Alzheimer's Disease, Non-injectable Drugs
PDL Reference Documents
PDL Status Values
Y = preferred
N = non-preferred. Non-preferred drugs listed as N but without clinical drug use criteria are subject to the
Non-Preferred Drugs in Select PDL Classes prior authorization criteria.
New drugs will be listed as N until reviewed by the P&T Committee and are subject to the
New Drug Policy.
V = voluntary non-preferred. Non-preferred mental health drugs are listed as V and prior authorization is not required.
Null (i.e. blank) = indicates the class or specific drug has not been reviewed for PDL placement.
To request a Prior Authorization, please use this form.
| Generic Name | Brand Name | Form | PDL Status |
Current Drug Use Criteria | Carveout ‐ Bill FFS |
New Drug Evaluation & Updates |
|---|---|---|---|---|---|---|
| donepezil HCl | ARICEPT | TABLET | Y | N | ||
| donepezil HCl | DONEPEZIL HCL | TABLET | Y | N | ||
| galantamine HBr | GALANTAMINE ER | CAP24H PEL | Y | N | ||
| memantine HCl | MEMANTINE HCL ER | CAP SPR 24 | Y | N | ||
| memantine HCl | NAMENDA | TAB DS PK | Y | N | ||
| memantine HCl | MEMANTINE HCL | TABLET | Y | N | ||
| memantine HCl/donepezil HCl | NAMZARIC | CAP SPR 24 | Y | N | ||
| rivastigmine | RIVASTIGMINE | PATCH TD24 | Y | N | ||
| benzgalantamine gluconate | ZUNVEYL | TABLET DR | N | N |