LYBALVI 15/10 mg Tablet, Film Coated
Also known as Olanzapine And Samidorphan L-Malate. Coverage in Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming (CMS PDP Region 25).
4 of 11 stand-alone Part D plans in Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming cover this drug on tier 5.
4 of 4 plans apply a prior authorization, step therapy or quantity limit.
121 Medicare Advantage plans in IA, MN, MT, NE, ND, SD, WY 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. IA: 26 plans · MN: 39 plans · MT: 20 plans · NE: 23 plans · ND: 5 plans · SD: 6 plans · WY: 2 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)$4.70/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $55.1461 | $165.443 units |
|
| Humana Value Rx Plan (PDP)$20.80/mo premium · $601.00 deductible | 5Specialty Tier | 26% | — | $55.1461 | $165.443 units |
|
| MedicareBlue Rx Standard (PDP)$101.00/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $60.2353 | $180.713 units |
|
| Humana Premier Rx Plan (PDP)$103.70/mo premium · $0.00 deductible | 5Specialty Tier | 33% | — | $55.1461 | $165.443 units |
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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.