olanzapine/samidorphan malate

10 mg-10 mg, 15 mg-10 mg, 20 mg-10 mg, 5 mg-10 mg — Tablet

Also known as: LYBALVI

Informational only — Coverage rules change frequently; verify tier placement and restrictions with your plan or pharmacy before acting.

1 plan

Source: Excel (XLSX) · Formulary date: Jan 5, 2026 · Checked: 1 hour, 57 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
TRICARE Uniform Formulary 2026	Tier 3 - Non-Formulary	✓	—	—	PA