GLEOSTINE 100 mg Capsule, Gelatin Coated
Also known as Lomustine. Coverage in Missouri (CMS PDP Region 18).
8 of 10 stand-alone Part D plans in Missouri cover this drug on tier 4–5.
3 of 8 plans apply a prior authorization, step therapy or quantity limit.
122 Medicare Advantage plans in MO 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. MO: 122 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)$70.70/mo premium · $615.00 deductible | 4Non-Preferred Drug | 30% | 30% | $1248.2019 | — | None |
| HealthSpring Assurance Rx (PDP)$74.30/mo premium · $615.00 deductible | 4Non-Preferred Drug | 30% | 30% | $1247.1864 | — | None |
| Humana Basic Rx Plan (PDP)$16.50/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $1314.6288 | — |
|
| Humana Value Rx Plan (PDP)$33.70/mo premium · $601.00 deductible | 5Specialty Tier | 26% | — | $1314.6288 | — |
|
| AARP Medicare Rx Saver from UHC (PDP)$71.90/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $1407.5040 | — | None |
| SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $1319.9950 | — | None |
| AARP Medicare Rx Preferred from UHC (PDP)$125.40/mo premium · $130.00 deductible | 5Specialty Tier | 31% | — | $1407.5040 | — | None |
| Humana Premier Rx Plan (PDP)$126.40/mo premium · $0.00 deductible | 5Specialty Tier | 33% | — | $1314.6288 | — |
|
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.