GLEOSTINE 100 mg Capsule, Gelatin Coated
Also known as Lomustine. Coverage in Delaware, DC and Maryland (CMS PDP Region 05).
8 of 10 stand-alone Part D plans in Delaware, DC and Maryland cover this drug on tier 4–5.
3 of 8 plans apply a prior authorization, step therapy or quantity limit.
63 Medicare Advantage plans in DE, DC, MD 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. DE: 22 plans · DC: 12 plans · MD: 29 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)$32.60/mo premium · $615.00 deductible | 4Non-Preferred Drug | 30% | 30% | $1186.4000 | — | None |
| HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible | 4Non-Preferred Drug | 32% | 32% | $1186.4000 | — | None |
| Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $1250.2388 | — |
|
| Humana Value Rx Plan (PDP)$4.30/mo premium · $601.00 deductible | 5Specialty Tier | 26% | — | $1250.2388 | — |
|
| AARP Medicare Rx Saver from UHC (PDP)$37.80/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $1321.6050 | — | None |
| AARP Medicare Rx Preferred from UHC (PDP)$94.50/mo premium · $130.00 deductible | 5Specialty Tier | 31% | — | $1321.6050 | — | None |
| SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $1319.9950 | — | None |
| Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible | 5Specialty Tier | 33% | — | $1250.2388 | — |
|
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.