LYBALVI 20/10 mg Tablet, Film Coated (Olanzapine And Samidorphan L-Malate) — Medicare Part D coverage and cost

Region	Plans covering	Tiers	Lowest 30-day cost	Restrictions
Kansas	6 of 12	5	—	6 of 6 plans
Connecticut, Massachusetts, Rhode Island and Vermont	5 of 11	4–5	—	5 of 5 plans
New Jersey	5 of 12	5	—	5 of 5 plans
North Carolina	5 of 12	5	—	5 of 5 plans
Florida	5 of 10	5	—	5 of 5 plans
Alabama and Tennessee	5 of 12	5	—	5 of 5 plans
Illinois	5 of 12	5	—	5 of 5 plans
Arkansas	5 of 12	4–5	—	5 of 5 plans
Texas	5 of 12	5	—	5 of 5 plans
Oklahoma	5 of 11	5	—	5 of 5 plans
New Mexico	5 of 11	5	—	5 of 5 plans
South Carolina	4 of 11	5	—	4 of 4 plans
Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming	4 of 11	5	—	4 of 4 plans
Maine and New Hampshire	3 of 9	5	—	3 of 3 plans
New York	3 of 10	5	—	3 of 3 plans
Delaware, DC and Maryland	3 of 10	5	—	3 of 3 plans
Pennsylvania and West Virginia	3 of 12	5	—	3 of 3 plans
Virginia	3 of 9	5	—	3 of 3 plans
Georgia	3 of 10	5	—	3 of 3 plans
Michigan	3 of 12	5	—	3 of 3 plans
Ohio	3 of 10	5	—	3 of 3 plans
Indiana and Kentucky	3 of 10	5	—	3 of 3 plans
Wisconsin	3 of 10	5	—	3 of 3 plans
Missouri	3 of 10	5	—	3 of 3 plans
Mississippi	3 of 10	5	—	3 of 3 plans
Louisiana	3 of 10	5	—	3 of 3 plans
Colorado	3 of 10	5	—	3 of 3 plans
Arizona	3 of 10	5	—	3 of 3 plans
Nevada	3 of 10	5	—	3 of 3 plans
Oregon and Washington	3 of 10	5	—	3 of 3 plans
Idaho and Utah	3 of 10	5	—	3 of 3 plans
California	3 of 12	5	—	3 of 3 plans
Hawaii	3 of 8	5	—	3 of 3 plans
Alaska	3 of 9	5	—	3 of 3 plans
American Samoa	no PDP	—	—	—
Guam	no PDP	—	—	—
Northern Mariana Islands	no PDP	—	—	—
Puerto Rico	no PDP	—	—	—
U.S. Virgin Islands	no PDP	—	—	—

Kansas — 6 plans, 6 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Blue MedicareRx Essentials (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	5Specialty Tier	25%	—	$61.6158	$184.853 units	Prior authorization Quantity limit 3 per 30 days
Blue MedicareRx Value (PDP)$0.70/mo premium · $615.00 deductible · $0 with full Extra Help	5Specialty Tier	25%	—	$61.5851	$184.763 units	Prior authorization Quantity limit 3 per 30 days
Humana Basic Rx Plan (PDP)$15.50/mo premium · $615.00 deductible · $0 with full Extra Help	5Specialty Tier	25%	—	$55.1298	$165.393 units	Prior authorization Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$55.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$55.1298	$165.393 units	Prior authorization Quantity limit 3 per 30 days
Blue MedicareRx Plus (PDP)$67.40/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$61.5851	$184.763 units	Prior authorization Quantity limit 3 per 30 days
Humana Premier Rx Plan (PDP)$116.30/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$55.1298	$165.393 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 — elsewhere it depends on what is prescribed.

Connecticut, Massachusetts, Rhode Island and Vermont — 5 plans, 5 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$8.40/mo premium · $615.00 deductible · $0 with full Extra Help	5Specialty Tier	25%	—	$55.1184	$165.363 units	Prior authorization Quantity limit 3 per 30 days
Blue MedicareRx Value Plus (PDP)$20.70/mo premium · $615.00 deductible · $0 with full Extra Help	4Non-Preferred Drug	32%	32%	$55.0470	$165.143 units	Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$73.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$55.1184	$165.363 units	Prior authorization Quantity limit 3 per 30 days
Humana Premier Rx Plan (PDP)$138.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$55.1184	$165.363 units	Prior authorization Quantity limit 3 per 30 days
Blue MedicareRx Premier (PDP)$238.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$55.0470	$165.143 units	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 — elsewhere it depends on what is prescribed.

