acetaminophen 300 MG / butalbital 50 MG / caffeine 40 MG / codeine phosphate 30 MG Oral Capsule
acetaminophen
RxCUI: 1431286
What the CMS Formulary Data Shows for acetaminophen 300 MG / butalbital 50 MG / caffeine 40 MG / codeine phosphate 30 MG Oral Capsule
Per the CMS 2026 Part D formulary file, acetaminophen 300 MG / butalbital 50 MG / caffeine 40 MG / codeine phosphate 30 MG Oral Capsule (RxNorm concept RXCUI 1431286, generic name acetaminophen) appears on 15 distinct formulary files spanning 130 Medicare Part D plan offerings - 2.6% of enrollable Part D products, selective placement; verify formulary inclusion before enrolling. Tier placement ranges from Tier 1 to Tier 4, with a cross-plan average of Tier 2.9.
Real-world access to acetaminophen 300 MG / butalbital 50 MG / caffeine 40 MG / codeine phosphate 30 MG Oral Capsule depends on utilization management as much as tier placement: 46.7% of covering formularies require prior authorization. 0% require step therapy. 80% apply quantity limits.
Historical spending context from the CMS Medicare Part D Drug Spending Dashboard shows 156 Part D beneficiaries filled acetaminophen 300 MG / butalbital 50 MG / caffeine 40 MG / codeine phosphate 30 MG Oral Capsule in 2023, with total plan-and-beneficiary spending of $48,943 and an average per-beneficiary annual cost of $313.74. The plan-by-plan detail below lists exactly which PDP and MA-PD contracts carry acetaminophen 300 MG / butalbital 50 MG / caffeine 40 MG / codeine phosphate 30 MG Oral Capsule today.
Coverage Details
- Formularies covering
- 15
- Plans covering
- 130
- Coverage rate
- 2.6%
- Tier range
- Tier 1 – Tier 4
- Average tier
- Tier 3, Preferred Brand
Restrictions
- Prior authorization required
- 46.7% of formularies
- Step therapy required
- 0% of formularies
- Quantity limits
- 80% of formularies
2023 Medicare Spending
- Beneficiaries
- 156
- Total spending
- $48,943
- Avg per beneficiary
- $313.74
Tier Distribution Across Plans
Medicare Advantage Plans (MA-PD) Covering acetaminophen 300 MG / butalbital 50 MG / caffeine 40 MG / codeine phosphate 30 MG Oral Capsule
100 Medicare Advantage plans with Part D drug coverage include this drug.
| Plan | Insurer | Tier | PA | Premium | States |
|---|---|---|---|---|---|
| PHP (HMO C-SNP) | AIDS HEALTHCARE FOUNDATION | T1 | Yes | $0 | CA |
| VNS Health Total (HMO D-SNP) | VNS CHOICE | T1 | No | $0 | NY |
| Gold Dialysis & Kidney Complete (HMO-POS C-SNP) | GOLD KIDNEY OF FLORIDA INC | T1 | No | $4.80 | FL |
| Gold Dialysis & Kidney Complete (HMO-POS C-SNP) | GOLD KIDNEY OF ARIZONA | T1 | No | $17.00 | AZ |
| VNS Health EasyCare Plus (HMO D-SNP) | VNS CHOICE | T1 | No | $51.60 | NY |
| DrMax (HMO) | DOCTORS HEALTHCARE PLANS, INC. | T2 | No | $0 | FL |
| DrExtraCare (HMO C-SNP) | DOCTORS HEALTHCARE PLANS, INC. | T2 | No | $0 | FL |
| DrSelect (HMO) | DOCTORS HEALTHCARE PLANS, INC. | T2 | No | $0 | FL |
| DrSelect-CFL (HMO) | DOCTORS HEALTHCARE PLANS, INC. | T2 | No | $0 | FL |
| DrPlatinum-CFL (HMO D-SNP) | DOCTORS HEALTHCARE PLANS, INC. | T2 | No | $0 | FL |
| DrTotalCare-CFL (HMO C-SNP) | DOCTORS HEALTHCARE PLANS, INC. | T2 | No | $0 | FL |
| DrElite-SFL (HMO) | DOCTORS HEALTHCARE PLANS, INC. | T2 | No | $0 | FL |
| Healthy Mississippi Premier Advantage (HMO-POS) | Healthy Mississippi, Inc. | T2 | No | $0 | MS |
| Gold Heart & Diabetes (HMO-POS C-SNP) | GOLD KIDNEY OF FLORIDA INC | T2 | No | $0 | FL |
| Gold Heart & Diabetes Complete (HMO-POS C-SNP) | GOLD KIDNEY OF FLORIDA INC | T2 | No | $0 | FL |
| Gold Dialysis & Kidney (HMO-POS C-SNP) | GOLD KIDNEY OF FLORIDA INC | T2 | No | $0 | FL |
| Gold Health (HMO-POS C-SNP) | GOLD KIDNEY OF FLORIDA INC | T2 | No | $0 | FL |
| Gold Dialysis & Kidney (HMO-POS C-SNP) | GOLD KIDNEY OF FLORIDA INC | T2 | No | $0 | FL |
| Gold Heart & Diabetes (HMO-POS C-SNP) | GOLD KIDNEY OF ARIZONA | T2 | No | $0 | AZ |
| Gold Dialysis & Kidney (HMO-POS C-SNP) | GOLD KIDNEY OF ARIZONA | T2 | No | $0 | AZ |
