CurrentIndependent HealthPolicy N/A

Formulary deletion: Namzaric (memantine‑donepezil) ER capsules — PDP 3‑Tier

Announcement of formulary deletions for Namzaric extended‑release capsules (14/10 mg, 21/10 mg, 28/10 mg) from the PDP 3‑Tier formulary and replacement with generic memantine‑donepezil alternatives; affects Independent Health Pharmacy PDP beneficiaries and prescribing pharmacies.

Policy Summary

PayerIndependent Health

PolicyFormulary deletion: Namzaric (memantine‑donepezil) ER capsules — PDP 3‑Tier

Policy CodePolicy N/A

Change TypeFormulary deletion / replacement

Effective DateMay 1, 2025

Next Review DateN/A

Key ActionPrescribers should transition patients to generic memantine‑donepezil ER alternatives on Tier 1 or submit a coverage determination/exception with a supporting medical statement.

SourceLink

POLICY UPDATE CHANGES

Namzaric 14-10mg ER cap removed from PDP 3 Tier formulary.

Namzaric 21-10mg ER cap removed from PDP 3 Tier formulary.

Namzaric 28-10mg ER cap removed from PDP 3 Tier formulary.

3NDC/formulation strengths removed

2025-05-01Effective date

Formulary Changes and Coverage Stance

Formulary Deletion / Replacement

Covered status and transition instructions for removed Namzaric extended‑release capsule strengths.

Policy Summary

PayerIndependent Health

PolicyFormulary deletion: Namzaric (memantine‑donepezil) ER capsules — PDP 3‑Tier

Policy CodePolicy N/A

Change TypeFormulary deletion / replacement

Effective DateMay 1, 2025

Next Review DateN/A

Key ActionPrescribers should transition patients to generic memantine‑donepezil ER alternatives on Tier 1 or submit a coverage determination/exception with a supporting medical statement.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

What Providers and Pharmacies Must Do

Prior Authorization

How to request coverage determination / exception

To request a coverage determination or an exception, providers may contact Independent Health by mail, fax, or phone. Mail requests to Independent Health's Pharmacy Department, 511 Farber Lakes Drive, Buffalo, NY 14221. Fax requests to (716) 631-9636 or 1-800-273-7397. Phone requests: (716) 631-2934 or 1-800-247-1466, Monday–Friday, 8:00 a.m. to 5:00 p.m. Requests for coverage of a non-formulary drug or an exception to a coverage rule must include a supporting statement documenting medical necessity (see documentation callout). Expedited requests will be decided within 24 hours of receipt; standard requests will be decided within 72 hours of receipt. For exception requests, the decision time frame begins when Independent Health receives the supporting statement. We will expedite if waiting could seriously jeopardize the patient's life, health, or ability to regain maximum function.

Mail: Independent Health Pharmacy Department, 511 Farber Lakes Drive, Buffalo, NY 14221
Fax: (716) 631-9636 or 1-800-273-7397
Phone: (716) 631-2934 or 1-800-247-1466 (M–F, 8:00 a.m.–5:00 p.m.)
Expedited decision timeline: 24 hours from receipt
Standard decision timeline: 72 hours from receipt
Exception timing begins when supporting statement is obtained

Step Therapy

Preferred alternative / Tier placement

Preferred alternatives and tier placement: generic memantine-donepezil combination products are the preferred alternatives and are placed on Tier 1. When Namzaric (extended-release memantine-donepezil) formulations are removed from the formulary effective 2025-05-01, prescribers should consider switching to the generic memantine-donepezil ER capsule equivalents on Tier 1. Provide clinical rationale in the supporting statement if continuation of a brand formulation is requested despite the generic alternative being available on Tier 1.

Preferred alternative: memantine-donepezil generic ER capsule equivalents (14/10 mg, 21/10 mg, 28/10 mg)
Tier placement: Generic memantine-donepezil products — Tier 1
Effective date for Namzaric formulary deletion: 2025-05-01

Documentation Required

Supporting statement required for exceptions

A supporting statement is required for exception requests and non-formulary drug coverage determinations. The statement must explain why the requested drug is medically necessary for the patient — for example, that all formulary alternatives would be less effective or would cause adverse reactions, or that application of the coverage rule (such as step therapy or prior authorization) would be inappropriate or harmful for this patient. Include relevant clinical information, prior medication history, documented intolerances or contraindications, and any laboratory or diagnostic data that support medical necessity.

Include clinical rationale why formulary alternatives are inappropriate or harmful
Document prior medication trials, intolerances, contraindications, labs, and diagnostic findings
For prior authorization exceptions, explain why the coverage rule would be inappropriate given the patient's condition

Denial Risk

Formulary deletion may trigger denial

Formulary deletions (including removal of Namzaric ER capsule formulations effective 2025-05-01) may result in coverage denial for those specific brand products after the effective date unless an approved exception is granted. Prescribers wishing to continue a removed formulation must submit an exception request with a supporting statement demonstrating medical necessity.

Namzaric ER capsule formulations removed effective 2025-05-01
Coverage denial risk for removed formulations unless an exception is approved
Submit exception with supporting statement to request continuation of removed product

Clinical and Policy Background

Namzaric is a branded combination product containing memantine and donepezil used in management of Alzheimer’s disease. Independent Health is removing the Namzaric extended‑release capsule strengths—14/10 mg, 21/10 mg, and 28/10 mg—from the PDP 3‑Tier formulary effective 2025-05-01 and replacing them with generic memantine‑donepezil alternatives placed on Tier 1.

This formulary change is driven by availability of generic memantine‑donepezil ER products that match the removed strengths and are listed as the preferred alternatives. Providers should anticipate that coverage for the brand Namzaric formulations will be contingent on formulary status after the effective date and may require a non‑formulary coverage determination or exception if the brand is requested instead of the listed generic alternatives.

To request coverage of a non‑formulary product or an exception, providers must submit a supporting statement demonstrating medical necessity or that formulary alternatives would be less effective or cause adverse effects; expedited requests receive notice within 24 hours and standard requests within 72 hours once the request and supporting documentation are received.

Product Definitions and Affected Formulations

inv-07: Namzaric 14/10 mg extended‑release capsule — identifier

ProductNamzaric (memantine–donepezil) 14/10 mg extended‑release capsule

Formulary actionRemoved from PDP 3‑Tier formulary (Formulary Deletion)

Effective date2025-05-01

Replacement alternativeGeneric memantine‑donepezil 14/10 mg extended‑release capsule (placed on Tier 1)

Therapeutic classAntidementia Agents

inv-08: Namzaric 21/10 mg and 28/10 mg extended‑release capsules — removed strengths

ProductsNamzaric (memantine–donepezil) 21/10 mg and 28/10 mg extended‑release capsules

Formulary actionRemoved from PDP 3‑Tier formulary (Formulary Deletion)

Effective date2025-05-01

Replacement alternativesGeneric memantine‑donepezil 21/10 mg and 28/10 mg extended‑release capsules (placed on Tier 1)

Reason for changeGeneric alternative available on Tier 1