Prior authorization required

Does Mount Carmel Health Plan, INC. require prior authorization for Fetzima?

Mount Carmel Health Plan, INC. 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	Qty limit	Status
24 HR levomilnacipran 120 MG Extended Release Oral Capsule [Fetzima]1433223	11 / 11	11	11	Prior authorization required
24 HR levomilnacipran 20 MG Extended Release Oral Capsule [Fetzima]1433229	11 / 11	11	11	Prior authorization required
24 HR levomilnacipran 40 MG Extended Release Oral Capsule [Fetzima]1433235	11 / 11	11	11	Prior authorization required
24 HR levomilnacipran 80 MG Extended Release Oral Capsule [Fetzima]1433241	11 / 11	11	11	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
MercyOne Health Plan Cash Back (HMO)	H3668-031	4	Yes	No	Yes
MercyOne Health Plan No Premium (HMO)	H3668-025	4	Yes	No	Yes
MercyOne Health Plan Plus (HMO)	H3668-026	4	Yes	No	Yes
Mount Carmel MediGold Cash Back (HMO)	H3668-030	4	Yes	No	Yes
Mount Carmel MediGold No Premium (HMO)	H3668-019	4	Yes	No	Yes
Mount Carmel MediGold No Premium (HMO)	H3668-019	4	Yes	No	Yes
Mount Carmel MediGold No Premium (HMO)	H3668-020	4	Yes	No	Yes
Mount Carmel MediGold Plus (HMO)	H3668-022	4	Yes	No	Yes
Mount Carmel MediGold Plus (HMO)	H3668-023	4	Yes	No	Yes
Mount Carmel MediGold Premier (HMO)	H3668-018	4	Yes	No	Yes
Mount Carmel MediGold Premier (HMO)	H3668-018	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.