Varies by plan
Does Blue Cross Blue Shield (affiliate) require prior authorization for Caplyta?
Prior authorization for Caplyta differs across Blue Cross Blue Shield (affiliate)'s Medicare Part D plans and product strengths — 3 of 3 Caplyta products in the corpus appear on their formularies, and the requirement is not uniform. Check the member's specific plan.
Some plans require authorization and others do not. The member's specific plan decides.
- Prior authorization requirements differ across this payer's plans: 99 of 269 covering plans require it. Check the specific plan the member is enrolled in — the plan name and contract number are on their insurance card.
By product strength
| RxNorm product | Plans covering | Require prior auth | Step therapy | Qty limit | Status |
|---|---|---|---|---|---|
| lumateperone 42 MG Oral Capsule [Caplyta]2275613 | 269 / 269 | 99 | 29 | 269 | Varies by plan |
| lumateperone 10.5 MG Oral Capsule [Caplyta]2607531 | 269 / 269 | 99 | 29 | 269 | Varies by plan |
| lumateperone 21 MG Oral Capsule [Caplyta]2607535 | 269 / 269 | 99 | 29 | 269 | Varies by plan |
Product names come from RxNorm (U.S. National Library of Medicine).
Plan-by-plan detail — lumateperone 42 MG Oral Capsule [Caplyta]
Caplyta has 3 products in the corpus; this table is for lumateperone 42 MG Oral Capsule [Caplyta], the one carried on the most plans. The product table above covers every strength.
| Plan | Contract | Tier | Prior auth | Step therapy | Qty limit |
|---|---|---|---|---|---|
| Anthem Dual Advantage (HMO D-SNP) | H5422-018 | 5 | No | No | Yes |
| Anthem Extra Help (HMO-POS) | H5422-013 | 5 | No | No | Yes |
| Anthem Full Dual Advantage (HMO D-SNP) | H5422-019 | 5 | No | No | Yes |
| Anthem Full Dual Advantage Aligned (HMO D-SNP) | H4471-010 | 5 | No | No | Yes |
| Anthem Full Dual Advantage Aligned (HMO D-SNP) | H4471-010 | 5 | No | No | Yes |
| Anthem Full Dual Advantage Aligned (HMO D-SNP) | H4471-011 | 5 | No | No | Yes |
| Anthem I CareMore Chronic Care (HMO-POS C-SNP) | H0544-004 | 5 | No | No | Yes |
| Anthem I CareMore Chronic Care (HMO-POS C-SNP) | H0544-010 | 5 | No | No | Yes |
| Anthem I CareMore Chronic Care 2 (HMO-POS C-SNP) | H4161-014 | 5 | No | No | Yes |
| Anthem I CareMore Chronic Care 2 (HMO-POS C-SNP) | H4161-015 | 5 | No | No | Yes |
| Anthem I CareMore Home Care (HMO I-SNP) | H0544-005 | 5 | No | No | Yes |
| Anthem I CareMore Kidney Care (HMO-POS C-SNP) | H0544-015 | 5 | No | No | Yes |
| Anthem I CareMore Kidney Care (HMO-POS C-SNP) | H0544-020 | 5 | No | No | Yes |
| Anthem I CareMore Lung Care (HMO-POS C-SNP) | H0544-014 | 5 | No | No | Yes |
| Anthem I CareMore Lung Care (HMO-POS C-SNP) | H0544-019 | 5 | No | No | Yes |
| Anthem I CareMore Lung Care 2 (HMO-POS C-SNP) | H4161-016 | 5 | No | No | Yes |
| Anthem I CareMore Lung Care 2 (HMO-POS C-SNP) | H4161-017 | 5 | No | No | Yes |
| Anthem I CareMore Medicare Advantage (HMO-POS) | H4161-011 | 5 | No | No | Yes |
