Does Ultimate Health Plans, INC. require prior authorization for Fetzima?
Ultimate Health Plans, 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 16 of 16 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 | Require prior auth | Step therapy | Qty limit | Status |
|---|---|---|---|---|---|
| 24 HR levomilnacipran 120 MG Extended Release Oral Capsule [Fetzima]1433223 | 16 / 16 | 0 | 16 | 16 | No prior authorization |
| 24 HR levomilnacipran 20 MG Extended Release Oral Capsule [Fetzima]1433229 | 16 / 16 | 0 | 16 | 16 | No prior authorization |
| 24 HR levomilnacipran 40 MG Extended Release Oral Capsule [Fetzima]1433235 | 16 / 16 | 0 | 16 | 16 | No prior authorization |
| 24 HR levomilnacipran 80 MG Extended Release Oral Capsule [Fetzima]1433241 | 0 / 16 | 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 |
|---|---|---|---|---|---|
| Advantage Care by Ultimate (HMO C-SNP) | H2962-021 | 4 | No | Yes | Yes |
| Advantage Care by Ultimate (HMO C-SNP) | H2962-026 | 4 | No | Yes | Yes |
| Advantage Care by Ultimate (HMO C-SNP) | H2962-029 | 4 | No | Yes | Yes |
| Advantage Care by Ultimate (HMO C-SNP) | H2962-033 | 4 | No | Yes | Yes |
| Advantage Care by Ultimate (HMO C-SNP) | H2962-050 | 4 | No | Yes | Yes |
| Advantage Care by Ultimate (HMO C-SNP) | H2962-051 | 4 | No | Yes | Yes |
| Advantage Care by Ultimate (HMO C-SNP) | H2962-052 | 4 | No | Yes | Yes |
| Advantage Care COPD by Ultimate (HMO C-SNP) | H2962-023 | 4 | No | Yes | Yes |
| Advantage Care COPD by Ultimate (HMO C-SNP) | H2962-025 | 4 | No | Yes | Yes |
| Advantage Plus by Ultimate (Full) (HMO D-SNP) | H2962-035 | 4 | No | Yes | Yes |
| Advantage Plus by Ultimate (Partial) (HMO D-SNP) | H2962-036 | 4 | No | Yes | Yes |
| Premier by Ultimate (HMO) | H2962-001 | 4 | No | Yes | Yes |
| Premier by Ultimate (HMO) | H2962-028 | 4 | No | Yes | Yes |
| Premier by Ultimate (HMO) | H2962-045 | 4 | No | Yes | Yes |
| Premier by Ultimate (HMO) | H2962-046 | 4 | No | Yes | Yes |
| Premier by Ultimate (HMO) | H2962-047 | 4 | No | Yes | 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.