Perphenazine-Amitriptyline
2 Mg, 10 Mg — Tablet
Also known as:
perphenazine-amitriptyline tab 2-10 mg
perphenazine-amitriptyline tab 2-25 mg
perphenazine-amitriptyline tab 4-10 mg
perphenazine-amitriptyline tab 4-25 mg
perphenazine-amitriptyline tab 4-50 mg
Perphenazine-Amitriptyline 2 Mg-10 Mg Tablet
Perphenazine-Amitriptyline 2 Mg-25 Mg Tablet
Perphenazine-Amitriptyline 4 Mg-10 Mg Tablet
Perphenazine-Amitriptyline 4 Mg-25 Mg Tablet
Perphenazine-Amitriptyline 4 Mg-50 Mg Tablet
Perphenazine-Amitriptyline Oral Tablet
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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.
AmeriHealth Caritas NC
10 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas Next Silver Premier + No Referrals | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas Next Silver Off-Marketplace Low + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 2 - Generic | — | — | — | None |
| AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals | Tier 2 - Generic | — | — | — | None |
Blue Cross Blue Shield Federal
3 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| BCBS Federal Standard Option 2026 | Tier 1 - Generic | — | — | — | None |
| BCBS Federal Basic Option 2026 | Tier 1 - Generic | — | — | — | None |
| BCBS Federal Focus 2026 | Tier 1 - Generic | — | — | — | None |
Blue Cross Blue Shield of NC
5 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
|
BCBSNC Blue Care 2026
via Perphenazine/Amitriptylin |
Tier 4 - Higher Cost Brand | — | — | — Restricted Access | None |
|
BCBSNC Blue Value 2026
via Perphenazine/Amitriptylin |
Tier 4 - Higher Cost Brand | — | — | — Restricted Access | None |
|
BCBSNC Blue Advantage 2026
via Perphenazine/Amitriptylin |
Tier 4 - Higher Cost Brand | — | — | — Restricted Access | None |
|
BCBSNC Blue Home with UNC Health Alliance 2026
via Perphenazine/Amitriptylin |
Tier 4 - Higher Cost Brand | — | — | — Restricted Access | None |
|
BCBSNC Blue Local 2026
via Perphenazine/Amitriptylin |
Tier 4 - Higher Cost Brand | — | — | — Restricted Access | None |
Medicare Part D
27 plans| 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 TotalCare (HMO D-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| HealthSpring Preferred (HMO) | Tier 4 - Non-Preferred | — | — | — | None |
| HealthSpring TotalCare Plus (HMO D-SNP) | Tier 4 - Non-Preferred | — | — | — | None |
| HealthSpring Preferred Select (HMO) | Tier 4 - Non-Preferred | — | — | — | None |
| HealthSpring Preferred Plus (HMO) | Tier 4 - Non-Preferred | — | — | — | None |
| HealthSpring Preferred Savings (HMO) | Tier 4 - Non-Preferred | — | — | — | None |
| Aetna Medicare Signature (HMO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| 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 Chronic Care (HMO C-SNP) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Aetna Medicare Enhanced (HMO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Aetna Medicare Chronic Care Value (HMO C-SNP) | 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 |
| HealthSpring True Choice (PPO) | Tier 4 - Non-Preferred | — | — | — | None |
NC State Health Plan
3 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| NC State Health Plan - HDHP 2026 | Tier 1 - Preferred Generic | — | — | — | None |
| NC State Health Plan - 70/30 Standard PPO 2026 | Tier 1 - Preferred Generic | — | — | — | None |
| NC State Health Plan - 80/20 Plus PPO 2026 | Tier 1 - Preferred Generic | — | — | — | None |