PROTRIPTYLINE HYDROCHLORIDE 5 mg Tablet, Film Coated
Coverage in Georgia (CMS PDP Region 10).
10 of 10 stand-alone Part D plans in Georgia cover this drug on tier 4.
1 of 10 plans apply a prior authorization, step therapy or quantity limit.
142 Medicare Advantage plans in GA do cover it
Medicare Advantage plans carry their own formularies, separate from stand-alone Part D. A patient on an MA-PD plan may have coverage even where no PDP lists the drug. GA: 142 plans.
Every plan that covers it
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible | 4Non-Preferred Drug | 28% | 28% | $4.8736 | — | None |
| Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible | 4Non-Preferred Drug | 40% | 40% | $4.9276 | — | None |
| Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible | 4Non-Preferred Drug | 34% | — | $5.5600 | — | None |
| Humana Value Rx Plan (PDP)$36.40/mo premium · $601.00 deductible | 4Non-Preferred Drug | 34% | — | $5.6180 | — | None |
| HealthSpring Extra Rx (PDP)$71.20/mo premium · $615.00 deductible | 4Non-Preferred Drug | 30% | 30% | $4.6718 | — | None |
| AARP Medicare Rx Saver from UHC (PDP)$98.00/mo premium · $615.00 deductible | 4Non-Preferred Drug | 35% | — | $3.4424 | — | None |
| SilverScript Choice (PDP)$100.70/mo premium · $615.00 deductible | 4Non-Preferred Drug | 33% | 33% | $1.7297 | — |
|
| Humana Premier Rx Plan (PDP)$129.50/mo premium · $0.00 deductible | 4Non-Preferred Drug | 50% | 50% | $5.5274 | — | None |
| AARP Medicare Rx Preferred from UHC (PDP)$139.80/mo premium · $130.00 deductible | 4Non-Preferred Drug | 36% | — | $3.5122 | — | None |
| HealthSpring Assurance Rx (PDP)$149.30/mo premium · $615.00 deductible | 4Non-Preferred Drug | 31% | 31% | $4.6061 | — | None |
Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity.