COVERED USES:

FDA Approved Indication:

Tobacco cessation.

All FDA approved indications not otherwise excluded from Part D.

AGE RESTRICTIONS:

NA

PRESCRIBER RESTRICTIONS:

NA

REQUIRED MEDICAL INFORMATION:

For initiation of treatment, a prior authorization form and relevant chart notes documenting medical rationale are required and for continuation of therapy, ongoing documentation of successful response to the medication may be necessary.

CRITERIA:

1. Member must be actively enrolled in or have completed one of the following smoking cessation programs:
   • Pharmacist-Assisted Smoking Cessation Program through Providence Hospitals in the Portland Service Area
   • Free & Clear (telephonic based program)
   • Smoking cessation classes at PHP contracted facilities outside of the Portland Service Area
OR
2. Medical rationale is required why the member cannot participate in one of the above programs.

EXCLUSION CRITERIA:

NA

COVERAGE DURATION:

Authorization (including class):

• nicotine replacement is up to 8 weeks.
• Chantix is up to 24 weeks.