amitriptyline hydrochloride 25 MG / perphenazine 2 MG Oral Tablet
amitriptyline hydrochloride
RxCUI: 856797
What the CMS Formulary Data Shows for amitriptyline hydrochloride 25 MG / perphenazine 2 MG Oral Tablet
Per the CMS 2026 Part D formulary file, amitriptyline hydrochloride 25 MG / perphenazine 2 MG Oral Tablet (RxNorm concept RXCUI 856797, generic name amitriptyline hydrochloride) appears on 106 distinct formulary files spanning 1,613 Medicare Part D plan offerings - 31.8% 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 2.4.
Real-world access to amitriptyline hydrochloride 25 MG / perphenazine 2 MG Oral Tablet depends on utilization management as much as tier placement: 22.6% 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 25 MG / perphenazine 2 MG Oral Tablet in 2023, with total plan-and-beneficiary spending of $74,066,594 and an average per-beneficiary annual cost of $88.34. The plan-by-plan detail below lists exactly which PDP and MA-PD contracts carry amitriptyline hydrochloride 25 MG / perphenazine 2 MG Oral Tablet today.
Coverage Details
- Formularies covering
- 106
- Plans covering
- 1,613
- Coverage rate
- 31.8%
- Tier range
- Tier 1 – Tier 4
- Average tier
- Tier 2, Generic
Restrictions
- Prior authorization required
- 22.6% of formularies
- Step therapy required
- 0% of formularies
- Quantity limits
- 0% of formularies
2023 Medicare Spending
- Beneficiaries
- 838,449
- Total spending
- $74,066,594
- Avg per beneficiary
- $88.34
Tier Distribution Across Plans
Medicare Advantage Plans (MA-PD) Covering amitriptyline hydrochloride 25 MG / perphenazine 2 MG Oral Tablet
100 Medicare Advantage plans with Part D drug coverage include this drug.
| Plan | Insurer | Tier | PA | Premium | States |
|---|---|---|---|---|---|
| CareAdvantage (HMO D-SNP) | SAN MATEO HEALTH COMMISSION | T1 | No | $0 | CA |
| SeniorCare Complete (HMO D-SNP) | SOUTH COUNTRY HEALTH ALLIANCE | T1 | Yes | $0 | MN |
| AbilityCare (HMO D-SNP) | SOUTH COUNTRY HEALTH ALLIANCE | T1 | Yes | $0 | MN |
| Alameda Alliance Wellness (HMO D-SNP) | ALAMEDA ALLIANCE FOR HEALTH | T1 | Yes | $0 | CA |
| PHP (HMO C-SNP) | AIDS HEALTHCARE FOUNDATION | T1 | No | $0 | CA |
| Elevate Medicare Choice (HMO D-SNP) | DENVER HEALTH MEDICAL PLAN, INC. | T1 | No | $0 | CO |
| AllCare Advantage Redwood Rx (HMO D-SNP) | ALLCARE HEALTH PLAN, INC. | T1 | No | $0 | OR |
| PrimeWest Senior Health Complete (HMO D-SNP) | PRIMEWEST RURAL MN HEALTH CARE ACCESS INITIATIVE | T1 | No | $0 | MN |
| Prime Health Complete (HMO D-SNP) | PRIMEWEST RURAL MN HEALTH CARE ACCESS INITIATIVE | T1 | No | $0 | MN |
| DualConnect (HMO D-SNP) | SANTA CLARA COUNTY HEALTH AUTHORITY | T1 | No | $0 | CA |
| VNS Health Total (HMO D-SNP) | VNS CHOICE | T1 | No | $0 | NY |
| Alterwood Advantage Dual Secure (HMO D-SNP) | ALTERWOOD ADVANTAGE, INC. | T1 | No | $0 | MD |
| Nascentia Dual Advantage (HMO D-SNP) | VISITING NURSE ASSOCIATION OF CENTRAL NEW YORK | T1 | No | $0 | NY |
| Abilis Health Community (HMO I-SNP) | SIGNATURE ADVANTAGE, LLC | T1 | No | $0 | KY, TN |
| Arkansas Integrated Providers (AIP) Dual Advantage (HMO D-SNP) | ARKANSAS SUPERIOR SELECT, INC. | T1 | No | $0 | AR |
| CalOptima Health OneCare Complete (HMO D-SNP) | ORANGE COUNTY HEALTH AUTHORITY | T1 | Yes | $0 | CA |
| Mass General Brigham SCO (HMO D-SNP) | MASS GENERAL BRIGHAM HEALTH PLAN, INC | T1 | No | $0 | MA |
| Mass General Brigham One Care (HMO D-SNP) | MASS GENERAL BRIGHAM HEALTH PLAN, INC | T1 | No | $0 | MA |
| Leon MediExtra (HMO) | LEON HEALTH, INC. | T1 | No | $0 | FL |
| Leon MediDual (HMO D-SNP) | LEON HEALTH, INC. | T1 | No | $0 | FL |
| Leon MediMore (HMO) | LEON HEALTH, INC. | T1 | No | $0 | FL |
| Leon MediMax (HMO D-SNP) | LEON HEALTH, INC. | T1 | No | $0 | FL |
