FETZIMA Kit

Also known as Levomilnacipran Hydrochloride. Coverage in Arizona (CMS PDP Region 28).

10 of 10 stand-alone Part D plans in Arizona cover this drug on tier 3–4.

10 of 10 plans apply a prior authorization, step therapy or quantity limit.

125 Medicare Advantage plans in AZ do cover it

Medicare Advantage plans carry their own formularies, separate from stand-alone Part D. A patient on an MA-PD plan may have coverage even where no PDP lists the drug. AZ: 125 plans.

Every plan that covers it

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$17.6018	$88.015 units	Quantity limit 28 per 180 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$17.6018	$88.015 units	Quantity limit 28 per 180 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$17.5694	$87.855 units	Step therapy Quantity limit 56 per 365 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	—	$18.4375	$553.1230 units	Prior authorization Quantity limit 28 per 28 days
Humana Value Rx Plan (PDP)$2.50/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$18.4375	$553.1230 units	Prior authorization Quantity limit 28 per 28 days
AARP Medicare Rx Saver from UHC (PDP)$38.70/mo premium · $615.00 deductible	4Non-Preferred Drug	36%	—	$19.1690	$95.845 units	Step therapy Quantity limit 56 per 365 days
HealthSpring Extra Rx (PDP)$66.40/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$17.5670	$87.845 units	Step therapy Quantity limit 56 per 365 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$19.1656	—	Prior authorization
AARP Medicare Rx Preferred from UHC (PDP)$97.50/mo premium · $130.00 deductible	4Non-Preferred Drug	35%	—	$19.1690	$95.845 units	Step therapy Quantity limit 56 per 365 days
Humana Premier Rx Plan (PDP)$119.20/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$18.4375	$553.1230 units	Prior authorization Quantity limit 28 per 28 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity.

See coverage in all 39 regions →