Pharmacy Prior Authorization Criteria

Namzaric (memantine/donepezil)

Indications for Prior Authorization

Namzaric (memantine and donepezil hydrochloride)

• For diagnosis of Dementia of the Alzheimer's type
  Indicated for the treatment of moderate to severe dementia of the Alzheimer's type in patients stabilized on 10 mg of donepezil hydrochloride once daily.

Criteria

Brand Namzaric

For state-mandated plans in Illinois or other states where applicable: Step therapy requirements do NOT apply. Beginning January 1, 2026, step therapy requirements or use of the authorization of alternative covered medications in a manner that effectively creates a step therapy requirement will not be imposed.

Step Therapy

Length of Approval: 12 Month(s)

• Requested drug is being used for a Food and Drug Administration (FDA)-approved indication
AND
• Trial and failure (of a minimum 30-day supply), or intolerance to one of the following:
• Generic memantine AND generic donepezil
• Generic combination memantine/donepezil

P & T Revisions

1970-01-01, 2025-12-18, 2025-09-17

References

1. Namzaric Prescribing Information. Forest Pharmaceuticals, Inc. Cincinnati, Ohio. July 2016.

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Revision History

• 2025-12-18: no criteria changes, added IL statute operational note
• 2025-09-17: New drug-specific ST program

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