Does Health Alliance Plan Of Michigan require prior authorization for Fetzima?
Health Alliance Plan Of Michigan 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 | 7 / 7 | 7 | 0 | 7 | Prior authorization required |
| 24 HR levomilnacipran 20 MG Extended Release Oral Capsule [Fetzima]1433229 | 7 / 7 | 7 | 0 | 7 | Prior authorization required |
| 24 HR levomilnacipran 40 MG Extended Release Oral Capsule [Fetzima]1433235 | 7 / 7 | 7 | 0 | 7 | Prior authorization required |
| 24 HR levomilnacipran 80 MG Extended Release Oral Capsule [Fetzima]1433241 | 7 / 7 | 7 | 0 | 7 | 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 |
|---|---|---|---|---|---|
| HAP Medicare Complete Duals (HMO D-SNP) | H2354-025 | 4 | Yes | No | Yes |
| HAP Medicare Connect (HMO) | H2354-015 | 4 | Yes | No | Yes |
| HAP Medicare Diabetes and Heart (HMO C-SNP) | H2354-030 | 4 | Yes | No | Yes |
| HAP Medicare Superior (HMO) | H2354-028 | 4 | Yes | No | Yes |
| HAP Senior Plus (HMO-POS) | H2354-021 | 4 | Yes | No | Yes |
| HAP Senior Plus Henry Ford Tiered Access (HMO) | H2354-018 | 4 | Yes | No | Yes |
| Henry Ford Select (HMO) | H2354-029 | 4 | Yes | No | Yes |
- 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.