ACETAMINOPHEN AND CODEINE PHOSPHATE 300/30 mg Tablet

Coverage in Virginia (CMS PDP Region 07).

9 of 9 stand-alone Part D plans in Virginia cover this drug on tier 3–4.

Lowest 30-day cost $45.00 at a preferred pharmacy. 9 of 9 plans apply a prior authorization, step therapy or quantity limit.

128 Medicare Advantage plans in VA 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. VA: 128 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%	$0.3555	$12.8036 units	Quantity limit 36 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.3624	$13.0536 units	Quantity limit 36 per 30 days
SilverScript Choice (PDP)$78.20/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.3559	$6.4118 units	Quantity limit 18 per 30 days
Humana Premier Rx Plan (PDP)$87.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.3517	$12.6636 units	Quantity limit 36 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$100.80/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.2834	$11.0539 units	Quantity limit 39 per 30 days
HealthSpring Assurance Rx (PDP)$133.80/mo premium · $615.00 deductible	3Preferred Brand	22%	22%	$0.7184	$25.8636 units	Quantity limit 36 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.4853	$17.4736 units	Quantity limit 36 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.4853	$17.4736 units	Quantity limit 36 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$39.60/mo premium · $615.00 deductible	4Non-Preferred Drug	34%	—	$0.2849	$11.1139 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 →