Prior authorization required
Does Aetna (CVS Health) require prior authorization for Fetzima?
Aetna (CVS Health) requires prior authorization for Fetzima on every Medicare Part D plan of theirs that covers it.
Every plan from this payer that covers the drug requires authorization before it is dispensed.
By product strength
| RxNorm product | Plans covering | Require prior auth | Step therapy | Qty limit | Status |
|---|---|---|---|---|---|
| 24 HR levomilnacipran 120 MG Extended Release Oral Capsule [Fetzima]1433223 | 658 / 658 | 658 | 0 | 658 | Prior authorization required |
| 24 HR levomilnacipran 20 MG Extended Release Oral Capsule [Fetzima]1433229 | 658 / 658 | 658 | 0 | 658 | Prior authorization required |
| 24 HR levomilnacipran 40 MG Extended Release Oral Capsule [Fetzima]1433235 | 658 / 658 | 658 | 0 | 658 | Prior authorization required |
| 24 HR levomilnacipran 80 MG Extended Release Oral Capsule [Fetzima]1433241 | 636 / 658 | 636 | 0 | 636 | Prior authorization required |
Product names come from RxNorm (U.S. National Library of Medicine).
Plan-by-plan detail — 24 HR levomilnacipran 120 MG Extended Release Oral Capsule [Fetzima]
Fetzima has 4 products in the corpus; this table is for 24 HR levomilnacipran 120 MG Extended Release Oral Capsule [Fetzima], the one carried on the most plans. The product table above covers every strength.
| Plan | Contract | Tier | Prior auth | Step therapy | Qty limit |
|---|---|---|---|---|---|
| Aetna Community HealthChoices (HMO D-SNP) | H3959-069 | 4 | Yes | No | Yes |
| Aetna Community HealthChoices (HMO D-SNP) | H3959-070 | 4 | Yes | No | Yes |
| Aetna Community HealthChoices (HMO D-SNP) | H3959-071 | 4 | Yes | No | Yes |
| Aetna Community HealthChoices (HMO D-SNP) | H3959-072 | 4 | Yes | No | Yes |
| Aetna Community HealthChoices (HMO D-SNP) | H3959-073 | 4 | Yes | No | Yes |
| Aetna Medicare Advantra (PPO) | H1608-029 | 4 | Yes | No | Yes |
| Aetna Medicare Advantra (PPO) | H7301-002 | 4 | Yes | No | Yes |
| Aetna Medicare Advantra Dual (HMO D-SNP) | H1692-005 | 4 | Yes | No | Yes |
| Aetna Medicare Advantra Dual (HMO D-SNP) | H3959-036 | 4 | Yes | No | Yes |
| Aetna Medicare Advantra Dual Care (HMO D-SNP) | H3959-035 | 4 | Yes | No | Yes |
| Aetna Medicare Advantra Elite (HMO) | H1692-003 | 4 | Yes | No | Yes |
| Aetna Medicare Advantra Enhanced (HMO-POS) | H3959-001 | 4 | Yes | No | Yes |
| Aetna Medicare Advantra Enhanced (HMO-POS) | H3959-039 | 4 | Yes | No | Yes |
| Aetna Medicare Advantra Enhanced (PPO) | H1608-027 | 4 | Yes | No | Yes |
| Aetna Medicare Advantra Extra (PPO) | H7301-006 | 4 | Yes | No | Yes |
| Aetna Medicare Advantra Premier (HMO-POS) | H3959-002 | 4 | Yes | No | Yes |
| Aetna Medicare Advantra Premier (PPO) | H5522-002 | 4 | Yes | No | Yes |
| Aetna Medicare Advantra Premier (PPO) | H5522-014 | 4 | Yes | No | Yes |
| Aetna Medicare Advantra Prime Plus (HMO-POS) | H3959-053 | 4 | Yes | No | Yes |
| Aetna Medicare Advantra Signature (HMO-POS) | H3959-010 | 4 | Yes | No | Yes |
| Aetna Medicare Advantra Signature (HMO-POS) | H3959-037 | 4 | Yes | No | Yes |
