Medicare Part D coverage · amitriptyline hydrochloride · RxCUI 856769
amitriptyline hydrochloride 12.5 MG / chlordiazepoxide 5 MG Oral Tablet
Per the CMS 2026 Part D formulary file, amitriptyline hydrochloride 12.5 MG / chlordiazepoxide 5 MG Oral Tablet is covered by 329 Medicare Part D plans (6.5% of enrollable products), averaging Tier 2.5, with prior authorization required on 25.9% of covering formularies.
- 6.5%
- Plan coverage
- 329
- Plans covering
- T2.5
- Avg tier
- 25.9%
- Prior auth required
What the CMS Formulary Data Shows for amitriptyline hydrochloride 12.5 MG / chlordiazepoxide 5 MG Oral Tablet
Per the CMS 2026 Part D formulary file, amitriptyline hydrochloride 12.5 MG / chlordiazepoxide 5 MG Oral Tablet (RxNorm concept RXCUI 856769, generic name amitriptyline hydrochloride) appears on 27 distinct formulary files spanning 329 Medicare Part D plan offerings - 6.5% of enrollable Part D products, selective placement; verify formulary inclusion before enrolling. Tier placement ranges from Tier 1 to Tier 4, with a cross-plan average of Tier 2.5.
Real-world access to amitriptyline hydrochloride 12.5 MG / chlordiazepoxide 5 MG Oral Tablet depends on utilization management as much as tier placement: 25.9% of covering formularies require prior authorization. 0% require step therapy. 0% apply quantity limits.
Historical spending context from the CMS Medicare Part D Drug Spending Dashboard shows 838,449 Part D beneficiaries filled amitriptyline hydrochloride 12.5 MG / chlordiazepoxide 5 MG Oral Tablet in 2023, with total plan-and-beneficiary spending of $73,881,287 and an average per-beneficiary annual cost of $88.12. The plan-by-plan detail below lists exactly which PDP and MA-PD contracts carry amitriptyline hydrochloride 12.5 MG / chlordiazepoxide 5 MG Oral Tablet today.
Coverage Details
- Formularies covering
- 27
- Plans covering
- 329
- Coverage rate
- 6.5%
- Tier range
- Tier 1 – Tier 4
- Average tier
- Tier 2, Generic
Restrictions
- Prior authorization required
- 25.9% of formularies
- Step therapy required
- 0% of formularies
- Quantity limits
- 0% of formularies
2023 Medicare Spending
- Beneficiaries
- 838,449
- Total spending
- $73,881,287
- Avg per beneficiary
- $88.12
Tier Distribution Across Plans
Medicare Advantage Plans (MA-PD) Covering amitriptyline hydrochloride 12.5 MG / chlordiazepoxide 5 MG Oral Tablet
100 Medicare Advantage plans with Part D drug coverage include this drug.
| Plan | Insurer | Tier | PA | Premium | States |
|---|---|---|---|---|---|
| Freedom VIP Care (HMO C-SNP) | Freedom Health, Inc. | T1 | Yes | $0 | FL |
| Freedom VIP Savings (HMO C-SNP) | Freedom Health, Inc. | T1 | Yes | $0 | FL |
| Freedom VIP Savings (HMO C-SNP) | Freedom Health, Inc. | T1 | Yes | $0 | FL |
| Freedom VIP Rewards (HMO C-SNP) | Freedom Health, Inc. | T1 | Yes | $0 | FL |
| Freedom VIP Rewards (HMO C-SNP) | Freedom Health, Inc. | T1 | Yes | $0 | FL |
| Optimum Diamond Rewards (HMO C-SNP) | Optimum Healthcare, Inc. | T1 | Yes | $0 | FL |
| Optimum Diamond Savings (HMO C-SNP) | Optimum Healthcare, Inc. | T1 | Yes | $0 | FL |
| Optimum Diamond Rewards (HMO C-SNP) | Optimum Healthcare, Inc. | T1 | Yes | $0 | FL |
| Optimum Diamond (HMO C-SNP) | Optimum Healthcare, Inc. | T1 | Yes | $0 | FL |
| Freedom Medi-Medi Partial (HMO D-SNP) | Freedom Health, Inc. | T1 | Yes | $0 | FL |
