Does Pacificsource Community Health Plans require prior authorization for Lybalvi?
Pacificsource Community Health Plans does not require prior authorization for Lybalvi on the Medicare Part D plans that cover it.
No covering plan from this payer files a prior-authorization requirement for this drug.
- No prior authorization is filed, but step therapy applies on 11 of 11 covering plans — the plan requires another drug be tried first.
By product strength
| RxNorm product | Plans covering | Require prior auth | Step therapy | Qty limit | Status |
|---|---|---|---|---|---|
| olanzapine 5 MG / samidorphan 10 MG Oral Tablet [Lybalvi]2570398 | 11 / 11 | 0 | 11 | 11 | No prior authorization |
| olanzapine 10 MG / samidorphan 10 MG Oral Tablet [Lybalvi]2570401 | 11 / 11 | 0 | 11 | 11 | No prior authorization |
| olanzapine 15 MG / samidorphan 10 MG Oral Tablet [Lybalvi]2570404 | 11 / 11 | 0 | 11 | 11 | No prior authorization |
| olanzapine 20 MG / samidorphan 10 MG Oral Tablet [Lybalvi]2570407 | 11 / 11 | 0 | 11 | 11 | No prior authorization |
Product names come from RxNorm (U.S. National Library of Medicine).
Plan-by-plan detail — olanzapine 5 MG / samidorphan 10 MG Oral Tablet [Lybalvi]
Lybalvi has 4 products in the corpus; this table is for olanzapine 5 MG / samidorphan 10 MG Oral Tablet [Lybalvi], the one carried on the most plans. The product table above covers every strength.
| Plan | Contract | Tier | Prior auth | Step therapy | Qty limit |
|---|---|---|---|---|---|
| PacificSource Dual Care (HMO D-SNP) | H3864-043 | 5 | No | Yes | Yes |
| PacificSource Medicare Essentials Choice Rx 14 (HMO-POS) | H3864-014 | 5 | No | Yes | Yes |
| PacificSource Medicare Essentials Choice Rx 36 (HMO-POS) | H3864-036 | 5 | No | Yes | Yes |
| PacificSource Medicare Essentials Rx 27 (HMO) | H3864-027 | 5 | No | Yes | Yes |
| PacificSource Medicare Essentials Rx 41 (HMO) | H3864-041 | 5 | No | Yes | Yes |
| PacificSource Medicare Essentials Rx 6 (HMO) | H3864-006 | 5 | No | Yes | Yes |
| PacificSource Medicare Explorer Rx 4 (PPO) | H4754-004 | 5 | No | Yes | Yes |
| PacificSource Medicare MyCare Choice Rx 24 (HMO-POS) | H3864-024 | 5 | No | Yes | Yes |
| PacificSource Medicare MyCare Choice Rx 29 (HMO-POS) | H3864-029 | 5 | No | Yes | Yes |
| PacificSource Medicare MyCare Choice Rx 34 (HMO-POS) | H3864-034 | 5 | No | Yes | Yes |
| PacificSource Medicare MyCare Rx 40 (HMO) | H3864-040 | 5 | No | Yes | Yes |
- 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.
Lybalvi 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.