MEMANTINE HYDROCHLORIDE 5 mg Tablet, Film Coated

Coverage in Illinois (CMS PDP Region 17).

12 of 12 stand-alone Part D plans in Illinois cover this drug on tier 2–3.

Lowest 30-day cost $0.00 at a preferred pharmacy. 12 of 12 plans apply a prior authorization, step therapy or quantity limit.

137 Medicare Advantage plans in IL 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. IL: 137 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	$0.1691	—	Prior authorization
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	2Generic	$0.00	$0.00	$0.1718	—	Prior authorization
Humana Premier Rx Plan (PDP)$119.40/mo premium · $0.00 deductible	2Generic	$4.00	$0.00	$0.1691	—	Prior authorization
Blue Cross MedicareRx Value (PDP)$119.70/mo premium · $615.00 deductible	2Generic	$1.00	$3.00	$0.2050	—	Prior authorization
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$0.5823	—	Prior authorization
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$0.5823	—	Prior authorization
AARP Medicare Rx Saver from UHC (PDP)$40.20/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.1186	$1.079 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$0.4157	$3.749 units	Prior authorization Quantity limit 9 per 30 days
Blue Cross MedicareRx Basic (PDP)$89.70/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$0.1967	—	Prior authorization
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.0678	$0.416 units	Prior authorization Quantity limit 6 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$103.90/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$0.1275	$1.159 units	Prior authorization Quantity limit 9 per 30 days
HealthSpring Assurance Rx (PDP)$104.20/mo premium · $615.00 deductible	3Preferred Brand	21%	21%	$0.1287	$1.169 units	Prior authorization Quantity limit 9 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 →