No prior authorization

Does Tufts Associated Health Maintenance Organization require prior authorization for Fetzima?

Tufts Associated Health Maintenance Organization 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 21 of 21 covering plans — the plan requires another drug be tried first.
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	Step therapy	Status
24 HR levomilnacipran 120 MG Extended Release Oral Capsule [Fetzima]1433223	21 / 21	21	No prior authorization
24 HR levomilnacipran 20 MG Extended Release Oral Capsule [Fetzima]1433229	21 / 21	21	No prior authorization
24 HR levomilnacipran 40 MG Extended Release Oral Capsule [Fetzima]1433235	21 / 21	21	No prior authorization
24 HR levomilnacipran 80 MG Extended Release Oral Capsule [Fetzima]1433241	0 / 21	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
Tufts Health Plan Senior Care Options (HMO D-SNP)	H8330-001	1	No	Yes	No
Tufts Health Plan Senior Care Options CW (HMO D-SNP)	H8330-002	1	No	Yes	No
Tufts Medicare Preferred HMO Basic Rx (HMO)	H2256-026	4	No	Yes	No
Tufts Medicare Preferred HMO Basic Rx (HMO)	H2256-026	4	No	Yes	No
Tufts Medicare Preferred HMO Basic Rx (HMO)	H2256-026	4	No	Yes	No
Tufts Medicare Preferred HMO Basic Rx (HMO)	H2256-036	4	No	Yes	No
Tufts Medicare Preferred HMO Prime Rx (HMO)	H2256-015	4	No	Yes	No
Tufts Medicare Preferred HMO Prime Rx (HMO)	H2256-015	4	No	Yes	No
Tufts Medicare Preferred HMO Prime Rx (HMO)	H2256-015	4	No	Yes	No
Tufts Medicare Preferred HMO Prime Rx (HMO)	H2256-033	4	No	Yes	No
Tufts Medicare Preferred HMO Prime Rx Plus (HMO)	H2256-001	4	No	Yes	No
Tufts Medicare Preferred HMO Prime Rx Plus (HMO)	H2256-001	4	No	Yes	No
Tufts Medicare Preferred HMO Prime Rx Plus (HMO)	H2256-001	4	No	Yes	No
Tufts Medicare Preferred HMO Smart Saver Rx (HMO)	H2256-046	4	No	Yes	No
Tufts Medicare Preferred HMO Value Rx (HMO)	H2256-018	4	No	Yes	No
Tufts Medicare Preferred HMO Value Rx (HMO)	H2256-018	4	No	Yes	No
Tufts Medicare Preferred HMO Value Rx (HMO)	H2256-018	4	No	Yes	No
Tufts Medicare Preferred HMO Value Rx (HMO)	H2256-034	4	No	Yes	No
Tufts Medicare Preferred PPO RX (PPO)	H9907-002	4	No	Yes	No
Tufts Medicare Preferred PPO RX (PPO)	H9907-002	4	No	Yes	No
Tufts Medicare Preferred PPO RX (PPO)	H9907-002	4	No	Yes	No

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.