LYBALVI 10/10 mg Tablet, Film Coated

Also known as Olanzapine And Samidorphan L-Malate. Coverage in South Carolina (CMS PDP Region 09).

4 of 11 stand-alone Part D plans in South Carolina cover this drug on tier 5.

4 of 4 plans apply a prior authorization, step therapy or quantity limit.

37 Medicare Advantage plans in SC 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. SC: 37 plans.

Every plan that covers it

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$10.10/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$55.5599	$166.683 units	Prior authorization Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$65.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$55.5599	$166.683 units	Prior authorization Quantity limit 3 per 30 days
BlueCross Rx Value (PDP)$139.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$55.4440	$166.333 units	Step therapy Quantity limit 3 per 30 days
Humana Premier Rx Plan (PDP)$145.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$55.5599	$166.683 units	Prior authorization Quantity limit 3 per 30 days

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.

See coverage in all 39 regions →