Perphenazine/Amitriptylin

Generic: perphenazine-amitriptyline

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ ANOREXIANTS

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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: CMS QHP JSON  ·  Checked: 10 hours, 15 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
AmeriHealth Caritas Next Silver Premier + No Referrals
via Perphenazine-Amitriptyline 		Tier 2 - Generic — — — None
AmeriHealth Caritas Next Silver Essential + No Referrals
via Perphenazine-Amitriptyline 		Tier 2 - Generic — — — None
AmeriHealth Caritas Next Gold Signature + No Referrals
via Perphenazine-Amitriptyline 		Tier 2 - Generic — — — None
AmeriHealth Caritas Next Bronze Essential + No Referrals
via Perphenazine-Amitriptyline 		Tier 2 - Generic — — — None
AmeriHealth Caritas Next Gold Premier + No Referrals
via Perphenazine-Amitriptyline 		Tier 2 - Generic — — — None
AmeriHealth Caritas Next Bronze Premier + No Referrals
via Perphenazine-Amitriptyline 		Tier 2 - Generic — — — None
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals
via Perphenazine-Amitriptyline 		Tier 2 - Generic — — — None
AmeriHealth Caritas Next Silver Signature + No Referrals
via Perphenazine-Amitriptyline 		Tier 2 - Generic — — — None
AmeriHealth Caritas Next Bronze Signature + No Referrals
via Perphenazine-Amitriptyline 		Tier 2 - Generic — — — None
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals
via Perphenazine-Amitriptyline 		Tier 2 - Generic — — — None
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 10 hours, 15 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBS Federal Basic Option 2026
via Perphenazine-Amitriptyline 		Tier 1 - Generic — — — None
BCBS Federal Focus 2026
via Perphenazine-Amitriptyline 		Tier 1 - Generic — — — None
BCBS Federal Standard Option 2026
via Perphenazine-Amitriptyline 		Tier 1 - Generic — — — None
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 10 hours, 15 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
BCBSNC Blue Local 2026 Tier 4 - Higher Cost Brand — — — Restricted Access None
BCBSNC Blue Advantage 2026 Tier 4 - Higher Cost Brand — — — Restricted Access None
BCBSNC Blue Home with UNC Health Alliance 2026 Tier 4 - Higher Cost Brand — — — Restricted Access None
BCBSNC Blue Care 2026 Tier 4 - Higher Cost Brand — — — Restricted Access None
BCBSNC Blue Value 2026 Tier 4 - Higher Cost Brand — — — Restricted Access None
Source: CMS QHP JSON  ·  Formulary date: Jun 10, 2026  ·  Checked: 10 hours, 15 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Troy Medicare (HMO)
via Perphenazine-Amitriptyline 		Tier 2 - Generic ✓ — — PA
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP)
via Perphenazine-Amitriptyline 		Tier 2 - Generic ✓ — — PA
HealthSpring TotalCare (HMO D-SNP)
via Perphenazine-Amitriptyline 		Tier 4 - Non-Preferred — — — None
HealthSpring TotalCare Plus (HMO D-SNP)
via Perphenazine-Amitriptyline 		Tier 4 - Non-Preferred — — — None
HealthSpring Preferred (HMO)
via Perphenazine-Amitriptyline 		Tier 4 - Non-Preferred — — — None
HealthSpring Preferred Select (HMO)
via Perphenazine-Amitriptyline 		Tier 4 - Non-Preferred — — — None
HealthSpring Preferred Savings (HMO)
via Perphenazine-Amitriptyline 		Tier 4 - Non-Preferred — — — None
HealthSpring Preferred Plus (HMO)
via Perphenazine-Amitriptyline 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (PPO)
via Perphenazine-Amitriptyline 		Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Signature Extra (PPO)
via Perphenazine-Amitriptyline 		Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Prime (HMO)
via Perphenazine-Amitriptyline 		Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Value Plus (HMO)
via Perphenazine-Amitriptyline 		Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Signature (HMO)
via Perphenazine-Amitriptyline 		Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Signature (HMO)
via Perphenazine-Amitriptyline 		Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Dual (HMO D-SNP)
via Perphenazine-Amitriptyline 		Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Chronic Care Value (HMO C-SNP)
via Perphenazine-Amitriptyline 		Tier 4 - Non-Preferred ✓ — — PA
HealthSpring True Choice (PPO)
via Perphenazine-Amitriptyline 		Tier 4 - Non-Preferred — — — None
Aetna Medicare Signature (PPO)
via Perphenazine-Amitriptyline 		Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Chronic Care (HMO C-SNP)
via Perphenazine-Amitriptyline 		Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Signature (PPO)
via Perphenazine-Amitriptyline 		Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Enhanced (PPO)
via Perphenazine-Amitriptyline 		Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Enhanced (PPO)
via Perphenazine-Amitriptyline 		Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Signature (PPO)
via Perphenazine-Amitriptyline 		Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Enhanced (HMO)
via Perphenazine-Amitriptyline 		Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Full Dual Care (HMO D-SNP)
via Perphenazine-Amitriptyline 		Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Signature Care (HMO)
via Perphenazine-Amitriptyline 		Tier 4 - Non-Preferred ✓ — — PA
Aetna Medicare Signature Giveback (PPO)
via Perphenazine-Amitriptyline 		Tier 4 - Non-Preferred ✓ — — PA
Source: PDF  ·  Formulary date: Jul 1, 2026  ·  Checked: 10 hours, 15 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC State Health Plan - 80/20 Plus PPO 2026
via Perphenazine-Amitriptyline 		Tier 1 - Preferred Generic — — — None
NC State Health Plan - 70/30 Standard PPO 2026
via Perphenazine-Amitriptyline 		Tier 1 - Preferred Generic — — — None
NC State Health Plan - HDHP 2026
via Perphenazine-Amitriptyline 		Tier 1 - Preferred Generic — — — None
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