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

Coverage in New York (CMS PDP Region 03).

10 of 10 stand-alone Part D plans in New York 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.

192 Medicare Advantage plans in NY 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. NY: 192 plans.

Every plan that covers it

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Assurance Rx (PDP)$35.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$0.4545	$20.4545 units	Quantity limit 45 per 30 days
HealthSpring Extra Rx (PDP)$91.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.4545	$20.4545 units	Quantity limit 45 per 30 days
SilverScript Choice (PDP)$116.00/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.4913	$13.2727 units	Quantity limit 27 per 30 days
Humana Basic Rx Plan (PDP)$140.90/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.7203	$19.4527 units	Quantity limit 27 per 30 days
Humana Value Rx Plan (PDP)$158.90/mo premium · $601.00 deductible	3Preferred Brand	17%	12%	$0.7271	$19.6327 units	Quantity limit 27 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$163.70/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$0.4411	$19.8545 units	Quantity limit 45 per 30 days
Humana Premier Rx Plan (PDP)$173.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.7164	$19.3427 units	Quantity limit 27 per 30 days
Wellcare Value Script (PDP)$42.40/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.4586	$12.3827 units	Quantity limit 27 per 30 days
Wellcare Classic (PDP)$45.70/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	28%	$0.4507	$12.1727 units	Quantity limit 27 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$105.80/mo premium · $615.00 deductible	4Non-Preferred Drug	38%	—	$0.3904	$17.5745 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 →