{21 (memantine hydrochloride 10 MG Oral Tablet) / 28 (memantine hydrochloride 5 MG Oral Tablet) } Pack
memantine hydrochloride
RxCUI: 996572
What the CMS Formulary Data Shows for {21 (memantine hydrochloride 10 MG Oral Tablet) / 28 (memantine hydrochloride 5 MG Oral Tablet) } Pack
Per the CMS 2026 Part D formulary file, {21 (memantine hydrochloride 10 MG Oral Tablet) / 28 (memantine hydrochloride 5 MG Oral Tablet) } Pack (RxNorm concept RXCUI 996572, generic name memantine hydrochloride) appears on 171 distinct formulary files spanning 3,567 Medicare Part D plan offerings - 70.4% of enrollable Part D products, mid-range placement; shopping across contracts changes access. Tier placement ranges from Tier 1 to Tier 4, with a cross-plan average of Tier 2.4.
Real-world access to {21 (memantine hydrochloride 10 MG Oral Tablet) / 28 (memantine hydrochloride 5 MG Oral Tablet) } Pack depends on utilization management as much as tier placement: 56.1% of covering formularies require prior authorization. 0% require step therapy. 27.5% apply quantity limits.
Medicare Part D spending dashboard figures are not published for this drug. The plan-by-plan detail below lists exactly which PDP and MA-PD contracts carry {21 (memantine hydrochloride 10 MG Oral Tablet) / 28 (memantine hydrochloride 5 MG Oral Tablet) } Pack today.
Coverage Details
- Formularies covering
- 171
- Plans covering
- 3,567
- Coverage rate
- 70.4%
- Tier range
- Tier 1 – Tier 4
- Average tier
- Tier 2, Generic
Restrictions
- Prior authorization required
- 56.1% of formularies
- Step therapy required
- 0% of formularies
- Quantity limits
- 27.5% of formularies
Tier Distribution Across Plans
Medicare Advantage Plans (MA-PD) Covering {21 (memantine hydrochloride 10 MG Oral Tablet) / 28 (memantine hydrochloride 5 MG Oral Tablet) } Pack
100 Medicare Advantage plans with Part D drug coverage include this drug.
| Plan | Insurer | Tier | PA | Premium | States |
|---|---|---|---|---|---|
| Freedom VIP Care (HMO C-SNP) | FREEDOM HEALTH, INC. | T1 | Yes | $0 | FL |
| Freedom VIP Savings (HMO C-SNP) | FREEDOM HEALTH, INC. | T1 | Yes | $0 | FL |
| Freedom VIP Savings (HMO C-SNP) | FREEDOM HEALTH, INC. | T1 | Yes | $0 | FL |
| Freedom VIP Rewards (HMO C-SNP) | FREEDOM HEALTH, INC. | T1 | Yes | $0 | FL |
| Freedom VIP Rewards (HMO C-SNP) | FREEDOM HEALTH, INC. | T1 | Yes | $0 | FL |
| Optimum Diamond Rewards (HMO C-SNP) | OPTIMUM HEALTHCARE, INC. | T1 | Yes | $0 | FL |
| Optimum Diamond Savings (HMO C-SNP) | OPTIMUM HEALTHCARE, INC. | T1 | Yes | $0 | FL |
| Optimum Diamond Rewards (HMO C-SNP) | OPTIMUM HEALTHCARE, INC. | T1 | Yes | $0 | FL |
| Optimum Diamond (HMO C-SNP) | OPTIMUM HEALTHCARE, INC. | T1 | Yes | $0 | FL |
| Freedom Medi-Medi Partial (HMO D-SNP) | FREEDOM HEALTH, INC. | T1 | Yes | $0 | FL |
| Freedom Medi-Medi Full (HMO D-SNP) | FREEDOM HEALTH, INC. | T1 | Yes | $0 | FL |
| Optimum Emerald Partial (HMO D-SNP) | OPTIMUM HEALTHCARE, INC. | T1 | Yes | $0 | FL |
| Optimum Emerald Full (HMO D-SNP) | OPTIMUM HEALTHCARE, INC. | T1 | Yes | $0 | FL |
| Freedom Medicare Plan Rx (HMO) | FREEDOM HEALTH, INC. | T1 | Yes | $0 | FL |
| Freedom Medicare Plan Rx (HMO) | FREEDOM HEALTH, INC. | T1 | Yes | $0 | FL |
| Freedom VIP Savings COPD (HMO C-SNP) | FREEDOM HEALTH, INC. | T1 | Yes | $0 | FL |
| Freedom VIP Savings COPD (HMO C-SNP) | FREEDOM HEALTH, INC. | T1 | Yes | $0 | FL |
| Freedom Platinum Plan Rx (HMO) | FREEDOM HEALTH, INC. | T1 | Yes | $0 | FL |
| Freedom Platinum Plan Rx (HMO) | FREEDOM HEALTH, INC. | T1 | Yes | $0 | FL |
| Freedom Platinum Plan Rx (HMO) | FREEDOM HEALTH, INC. | T1 | Yes | $0 | FL |
