No prior authorization
Does Devoted Health require prior authorization for Gleostine?
Devoted Health does not require prior authorization for Gleostine on the Medicare Part D plans that cover it.
No covering plan from this payer files a prior-authorization requirement for this drug.
By product strength
| RxNorm product | Plans covering | Require prior auth | Step therapy | Qty limit | Status |
|---|---|---|---|---|---|
| lomustine 10 MG Oral Capsule [Gleostine]1545776 | 415 / 415 | 0 | 0 | 0 | No prior authorization |
| lomustine 100 MG Oral Capsule [Gleostine]1545778 | 415 / 415 | 0 | 0 | 0 | No prior authorization |
| lomustine 40 MG Oral Capsule [Gleostine]1545780 | 415 / 415 | 0 | 0 | 0 | No prior authorization |
Product names come from RxNorm (U.S. National Library of Medicine).
Plan-by-plan detail — lomustine 10 MG Oral Capsule [Gleostine]
Gleostine has 3 products in the corpus; this table is for lomustine 10 MG Oral Capsule [Gleostine], the one carried on the most plans. The product table above covers every strength.
| Plan | Contract | Tier | Prior auth | Step therapy | Qty limit |
|---|---|---|---|---|---|
| DEVOTED C-SNP 003 NM (HMO C-SNP) | H9977-003 | 4 | No | No | No |
| DEVOTED C-SNP 007 NM (HMO C-SNP) | H9977-007 | 4 | No | No | No |
| DEVOTED C-SNP 011 AZ (HMO C-SNP) | H8173-011 | 4 | No | No | No |
| DEVOTED C-SNP 023 AZ (HMO C-SNP) | H8173-023 | 4 | No | No | No |
| DEVOTED C-SNP 027 TX (HMO C-SNP) | H7993-027 | 4 | No | No | No |
| DEVOTED C-SNP 046 TX (HMO C-SNP) | H7993-046 | 4 | No | No | No |
| DEVOTED C-SNP CHOICE 004 SC (PPO C-SNP) | H7028-004 | 4 | No | No | No |
| DEVOTED C-SNP CHOICE 006 AR (PPO C-SNP) | H7397-006 | 4 | No | No | No |
| DEVOTED C-SNP CHOICE 006 MS (PPO C-SNP) | H7355-006 | 4 | No | No | No |
| DEVOTED C-SNP CHOICE 008 AL (PPO C-SNP) | H9888-008 | 4 | No | No | No |
| DEVOTED C-SNP CHOICE 010 AL (PPO C-SNP) | H9888-010 | 4 | No | No | No |
| DEVOTED C-SNP CHOICE PLUS 003 DE (PPO C-SNP) | H0413-003 | 4 | No | No | No |
| DEVOTED C-SNP CHOICE PLUS 004 KS (PPO C-SNP) | H4348-004 | 4 | No | No | No |
| DEVOTED C-SNP CHOICE PLUS 004 KY (PPO C-SNP) | H5718-004 | 4 | No | No | No |
| DEVOTED C-SNP CHOICE PLUS 006 NE (PPO C-SNP) | H9802-006 | 4 | No | No | No |
| DEVOTED C-SNP CHOICE PLUS 006 SC (PPO C-SNP) | H7028-006 | 4 | No | No | No |
| DEVOTED C-SNP CHOICE PLUS 006 WA (PPO C-SNP) | H8917-006 | 4 | No | No | No |
| DEVOTED C-SNP CHOICE PLUS 007 UT (PPO C-SNP) | H4473-007 | 4 | No | No | No |
| DEVOTED C-SNP CHOICE PLUS 008 OK (PPO C-SNP) | H2845-008 | 4 | No | No | No |
| DEVOTED C-SNP CHOICE PLUS 010 AR (PPO C-SNP) | H7397-010 | 4 | No | No | No |
| DEVOTED C-SNP CHOICE PLUS 010 MS (PPO C-SNP) | H7355-010 | 4 | No | No | No |
| DEVOTED C-SNP CHOICE PLUS 012 AL (PPO C-SNP) | H9888-012 | 4 | No | No | No |
| DEVOTED C-SNP CHOICE PLUS 012 IL (PPO C-SNP) | H8320-012 | 4 | No | No | No |
| DEVOTED C-SNP CHOICE PLUS 013 IN (PPO C-SNP) | H7471-013 | 4 | No | No | No |
| DEVOTED C-SNP CHOICE PLUS 014 LA (PPO C-SNP) | H7766-014 | 4 | No | No | No |
| DEVOTED C-SNP CHOICE PLUS 015 AL (PPO C-SNP) | H9888-015 | 4 | No | No | No |
| DEVOTED C-SNP CHOICE PLUS 016 GA (PPO C-SNP) | H5453-016 | 4 | No | No | No |
