Alzheimer's Disease, Non-injectable Drugs
PDL Reference Documents
- Alzheimer's Disease Drugs (Monoclonal antibodies) - Oct 05, 2023
- Alzheimer's Disease - Oct 07, 2021
- Alzheimer's Disease - Sep 24, 2015
- Alzheimer's Disease - Sep 23, 2014
- Alzheimer's Disease Scan Summary - Sep 23, 2014
- Class Scan: Alzheimers Medications - Sep 26, 2013
- Class Scan: Alzheimer's Drugs - Feb 23, 2012
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 | New Drug Evaluation & Updates |
|---|---|---|---|---|---|
| donepezil HCl | DONEPEZIL HCL ODT | TAB RAPDIS | Y | ||
| donepezil HCl | ARICEPT | TABLET | Y | ||
| donepezil HCl | DONEPEZIL HCL | TABLET | Y | ||
| galantamine HBr | GALANTAMINE ER | CAP24H PEL | Y | ||
| galantamine HBr | GALANTAMINE HBR | TABLET | Y | ||
| memantine HCl | MEMANTINE HCL ER | CAP SPR 24 | Y | ||
| memantine HCl | MEMANTINE HCL | SOLUTION | Y | ||
| memantine HCl | MEMANTINE HCL | TAB DS PK | Y | ||
| memantine HCl | NAMENDA | TAB DS PK | Y | ||
| memantine HCl | MEMANTINE HCL | TABLET | Y | ||
| memantine HCl/donepezil HCl | NAMZARIC | CAP SPR 24 | Y | ||
| memantine HCl/donepezil HCl | MEMANTINE HCL-DONEPEZIL HCL ER | CAP SPR 24 | Y | ||
| rivastigmine | RIVASTIGMINE | PATCH TD24 | Y | ||
| rivastigmine | EXELON | PATCH TD24 | Y | ||
| rivastigmine tartrate | RIVASTIGMINE | CAPSULE | Y | ||
| donepezil HCl | ADLARITY | PATCH TDWK | N | ||
| galantamine HBr | GALANTAMINE HYDROBROMIDE | SOLUTION | N |