Lybalvi (olanzapine/samidorphan) — United Healthcare
bipolar 1 disorder
Preferred products
- aripiprazole
- olanzapine
- quetiapine IR
- quetiapine XR
- risperidone
- ziprasidone
Initial criteria
- Submission of medical records documenting BOTH of the following:
- 1. The patient has a diagnosis of ONE of the following: schizophrenia OR bipolar 1 disorder
- AND
- 2. The patient has a history of failure, contraindication or intolerance to a trial of at least THREE of the following: aripiprazole, olanzapine, quetiapine IR or XR, risperidone, ziprasidone
Reauthorization criteria
- Documentation of positive clinical response to therapy
Approval duration
12 months