FETZIMA 120 mg Capsule, Extended Release

Also known as Levomilnacipran Hydrochloride. Coverage in Pennsylvania and West Virginia (CMS PDP Region 06).

12 of 12 stand-alone Part D plans in Pennsylvania and West Virginia cover this drug on tier 3–4.

12 of 12 plans apply a prior authorization, step therapy or quantity limit.

365 Medicare Advantage plans in PA, WV 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. PA: 306 plans · WV: 59 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)$8.20/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$16.7757	$50.333 units	Quantity limit 3 per 30 days
Wellcare Classic (PDP)$14.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$16.7757	$50.333 units	Quantity limit 3 per 30 days
Humana Basic Rx Plan (PDP)$6.60/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	—	$17.6167	$52.853 units	Prior authorization Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible	4Non-Preferred Drug	33%	—	$17.6167	$52.853 units	Prior authorization Quantity limit 3 per 30 days
SilverScript Choice (PDP)$22.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	35%	$18.1289	$54.393 units	Prior authorization Quantity limit 3 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$43.50/mo premium · $615.00 deductible	4Non-Preferred Drug	41%	—	$18.6230	$55.873 units	Step therapy Quantity limit 3 per 30 days
HealthSpring Extra Rx (PDP)$62.60/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$17.1377	$51.413 units	Step therapy Quantity limit 3 per 30 days
HealthSpring Assurance Rx (PDP)$74.00/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$17.1341	$51.403 units	Step therapy Quantity limit 3 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$121.90/mo premium · $130.00 deductible	4Non-Preferred Drug	33%	—	$18.6230	$55.873 units	Step therapy Quantity limit 3 per 30 days
Humana Premier Rx Plan (PDP)$123.60/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$17.6167	$52.853 units	Prior authorization Quantity limit 3 per 30 days
Blue Rx PDP Complete (PDP)$164.80/mo premium · $200.00 deductible	4Non-Preferred Drug	25%	25%	$17.2215	$516.6430 units	Prior authorization Quantity limit 31 per 31 days
Blue Rx PDP Plus (PDP)$193.20/mo premium · $615.00 deductible	4Non-Preferred Drug	25%	25%	$17.2159	$516.4830 units	Prior authorization Quantity limit 31 per 31 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 →