| Aetna Medicare Advantra Signature (HMO-POS) | H3959-052 | 4 | Yes | No | Yes |
| Aetna Medicare Advantra Signature (HMO) | H1692-002 | 4 | Yes | No | Yes |
| Aetna Medicare Advantra Signature (HMO) | H3959-055 | 4 | Yes | No | Yes |
| Aetna Medicare Advantra Signature (PPO) | H1608-040 | 4 | Yes | No | Yes |
| Aetna Medicare Advantra Signature (PPO) | H5522-004 | 4 | Yes | No | Yes |
| Aetna Medicare Advantra Signature Giveback (PPO) | H1608-031 | 4 | Yes | No | Yes |
| Aetna Medicare Advantra Signature Giveback (PPO) | H5522-017 | 4 | Yes | No | Yes |
| Aetna Medicare Advantra Signature Plus (HMO-POS) | H3959-011 | 4 | Yes | No | Yes |
| Aetna Medicare Advantra Signature Plus (HMO-POS) | H3959-032 | 4 | Yes | No | Yes |
| Aetna Medicare Carilion Health Prime (HMO-POS) | H3931-158 | 4 | Yes | No | Yes |
| Aetna Medicare Chronic Care (HMO C-SNP) | H0628-036 | 4 | Yes | No | Yes |
| Aetna Medicare Chronic Care (HMO C-SNP) | H0628-037 | 4 | Yes | No | Yes |
| Aetna Medicare Chronic Care (HMO C-SNP) | H0628-038 | 4 | Yes | No | Yes |
| Aetna Medicare Chronic Care (HMO C-SNP) | H0628-039 | 4 | Yes | No | Yes |
| Aetna Medicare Chronic Care (HMO C-SNP) | H1609-080 | 4 | Yes | No | Yes |
| Aetna Medicare Chronic Care (HMO C-SNP) | H1609-081 | 4 | Yes | No | Yes |
| Aetna Medicare Chronic Care (HMO C-SNP) | H1609-082 | 4 | Yes | No | Yes |
| Aetna Medicare Chronic Care (HMO C-SNP) | H1609-083 | 4 | Yes | No | Yes |
| Aetna Medicare Chronic Care (HMO C-SNP) | H1609-084 | 4 | Yes | No | Yes |
| Aetna Medicare Chronic Care (HMO C-SNP) | H1609-085 | 4 | Yes | No | Yes |
| Aetna Medicare Chronic Care (HMO C-SNP) | H1609-094 | 4 | Yes | No | Yes |
| Aetna Medicare Chronic Care (HMO C-SNP) | H2663-098 | 4 | Yes | No | Yes |
| Aetna Medicare Chronic Care (HMO C-SNP) | H2663-100 | 4 | Yes | No | Yes |
| Aetna Medicare Chronic Care (HMO C-SNP) | H2663-102 | 4 | Yes | No | Yes |
| Aetna Medicare Chronic Care (HMO C-SNP) | H3146-037 | 4 | Yes | No | Yes |
| Aetna Medicare Chronic Care (HMO C-SNP) | H3146-038 | 4 | Yes | No | Yes |
| Aetna Medicare Chronic Care (HMO C-SNP) | H3192-033 | 4 | Yes | No | Yes |
| Aetna Medicare Chronic Care (HMO C-SNP) | H3239-030 | 4 | Yes | No | Yes |
| Aetna Medicare Chronic Care (HMO C-SNP) | H3312-091 | 4 | Yes | No | Yes |
| Aetna Medicare Chronic Care (HMO C-SNP) | H3931-191 | 4 | Yes | No | Yes |
| Aetna Medicare Chronic Care (HMO C-SNP) | H3959-076 | 4 | Yes | No | Yes |
| Aetna Medicare Chronic Care (HMO C-SNP) | H3959-084 | 4 | Yes | No | Yes |
| Aetna Medicare Chronic Care (HMO C-SNP) | H5302-026 | 4 | Yes | No | Yes |
| Aetna Medicare Chronic Care (PPO C-SNP) | H2293-035 | 4 | Yes | No | Yes |
| Aetna Medicare Chronic Care Total (HMO C-SNP) | H0628-031 | 4 | Yes | No | Yes |
| Aetna Medicare Chronic Care Total (HMO C-SNP) | H0628-032 | 4 | Yes | No | Yes |
| Aetna Medicare Chronic Care Total (HMO C-SNP) | H0628-033 | 4 | Yes | No | Yes |
| Aetna Medicare Chronic Care Total (HMO C-SNP) | H0628-034 | 4 | Yes | No | Yes |
| Aetna Medicare Chronic Care Total (HMO C-SNP) | H0628-035 | 4 | Yes | No | Yes |
| Aetna Medicare Chronic Care Total (HMO C-SNP) | H2663-099 | 4 | Yes | No | Yes |
