FETZIMA Kit

Also known as Levomilnacipran Hydrochloride. Coverage in Ohio (CMS PDP Region 14).

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

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

193 Medicare Advantage plans in OH 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. OH: 193 plans.

Every plan that covers it

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$7.60/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$17.0600	$85.305 units	Quantity limit 28 per 180 days
Wellcare Classic (PDP)$7.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$17.0600	$85.305 units	Quantity limit 28 per 180 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	—	$17.6873	$530.6230 units	Prior authorization Quantity limit 28 per 28 days
Humana Value Rx Plan (PDP)$23.70/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$17.6873	$530.6230 units	Prior authorization Quantity limit 28 per 28 days
HealthSpring Extra Rx (PDP)$65.70/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$17.3800	$86.905 units	Step therapy Quantity limit 56 per 365 days
AARP Medicare Rx Saver from UHC (PDP)$73.70/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$19.2906	$96.455 units	Step therapy Quantity limit 56 per 365 days
SilverScript Choice (PDP)$90.30/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$18.1297	—	Prior authorization
HealthSpring Assurance Rx (PDP)$109.50/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$17.3600	$86.805 units	Step therapy Quantity limit 56 per 365 days
Humana Premier Rx Plan (PDP)$117.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$17.6873	$530.6230 units	Prior authorization Quantity limit 28 per 28 days
AARP Medicare Rx Preferred from UHC (PDP)$123.40/mo premium · $130.00 deductible	4Non-Preferred Drug	36%	—	$19.2906	$96.455 units	Step therapy Quantity limit 56 per 365 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 →