Levomilnacipran (Fetzima)

How Medicare covers it

Part D (forms used at home). Part A during a covered inpatient stay. No Part B clinician-administered form in the CMS Part B spending file.

What it treats

Levomilnacipran (Fetzima) extended-release capsules treat major depressive disorder (MDD) in adults. Limitation of use: Fetzima is not approved for the management of fibromyalgia, and its efficacy and safety for fibromyalgia have not been established. It is not approved for use in pediatric patients.

What it is for, in depth

Levomilnacipran, sold as Fetzima, treats major depressive disorder in adults. It is an antidepressant in the serotonin and norepinephrine reuptake inhibitor group, often called an SNRI. It works by raising the amounts of serotonin and norepinephrine, natural substances in the brain that help maintain mental balance. It is prescribed for adults with major depression, taken once a day. The label states clearly that it is not approved to manage fibromyalgia, and it is not approved for use in children. It comes only as an extended-release capsule taken by mouth, swallowed whole, in four strengths sold under the Fetzima name.

How it works

Levomilnacipran is a serotonin and norepinephrine reuptake inhibitor (SNRI). It works by increasing the amounts of serotonin and norepinephrine, natural substances in the brain that help maintain mental balance. The exact mechanism of its antidepressant action is unknown, but it is thought to be related to this effect in the central nervous system.

How it is taken

It is an extended-release capsule taken by mouth once daily, with or without food, at about the same time each day. Swallow the capsule whole — do not open, chew, or crush it. Treatment starts at 20 mg once daily for 2 days, then increases to 40 mg once daily; the doctor may raise the dose in 40 mg steps at intervals of 2 or more days. The recommended dose range is 40 mg to 120 mg once daily, and 120 mg is the maximum. Lower maximum doses apply for people with kidney problems (for example, 80 mg with severe renal impairment or with strong CYP3A4 inhibitors). Do not stop suddenly — the dose should be lowered gradually.

Common side effects

Nausea, vomiting, constipation, excessive sweating, fast heartbeat, and sexual problems — in males, decreased sex drive, inability to get or keep an erection, or delayed or absent ejaculation; in females, decreased sex drive or delayed or unable orgasm.

Serious warnings

Serotonin syndrome, a potentially life-threatening condition, can occur with Fetzima alone or with other serotonergic drugs. Fetzima raises blood pressure and heart rate, which should be measured before starting and regularly during treatment. It raises the risk of bleeding, especially with aspirin, NSAIDs, warfarin, or other anticoagulants, and exposure near delivery has been associated with an increased risk of postpartum hemorrhage. Other serious warnings include angle-closure glaucoma (sudden eye pressure attack in people with narrow angles), urinary hesitation or retention, activation of mania or hypomania (screen for bipolar disorder before starting), seizures, discontinuation syndrome if stopped suddenly, low blood sodium (hyponatremia, a greater risk in older patients), and sexual dysfunction.

Boxed warning

WARNING: SUICIDAL THOUGHTS AND BEHAVIORS. Antidepressants increased the risk of suicidal thoughts and behaviors in pediatric and young adult patients in short-term studies. Closely monitor all antidepressant-treated patients for clinical worsening, and for emergence of suicidal thoughts and behaviors. FETZIMA is not approved for use in pediatric patients.

Who should be careful

People with uncontrolled high blood pressure, heart disease or fast heart rhythms, bleeding problems, narrow-angle glaucoma, urinary retention or trouble urinating, a history of mania or bipolar disorder, seizures, low blood sodium, or kidney impairment. Older patients are at greater risk of low blood sodium. Women who are pregnant, plan to become pregnant, or are breastfeeding should talk with their doctor — babies exposed to SNRIs late in pregnancy can have complications after delivery, and racemic milnacipran is present in human milk. People with an allergy to levomilnacipran, milnacipran, or any ingredient should not take it.

Major interactions

Monoamine oxidase inhibitors (MAOIs) are contraindicated: do not use Fetzima with MAOIs intended to treat psychiatric disorders, within 7 days of stopping Fetzima, or within 14 days of stopping an MAOI, and do not start Fetzima in a patient being treated with linezolid or intravenous methylene blue. Other serotonergic drugs (SSRIs, SNRIs, triptans, tricyclic antidepressants, fentanyl, lithium, tramadol, meperidine, methadone, tryptophan, buspirone, amphetamines, and St. John's Wort) raise the risk of serotonin syndrome. Strong CYP3A4 inhibitors raise levomilnacipran levels, so the dose should not exceed 80 mg once daily with them. Aspirin, NSAIDs, warfarin, and other anticoagulants add to bleeding risk. Drinking alcohol with Fetzima may cause the drug to be released faster and should be avoided.

