GLEOSTINE 40 mg Capsule, Gelatin Coated
Also known as Lomustine. Coverage in Ohio (CMS PDP Region 14).
8 of 10 stand-alone Part D plans in Ohio cover this drug on tier 4–5.
3 of 8 plans apply a prior authorization, step therapy or quantity limit.
155 Medicare Advantage plans in OH 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. OH: 155 plans.
Every plan that covers it
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| HealthSpring Extra Rx (PDP)$65.70/mo premium · $615.00 deductible | 4Non-Preferred Drug | 30% | 30% | $446.0584 | — | None |
| AARP Medicare Rx Saver from UHC (PDP)$73.70/mo premium · $615.00 deductible | 4Non-Preferred Drug | 32% | — | $489.6956 | — | None |
| SilverScript Choice (PDP)$90.30/mo premium · $615.00 deductible | 4Non-Preferred Drug | 33% | 33% | $478.1716 | — | None |
| HealthSpring Assurance Rx (PDP)$109.50/mo premium · $615.00 deductible | 4Non-Preferred Drug | 33% | 33% | $445.9838 | — | None |
| AARP Medicare Rx Preferred from UHC (PDP)$123.40/mo premium · $130.00 deductible | 4Non-Preferred Drug | 36% | — | $489.6956 | — | None |
| Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $462.5322 | — |
|
| Humana Value Rx Plan (PDP)$23.70/mo premium · $601.00 deductible | 5Specialty Tier | 26% | — | $462.5322 | — |
|
| Humana Premier Rx Plan (PDP)$117.60/mo premium · $0.00 deductible | 5Specialty Tier | 33% | — | $462.5322 | — |
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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.