| Aetna Medicare Chronic Care Total (HMO C-SNP) | H3146-036 | 4 | Yes | No | Yes |
| Aetna Medicare Chronic Care Total (HMO C-SNP) | H3192-028 | 4 | Yes | No | Yes |
| Aetna Medicare Chronic Care Total (HMO C-SNP) | H3192-029 | 4 | Yes | No | Yes |
| Aetna Medicare Chronic Care Total (HMO C-SNP) | H3959-083 | 4 | Yes | No | Yes |
| Aetna Medicare Chronic Care Value (HMO C-SNP) | H3146-044 | 4 | Yes | No | Yes |
| Aetna Medicare Chronic Care Value (HMO C-SNP) | H3959-074 | 4 | Yes | No | Yes |
| Aetna Medicare Chronic Care Value (HMO C-SNP) | H3959-075 | 4 | Yes | No | Yes |
| Aetna Medicare Chronic Care Value (HMO C-SNP) | H3959-085 | 4 | Yes | No | Yes |
| Aetna Medicare Dual (HMO D-SNP) | H3146-002 | 4 | Yes | No | Yes |
| Aetna Medicare Dual (HMO D-SNP) | H4711-013 | 4 | Yes | No | Yes |
| Aetna Medicare Dual (HMO D-SNP) | H5325-004 | 4 | Yes | No | Yes |
| Aetna Medicare Dual (HMO D-SNP) | H5325-005 | 4 | Yes | No | Yes |
| Aetna Medicare Dual (HMO D-SNP) | H5325-006 | 4 | Yes | No | Yes |
| Aetna Medicare Dual (PPO D-SNP) | H1608-062 | 4 | Yes | No | Yes |
| Aetna Medicare Dual (PPO D-SNP) | H1608-077 | 4 | Yes | No | Yes |
| Aetna Medicare Dual Care (HMO D-SNP) | H0628-013 | 4 | Yes | No | Yes |
| Aetna Medicare Dual Care (HMO D-SNP) | H3239-010 | 4 | Yes | No | Yes |
| Aetna Medicare Dual Care (HMO D-SNP) | H3239-012 | 4 | Yes | No | Yes |
| Aetna Medicare Dual Care (HMO D-SNP) | H3239-023 | 4 | Yes | No | Yes |
| Aetna Medicare Dual Care (HMO D-SNP) | H4711-012 | 4 | Yes | No | Yes |
| Aetna Medicare Dual Care (HMO D-SNP) | H5302-020 | 4 | Yes | No | Yes |
| Aetna Medicare Dual Care (HMO D-SNP) | H5325-003 | 4 | Yes | No | Yes |
| Aetna Medicare Dual Care (HMO D-SNP) | H5593-001 | 4 | Yes | No | Yes |
| Aetna Medicare Dual Care (HMO D-SNP) | H7149-006 | 4 | Yes | No | Yes |
| Aetna Medicare Dual Care (HMO D-SNP) | H8597-001 | 4 | Yes | No | Yes |
| Aetna Medicare Dual Care (HMO D-SNP) | H8597-002 | 4 | Yes | No | Yes |
| Aetna Medicare Dual Care (HMO D-SNP) | H8597-003 | 4 | Yes | No | Yes |
| Aetna Medicare Dual Care (PPO D-SNP) | H2293-004 | 4 | Yes | No | Yes |
| Aetna Medicare Dual Care (PPO D-SNP) | H3288-053 | 4 | Yes | No | Yes |
| Aetna Medicare Dual Care (PPO D-SNP) | H5521-465 | 4 | Yes | No | Yes |
| Aetna Medicare Dual Care (PPO D-SNP) | H5521-472 | 4 | Yes | No | Yes |
| Aetna Medicare Dual Extra (HMO D-SNP) | H3239-005 | 4 | Yes | No | Yes |
| Aetna Medicare Dual Extra (PPO D-SNP) | H1608-076 | 4 | Yes | No | Yes |
| Aetna Medicare Dual Extra (PPO D-SNP) | H2293-021 | 4 | Yes | No | Yes |
| Aetna Medicare Dual Extra Care (HMO D-SNP) | H3239-001 | 4 | Yes | No | Yes |
| Aetna Medicare Dual Extra Care (HMO D-SNP) | H3239-002 | 4 | Yes | No | Yes |
| Aetna Medicare Dual Extra Care (HMO D-SNP) | H3239-007 | 4 | Yes | No | Yes |
| Aetna Medicare Dual Extra Care (HMO D-SNP) | H3239-015 | 4 | Yes | No | Yes |
| Aetna Medicare Dual Extra Care (HMO D-SNP) | H3931-175 | 4 | Yes | No | Yes |
Showing 100 of 658 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.
Fetzima 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.