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

Step Therapy

Length of Approval: 12 Month(s)

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

P & T Revisions

2026-08-21, 2025-12-18, 2025-09-17

References

1. Namzaric Prescribing Information. AbbVie Inc. North Chicago, IL. March 2026.

---

Revision History

• 2026-08-21: Annual Review 2026 - Updated for standard ST verbiage through alts with same active ingredients with no change to clinical intent. Background updates
• 2025-12-18: no criteria changes, added IL statute operational note
• 2025-09-17: New drug-specific ST program

---