| Freedom Platinum Plan Rx (HMO) | FREEDOM HEALTH, INC. | T1 | Yes | $0 | FL |
| Freedom Platinum Plan Rx (HMO) | FREEDOM HEALTH, INC. | T1 | Yes | $0 | FL |
| Freedom Platinum Rewards Plan Rx (HMO) | FREEDOM HEALTH, INC. | T1 | Yes | $0 | FL |
| Freedom Platinum Rewards Plan Rx (HMO) | FREEDOM HEALTH, INC. | T1 | Yes | $0 | FL |
| Freedom Platinum Rewards Plan Rx (HMO) | FREEDOM HEALTH, INC. | T1 | Yes | $0 | FL |
| Freedom Platinum Rewards Plan Rx (HMO) | FREEDOM HEALTH, INC. | T1 | Yes | $0 | FL |
| Freedom Platinum Rewards Plan Rx (HMO) | FREEDOM HEALTH, INC. | T1 | Yes | $0 | FL |
| Freedom Platinum Rewards Plan Rx (HMO) | FREEDOM HEALTH, INC. | T1 | Yes | $0 | FL |
| Freedom Máximo (HMO-POS) | FREEDOM HEALTH, INC. | T1 | Yes | $0 | FL |
| Freedom Máximo (HMO-POS) | FREEDOM HEALTH, INC. | T1 | Yes | $0 | FL |
| Optimum Gold Rewards Plan (HMO) | OPTIMUM HEALTHCARE, INC. | T1 | Yes | $0 | FL |
| Optimum Platinum Plan (HMO) | OPTIMUM HEALTHCARE, INC. | T1 | Yes | $0 | FL |
| Optimum Gold Plan (HMO) | OPTIMUM HEALTHCARE, INC. | T1 | Yes | $0 | FL |
| Optimum Gold Rewards Plan (HMO) | OPTIMUM HEALTHCARE, INC. | T1 | Yes | $0 | FL |
| Optimum Gold Rewards Plan (HMO) | OPTIMUM HEALTHCARE, INC. | T1 | Yes | $0 | FL |
| Optimum Diamond Rewards COPD (HMO C-SNP) | OPTIMUM HEALTHCARE, INC. | T1 | Yes | $0 | FL |
| Optimum Diamond Savings COPD (HMO C-SNP) | OPTIMUM HEALTHCARE, INC. | T1 | Yes | $0 | FL |
| Optimum Gold Plus Plan (HMO) | OPTIMUM HEALTHCARE, INC. | T1 | Yes | $0 | FL |
| Optimum Diamond Rewards COPD (HMO C-SNP) | OPTIMUM HEALTHCARE, INC. | T1 | Yes | $0 | FL |
| Florida Complete Care-Duals VIP (HMO-POS D-SNP) | HPMP OF FLORIDA, INC. | T1 | Yes | $0 | FL |
| Mercy Care Advantage (HMO D-SNP) | MERCY CARE | T1 | Yes | $0 | AZ |
| Mercy Care Advantage (HMO D-SNP) | MERCY CARE | T1 | Yes | $0 | AZ |
| Mercy Care Advantage (HMO D-SNP) | MERCY CARE | T1 | Yes | $0 | AZ |
| Elderplan Plus Long-Term Care (HMO-POS D-SNP) | ELDERPLAN, INC. | T1 | Yes | $0 | NY |
| Health Choice Pathway (HMO D-SNP) | HEALTH CHOICE ARIZONA, INC. | T1 | Yes | $0 | AZ |
| Healthfirst CompleteCare (HMO D-SNP) | HEALTHFIRST HEALTH PLAN, INC. | T1 | Yes | $0 | NY |
| IMCare Classic (HMO D-SNP) | ITASCA MEDICAL CARE | T1 | Yes | $0 | MN |
| Johns Hopkins Advantage MD D-SNP (HMO D-SNP) | HOPKINS HEALTH ADVANTAGE, INC. | T1 | Yes | $0 | MD |
| MetroPlus UltraCare (HMO D-SNP) | METROPLUS HEALTH PLAN, INC. | T1 | Yes | $0 | NY |
| Senior Whole Health SCO (HMO D-SNP) | SENIOR WHOLE HEALTH, LLC | T1 | Yes | $0 | MA |
Frequently Asked Questions
Is {21 (memantine hydrochloride 10 MG Oral Tablet) / 28 (memantine hydrochloride 5 MG Oral Tablet) } Pack covered by Medicare Part D?
Yes, {21 (memantine hydrochloride 10 MG Oral Tablet) / 28 (memantine hydrochloride 5 MG Oral Tablet) } Pack is covered by 3,567 Medicare Part D plans (70.4% of all Part D formularies).
What tier is {21 (memantine hydrochloride 10 MG Oral Tablet) / 28 (memantine hydrochloride 5 MG Oral Tablet) } Pack on Medicare Part D plans?
{21 (memantine hydrochloride 10 MG Oral Tablet) / 28 (memantine hydrochloride 5 MG Oral Tablet) } Pack averages Tier 2.4 across Part D plans, ranging from Tier 1 to Tier 4.
Does {21 (memantine hydrochloride 10 MG Oral Tablet) / 28 (memantine hydrochloride 5 MG Oral Tablet) } Pack require prior authorization?
56.1% of Part D formularies require prior authorization for {21 (memantine hydrochloride 10 MG Oral Tablet) / 28 (memantine hydrochloride 5 MG Oral Tablet) } Pack. Step therapy: 0%. Quantity limits: 27.5%.
Read our methodology - how this data is sourced, computed, and verified.