Does Select Health Of South Carolina, INC. require prior authorization for Fetzima?
Select Health Of South Carolina, INC. 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.
- No prior authorization is filed, but step therapy applies on 1 of 1 covering plans — the plan requires another drug be tried first.
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 | 1 / 1 | 0 | 1 | 1 | No prior authorization |
| 24 HR levomilnacipran 20 MG Extended Release Oral Capsule [Fetzima]1433229 | 1 / 1 | 0 | 1 | 1 | No prior authorization |
| 24 HR levomilnacipran 40 MG Extended Release Oral Capsule [Fetzima]1433235 | 1 / 1 | 0 | 1 | 1 | No prior authorization |
| 24 HR levomilnacipran 80 MG Extended Release Oral Capsule [Fetzima]1433241 | 1 / 1 | 0 | 1 | 1 | No prior authorization |
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 |
|---|---|---|---|---|---|
| First Choice VIP Care (HMO D-SNP) | H4739-001 | 4 | No | Yes | 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.