New Jersey — 5 plans, 5 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$4.40/mo premium · $615.00 deductible · $0 with full Extra Help	5Specialty Tier	25%	—	$54.8658	$164.603 units	Prior authorization Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$35.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$54.8658	$164.603 units	Prior authorization Quantity limit 3 per 30 days
Horizon Medicare Blue Rx Standard (PDP)$72.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$60.4090	$181.233 units	Prior authorization Quantity limit 3 per 30 days
Humana Premier Rx Plan (PDP)$111.90/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$54.8658	$164.603 units	Prior authorization Quantity limit 3 per 30 days
Horizon Medicare Blue Rx Enhanced (PDP)$139.10/mo premium · $200.00 deductible	5Specialty Tier	30%	—	$60.4090	$181.233 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 — elsewhere it depends on what is prescribed.

North Carolina — 5 plans, 5 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$6.80/mo premium · $615.00 deductible · $0 with full Extra Help	5Specialty Tier	25%	—	$55.0182	$165.053 units	Prior authorization Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$32.00/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$55.0182	$165.053 units	Prior authorization Quantity limit 3 per 30 days
Blue Medicare Rx Standard (PDP)$83.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$60.0218	$180.073 units	Prior authorization Quantity limit 3 per 30 days
Humana Premier Rx Plan (PDP)$110.90/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$55.0182	$165.053 units	Prior authorization Quantity limit 3 per 30 days
Blue Medicare Rx Enhanced (PDP)$163.20/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$60.0218	$180.073 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 — elsewhere it depends on what is prescribed.

Florida — 5 plans, 5 with restrictions

Maximum premiumMaximum deductiblePlan familyPlanSort by

Showing 5 of 5 plans

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Value Rx Plan (PDP)$25.90/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$55.1462	$165.443 units	Prior authorization Quantity limit 3 per 30 days
Humana Basic Rx Plan (PDP)$92.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$55.1462	$165.443 units	Prior authorization Quantity limit 3 per 30 days
BlueMedicare Premier Rx (PDP)$98.60/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$59.5307	$178.593 units	Prior authorization Quantity limit 3 per 30 days
Humana Premier Rx Plan (PDP)$115.90/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$55.1462	$165.443 units	Prior authorization Quantity limit 3 per 30 days
BlueMedicare Complete Rx (PDP)$217.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$59.5307	$178.593 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 — elsewhere it depends on what is prescribed.

Alabama and Tennessee — 5 plans, 5 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	5Specialty Tier	25%	—	$55.1145	$165.343 units	Prior authorization Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$37.70/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$55.1145	$165.343 units	Prior authorization Quantity limit 3 per 30 days
BlueRx Essential (PDP)$76.20/mo premium · $615.00 deductible	5Specialty Tier	25%	25%	$60.6638	$181.993 units	Prior authorization Quantity limit 3 per 30 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$55.1145	$165.343 units	Prior authorization Quantity limit 3 per 30 days
BlueRx Enhanced Plus (PDP)$129.50/mo premium · $150.00 deductible	5Specialty Tier	31%	31%	$60.6638	$181.993 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 — elsewhere it depends on what is prescribed.

Illinois — 5 plans, 5 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	5Specialty Tier	25%	—	$55.3041	$165.913 units	Prior authorization Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible · $0 with full Extra Help	5Specialty Tier	26%	—	$55.3041	$165.913 units	Prior authorization Quantity limit 3 per 30 days
Blue Cross MedicareRx Basic (PDP)$89.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$61.1205	$183.363 units	Prior authorization Quantity limit 3 per 30 days
Humana Premier Rx Plan (PDP)$119.40/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$55.3041	$165.913 units	Prior authorization Quantity limit 3 per 30 days
Blue Cross MedicareRx Value (PDP)$119.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$60.5378	$181.613 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 — elsewhere it depends on what is prescribed.

Arkansas — 5 plans, 5 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	5Specialty Tier	25%	—	$55.4213	$166.263 units	Prior authorization Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible · $0 with full Extra Help	5Specialty Tier	26%	—	$55.4213	$166.263 units	Prior authorization Quantity limit 3 per 30 days
BlueMedicare Value Rx (PDP)$52.50/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	34%	$55.9680	$167.903 units	Quantity limit 3 per 30 days
Humana Premier Rx Plan (PDP)$92.40/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$55.4213	$166.263 units	Prior authorization Quantity limit 3 per 30 days
BlueMedicare Premier Rx (PDP)$181.20/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$55.9680	$167.903 units	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 — elsewhere it depends on what is prescribed.

Texas — 5 plans, 5 with restrictions

Maximum premiumMaximum deductiblePlan familyPlanSort by

Showing 5 of 5 plans

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Value Rx Plan (PDP)$22.90/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$54.9828	$164.953 units	Prior authorization Quantity limit 3 per 30 days
Humana Basic Rx Plan (PDP)$41.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$54.9828	$164.953 units	Prior authorization Quantity limit 3 per 30 days
Blue Cross MedicareRx Basic (PDP)$104.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$60.2650	$180.803 units	Prior authorization Quantity limit 3 per 30 days
Humana Premier Rx Plan (PDP)$118.20/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$54.9828	$164.953 units	Prior authorization Quantity limit 3 per 30 days
Blue Cross MedicareRx Value (PDP)$167.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$59.8061	$179.423 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 — elsewhere it depends on what is prescribed.

Oklahoma — 5 plans, 5 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Blue Cross MedicareRx Basic (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	5Specialty Tier	25%	—	$61.2494	$183.753 units	Prior authorization Quantity limit 3 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	5Specialty Tier	25%	—	$54.9380	$164.813 units	Prior authorization Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$33.70/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$54.9380	$164.813 units	Prior authorization Quantity limit 3 per 30 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$54.9380	$164.813 units	Prior authorization Quantity limit 3 per 30 days
Blue Cross MedicareRx Value (PDP)$167.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$61.0848	$183.253 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 — elsewhere it depends on what is prescribed.

New Mexico — 5 plans, 5 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	5Specialty Tier	25%	—	$55.6973	$167.093 units	Prior authorization Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$69.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$55.6973	$167.093 units	Prior authorization Quantity limit 3 per 30 days
Humana Premier Rx Plan (PDP)$75.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$55.6973	$167.093 units	Prior authorization Quantity limit 3 per 30 days
Blue Cross MedicareRx Value (PDP)$111.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$58.6575	$175.973 units	Prior authorization Quantity limit 3 per 30 days
Blue Cross MedicareRx Basic (PDP)$145.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$60.8673	$182.603 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 — elsewhere it depends on what is prescribed.

South Carolina — 4 plans, 4 with restrictions

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 · $0 with full Extra Help	5Specialty Tier	25%	—	$55.5357	$166.613 units	Prior authorization Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$65.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$55.5357	$166.613 units	Prior authorization Quantity limit 3 per 30 days
BlueCross Rx Value (PDP)$139.70/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$55.4330	$166.303 units	Step therapy Quantity limit 3 per 30 days
Humana Premier Rx Plan (PDP)$145.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$55.5357	$166.613 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 — elsewhere it depends on what is prescribed.

Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming — 4 plans, 4 with restrictions

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 · $0 with full Extra Help	5Specialty Tier	25%	—	$55.0575	$165.173 units	Prior authorization Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$20.80/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$55.0575	$165.173 units	Prior authorization Quantity limit 3 per 30 days
MedicareBlue Rx Standard (PDP)$101.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$60.7036	$182.113 units	Prior authorization Quantity limit 3 per 30 days
Humana Premier Rx Plan (PDP)$103.70/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$55.0575	$165.173 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 — elsewhere it depends on what is prescribed.