| Gold Heart & Diabetes (HMO-POS C-SNP) | GOLD KIDNEY OF ARIZONA | T2 | No | $0 | AZ |
| Gold Dialysis & Kidney (HMO-POS C-SNP) | GOLD KIDNEY OF ARIZONA | T2 | No | $0 | AZ |
| DrFlex (HMO D-SNP) | DOCTORS HEALTHCARE PLANS, INC. | T2 | No | $1.10 | FL |
| DrPlus (HMO D-SNP) | DOCTORS HEALTHCARE PLANS, INC. | T2 | No | $4.80 | FL |
| Select Health Medicare Essential (HMO) | SELECTHEALTH, INC. | T3 | No | $0 | UT |
| Select Health Medicare Essential (HMO) | SELECTHEALTH, INC. | T3 | No | $0 | NV |
| Select Health Medicare Dual (HMO D-SNP) | SELECTHEALTH, INC. | T3 | No | $0 | UT |
| Select Health Medicare Essential (HMO) | SELECTHEALTH, INC. | T3 | No | $0 | UT |
| Select Health Medicare + Kroger (HMO) | SELECTHEALTH, INC. | T3 | No | $0 | NV |
| Select Health Medicare + Kroger (HMO) | SELECTHEALTH, INC. | T3 | No | $0 | UT |
| Select Health Medicare Essential (HMO) | SELECTHEALTH, INC. | T3 | No | $0 | CO |
| Select Health Medicare Essential (HMO) | SELECTHEALTH, INC. | T3 | No | $0 | CO |
| Select Health Medicare + Kroger (HMO) | SELECTHEALTH, INC. | T3 | No | $0 | CO |
| Select Health Medicare Flex (HMO) | SELECTHEALTH, INC. | T3 | No | $0 | CO |
| Select Health Medicare + Kroger (HMO) | SELECTHEALTH, INC. | T3 | No | $0 | CO |
| Select Health Medicare Active (HMO) | SELECTHEALTH, INC. | T3 | No | $0 | CO |
| Select Health Medicare Dual (HMO D-SNP) | SELECTHEALTH, INC. | T3 | No | $0 | NV |
| Select Health Medicare Wellness (HMO) | SELECTHEALTH, INC. | T3 | No | $0 | NV |
| Alignment Health the ONE + Walgreens (HMO) | ALIGNMENT HEALTH PLAN OF ARIZONA, INC. | T3 | No | $0 | AZ |
| Alignment Health the ONE + Walgreens (HMO) | ALIGNMENT HEALTH PLAN OF ARIZONA, INC. | T3 | No | $0 | AZ |
| Alignment Health Heart & Diabetes (HMO C-SNP) | ALIGNMENT HEALTH PLAN OF ARIZONA, INC. | T3 | No | $0 | AZ |
| Alignment Health smartHMO (HMO) | ALIGNMENT HEALTH PLAN OF ARIZONA, INC. | T3 | No | $0 | AZ |
| Alignment Health My Choice (HMO) | ALIGNMENT HEALTH PLAN | T3 | No | $0 | CA |
| Alignment Health Platinum + Instacart (HMO) | ALIGNMENT HEALTH PLAN | T3 | No | $0 | CA |
| Alignment Health Heart & Diabetes (HMO C-SNP) | ALIGNMENT HEALTH PLAN | T3 | No | $0 | CA |
| Alignment Health AllCare Preferred (HMO) | ALIGNMENT HEALTH PLAN | T3 | No | $0 | CA |
| Alignment Health smartHMO (HMO) | ALIGNMENT HEALTH PLAN | T3 | No | $0 | CA |
| Alignment Health Platinum + Instacart (HMO-POS) | ALIGNMENT HEALTH PLAN | T3 | No | $0 | CA |
| Alignment Health My Choice (HMO) | ALIGNMENT HEALTH PLAN | T3 | No | $0 | CA |
| Alignment Health Harmony (HMO) | ALIGNMENT HEALTH PLAN | T3 | No | $0 | CA |
Frequently Asked Questions
Is acetaminophen 300 MG / butalbital 50 MG / caffeine 40 MG / codeine phosphate 30 MG Oral Capsule covered by Medicare Part D?
Yes, acetaminophen 300 MG / butalbital 50 MG / caffeine 40 MG / codeine phosphate 30 MG Oral Capsule is covered by 130 Medicare Part D plans (2.6% of all Part D formularies).
What tier is acetaminophen 300 MG / butalbital 50 MG / caffeine 40 MG / codeine phosphate 30 MG Oral Capsule on Medicare Part D plans?
acetaminophen 300 MG / butalbital 50 MG / caffeine 40 MG / codeine phosphate 30 MG Oral Capsule averages Tier 2.9 across Part D plans, ranging from Tier 1 to Tier 4.
Does acetaminophen 300 MG / butalbital 50 MG / caffeine 40 MG / codeine phosphate 30 MG Oral Capsule require prior authorization?
46.7% of Part D formularies require prior authorization for acetaminophen 300 MG / butalbital 50 MG / caffeine 40 MG / codeine phosphate 30 MG Oral Capsule. Step therapy: 0%. Quantity limits: 80%.
How much does Medicare spend on acetaminophen 300 MG / butalbital 50 MG / caffeine 40 MG / codeine phosphate 30 MG Oral Capsule?
In 2023, total Medicare Part D spending on acetaminophen 300 MG / butalbital 50 MG / caffeine 40 MG / codeine phosphate 30 MG Oral Capsule was $48,943, covering 156 beneficiaries. The average spend per beneficiary was $313.74.
Read our methodology - how this data is sourced, computed, and verified.