| Gold Dialysis & Kidney Complete (HMO-POS C-SNP) | GOLD KIDNEY OF FLORIDA INC | T1 | No | $4.80 | FL |
| Texas Independence Health Plan, Inc. (HMO I-SNP) | TEXAS INDEPENDENCE HEALTH PLAN, INC. | T1 | No | $4.80 | TX |
| Texas Independence Community Plan (HMO I-SNP) | TEXAS INDEPENDENCE HEALTH PLAN, INC. | T1 | No | $4.80 | TX |
| Tribute Select (HMO-POS I-SNP) | ARKANSAS SUPERIOR SELECT, INC. | T1 | No | $8.90 | AR |
| ATRIO Special Needs Plan (HMO D-SNP) | ATRIO HEALTH PLANS | T1 | No | $10.50 | OR |
| ATRIO Special Needs Plan (HMO D-SNP) | ATRIO HEALTH PLANS | T1 | No | $10.50 | OR |
| Gold Dialysis & Kidney Complete (HMO-POS C-SNP) | GOLD KIDNEY OF ARIZONA | T1 | No | $17.00 | AZ |
| Alterwood Advantage Dual Value (HMO D-SNP) | ALTERWOOD ADVANTAGE, INC. | T1 | No | $31.20 | MD |
| Valor Health Plan (HMO I-SNP) | TSG GUARD, INC. | T1 | No | $31.40 | OH |
| WV Senior Advantage (HMO I-SNP) | WEST VIRGINIA SENIOR ADVANTAGE, INC. | T1 | No | $32.70 | WV |
| Abilis Health (HMO I-SNP) | SIGNATURE ADVANTAGE, LLC | T1 | No | $35.90 | KY, TN |
| CommuniCare Advantage ISNP (HMO I-SNP) | OH CHS SNP INC. | T1 | No | $38.40 | IN, MD, OH |
| VNS Health EasyCare Plus (HMO D-SNP) | VNS CHOICE | T1 | No | $51.60 | NY |
| Nascentia Skilled Nursing Facility (HMO I-SNP) | VISITING NURSE ASSOCIATION OF CENTRAL NEW YORK | T1 | No | $58.80 | NY |
| Wellpoint Medicare Advantage (HMO-POS) | WELLPOINT WEST VIRGINIA , INC. | T2 | Yes | $0 | WV |
| Anthem Medicare Advantage 3 (HMO-POS) | HealthKeepers, Inc. | T2 | Yes | $0 | VA |
| Anthem Medicare Advantage 3 (HMO-POS) | HealthKeepers, Inc. | T2 | Yes | $0 | VA |
| Anthem Medicare Advantage 3 (HMO-POS) | HealthKeepers, Inc. | T2 | Yes | $0 | VA |
| Wellpoint Medicare Advantage 2 (HMO-POS) | WELLPOINT TENNESSEE, INC. | T2 | Yes | $0 | TN |
| Wellpoint Medicare Advantage 2 (HMO-POS) | WELLPOINT TENNESSEE, INC. | T2 | Yes | $0 | TN |
| Wellpoint Medicare Advantage 2 (HMO-POS) | WELLPOINT TENNESSEE, INC. | T2 | Yes | $0 | TN |
| Wellpoint Medicare Advantage 2 (HMO-POS) | WELLPOINT TENNESSEE, INC. | T2 | Yes | $0 | TN |
| Freedom VIP Care (HMO C-SNP) | FREEDOM HEALTH, INC. | T2 | Yes | $0 | FL |
| Freedom VIP Savings (HMO C-SNP) | FREEDOM HEALTH, INC. | T2 | Yes | $0 | FL |
| Freedom VIP Savings (HMO C-SNP) | FREEDOM HEALTH, INC. | T2 | Yes | $0 | FL |
| Freedom VIP Rewards (HMO C-SNP) | FREEDOM HEALTH, INC. | T2 | Yes | $0 | FL |
| Freedom VIP Rewards (HMO C-SNP) | FREEDOM HEALTH, INC. | T2 | Yes | $0 | FL |
| Optimum Diamond Rewards (HMO C-SNP) | OPTIMUM HEALTHCARE, INC. | T2 | Yes | $0 | FL |
Frequently Asked Questions
Is amitriptyline hydrochloride 25 MG / perphenazine 2 MG Oral Tablet covered by Medicare Part D?
Yes, amitriptyline hydrochloride 25 MG / perphenazine 2 MG Oral Tablet is covered by 1,613 Medicare Part D plans (31.8% of all Part D formularies).
What tier is amitriptyline hydrochloride 25 MG / perphenazine 2 MG Oral Tablet on Medicare Part D plans?
amitriptyline hydrochloride 25 MG / perphenazine 2 MG Oral Tablet averages Tier 2.4 across Part D plans, ranging from Tier 1 to Tier 4.
Does amitriptyline hydrochloride 25 MG / perphenazine 2 MG Oral Tablet require prior authorization?
22.6% of Part D formularies require prior authorization for amitriptyline hydrochloride 25 MG / perphenazine 2 MG Oral Tablet. Step therapy: 0%. Quantity limits: 0%.
How much does Medicare spend on amitriptyline hydrochloride 25 MG / perphenazine 2 MG Oral Tablet?
In 2023, total Medicare Part D spending on amitriptyline hydrochloride 25 MG / perphenazine 2 MG Oral Tablet was $74,066,594, covering 838,449 beneficiaries. The average spend per beneficiary was $88.34.
Read our methodology - how this data is sourced, computed, and verified.