memantine HCl/donepezil HCl

14 mg-10 mg, 21 mg-10 mg, 28 mg-10 mg, 7 mg-10 mg, 7 mg-10 mg (7)/14 mg-10 mg (7)/21 mg-10 mg(7)/28 mg-10 mg(7) — Extended Release Capsule

Also known as: MEMANTINE HCL-DONEPEZIL HCL ER NAMZARIC

Informational only — Coverage rules change frequently; verify tier placement and restrictions with your plan or pharmacy before acting.

1 plan

Source: Excel (XLSX) · Formulary date: Jan 5, 2026 · Checked: 16 hours, 11 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
TRICARE Uniform Formulary 2026	Tier 3 - Non-Formulary	✓	—	—	PA