Levomilnacipran (Fetzima) coverage/medical necessity policy
Defines clinical and administrative criteria for initial and continued authorization of levomilnacipran (Fetzima) for major depressive disorder in adults within Centene-affiliated health plans, including required trials of alternative antidepressants, dosing limits, exclusions (e.g., fibromyalgia), and documentation/approval duration.
3Q 2025 annual review: clarified failure of two antidepressants from at least two different drug classes and added step therapy bypass for IL HIM per IL HB 5395; updated therapeutic alternatives.
3Q 2024 annual review: revised continued therapy to allow continuity of care for antidepressants; added Wellbutrin SR to therapeutic alternatives and clarified fluvoxamine used in depression is off-label.
3Q 2023 annual review: added vilazodone (generic Viibryd) to list of redirect options and added redirection bypass for states with limitations on step therapy.