FETZIMA 20 mg Capsule, Extended Release

Also known as Levomilnacipran Hydrochloride. Coverage in New Jersey (CMS PDP Region 04).

12 of 12 stand-alone Part D plans in New Jersey cover this drug on tier 3–4.

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

72 Medicare Advantage plans in NJ 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. NJ: 72 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)$22.80/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$16.6881	$50.063 units	Quantity limit 3 per 30 days
Wellcare Classic (PDP)$28.20/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$16.6881	$50.063 units	Quantity limit 3 per 30 days
Humana Basic Rx Plan (PDP)$4.40/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	—	$17.6680	$53.003 units	Prior authorization Quantity limit 3 per 30 days
Humana Value Rx Plan (PDP)$35.60/mo premium · $601.00 deductible	4Non-Preferred Drug	32%	—	$17.6680	$53.003 units	Prior authorization Quantity limit 3 per 30 days
HealthSpring Extra Rx (PDP)$59.90/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$17.1639	$51.493 units	Step therapy Quantity limit 3 per 30 days
Horizon Medicare Blue Rx Standard (PDP)$72.30/mo premium · $615.00 deductible	4Non-Preferred Drug	45%	45%	$18.5892	$55.773 units	Quantity limit 3 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$77.40/mo premium · $615.00 deductible	4Non-Preferred Drug	36%	—	$18.7324	$56.203 units	Step therapy Quantity limit 3 per 30 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$18.1289	$108.776 units	Prior authorization Quantity limit 6 per 30 days
HealthSpring Assurance Rx (PDP)$109.30/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$17.1592	$51.483 units	Step therapy Quantity limit 3 per 30 days
Humana Premier Rx Plan (PDP)$111.90/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$17.6680	$53.003 units	Prior authorization Quantity limit 3 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$118.90/mo premium · $130.00 deductible	4Non-Preferred Drug	33%	—	$18.7324	$56.203 units	Step therapy Quantity limit 3 per 30 days
Horizon Medicare Blue Rx Enhanced (PDP)$139.10/mo premium · $200.00 deductible	4Non-Preferred Drug	45%	45%	$18.5892	$55.773 units	Quantity limit 3 per 30 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.

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