ACETAMINOPHEN AND CODEINE PHOSPHATE 300/15 mg Tablet

Coverage in Connecticut, Massachusetts, Rhode Island and Vermont (CMS PDP Region 02).

11 of 11 stand-alone Part D plans in Connecticut, Massachusetts, Rhode Island and Vermont cover this drug on tier 2–4.

Lowest 30-day cost $3.00 at a preferred pharmacy. 11 of 11 plans apply a prior authorization, step therapy or quantity limit.

152 Medicare Advantage plans in CT, MA, RI, VT 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. CT: 42 plans · MA: 88 plans · RI: 20 plans · VT: 2 plans.

Every plan that covers it

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Blue MedicareRx Value Plus (PDP)$20.70/mo premium · $615.00 deductible	2Generic	$3.00	$6.00	$0.2365	$0.954 units	Quantity limit 4 per 30 days
SilverScript Choice (PDP)$32.70/mo premium · $615.00 deductible	2Generic	$10.00	$30.00	$0.2418	$4.3518 units	Quantity limit 18 per 30 days
Blue MedicareRx Premier (PDP)$238.60/mo premium · $0.00 deductible	2Generic	$7.00	$14.00	$0.2365	$0.954 units	Quantity limit 4 per 30 days
Humana Basic Rx Plan (PDP)$8.40/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.4258	$16.6139 units	Quantity limit 39 per 30 days
Humana Value Rx Plan (PDP)$73.60/mo premium · $601.00 deductible	3Preferred Brand	18%	13%	$0.4281	$16.7039 units	Quantity limit 39 per 30 days
Humana Premier Rx Plan (PDP)$138.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.4245	$16.5639 units	Quantity limit 39 per 30 days
HealthSpring Assurance Rx (PDP)$139.30/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$0.5370	$19.3336 units	Quantity limit 36 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$155.10/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$0.3231	$12.6039 units	Quantity limit 39 per 30 days
Wellcare Value Script (PDP)$16.40/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.4879	$17.5636 units	Quantity limit 36 per 30 days
Wellcare Classic (PDP)$21.70/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$0.4548	$16.3736 units	Quantity limit 36 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$38.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$0.3406	$13.2839 units	Quantity limit 39 per 30 days

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.

See coverage in all 39 regions →