Maine and New Hampshire — 3 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	5Specialty Tier	25%	—	$55.6803	$167.043 units	Prior authorization Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$54.40/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$55.6803	$167.043 units	Prior authorization Quantity limit 3 per 30 days
Humana Premier Rx Plan (PDP)$150.20/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$55.6803	$167.043 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 — elsewhere it depends on what is prescribed.

New York — 3 plans, 3 with restrictions

Maximum premiumMaximum deductiblePlanSort by

Showing 3 of 3 plans

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$140.90/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$54.7631	$164.293 units	Prior authorization Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$158.90/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$54.7631	$164.293 units	Prior authorization Quantity limit 3 per 30 days
Humana Premier Rx Plan (PDP)$173.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$54.7631	$164.293 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 — elsewhere it depends on what is prescribed.

Delaware, DC and Maryland — 3 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	5Specialty Tier	25%	—	$55.0092	$165.033 units	Prior authorization Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$4.30/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$55.0092	$165.033 units	Prior authorization Quantity limit 3 per 30 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$55.0092	$165.033 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 — elsewhere it depends on what is prescribed.

Pennsylvania and West Virginia — 3 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$6.60/mo premium · $615.00 deductible · $0 with full Extra Help	5Specialty Tier	25%	—	$55.0971	$165.293 units	Prior authorization Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$55.0971	$165.293 units	Prior authorization Quantity limit 3 per 30 days
Humana Premier Rx Plan (PDP)$123.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$55.0971	$165.293 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 — elsewhere it depends on what is prescribed.

Virginia — 3 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	5Specialty Tier	25%	—	$55.5026	$166.513 units	Prior authorization Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible · $0 with full Extra Help	5Specialty Tier	26%	—	$55.5026	$166.513 units	Prior authorization Quantity limit 3 per 30 days
Humana Premier Rx Plan (PDP)$87.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$55.5026	$166.513 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 — elsewhere it depends on what is prescribed.

Georgia — 3 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	5Specialty Tier	25%	—	$55.0668	$165.203 units	Prior authorization Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$36.40/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$55.0668	$165.203 units	Prior authorization Quantity limit 3 per 30 days
Humana Premier Rx Plan (PDP)$129.50/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$55.0668	$165.203 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 — elsewhere it depends on what is prescribed.

Michigan — 3 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	5Specialty Tier	25%	—	$55.5093	$166.533 units	Prior authorization Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible · $0 with full Extra Help	5Specialty Tier	26%	—	$55.5093	$166.533 units	Prior authorization Quantity limit 3 per 30 days
Humana Premier Rx Plan (PDP)$98.10/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$55.5093	$166.533 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 — elsewhere it depends on what is prescribed.

Ohio — 3 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	5Specialty Tier	25%	—	$55.1358	$165.413 units	Prior authorization Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$23.70/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$55.1358	$165.413 units	Prior authorization Quantity limit 3 per 30 days
Humana Premier Rx Plan (PDP)$117.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$55.1358	$165.413 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 — elsewhere it depends on what is prescribed.

Indiana and Kentucky — 3 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	5Specialty Tier	25%	—	$54.9591	$164.883 units	Prior authorization Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$9.90/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$54.9591	$164.883 units	Prior authorization Quantity limit 3 per 30 days
Humana Premier Rx Plan (PDP)$125.30/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$54.9591	$164.883 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 — elsewhere it depends on what is prescribed.

Wisconsin — 3 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	5Specialty Tier	25%	—	$54.9957	$164.993 units	Prior authorization Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible · $0 with full Extra Help	5Specialty Tier	26%	—	$54.9957	$164.993 units	Prior authorization Quantity limit 3 per 30 days
Humana Premier Rx Plan (PDP)$110.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$54.9957	$164.993 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 — elsewhere it depends on what is prescribed.

Missouri — 3 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$16.50/mo premium · $615.00 deductible · $0 with full Extra Help	5Specialty Tier	25%	—	$55.0152	$165.053 units	Prior authorization Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$33.70/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$55.0152	$165.053 units	Prior authorization Quantity limit 3 per 30 days
Humana Premier Rx Plan (PDP)$126.40/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$55.0152	$165.053 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 — elsewhere it depends on what is prescribed.

