS INITIATIVE | T1 | Yes | $0 | MN |
| Alterwood Advantage Dual Secure (HMO D-SNP) | ALTERWOOD ADVANTAGE, INC. | T1 | Yes | $0 | MD |
| Nascentia Dual Advantage (HMO D-SNP) | VISITING NURSE ASSOCIATION OF CENTRAL NEW YORK | T1 | Yes | $0 | NY |
| Abilis Health Community (HMO I-SNP) | SIGNATURE ADVANTAGE, LLC | T1 | Yes | $0 | KY, TN |
| Arkansas Integrated Providers (AIP) Dual Advantage (HMO D-SNP) | ARKANSAS SUPERIOR SELECT, INC. | T1 | Yes | $0 | AR |
| Platino Blindao (HMO D-SNP) | TRIPLE S ADVANTAGE, INC. | T1 | Yes | $0 | PR |
| Platino Enlace (HMO D-SNP) | TRIPLE S ADVANTAGE, INC. | T1 | Yes | $0 | PR |
| PLATINO ADVANCE (HMO D-SNP) | TRIPLE S ADVANTAGE, INC. | T1 | Yes | $0 | PR |
| PLATINO PLUS (HMO D-SNP) | TRIPLE S ADVANTAGE, INC. | T1 | Yes | $0 | PR |
| Highmark Wholecare Medicare Assured Diamond (HMO D-SNP) | GATEWAY HEALTH PLAN, INC. | T1 | Yes | $0 | PA |
| Highmark Wholecare Medicare Assured Diamond (HMO D-SNP) | GATEWAY HEALTH PLAN, INC. | T1 | Yes | $0 | PA |
| Highmark Health Options Duals (HMO D-SNP) | HIGHMARK HEALTH OPTIONS WEST VIRGINIA INC. | T1 | Yes | $0 | WV |
| Highmark Health Options Duals (HMO D-SNP) | HIGHMARK BCBSD, INC. | T1 | Yes | $0 | DE |
| Florida Complete Care (HMO I-SNP) | HPMP OF FLORIDA, INC. | T1 | Yes | $4.80 | FL |
| Florida Complete Care- In The Community (HMO-POS I-SNP) | HPMP OF FLORIDA, INC. | T1 | Yes | $4.80 | FL |
| Blue Cross Medicare Advantage Dual Care Plus (HMO D-SNP) | HCSC INSURANCE SERVICES COMPANY | T1 | Yes | $4.80 | TX |
| Gold Dialysis & Kidney Complete (HMO-POS C-SNP) | GOLD KIDNEY OF FLORIDA INC | T1 | Yes | $4.80 | FL |
| Texas Independence Health Plan, Inc. (HMO I-SNP) | TEXAS INDEPENDENCE HEALTH PLAN, INC. | T1 | Yes | $4.80 | TX |
| Texas Independence Community Plan (HMO I-SNP) | TEXAS INDEPENDENCE HEALTH PLAN, INC. | T1 | Yes | $4.80 | TX |
| Blue Cross Medicare Advantage Dual Care Plus (HMO D-SNP) | GHS INSURANCE COMPANY | T1 | Yes | $5.00 | OK |
| Tribute Select (HMO-POS I-SNP) | ARKANSAS SUPERIOR SELECT, INC. | T1 | Yes | $8.90 | AR |
| ATRIO Special Needs Plan (HMO D-SNP) | ATRIO HEALTH PLANS | T1 | Yes | $10.50 | OR |
| ATRIO Special Needs Plan (HMO D-SNP) | ATRIO HEALTH PLANS | T1 | Yes | $10.50 | OR |
| Highmark Wholecare Medicare Assured Ruby (HMO D-SNP) | GATEWAY HEALTH PLAN, INC. | T1 | Yes | $13.10 | PA |
| Gold Dialysis & Kidney Complete (HMO-POS C-SNP) | GOLD KIDNEY OF ARIZONA | T1 | Yes | $17.00 | AZ |
| Highmark Wholecare Medicare Assured Ruby (HMO D-SNP) | GATEWAY HEALTH PLAN, INC. | T1 | Yes | $17.60 | PA |
Frequently Asked Questions
Is Pediatric 1.5 ML leuprolide acetate 30 MG/ML Prefilled Syringe [Lupron] covered by Medicare Part D?
Yes, Pediatric 1.5 ML leuprolide acetate 30 MG/ML Prefilled Syringe [Lupron] is covered by 3,028 Medicare Part D plans (59.8% of all Part D formularies).
What tier is Pediatric 1.5 ML leuprolide acetate 30 MG/ML Prefilled Syringe [Lupron] on Medicare Part D plans?
Pediatric 1.5 ML leuprolide acetate 30 MG/ML Prefilled Syringe [Lupron] averages Tier 4.3 across Part D plans, ranging from Tier 1 to Tier 5.
Does Pediatric 1.5 ML leuprolide acetate 30 MG/ML Prefilled Syringe [Lupron] require prior authorization?
93.7% of Part D formularies require prior authorization for Pediatric 1.5 ML leuprolide acetate 30 MG/ML Prefilled Syringe [Lupron]. Step therapy: 0%. Quantity limits: 30.7%.
Read our methodology - how this data is sourced, computed, and verified.
Data sourced from the Centers for Medicare & Medicaid Services (CMS). See our methodology for details. Retrieved and formatted by PlainMedicare Editorial