No prior authorization
Does Alignment Healthcare require prior authorization for Fetzima?
Alignment Healthcare does not require prior authorization for Fetzima on the Medicare Part D plans that cover it.
No covering plan from this payer files a prior-authorization requirement for this drug.
- This drug does not appear on any of this payer's Medicare Part D formularies. That means it is NOT COVERED under those plans — which is a different and generally worse outcome than requiring prior authorization. An exception or formulary-exception request may still be possible.
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 | 67 / 67 | 0 | 0 | 67 | No prior authorization |
| 24 HR levomilnacipran 20 MG Extended Release Oral Capsule [Fetzima]1433229 | 67 / 67 | 0 | 0 | 67 | No prior authorization |
| 24 HR levomilnacipran 40 MG Extended Release Oral Capsule [Fetzima]1433235 | 67 / 67 | 0 | 0 | 67 | No prior authorization |
| 24 HR levomilnacipran 80 MG Extended Release Oral Capsule [Fetzima]1433241 | 0 / 67 | 0 | 0 | 0 | Not on formulary |
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 |
|---|---|---|---|---|---|
| Alignment Health + Intermountain Health (HMO) | H9686-009 | 4 | No | No | Yes |
| Alignment Health Advantage PPO (PPO) | H8832-001 | 4 | No | No | Yes |
| Alignment Health Advantage PPO (PPO) | H8832-002 | 4 | No | No | Yes |
| Alignment Health AllCare Preferred (HMO) | H3815-011 | 4 | No | No | Yes |
| Alignment Health AVA (PPO) | H7074-001 | 4 | No | No | Yes |
| Alignment Health Balance (HMO C-SNP) | H3815-033 | 4 | No | No | Yes |
| Alignment Health Balance (PPO) | H4961-006 | 4 | No | No | Yes |
| Alignment Health BreathEasy (HMO C-SNP) | H3815-041 | 4 | No | No | Yes |
| Alignment Health Clarity (HMO C-SNP) | H3815-042 | 4 | No | No | Yes |
| Alignment Health CommUnity (HMO) | H3815-046 | 4 | No | No | Yes |
| Alignment Health Dual Select+ (HMO-POS D-SNP) | H5472-007 | 4 | No | No | Yes |
| Alignment Health Freedom (PPO) | H8832-003 | 4 | No | No | Yes |
| Alignment Health Harmony (HMO) | H3815-031 | 4 | No | No | Yes |
| Alignment Health Heart & Diabetes (HMO C-SNP) | H3443-003 | 4 | No | No | Yes |
| Alignment Health Heart & Diabetes (HMO C-SNP) | H3815-010 | 4 | No | No | Yes |
| Alignment Health Heart & Diabetes (HMO C-SNP) | H9686-004 | 4 | No | No | Yes |
| Alignment Health Heart & Diabetes (HMO-POS C-SNP) | H5472-002 | 4 | No | No | Yes |
| Alignment Health Heart & Diabetes Access (HMO C-SNP) | H3815-044 | 4 | No | No | Yes |
| Alignment Health Heart & Diabetes AZPlus (HMO C-SNP) | H3443-007 | 4 | No | No | Yes |
| Alignment Health Heart & Diabetes CalPlus (HMO C-SNP) | H3815-039 | 4 | No | No | Yes |
| Alignment Health Heart & Diabetes Care (HMO C-SNP) | H3815-048 | 4 | No | No | Yes |
| Alignment Health Heart & Diabetes Care (HMO C-SNP) | H3815-054 | 4 | No | No | Yes |
| Alignment Health Heart & Diabetes Care (HMO C-SNP) | H5296-011 | 4 | No | No | Yes |
| Alignment Health Heart & Diabetes Choice (HMO C-SNP) | H3815-051 | 4 | No | No | Yes |
| Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) | H5296-009 | 4 | No | No | Yes |
| Alignment Health Heart & Diabetes NVPlus (HMO C-SNP) | H9686-006 | 4 | No | No | Yes |