Why it is in its tier

Levomilnacipran is most often placed on Tier 4, listed by 100.0% of Part D plans. Among listing plans, 89.79% place it on Tier 4. Tier 4 is the non-preferred tier, where patients usually pay higher coinsurance, meaning a larger share of the drug cost, instead of a low flat copay. The data show a brand-only product, Fetzima, with no generic capsule form in the matched list, listed broadly but placed mostly on this higher tier, with a high program cost level. CMS dashboard average spending was $4,676.06 per beneficiary. That figure is a CMS program average, not a copay, and individual plans vary.

Sources

• FETZIMA- levomilnacipran hydrochloride capsule, extended release FETZIMA- levomilnacipran hydrochloride kit — DailyMed
• MedlinePlus — National Library of Medicine
• MedlinePlus — Levomilnacipran

What official patient guides say

Levomilnacipran comes as an extended-release (long-acting) capsule to take by mouth, taken once daily with or without food, at around the same time every day. Take it exactly as directed — do not take more or less of it or take it more often than prescribed by your doctor. Swallow the capsules whole; do not open, chew, or crush them. Your doctor may start you on a low dose and gradually increase your dose, not more than once every 2 days. It controls depression but does not cure it, and it may take several weeks or longer before you feel its full benefit; continue to take it even if you feel well, and do not stop taking it without talking to your doctor, who will probably decrease your dose gradually. If you miss a dose, take it as soon as you remember, unless it is almost time for the next dose — then skip the missed dose and continue your regular schedule; do not take a double dose. Keep the medication in the container it came in, tightly closed, at room temperature away from light, excess heat, and moisture, not in the bathroom, and out of sight and reach of children with safety caps locked. Dispose of unneeded medication through a medicine take-back program; do not flush it.

Source: MedlinePlus — Levomilnacipran

Part D formulary coverage

Source: CMS Prescription Drug Plan Formulary, Pharmacy Network, and Pricing Information Files — Monthly file 2026-10-15 (plan year 2027), file 2027_20261008.zip (data.cms.gov dataset ed1496ea-23e7-41f1-9292-172fa842ccfb): basic drugs formulary file + plan information file, both dated 20261031 inside the zip; downloaded and aggregated 2026-10-30. Medication RxCUI sets resolved through the NLM RxNav (RxNorm) API.

What you pay

Without insurance, the cash benchmark is 17.58773 per unit (FETZIMA ER 120 MG CAPSULE) — about nan for 30 units. NADAC benchmark — the average price pharmacies pay (CMS, as of 2026-11-04). Pharmacy shelf prices vary.

A tier is not a price; what you pay depends on your plan, pharmacy, and benefit stage; Extra Help or Medicaid can lower it further.

Sources: CMS Plan Benefit Package + formulary data; CMS NADAC · Checked 2026-11-07

Coverage by plan and tier

Of the 5,495 Medicare drug plans we track for 2027, 5,495 list Levomilnacipran (Fetzima) — 100% of plans. Most of those plans put it on Tier 4: 4,934 plans, 89.8% of the plans that list it. Other plans place it on Tier 2 (269 plans), Tier 3 (169 plans) or Tier 1 (123 plans). For example: Aetna Medicare Dual Extra (HMO D-SNP) puts it on Tier 4; Aetna Medicare Dual Extra Care (PPO D-SNP) puts it on Tier 4; Aetna Medicare Value Plus (PPO) puts it on Tier 4. You can compare these plans side by side on our Medicare Advantage hub. A tier is not a price. What you pay also depends on whether you have met your plan';s deductible, whether the drug costs a flat copay or a share of the price, and whether you get Extra Help or Medicaid.

Read next

• Extra Help in 2027: Lower Drug Copays and Who Qualifies
• Checking Medicare Savings Programs and Extra Help

Part D spending averages (2024)

Source: CMS Medicare Part D Spending by Drug (Drug Spending Dashboard), release RY26 P04 V10, data through 2024 (DSD_PTD_RY26_P04_V10_DY24_BGM.csv), downloaded 2026-10-30

Companies covering this drug

Part D and Medicare Advantage plan sponsors that list this drug on a formulary, 50 at a time.