ACETAMINOPHEN AND CODEINE PHOSPHATE 120/12 mg/5mL Solution

Coverage in Indiana and Kentucky (CMS PDP Region 15).

10 of 10 stand-alone Part D plans in Indiana and Kentucky cover this drug on tier 2–4.

Lowest 30-day cost $10.00 at a preferred pharmacy. 10 of 10 plans apply a prior authorization, step therapy or quantity limit.

219 Medicare Advantage plans in IN, KY 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. IN: 116 plans · KY: 103 plans.

Every plan that covers it

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible	2Generic	$10.00	$30.00	$0.4868	$13.1427 units	Quantity limit 27 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.7912	$21.3627 units	Quantity limit 27 per 30 days
Humana Value Rx Plan (PDP)$9.90/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.7942	$21.4427 units	Quantity limit 27 per 30 days
HealthSpring Extra Rx (PDP)$78.20/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.4920	$22.1445 units	Quantity limit 45 per 30 days
HealthSpring Assurance Rx (PDP)$117.80/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$0.4920	$22.1445 units	Quantity limit 45 per 30 days
Humana Premier Rx Plan (PDP)$125.30/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.7895	$21.3227 units	Quantity limit 27 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$127.10/mo premium · $130.00 deductible	3Preferred Brand	18%	18%	$0.4335	$19.5145 units	Quantity limit 45 per 30 days
Wellcare Value Script (PDP)$8.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.4949	$13.3627 units	Quantity limit 27 per 30 days
Wellcare Classic (PDP)$8.70/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$0.4890	$13.2027 units	Quantity limit 27 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$90.30/mo premium · $615.00 deductible	4Non-Preferred Drug	42%	—	$0.3644	$16.4045 units	Quantity limit 45 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 →