Mississippi — 3 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	5Specialty Tier	25%	—	$55.1867	$165.563 units	Prior authorization Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$37.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$55.1867	$165.563 units	Prior authorization Quantity limit 3 per 30 days
Humana Premier Rx Plan (PDP)$89.90/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$55.1867	$165.563 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 — elsewhere it depends on what is prescribed.

Louisiana — 3 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	5Specialty Tier	25%	—	$55.0426	$165.133 units	Prior authorization Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$19.30/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$55.0426	$165.133 units	Prior authorization Quantity limit 3 per 30 days
Humana Premier Rx Plan (PDP)$113.70/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$55.0426	$165.133 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 — elsewhere it depends on what is prescribed.

Colorado — 3 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	5Specialty Tier	25%	—	$55.1412	$165.423 units	Prior authorization Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$48.50/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$55.1412	$165.423 units	Prior authorization Quantity limit 3 per 30 days
Humana Premier Rx Plan (PDP)$137.10/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$55.1412	$165.423 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 — elsewhere it depends on what is prescribed.

Arizona — 3 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	5Specialty Tier	25%	—	$54.7727	$164.323 units	Prior authorization Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$2.50/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$54.7727	$164.323 units	Prior authorization Quantity limit 3 per 30 days
Humana Premier Rx Plan (PDP)$119.20/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$54.7727	$164.323 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 — elsewhere it depends on what is prescribed.

Nevada — 3 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	5Specialty Tier	25%	—	$54.9952	$164.993 units	Prior authorization Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$43.70/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$54.9952	$164.993 units	Prior authorization Quantity limit 3 per 30 days
Humana Premier Rx Plan (PDP)$148.70/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$54.9952	$164.993 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 — elsewhere it depends on what is prescribed.

Oregon and Washington — 3 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	5Specialty Tier	25%	—	$54.9654	$164.903 units	Prior authorization Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$22.10/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$54.9654	$164.903 units	Prior authorization Quantity limit 3 per 30 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$54.9654	$164.903 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 — elsewhere it depends on what is prescribed.

Idaho and Utah — 3 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	5Specialty Tier	25%	—	$54.6196	$163.863 units	Prior authorization Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$54.6196	$163.863 units	Prior authorization Quantity limit 3 per 30 days
Humana Premier Rx Plan (PDP)$115.50/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$54.6196	$163.863 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 — elsewhere it depends on what is prescribed.

California — 3 plans, 3 with restrictions

Maximum premiumMaximum deductiblePlanSort by

Showing 3 of 3 plans

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Value Rx Plan (PDP)$104.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$54.9933	$164.983 units	Prior authorization Quantity limit 3 per 30 days
Humana Basic Rx Plan (PDP)$132.20/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$54.9933	$164.983 units	Prior authorization Quantity limit 3 per 30 days
Humana Premier Rx Plan (PDP)$172.90/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$54.9933	$164.983 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 — elsewhere it depends on what is prescribed.

Hawaii — 3 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.40/mo premium · $615.00 deductible · $0 with full Extra Help	5Specialty Tier	25%	—	$55.5668	$166.703 units	Prior authorization Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$51.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$55.5668	$166.703 units	Prior authorization Quantity limit 3 per 30 days
Humana Premier Rx Plan (PDP)$90.20/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$55.5668	$166.703 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 — elsewhere it depends on what is prescribed.

Alaska — 3 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible · $0 with full Extra Help	5Specialty Tier	25%	—	$54.1922	$162.583 units	Prior authorization Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$10.60/mo premium · $601.00 deductible	5Specialty Tier	26%	—	$54.1922	$162.583 units	Prior authorization Quantity limit 3 per 30 days
Humana Premier Rx Plan (PDP)$112.40/mo premium · $0.00 deductible	5Specialty Tier	33%	—	$54.1922	$162.583 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 — elsewhere it depends on what is prescribed.

LYBALVI 20/10 mg Tablet, Film Coated

Medicare Advantage plans in your county

Coverage by region

Plan-by-plan detail

No stand-alone Part D plan in American Samoa

No stand-alone Part D plan in Guam

No stand-alone Part D plan in Northern Mariana Islands

No stand-alone Part D plan in Puerto Rico

No stand-alone Part D plan in U.S. Virgin Islands