GLEOSTINE 40 mg Capsule, Gelatin Coated
Also known as Lomustine. Coverage in Louisiana (CMS PDP Region 21).
8 of 10 stand-alone Part D plans in Louisiana cover this drug on tier 4–5.
3 of 8 plans apply a prior authorization, step therapy or quantity limit.
87 Medicare Advantage plans in LA 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. LA: 87 plans.
Every plan that covers it
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| AARP Medicare Rx Saver from UHC (PDP)$37.00/mo premium · $615.00 deductible | 4Non-Preferred Drug | 40% | — | $497.8526 | — | None |
| SilverScript Choice (PDP)$44.70/mo premium · $615.00 deductible | 4Non-Preferred Drug | 35% | 35% | $478.1716 | — | None |
| HealthSpring Assurance Rx (PDP)$48.40/mo premium · $615.00 deductible | 4Non-Preferred Drug | 30% | 30% | $453.4586 | — | None |
| HealthSpring Extra Rx (PDP)$60.60/mo premium · $615.00 deductible | 4Non-Preferred Drug | 30% | 30% | $453.8529 | — | None |
| AARP Medicare Rx Preferred from UHC (PDP)$139.50/mo premium · $130.00 deductible | 4Non-Preferred Drug | 36% | — | $497.8526 | — | None |
| Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $464.0784 | — |
|
| Humana Value Rx Plan (PDP)$19.30/mo premium · $601.00 deductible | 5Specialty Tier | 26% | — | $464.0784 | — |
|
| Humana Premier Rx Plan (PDP)$113.70/mo premium · $0.00 deductible | 5Specialty Tier | 33% | — | $464.0784 | — |
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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.