GLEOSTINE 100 mg Capsule, Gelatin Coated
Also known as Lomustine. Coverage in Connecticut, Massachusetts, Rhode Island and Vermont (CMS PDP Region 02).
9 of 11 stand-alone Part D plans in Connecticut, Massachusetts, Rhode Island and Vermont cover this drug on tier 4–5.
3 of 9 plans apply a prior authorization, step therapy or quantity limit.
124 Medicare Advantage plans in CT, MA, RI, VT 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. CT: 29 plans · MA: 78 plans · RI: 15 plans · VT: 2 plans.
Every plan that covers it
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| HealthSpring Assurance Rx (PDP)$139.30/mo premium · $615.00 deductible | 4Non-Preferred Drug | 31% | 31% | $1186.4000 | — | None |
| Humana Basic Rx Plan (PDP)$8.40/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $1263.7946 | — |
|
| Blue MedicareRx Value Plus (PDP)$20.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $1281.7193 | — | None |
| SilverScript Choice (PDP)$32.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $1319.9950 | — | None |
| AARP Medicare Rx Saver from UHC (PDP)$38.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $1344.1415 | — | None |
| Humana Value Rx Plan (PDP)$73.60/mo premium · $601.00 deductible | 5Specialty Tier | 26% | — | $1263.7946 | — |
|
| Humana Premier Rx Plan (PDP)$138.60/mo premium · $0.00 deductible | 5Specialty Tier | 33% | — | $1263.7946 | — |
|
| AARP Medicare Rx Preferred from UHC (PDP)$155.10/mo premium · $130.00 deductible | 5Specialty Tier | 31% | — | $1344.1415 | — | None |
| Blue MedicareRx Premier (PDP)$238.60/mo premium · $0.00 deductible | 5Specialty Tier | 33% | — | $1281.7193 | — | None |
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.