Varies by plan

Does Central Health Plan Of California, INC. require prior authorization for Fetzima?

Prior authorization for Fetzima differs across Central Health Plan Of California, INC.'s Medicare Part D plans and product strengths — 3 of 4 Fetzima products in the corpus appear on their formularies, and the requirement is not uniform. Check the member's specific plan.

Some plans require authorization and others do not. The member's specific plan decides.

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	Qty limit	Status
24 HR levomilnacipran 120 MG Extended Release Oral Capsule [Fetzima]1433223	15 / 15	15	15	Prior authorization required
24 HR levomilnacipran 20 MG Extended Release Oral Capsule [Fetzima]1433229	15 / 15	15	15	Prior authorization required
24 HR levomilnacipran 40 MG Extended Release Oral Capsule [Fetzima]1433235	15 / 15	15	15	Prior authorization required
24 HR levomilnacipran 80 MG Extended Release Oral Capsule [Fetzima]1433241	0 / 15	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
Central Health Classic Care Plan I (HMO)	H5649-027	4	Yes	No	Yes
Central Health Classic Care Plan II (HMO)	H5649-028	4	Yes	No	Yes
Central Health Classic Care Plan III (HMO)	H5649-023	4	Yes	No	Yes
Central Health Classic Care Plan IV (HMO)	H5649-018	4	Yes	No	Yes
Central Health Embrace Care Plan (HMO C-SNP)	H5649-025	4	Yes	No	Yes
Central Health Embrace Care Plan (HMO C-SNP)	H5649-025	4	Yes	No	Yes
Central Health Embrace Care Plan (HMO C-SNP)	H5649-025	4	Yes	No	Yes
Central Health Embrace Care Plan (HMO C-SNP)	H5649-025	4	Yes	No	Yes
Central Health Embrace Choice Plan (HMO C-SNP)	H5649-026	4	Yes	No	Yes
Central Health Embrace Choice Plan (HMO C-SNP)	H5649-026	4	Yes	No	Yes
Central Health Embrace Choice Plan (HMO C-SNP)	H5649-026	4	Yes	No	Yes
Central Health Embrace Choice Plan (HMO C-SNP)	H5649-026	4	Yes	No	Yes
Central Health Jade Plan (HMO)	H5649-022	4	Yes	No	Yes
Central Health Medicare Plan (HMO)	H5649-001	4	Yes	No	Yes
Central Health Part B Savings Plan (HMO)	H5649-029	4	Yes	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

Or see Fetzima across every payer at once.

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.