ACETAMINOPHEN AND CODEINE PHOSPHATE 300/15 mg Tablet

Coverage in Delaware, DC and Maryland (CMS PDP Region 05).

10 of 10 stand-alone Part D plans in Delaware, DC and Maryland cover this drug on tier 3–4.

Lowest 30-day cost $45.00 at a preferred pharmacy. 10 of 10 plans apply a prior authorization, step therapy or quantity limit.

97 Medicare Advantage plans in DE, DC, MD 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. DE: 32 plans · DC: 15 plans · MD: 50 plans.

Every plan that covers it

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.4154	$16.2039 units	Quantity limit 39 per 30 days
Humana Value Rx Plan (PDP)$4.30/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.4213	$16.4339 units	Quantity limit 39 per 30 days
HealthSpring Assurance Rx (PDP)$32.60/mo premium · $615.00 deductible	3Preferred Brand	22%	22%	$0.5240	$18.8636 units	Quantity limit 36 per 30 days
HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.4724	$17.0136 units	Quantity limit 36 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$94.50/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.3126	$12.1939 units	Quantity limit 39 per 30 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.3248	$5.8518 units	Quantity limit 18 per 30 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.4121	$16.0739 units	Quantity limit 39 per 30 days
Wellcare Value Script (PDP)$5.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.4879	$17.5636 units	Quantity limit 36 per 30 days
Wellcare Classic (PDP)$5.70/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.4532	$16.3236 units	Quantity limit 36 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$37.80/mo premium · $615.00 deductible	4Non-Preferred Drug	36%	—	$0.3375	$13.1639 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 →