| Freedom Medi-Medi Full (HMO D-SNP) | Freedom Health, Inc. | T1 | Yes | $0 | FL |
| Optimum Emerald Partial (HMO D-SNP) | Optimum Healthcare, Inc. | T1 | Yes | $0 | FL |
| Optimum Emerald Full (HMO D-SNP) | Optimum Healthcare, Inc. | T1 | Yes | $0 | FL |
| Freedom Medicare Plan Rx (HMO) | Freedom Health, Inc. | T1 | Yes | $0 | FL |
| Freedom Medicare Plan Rx (HMO) | Freedom Health, Inc. | T1 | Yes | $0 | FL |
| Freedom VIP Savings COPD (HMO C-SNP) | Freedom Health, Inc. | T1 | Yes | $0 | FL |
| Freedom VIP Savings COPD (HMO C-SNP) | Freedom Health, Inc. | T1 | Yes | $0 | FL |
| Freedom Platinum Plan Rx (HMO) | Freedom Health, Inc. | T1 | Yes | $0 | FL |
| Freedom Platinum Plan Rx (HMO) | Freedom Health, Inc. | T1 | Yes | $0 | FL |
| Freedom Platinum Plan Rx (HMO) | Freedom Health, Inc. | T1 | Yes | $0 | FL |
Show the next 30 plans
| Freedom Platinum Plan Rx (HMO) | Freedom Health, Inc. | T1 | Yes | $0 | FL |
| Freedom Platinum Plan Rx (HMO) | Freedom Health, Inc. | T1 | Yes | $0 | FL |
| Freedom Platinum Rewards Plan Rx (HMO) | Freedom Health, Inc. | T1 | Yes | $0 | FL |
| Freedom Platinum Rewards Plan Rx (HMO) | Freedom Health, Inc. | T1 | Yes | $0 | FL |
| Freedom Platinum Rewards Plan Rx (HMO) | Freedom Health, Inc. | T1 | Yes | $0 | FL |
| Freedom Platinum Rewards Plan Rx (HMO) | Freedom Health, Inc. | T1 | Yes | $0 | FL |
| Freedom Platinum Rewards Plan Rx (HMO) | Freedom Health, Inc. | T1 | Yes | $0 | FL |
| Freedom Platinum Rewards Plan Rx (HMO) | Freedom Health, Inc. | T1 | Yes | $0 | FL |
| Freedom Máximo (HMO-POS) | Freedom Health, Inc. | T1 | Yes | $0 | FL |
| Freedom Máximo (HMO-POS) | Freedom Health, Inc. | T1 | Yes | $0 | FL |
| Optimum Gold Rewards Plan (HMO) | Optimum Healthcare, Inc. | T1 | Yes | $0 | FL |
| Optimum Platinum Plan (HMO) | Optimum Healthcare, Inc. | T1 | Yes | $0 | FL |
| Optimum Gold Plan (HMO) | Optimum Healthcare, Inc. | T1 | Yes | $0 | FL |
| Optimum Gold Rewards Plan (HMO) | Optimum Healthcare, Inc. | T1 | Yes | $0 | FL |
| Optimum Gold Rewards Plan (HMO) | Optimum Healthcare, Inc. | T1 | Yes | $0 | FL |
| Optimum Diamond Rewards COPD (HMO C-SNP) | Optimum Healthcare, Inc. | T1 | Yes | $0 | FL |
| Optimum Diamond Savings COPD (HMO C-SNP) | Optimum Healthcare, Inc. | T1 | Yes | $0 | FL |
| Optimum Gold Plus Plan (HMO) | Optimum Healthcare, Inc. | T1 | Yes | $0 | FL |
| Optimum Diamond Rewards COPD (HMO C-SNP) | Optimum Healthcare, Inc. | T1 | Yes | $0 | FL |
| CareAdvantage (HMO D-SNP) | SAN Mateo Health Commission | T1 | No | $0 | CA |
| PHP (HMO C-snp) | Aids Healthcare Foundation | T1 | No | $0 | CA |
| VNS Health Total (HMO D-SNP) | VNS Choice | T1 | No | $0 | NY |
| Gold Dialysis & Kidney Complete (HMO-POS C-SNP) | Gold Kidney OF Florida Inc | T1 | No | $4.80 | FL |
| Gold Dialysis & Kidney Complete (HMO-POS C-SNP) | Gold Kidney OF Arizona | T1 | No | $17.00 | AZ |
| VNS Health EasyCare Plus (HMO D-SNP) | VNS Choice | T1 | No | $51.60 | NY |
| HealthSun HealthAdvantage Plan (HMO) | Healthsun Health Plans, Inc. | T2 | Yes | $0 | FL |
| HealthSun MediMax (HMO) | Healthsun Health Plans, Inc. | T2 | Yes | $0 | FL |
| HealthSun HealthAdvantage Plan (HMO) | Healthsun Health Plans, Inc. | T2 | Yes | $0 | FL |
| HealthSun HealthAdvantage Plan (HMO) | Healthsun Health Plans, Inc. | T2 | Yes | $0 | FL |
| HealthSun MediSun Plus (HMO D-SNP) | Healthsun Health Plans, Inc. | T2 | Yes | $0 | FL |
Showing top 50 of 100 plans.
