Brand/Generic Name

Dosage/Strength

Status

Restrictions

Notes

Relative Cost

Aricept donepezil 10 mg tablet; 5 mg tablet   $$$$$ Aricept donepezil 23 mg tablet   $$$$$ Aricept ODT donepezil 5 mg tablet,disintegrating; 10 mg tablet,disintegrating   $$$$$ Cognex Tacrine Hydrochloride     Not Applicable Exelon rivastigmine 1.5 mg capsule; 3 mg capsule; 6 mg capsule; 4.5 mg capsule   Not Applicable Exelon rivastigmine 2 mg/mL Solution   Not Applicable Exelon rivastigmine 4.6 mg/24 hour Patch 24 hr; 9.5 mg/24 hour Patch 24 hr   Not Applicable Namenda memantine 5 mg tablet; 10 mg tablet   $$$$$ Namenda Titration Pak memantine 5-10 mg tablets,dose pack   $$$$$ Razadyne galantamine 12 mg tablet; 4 mg tablet; 8 mg tablet   Not Applicable Razadyne ER galantamine 16 mg capsule,ext rel. pellets 24 hr; 24 mg capsule,ext rel. pellets 24 hr   Not Applicable Razadyne ER galantamine 8 mg capsule,ext rel. pellets 24 hr   Not Applicable Tacrine Hydrochloride Tacrine Hydrochloride     Not Applicable

Key for Product(s) Listed Above

Formulary Prior Authorization (PA may not be required for some benefit plans) Non-Formulary (Third tier coverage applies for selected plans) Not Reimbursed Quantity Limit Not available through mail order as 90-day supply* Step Therapy Generic Available. Brand name medication may be covered at a higher member cost or may not be covered for certain plans. Notes $Relative cost compared to others in category Specialty distribution for selected plans (Fourth or fifth tier coverage applied for selected plans)

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