GLEOSTINE 100 mg Capsule, Gelatin Coated
Also known as Lomustine. Coverage in Idaho and Utah (CMS PDP Region 31).
8 of 10 stand-alone Part D plans in Idaho and Utah cover this drug on tier 4–5.
3 of 8 plans apply a prior authorization, step therapy or quantity limit.
72 Medicare Advantage plans in ID, UT 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. ID: 31 plans · UT: 41 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)$56.30/mo premium · $615.00 deductible | 4Non-Preferred Drug | 31% | 31% | $1254.0100 | — | None |
| HealthSpring Assurance Rx (PDP)$128.60/mo premium · $615.00 deductible | 4Non-Preferred Drug | 30% | 30% | $1254.0100 | — | None |
| Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $1260.9705 | — |
|
| Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible | 5Specialty Tier | 26% | — | $1260.9705 | — |
|
| SilverScript Choice (PDP)$27.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $1319.9950 | — | None |
| AARP Medicare Rx Saver from UHC (PDP)$56.50/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $1344.1415 | — | None |
| Humana Premier Rx Plan (PDP)$115.50/mo premium · $0.00 deductible | 5Specialty Tier | 33% | — | $1260.9705 | — |
|
| AARP Medicare Rx Preferred from UHC (PDP)$132.60/mo premium · $130.00 deductible | 5Specialty Tier | 31% | — | $1344.1415 | — | 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.