LYBALVI 20/10 mg Tablet, Film Coated
Also known as Olanzapine And Samidorphan L-Malate. Coverage in Missouri (CMS PDP Region 18).
3 of 10 stand-alone Part D plans in Missouri cover this drug on tier 5.
3 of 3 plans apply a prior authorization, step therapy or quantity limit.
53 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: 53 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)$16.50/mo premium · $615.00 deductible | 5Specialty Tier | 25% | — | $55.0152 | $165.053 units |
|
| Humana Value Rx Plan (PDP)$33.70/mo premium · $601.00 deductible | 5Specialty Tier | 26% | — | $55.0152 | $165.053 units |
|
| Humana Premier Rx Plan (PDP)$126.40/mo premium · $0.00 deductible | 5Specialty Tier | 33% | — | $55.0152 | $165.053 units |
|
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.