MEMANTINE HYDROCHLORIDE Kit

Coverage in Wisconsin (CMS PDP Region 16).

8 of 10 stand-alone Part D plans in Wisconsin cover this drug on tier 2–3.

Lowest 30-day cost $0.00 at a preferred pharmacy. 8 of 8 plans apply a prior authorization, step therapy or quantity limit.

66 Medicare Advantage plans in WI 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. WI: 66 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	2Generic	$1.00	$0.00	$0.4274	$41.8998 units	Prior authorization Quantity limit 98 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$0.4274	$41.8998 units	Prior authorization Quantity limit 98 per 30 days
SilverScript Choice (PDP)$26.70/mo premium · $615.00 deductible	2Generic	$10.00	$30.00	$4.5822	$36.668 units	Prior authorization Quantity limit 98 per 365 days
Humana Premier Rx Plan (PDP)$110.60/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$0.4274	$41.8998 units	Prior authorization Quantity limit 98 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$4.8449	$38.768 units	Prior authorization Quantity limit 98 per 365 days
AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.4870	$3.908 units	Prior authorization Quantity limit 98 per 365 days
HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$4.8405	$38.728 units	Prior authorization Quantity limit 98 per 365 days
AARP Medicare Rx Preferred from UHC (PDP)$113.90/mo premium · $130.00 deductible	3Preferred Brand	15%	15%	$0.4870	$3.908 units	Prior authorization Quantity limit 98 per 365 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 →