Does Freedom Health, INC. require prior authorization for Fetzima?
Prior authorization for Fetzima differs across Freedom Health, 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 | Step therapy | Qty limit | Status |
|---|---|---|---|---|---|
| 24 HR levomilnacipran 120 MG Extended Release Oral Capsule [Fetzima]1433223 | 24 / 24 | 24 | 0 | 24 | Prior authorization required |
| 24 HR levomilnacipran 20 MG Extended Release Oral Capsule [Fetzima]1433229 | 24 / 24 | 24 | 0 | 24 | Prior authorization required |
| 24 HR levomilnacipran 40 MG Extended Release Oral Capsule [Fetzima]1433235 | 24 / 24 | 24 | 0 | 24 | Prior authorization required |
| 24 HR levomilnacipran 80 MG Extended Release Oral Capsule [Fetzima]1433241 | 0 / 24 | 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 |
|---|---|---|---|---|---|
| Freedom Medi-Medi Full (HMO D-SNP) | H5427-087 | 3 | Yes | No | Yes |
| Freedom Medi-Medi Partial (HMO D-SNP) | H5427-078 | 3 | Yes | No | Yes |
| Freedom Medicare Plan Rx (HMO) | H5427-059 | 3 | Yes | No | Yes |
| Freedom Medicare Plan Rx (HMO) | H5427-060 | 3 | Yes | No | Yes |
| Freedom M�ximo (HMO-POS) | H5427-112 | 3 | Yes | No | Yes |
| Freedom M�ximo (HMO-POS) | H5427-113 | 3 | Yes | No | Yes |
| Freedom Platinum Plan Rx (HMO) | H5427-088 | 3 | Yes | No | Yes |
| Freedom Platinum Plan Rx (HMO) | H5427-089 | 3 | Yes | No | Yes |
| Freedom Platinum Plan Rx (HMO) | H5427-091 | 3 | Yes | No | Yes |
| Freedom Platinum Plan Rx (HMO) | H5427-093 | 3 | Yes | No | Yes |
| Freedom Platinum Plan Rx (HMO) | H5427-094 | 3 | Yes | No | Yes |
| Freedom Platinum Rewards Plan Rx (HMO) | H5427-096 | 3 | Yes | No | Yes |
| Freedom Platinum Rewards Plan Rx (HMO) | H5427-102 | 3 | Yes | No | Yes |
| Freedom Platinum Rewards Plan Rx (HMO) | H5427-103 | 3 | Yes | No | Yes |
| Freedom Platinum Rewards Plan Rx (HMO) | H5427-105 | 3 | Yes | No | Yes |
| Freedom Platinum Rewards Plan Rx (HMO) | H5427-106 | 3 | Yes | No | Yes |
| Freedom Platinum Rewards Plan Rx (HMO) | H5427-107 | 3 | Yes | No | Yes |
| Freedom VIP Care (HMO C-SNP) | H5427-070 | 3 | Yes | No | Yes |
| Freedom VIP Rewards (HMO C-SNP) | H5427-099 | 3 | Yes | No | Yes |
| Freedom VIP Rewards (HMO C-SNP) | H5427-108 | 3 | Yes | No | Yes |
| Freedom VIP Savings (HMO C-SNP) | H5427-072 | 3 | Yes | No | Yes |
| Freedom VIP Savings (HMO C-SNP) | H5427-082 | 3 | Yes | No | Yes |
| Freedom VIP Savings COPD (HMO C-SNP) | H5427-077 | 3 | Yes | No | Yes |
| Freedom VIP Savings COPD (HMO C-SNP) | H5427-083 | 3 | Yes | No | Yes |
- Effective
- 2026-06-30
- Retrieved
- 2026-07-19
- SHA-256
- e626e6bcda1aa6a0071e6f0df6bafe686ae41842cdf0a9feffdc649b6d3ff3ae
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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.