MEMANTINE AND DONEPEZIL HYDROCHLORIDES 21/10 mg Capsule, Extended Release
Coverage in Michigan (CMS PDP Region 13).
6 of 12 stand-alone Part D plans in Michigan cover this drug on tier 3.
4 of 6 plans apply a prior authorization, step therapy or quantity limit.
76 Medicare Advantage plans in MI 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. MI: 76 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)$0.00/mo premium · $615.00 deductible | 3Preferred Brand | 25% | 25% | $12.7970 | — |
|
| AARP Medicare Rx Saver from UHC (PDP)$14.10/mo premium · $615.00 deductible | 3Preferred Brand | 17% | 17% | $16.7439 | $50.233 units |
|
| HealthSpring Extra Rx (PDP)$50.40/mo premium · $615.00 deductible | 3Preferred Brand | 17% | 17% | $12.7231 | — |
|
| AARP Medicare Rx Preferred from UHC (PDP)$78.30/mo premium · $130.00 deductible | 3Preferred Brand | 18% | 18% | $17.5859 | $52.763 units |
|
| Prescription Blue Select (PDP)$78.40/mo premium · $615.00 deductible | 3Preferred Brand | 20% | 20% | $17.4692 | — | None |
| Prescription Blue Premium (PDP)$106.70/mo premium · $0.00 deductible | 3Preferred Brand | 24% | 24% | $17.4692 | — | None |
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.