| Anthem I CareMore Medicare Advantage (HMO-POS) | H4161-013 | 5 | No | No | Yes |
| Anthem I CareMore Medicare Advantage 2 (HMO-POS) | H0544-002 | 5 | No | No | Yes |
| Anthem I CareMore Premium Savings (HMO-POS) | H4161-012 | 5 | No | No | Yes |
| Anthem Kidney Care (HMO-POS C-SNP) | H5422-015 | 5 | No | No | Yes |
| Anthem Medicare Advantage (HMO-POS) | H0544-056 | 5 | No | No | Yes |
| Anthem Medicare Advantage (HMO-POS) | H0544-061 | 5 | No | No | Yes |
| Anthem Medicare Advantage (HMO-POS) | H0544-062 | 5 | No | No | Yes |
| Anthem Medicare Advantage (HMO-POS) | H0544-063 | 5 | No | No | Yes |
| Anthem Medicare Advantage (HMO-POS) | H0544-064 | 5 | No | No | Yes |
| Anthem Medicare Advantage (HMO-POS) | H0544-065 | 5 | No | No | Yes |
| Anthem Medicare Advantage (HMO-POS) | H0544-095 | 5 | No | No | Yes |
| Anthem Medicare Advantage (HMO-POS) | H0544-096 | 5 | No | No | Yes |
| Anthem Medicare Advantage (HMO-POS) | H0544-108 | 5 | No | No | Yes |
| Anthem Medicare Advantage (HMO-POS) | H5422-011 | 5 | No | No | Yes |
| Anthem Prime (HMO-POS) | H4161-002 | 5 | No | No | Yes |
| Anthem Prime (HMO-POS) | H4161-003 | 5 | No | No | Yes |
| Anthem Prime (HMO-POS) | H4161-004 | 5 | No | No | Yes |
| Anthem Prime (HMO-POS) | H4161-005 | 5 | No | No | Yes |
| Anthem Prime (HMO-POS) | H4161-006 | 5 | No | No | Yes |
| Anthem Prime (HMO-POS) | H4161-007 | 5 | No | No | Yes |
| Anthem Prime (HMO-POS) | H4161-009 | 5 | No | No | Yes |
| Anthem Prime (HMO-POS) | H4161-010 | 5 | No | No | Yes |
| Anthem Select (HMO-POS) | H0544-058 | 5 | No | No | Yes |
| Anthem Select (HMO-POS) | H0544-066 | 5 | No | No | Yes |
| Anthem Select (HMO-POS) | H0544-069 | 5 | No | No | Yes |
| Anthem Select (HMO-POS) | H0544-091 | 5 | No | No | Yes |
| Anthem Select (HMO-POS) | H0544-098 | 5 | No | No | Yes |
| Blue Advantage Choice (PPO) | H0104-016 | 5 | No | No | Yes |
| Blue Advantage Complete (PPO) | H0104-012 | 5 | No | No | Yes |
| Blue Advantage Complete (PPO) | H0104-014 | 5 | No | No | Yes |
| Blue Advantage Premier (PPO) | H0104-015 | 5 | No | No | Yes |
| Blue Cross Medicare Advantage Choice (PPO) | H5959-009 | 5 | No | No | Yes |
| Blue Cross Medicare Advantage Choice (PPO) | H5959-014 | 5 | No | No | Yes |
| Blue Cross Medicare Advantage Choice (PPO) | H5959-014 | 5 | No | No | Yes |
| Blue Cross Medicare Advantage Comfort (PPO) | H5959-015 | 5 | No | No | Yes |
| Blue Cross Medicare Advantage Comfort (PPO) | H5959-016 | 5 | No | No | Yes |
| Blue Cross Medicare Advantage Complete (PPO) | H5959-010 | 5 | No | No | Yes |
| Blue Cross Medicare Advantage Complete (PPO) | H5959-010 | 5 | No | No | Yes |
| Blue Cross Medicare Advantage Complete (PPO) | H5959-011 | 5 | No | No | Yes |
| Blue Cross Medicare Advantage Core (PPO) | H5959-012 | 5 | No | No | Yes |
| Blue Cross Medicare Advantage Core (PPO) | H5959-013 | 5 | No | No | Yes |
