COVERED USES:

Tobacco cessation.

Requests for a non-FDA approved ("off-label") indication requires the proposed indication be listed in either the American Hospital Formulary System (AHFS), USP-DI, or Drugdex and is considered subject to evaluation of the prescriber's medical rationale, formulary alternatives, the available published evidence-based research and whether the proposed use is determined to be experimental/investigational.

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:

When prior authorization is submitted for a formulary tobacco cessation product, the following criteria apply:

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:

Initial auth. (including class): Nicotrol Inhaler is 8 weeks, Chantix is 24 weeks.