Subject: Namenda PA Policy 150-A 06-2022

Drug

NAMENDA  (memantine hydrochloride)

Policy:

FDA-approved Indications
Namenda, Namenda XR, and memantine hydrochloride oral solution are indicated for the treatment of moderate to severe dementia of the Alzheimer’s type.

Compendial Uses
Vascular Dementia^4,6,7

COVERAGE CRITERIA
The requested drug will be covered with prior authorization when the following criteria are met:
      •    The patient has any of the following diagnoses: A)
            moderate to severe dementia of the Alzheimer’s type,
            B) vascular dementia
      AND
      •     If the request is for continuation of therapy, the
             medication continues to provide benefit to the
             patient
             [Note: If slowing decline of cognitive function is no
             longer a goal, or if the patient is rapidly declining,
             treatment with the medication is no longer
             appropriate.]
             OR
      •     If the request is NOT for continuation of therapy, the
             diagnosis is supported by a validated cognitive
             assessment within the past 12 months

Place of Service:

Outpatient

The above policy is based on the following references:

1. Namenda [package insert]. Madison, NJ: Allergan USA, Inc.; November 2018.
2. Namenda XR [package insert]. Madison, NJ: Allergan USA, Inc.; November 2019.
3. Memantine Hydrochloride Oral Solution [package insert]. Wall, NJ: Seton Pharmaceuticals; June 2021.
4. Micromedex (electronic version). IBM Watson Health, Greenwood Village, Colorado, USA. Available at: https://www.micromedexsolutions.com. Accessed April 28, 2022.
5. Lexicomp Online, AHFS DI (Adult and Pediatric) Online, Hudson, Ohio: UpToDate, Inc.; 2022; Accessed April 28, 2022.
6. Orgogozo JM, Rigaud AS, Stoffler A, et al. Efficacy and Safety of Memantine in Patients with Mild to Moderate Vascular Dementia. Stroke. 2002;33:1834-39.
7. Wilcock G, Mobius HJ, Stoffler A. A Double-Blind, Placebo-Controlled Multicentre Study of Memantine in Mild to Moderate Vascular Dementia. Int Clin Psychopharmacol. 2002;17:297-305.
8. Rabins P, Blacker D, Rovner B, et al. Practice Guideline for the Treatment of Patients with Alzheimer’s Disease and Other Dementias, Second Edition. Am J Psychiatry. 2007;164(12S):1-56.
9. Rabins P, Rovner B, Rummans T, et al. Guideline Watch (October 2014): Practice Guideline for the Treatment of Patients with Alzheimer’s Disease and Other Dementias. 2014;1-26.
10. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA, American Psychiatric Association, 2013.

Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.

October 15, 2022