| Blue Cross Medicare Advantage Core (PPO) | H5959-013 | 5 | No | No | Yes |
| Blue Cross Medicare Advantage Secure (HMO) | H8547-001 | 5 | No | No | Yes |
| Blue Medicare Advantage Classic PPO (PPO) | H5900-008 | 5 | No | No | Yes |
| Blue Medicare Advantage Enhanced PPO (PPO) | H5900-004 | 5 | No | No | Yes |
| Blue Medicare Advantage PPO (PPO) | H5900-001 | 5 | No | No | Yes |
| Blue Medicare Choice (HMO) | H3449-026 | 5 | No | No | Yes |
| Blue Medicare Enhanced (HMO-POS) | H3449-024 | 5 | No | No | Yes |
| Blue Medicare Enhanced (HMO-POS) | H3449-024 | 5 | No | No | Yes |
| Blue Medicare Enhanced (HMO-POS) | H3449-024 | 5 | No | No | Yes |
| Blue Medicare Essential (HMO) | H3449-027 | 5 | No | No | Yes |
| Blue Medicare Essential (HMO) | H3449-027 | 5 | No | No | Yes |
| Blue Medicare Essential Plus (HMO-POS) | H3449-023 | 5 | No | No | Yes |
| Blue Medicare Essential Plus (HMO-POS) | H3449-023 | 5 | No | No | Yes |
| Blue Medicare Essential Plus (HMO-POS) | H3449-023 | 5 | No | No | Yes |
| Blue Medicare Essential Plus (HMO-POS) | H3449-023 | 5 | No | No | Yes |
| Blue Medicare PPO Enhanced (PPO) | H3404-003 | 5 | No | No | Yes |
| Blue Medicare PPO Enhanced (PPO) | H3404-003 | 5 | No | No | Yes |
| Blue Medicare Rx Enhanced (PDP) | S5540-004 | 5 | No | No | Yes |
| Blue Medicare Rx Standard (PDP) | S5540-002 | 5 | No | No | Yes |
| Blue MedicareRx Essentials (PDP) | S5726-020 | 5 | No | No | Yes |
| Blue MedicareRx Plus (PDP) | S5726-014 | 5 | No | No | Yes |
| Blue MedicareRx Value (PDP) | S5726-013 | 5 | No | No | Yes |
| BlueCHiP for Medicare Access (HMO-POS) | H4152-022 | 5 | No | No | Yes |
| BlueCHiP for Medicare Enhanced (HMO-POS) | H4152-013 | 5 | No | No | Yes |
| BlueCHiP for Medicare Essential (HMO-POS) | H4152-023 | 5 | No | No | Yes |
| BlueCHiP for Medicare Extra (HMO-POS) | H4152-018 | 5 | No | No | Yes |
| BlueMedicare Complete Rx (PDP) | S5904-002 | 5 | No | No | Yes |
| BlueMedicare Premier Rx (PDP) | S5904-001 | 5 | No | No | Yes |
| BlueMedicare Select (PPO) | H5434-002 | 5 | No | No | Yes |
| BlueMedicare Select (PPO) | H5434-045 | 5 | No | No | Yes |
| BlueMedicare Value (PPO) | H5434-023 | 5 | No | No | Yes |
| BlueMedicare Value (PPO) | H5434-024 | 5 | No | No | Yes |
| BlueMedicare Value (PPO) | H5434-025 | 5 | No | No | Yes |
| BlueMedicare Value (PPO) | H5434-026 | 5 | No | No | Yes |
| BlueMedicare Value (PPO) | H5434-030 | 5 | No | No | Yes |
| BlueMedicare Value (PPO) | H5434-031 | 5 | No | No | Yes |
| BlueMedicare Value (PPO) | H5434-034 | 5 | No | No | Yes |
| BlueMedicare Value (PPO) | H5434-035 | 5 | No | No | Yes |
| BlueMedicare Value (PPO) | H5434-036 | 5 | No | No | Yes |
| BlueRI for Duals (HMO D-SNP) | H4152-021 | 5 | No | No | Yes |
| BlueRx Enhanced Plus (PDP) | S1030-001 | 5 | No | No | Yes |
Showing 100 of 269 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.
Caplyta 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.