Lybalvi (olanzapine/samidorphan) — Highmark
schizophrenia
Preferred products
- aripiprazole
- risperidone
- quetiapine
Initial criteria
- age ≥ 18 years
- Diagnosis of schizophrenia (ICD-10: F20) OR bipolar I disorder OR bipolar II disorder (ICD-10: F31)
- Member has experienced therapeutic failure, intolerance, or contraindication to two (2) of the following plan-preferred generic agents: aripiprazole, risperidone, quetiapine OR provider attests that the member is currently stable on and responding to olanzapine but is experiencing weight gain from the medication
- Member has experienced therapeutic failure, intolerance, or contraindication to metformin in combination with an antipsychotic
Reauthorization criteria
- Prescriber attests that the member has experienced positive clinical response to therapy
Approval duration
12 months