MEMANTINE AND DONEPEZIL HYDROCHLORIDES EXTENDED-RELEASE 14/10 mg Capsule, Extended Release
Also known as Memantine And Donepezil. Coverage in Connecticut, Massachusetts, Rhode Island and Vermont (CMS PDP Region 02).
5 of 11 stand-alone Part D plans in Connecticut, Massachusetts, Rhode Island and Vermont cover this drug on tier 3–4.
3 of 5 plans apply a prior authorization, step therapy or quantity limit.
104 Medicare Advantage plans in CT, MA, RI 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. CT: 18 plans · MA: 74 plans · RI: 12 plans.
Every plan that covers it
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| AARP Medicare Rx Saver from UHC (PDP)$38.70/mo premium · $615.00 deductible | 3Preferred Brand | 17% | 17% | $16.7081 | $50.123 units |
|
| HealthSpring Assurance Rx (PDP)$139.30/mo premium · $615.00 deductible | 3Preferred Brand | 21% | 21% | $11.4553 | — |
|
| AARP Medicare Rx Preferred from UHC (PDP)$155.10/mo premium · $130.00 deductible | 3Preferred Brand | 15% | 15% | $16.7607 | $50.283 units |
|
| Blue MedicareRx Value Plus (PDP)$20.70/mo premium · $615.00 deductible | 4Non-Preferred Drug | 32% | 32% | $10.4331 | — | None |
| Blue MedicareRx Premier (PDP)$238.60/mo premium · $0.00 deductible | 4Non-Preferred Drug | 35% | 35% | $10.4331 | — | 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.