| DEVOTED C-SNP CHOICE PLUS 020 TN (PPO C-SNP) | H9231-020 | 4 | No | No | No |
| DEVOTED C-SNP CHOICE PREMIUM 003 KS (PPO C-SNP) | H4348-003 | 4 | No | No | No |
| DEVOTED C-SNP CHOICE PREMIUM 003 UT (PPO C-SNP) | H4473-003 | 4 | No | No | No |
| DEVOTED C-SNP CHOICE PREMIUM 005 KY (PPO C-SNP) | H5718-005 | 4 | No | No | No |
| DEVOTED C-SNP CHOICE PREMIUM 005 SC (PPO C-SNP) | H7028-005 | 4 | No | No | No |
| DEVOTED C-SNP CHOICE PREMIUM 005 WA (PPO C-SNP) | H8917-005 | 4 | No | No | No |
| DEVOTED C-SNP CHOICE PREMIUM 006 KY (PPO C-SNP) | H5718-006 | 4 | No | No | No |
| DEVOTED C-SNP CHOICE PREMIUM 007 AR (PPO C-SNP) | H7397-007 | 4 | No | No | No |
| DEVOTED C-SNP CHOICE PREMIUM 007 KS (PPO C-SNP) | H4348-007 | 4 | No | No | No |
| DEVOTED C-SNP CHOICE PREMIUM 007 MS (PPO C-SNP) | H7355-007 | 4 | No | No | No |
| DEVOTED C-SNP CHOICE PREMIUM 009 AL (PPO C-SNP) | H9888-009 | 4 | No | No | No |
| DEVOTED C-SNP CHOICE PREMIUM 009 NE (PPO C-SNP) | H9802-009 | 4 | No | No | No |
| DEVOTED C-SNP CHOICE PREMIUM 009 OK (PPO C-SNP) | H2845-009 | 4 | No | No | No |
| DEVOTED C-SNP CHOICE PREMIUM 010 OK (PPO C-SNP) | H2845-010 | 4 | No | No | No |
| DEVOTED C-SNP CHOICE PREMIUM 011 AL (PPO C-SNP) | H9888-011 | 4 | No | No | No |
| DEVOTED C-SNP CHOICE PREMIUM 011 IL (PPO C-SNP) | H8320-011 | 4 | No | No | No |
| DEVOTED C-SNP CHOICE PREMIUM 012 LA (PPO C-SNP) | H7766-012 | 4 | No | No | No |
| DEVOTED C-SNP CHOICE PREMIUM 013 IL (PPO C-SNP) | H8320-013 | 4 | No | No | No |
| DEVOTED C-SNP CHOICE PREMIUM 013 LA (PPO C-SNP) | H7766-013 | 4 | No | No | No |
| DEVOTED C-SNP CHOICE PREMIUM 014 IL (PPO C-SNP) | H8320-014 | 4 | No | No | No |
| DEVOTED C-SNP CHOICE PREMIUM 014 IN (PPO C-SNP) | H7471-014 | 4 | No | No | No |
| DEVOTED C-SNP CHOICE PREMIUM 015 GA (PPO C-SNP) | H5453-015 | 4 | No | No | No |
| DEVOTED C-SNP CHOICE PREMIUM 015 IN (PPO C-SNP) | H7471-015 | 4 | No | No | No |
| DEVOTED C-SNP CHOICE PREMIUM 016 IN (PPO C-SNP) | H7471-016 | 4 | No | No | No |
| DEVOTED C-SNP CHOICE PREMIUM 016 TN (PPO C-SNP) | H9231-016 | 4 | No | No | No |
| DEVOTED C-SNP CHOICE PREMIUM 017 GA (PPO C-SNP) | H5453-017 | 4 | No | No | No |
| DEVOTED C-SNP CHOICE PREMIUM 017 IN (PPO C-SNP) | H7471-017 | 4 | No | No | No |
| DEVOTED C-SNP CHOICE PREMIUM 017 TN (PPO C-SNP) | H9231-017 | 4 | No | No | No |
| DEVOTED C-SNP CHOICE PREMIUM 018 GA (PPO C-SNP) | H5453-018 | 4 | No | No | No |
| DEVOTED C-SNP CHOICE PREMIUM 018 TN (PPO C-SNP) | H9231-018 | 4 | No | No | No |
| DEVOTED C-SNP CHOICE PREMIUM 019 TN (PPO C-SNP) | H9231-019 | 4 | No | No | No |
| DEVOTED C-SNP PLUS 003 HI (HMO C-SNP) | H5397-003 | 4 | No | No | No |
| DEVOTED C-SNP PLUS 004 NM (HMO C-SNP) | H9977-004 | 4 | No | No | No |
| DEVOTED C-SNP PLUS 004 VA (HMO C-SNP) | H6994-004 | 4 | No | No | No |
| DEVOTED C-SNP PLUS 006 IL (HMO C-SNP) | H7151-006 | 4 | No | No | No |
| DEVOTED C-SNP PLUS 009 OR (HMO C-SNP) | H2923-009 | 4 | No | No | No |
| DEVOTED C-SNP PLUS 013 CO (HMO C-SNP) | H7147-013 | 4 | No | No | No |
| DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) | H5299-015 | 4 | No | No | No |
| DEVOTED C-SNP PLUS 016 MO (HMO C-SNP) | H2041-016 | 4 | No | No | No |
| DEVOTED C-SNP PLUS 016 OH (HMO C-SNP) | H2697-016 | 4 | No | No | No |
