PERPHEN-AMITRIP

4 MG

Tricyclic Antidepressant

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Coverage by Insurer

Informational only — Coverage rules change frequently; verify tier placement and restrictions with your plan or pharmacy before acting.
Source: PDF  ·  Formulary date: Jul 24, 2026  ·  Checked: 6 hours, 34 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Connect Silver 3500 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Bronze 7000 HSA Indiv Med Deductible Tier 2 - Generic — — — None
Connect myDiabetesCare Bronze Tier 2 - Generic — — — None
Connect myDiabetesCare Silver Tier 2 - Generic — — — None
Connect Bronze RD 6000 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Silver RD 2200 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Silver 4400 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Bronze RD 5000 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Silver 3000 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Silver RD 5000 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Bronze 5500 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Gold 1500 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Silver RD 3500 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Bronze 6500 Indiv Med Deductible Tier 2 - Generic — — — None
Connect Silver RD CMS Standard Tier 2 - Generic — — — None
Connect Bronze RD CMS Standard Tier 2 - Generic — — — None
Connect Bronze CMS Standard Tier 2 - Generic — — — None
Connect Gold CMS Standard Tier 2 - Generic — — — None
Connect Gold RD CMS Standard Tier 2 - Generic — — — None
Connect Silver CMS Standard Tier 2 - Generic — — — None
Source: CMS QHP JSON  ·  Formulary date: Jun 10, 2026  ·  Checked: 6 hours, 34 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Troy Medicare (HMO) Tier 2 - Generic ✓ — — PA
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) Tier 2 - Generic ✓ — — PA
HealthSpring Preferred Select (HMO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (HMO) Tier 4 - Non-Preferred ✓ — — PA
HealthSpring Preferred Plus (HMO) Tier 4 - Non-Preferred — — — None
HealthSpring Preferred Savings (HMO) Tier 4 - Non-Preferred — — — None
Aetna Medicare Dual (HMO D-SNP) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Signature (HMO) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Value Plus (HMO) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Prime (HMO) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Signature Care (HMO) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Full Dual Care (HMO D-SNP) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Enhanced (HMO) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Enhanced (PPO) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Enhanced (PPO) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Signature Extra (PPO) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Signature Giveback (PPO) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Signature (PPO) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Chronic Care (HMO C-SNP) Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Chronic Care Value (HMO C-SNP) Tier 4 - Non-Preferred ✓ — — PA
HealthSpring True Choice (PPO) Tier 4 - Non-Preferred — — — None
HealthSpring TotalCare (HMO D-SNP) Tier 4 - Non-Preferred — — — None
HealthSpring TotalCare Plus (HMO D-SNP) Tier 4 - Non-Preferred — — — None
HealthSpring Preferred (HMO) Tier 4 - Non-Preferred — — — None
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