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Memantine Prior Authorization Criteria - Medicare Part D
Prior Authorization Criteria for Approval
Prior Authorization does NOT apply to patients greater than or equal to 30 years of age
The following products are included in this PA program (formulary specific):
Enhanced and MAPD formularies: memantine tablets, memantine ER capsules, memantine oral solution
Basic formulary: memantine tablets, memantine oral solution
Memantine will be approved when the following is met:
- The patient is younger than 30 years of age AND ONE of the following:
- The patient has a diagnosis of moderate to severe dementia of the Alzheimer’s type
OR - The patient has an indication that is supported in CMS approved compendia for the requested medication
- The patient has a diagnosis of moderate to severe dementia of the Alzheimer’s type
Length of Approval: 12 months
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