| DEVOTED C-SNP PLUS 021 PA (HMO C-SNP) | H6852-021 | 4 | No | No | No |
| DEVOTED C-SNP PLUS 022 AZ (HMO C-SNP) | H8173-022 | 4 | No | No | No |
| DEVOTED C-SNP PLUS 022 PA (HMO C-SNP) | H6852-022 | 4 | No | No | No |
| DEVOTED C-SNP PLUS 024 TX (HMO C-SNP) | H7993-024 | 4 | No | No | No |
| DEVOTED C-SNP PLUS 025 AZ (HMO C-SNP) | H8173-025 | 4 | No | No | No |
| DEVOTED C-SNP PLUS 027 AZ (HMO C-SNP) | H8173-027 | 4 | No | No | No |
| DEVOTED C-SNP PLUS 029 TX (HMO C-SNP) | H7993-029 | 4 | No | No | No |
| DEVOTED C-SNP PLUS 031 TX (HMO C-SNP) | H7993-031 | 4 | No | No | No |
| DEVOTED C-SNP PLUS 033 TX (HMO C-SNP) | H7993-033 | 4 | No | No | No |
| DEVOTED C-SNP PLUS 036 IA (HMO C-SNP) | H7993-036 | 4 | No | No | No |
| DEVOTED C-SNP PLUS 084 FL (HMO C-SNP) | H1290-084 | 4 | No | No | No |
| DEVOTED C-SNP PLUS 085 FL (HMO C-SNP) | H1290-085 | 4 | No | No | No |
| DEVOTED C-SNP PLUS 086 FL (HMO C-SNP) | H1290-086 | 4 | No | No | No |
| DEVOTED C-SNP PLUS 087 FL (HMO C-SNP) | H1290-087 | 4 | No | No | No |
| DEVOTED C-SNP PLUS 088 FL (HMO C-SNP) | H1290-088 | 4 | No | No | No |
| DEVOTED C-SNP PLUS 089 FL (HMO C-SNP) | H1290-089 | 4 | No | No | No |
| DEVOTED C-SNP PLUS 090 FL (HMO C-SNP) | H1290-090 | 4 | No | No | No |
| DEVOTED C-SNP PLUS 091 FL (HMO C-SNP) | H1290-091 | 4 | No | No | No |
| DEVOTED C-SNP PREMIUM 003 VA (HMO C-SNP) | H6994-003 | 4 | No | No | No |
| DEVOTED C-SNP PREMIUM 005 IL (HMO C-SNP) | H7151-005 | 4 | No | No | No |
| DEVOTED C-SNP PREMIUM 009 CO (HMO C-SNP) | H7147-009 | 4 | No | No | No |
| DEVOTED C-SNP PREMIUM 010 CO (HMO C-SNP) | H7147-010 | 4 | No | No | No |
| DEVOTED C-SNP PREMIUM 010 VA (HMO C-SNP) | H6994-010 | 4 | No | No | No |
| DEVOTED C-SNP PREMIUM 011 CO (HMO C-SNP) | H7147-011 | 4 | No | No | No |
| DEVOTED C-SNP PREMIUM 012 MO (HMO C-SNP) | H2041-012 | 4 | No | No | No |
| DEVOTED C-SNP PREMIUM 013 MO (HMO C-SNP) | H2041-013 | 4 | No | No | No |
| DEVOTED C-SNP PREMIUM 013 VA (HMO C-SNP) | H6994-013 | 4 | No | No | No |
| DEVOTED C-SNP PREMIUM 014 AZ (HMO C-SNP) | H8173-014 | 4 | No | No | No |
| DEVOTED C-SNP PREMIUM 014 MO (HMO C-SNP) | H2041-014 | 4 | No | No | No |
| DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) | H5299-014 | 4 | No | No | No |
| DEVOTED C-SNP PREMIUM 015 MO (HMO C-SNP) | H2041-015 | 4 | No | No | No |
| DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) | H5299-016 | 4 | No | No | No |
| DEVOTED C-SNP PREMIUM 016 PA (HMO C-SNP) | H6852-016 | 4 | No | No | No |
Showing 100 of 415 covering plans.
Source
Monthly Prescription Drug Plan Formulary and Pharmacy Network Information — Basic Drugs Formulary File- Effective
- 2026-06-30
- Retrieved
- 2026-07-19
- SHA-256
- e626e6bcda1aa6a0071e6f0df6bafe686ae41842cdf0a9feffdc649b6d3ff3ae
We publish the hash of the exact file we ingested so any answer can be audited against the bytes CMS served that day.
Gleostine at other payers
Administrative information only. Benefily reports what a payer has published in its own prior-authorization policy as of the effective date shown. It is not medical advice, not a coverage or payment guarantee, and not an authorization. Requirements vary by plan, place of service and member benefits — always verify with the payer before rendering service.