ACETAMINOPHEN AND CODEINE PHOSPHATE 300/15 mg Tablet

Coverage in Pennsylvania and West Virginia (CMS PDP Region 06).

12 of 12 stand-alone Part D plans in Pennsylvania and West Virginia cover this drug on tier 2–4.

Lowest 30-day cost $5.00 at a preferred pharmacy. 12 of 12 plans apply a prior authorization, step therapy or quantity limit.

365 Medicare Advantage plans in PA, WV 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. PA: 306 plans · WV: 59 plans.

Every plan that covers it

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
SilverScript Choice (PDP)$22.70/mo premium · $615.00 deductible	2Generic	$10.00	$30.00	$0.2451	$4.4118 units	Quantity limit 18 per 30 days
Blue Rx PDP Complete (PDP)$164.80/mo premium · $200.00 deductible	2Generic	$5.00	$12.50	$0.3385	$132.02390 units	Prior authorization Quantity limit 403 per 31 days
Blue Rx PDP Plus (PDP)$193.20/mo premium · $615.00 deductible	2Generic	25%	25%	$0.3386	$132.05390 units	Prior authorization Quantity limit 403 per 31 days
Humana Basic Rx Plan (PDP)$6.60/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.3816	$14.8839 units	Quantity limit 39 per 30 days
Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.3881	$15.1439 units	Quantity limit 39 per 30 days
HealthSpring Extra Rx (PDP)$62.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.4378	$15.7636 units	Quantity limit 36 per 30 days
HealthSpring Assurance Rx (PDP)$74.00/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$0.5081	$18.2936 units	Quantity limit 36 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$121.90/mo premium · $130.00 deductible	3Preferred Brand	16%	16%	$0.3047	$11.8839 units	Quantity limit 39 per 30 days
Humana Premier Rx Plan (PDP)$123.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.3781	$14.7539 units	Quantity limit 39 per 30 days
Wellcare Value Script (PDP)$8.20/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.4662	$16.7836 units	Quantity limit 36 per 30 days
Wellcare Classic (PDP)$14.70/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	28%	$0.4413	$15.8936 units	Quantity limit 36 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$43.50/mo premium · $615.00 deductible	4Non-Preferred Drug	41%	—	$0.3401	$13.2639 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 →