Frequently Asked Questions
Is amitriptyline hydrochloride 12.5 MG / chlordiazepoxide 5 MG Oral Tablet covered by Medicare Part D?
Yes, amitriptyline hydrochloride 12.5 MG / chlordiazepoxide 5 MG Oral Tablet is covered by 329 Medicare Part D plans (6.5% of all Part D formularies).
What tier is amitriptyline hydrochloride 12.5 MG / chlordiazepoxide 5 MG Oral Tablet on Medicare Part D plans?
amitriptyline hydrochloride 12.5 MG / chlordiazepoxide 5 MG Oral Tablet averages Tier 2.5 across Part D plans, ranging from Tier 1 to Tier 4.
Does amitriptyline hydrochloride 12.5 MG / chlordiazepoxide 5 MG Oral Tablet require prior authorization?
25.9% of Part D formularies require prior authorization for amitriptyline hydrochloride 12.5 MG / chlordiazepoxide 5 MG Oral Tablet. Step therapy: 0%. Quantity limits: 0%.
How much does Medicare spend on amitriptyline hydrochloride 12.5 MG / chlordiazepoxide 5 MG Oral Tablet?
In 2023, total Medicare Part D spending on amitriptyline hydrochloride 12.5 MG / chlordiazepoxide 5 MG Oral Tablet was $73,881,287, covering 838,449 beneficiaries. The average spend per beneficiary was $88.12.
Read our methodology - how this data is sourced, computed, and verified.
Nationwide similar Part D drugs
Data-derived peers across the CMS Part D formulary extract: nearest average tier placement and nearest prior-authorization rate. Not therapeutic alternatives or same-generic strengths.
Closest average formulary tier
- ethosuximide 50 MG/ML Oral Solution T2.5
- Sugar-Free cholestyramine resin 4000 MG Powder for Oral Suspension T2.5
- 24 HR niacin 500 MG Extended Release Oral Tablet T2.5
- fluocinolone acetonide 0.00025 MG/MG Topical Ointment T2.5
- theophylline 100 MG Extended Release Oral Tablet T2.5
- amiodarone hydrochloride 100 MG Oral Tablet T2.5
Similar prior-authorization rate
- {2 (0.1 ML) (diazepam 100 MG/ML Nasal Spray [Valtoco]) } Pack [Valtoco 20 MG Dose Kit] 25.9% PA
- {1 (0.1 ML) (diazepam 100 MG/ML Nasal Spray [Valtoco]) } Pack [Valtoco 10 MG Dose Kit] 25.9% PA
- {2 (0.1 ML) (diazepam 75 MG/ML Nasal Spray [Valtoco]) } Pack [Valtoco 15 MG Dose Kit] 25.9% PA
- opicapone 25 MG Oral Capsule [Ongentys] 25.8% PA
- acyclovir 0.05 MG/MG Topical Ointment 25.8% PA
- paricalcitol 0.001 MG Oral Capsule 26.1% PA