| Alignment Health Heart & Diabetes Plus (HMO C-SNP) | H3443-006 | 4 | No | No | Yes |
| Alignment Health Heart & Diabetes Plus (HMO-POS C-SNP) | H5472-004 | 4 | No | No | Yes |
| Alignment Health Honor+ Plan (HMO) | H3815-052 | 4 | No | No | Yes |
| Alignment Health L.A. Premium Giveback (HMO) | H3815-055 | 4 | No | No | Yes |
| Alignment Health My Choice (HMO) | H3815-001 | 4 | No | No | Yes |
| Alignment Health My Choice (HMO) | H3815-028 | 4 | No | No | Yes |
| Alignment Health My Choice (PPO) | H4961-001 | 4 | No | No | Yes |
| Alignment Health My Choice (PPO) | H4961-003 | 4 | No | No | Yes |
| Alignment Health My Choice CalCare (HMO) | H3815-050 | 4 | No | No | Yes |
| Alignment Health My Choice Select (HMO) | H3815-049 | 4 | No | No | Yes |
| Alignment Health NC Duals (HMO-POS D-SNP) | H5296-004 | 4 | No | No | Yes |
| Alignment Health Platinum (HMO) | H5296-003 | 4 | No | No | Yes |
| Alignment Health Platinum + Instacart (HMO-POS) | H3815-016 | 4 | No | No | Yes |
| Alignment Health Platinum + Instacart (HMO) | H3815-008 | 4 | No | No | Yes |
| Alignment Health Platinum + Instacart (HMO) | H5296-007 | 4 | No | No | Yes |
| Alignment Health Platinum + Instacart (HMO) | H9686-007 | 4 | No | No | Yes |
| Alignment Health Platinum Select (HMO) | H5296-010 | 4 | No | No | Yes |
| Alignment Health S.D. Premium Giveback (HMO) | H3815-056 | 4 | No | No | Yes |
| Alignment Health Silicon (HMO C-SNP) | H3815-045 | 4 | No | No | Yes |
| Alignment Health smartHMO (HMO-POS) | H5472-003 | 4 | No | No | Yes |
| Alignment Health smartHMO (HMO) | H3443-005 | 4 | No | No | Yes |
| Alignment Health smartHMO (HMO) | H3815-013 | 4 | No | No | Yes |
| Alignment Health smartHMO (HMO) | H3815-038 | 4 | No | No | Yes |
| Alignment Health smartHMO (HMO) | H3815-040 | 4 | No | No | Yes |
| Alignment Health smartHMO (HMO) | H5296-006 | 4 | No | No | Yes |
| Alignment Health smartHMO (HMO) | H5296-008 | 4 | No | No | Yes |
| Alignment Health smartHMO (HMO) | H9686-008 | 4 | No | No | Yes |
| Alignment Health smartSavings (HMO-POS) | H5472-010 | 4 | No | No | Yes |
| Alignment Health smartSavings (HMO) | H3815-047 | 4 | No | No | Yes |
| Alignment Health Sutter Advantage +More (HMO) | H3815-019 | 4 | No | No | Yes |
| Alignment Health Sutter Advantage +More (HMO) | H3815-020 | 4 | No | No | Yes |
| Alignment Health Sutter Advantage +More (HMO) | H3815-021 | 4 | No | No | Yes |
| Alignment Health Sutter Advantage +More (HMO) | H3815-023 | 4 | No | No | Yes |
| Alignment Health the ONE (HMO D-SNP) | H9686-005 | 4 | No | No | Yes |
| Alignment Health the ONE (HMO) | H3815-034 | 4 | No | No | Yes |
| Alignment Health the ONE + Walgreens (HMO-POS) | H5472-001 | 4 | No | No | Yes |
| Alignment Health the ONE + Walgreens (HMO) | H3443-001 | 4 | No | No | Yes |
| Alignment Health the ONE + Walgreens (HMO) | H3443-002 | 4 | No | No | Yes |
| Alignment Health the ONE + Walgreens (HMO) | H3815-035 | 4 | No | No | Yes |
| Alignment Health Total Dual+ (HMO-POS D-SNP) | H5472-009 | 4 | No | No | Yes |
| Alignment Health ValorCare (HMO) | H3815-053 | 4 | No | No | Yes |
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.