Limited Coverage Drugs – Bupropion

Generic Name

bupropion
Strength 100 mg SR, 150 mg SR, 150 mg XL, 300 mg XL
Form tablet

Special Authority Criteria

Approval Period

Diagnosis indicating depression (GENERIC)

Indefinite

 

Smoking cessation (Zyban® ONLY) for patients who want to stop smoking or using other tobacco products. 12 weeks within a calendar year—No Special Authority required

Practitioner Exemptions

  • Bupropion (generic): Psychiatrists, when prescribed for depression only.
  • Zyban® only: No Special Authority required when prescribed under the Smoking Cessation Program. See details below.

Special Notes

Generic bupropion for depression

  • Criteria applicable for all plans including Plan G.
  • Generic bupropion is eligible for PharmaCare coverage only when prescribed for depression; coverage is not available when it is prescribed for any other indication.

Zyban® for smoking cessation

  • For smoking cessation, PharmaCare covers only the Zyban® brand; that is, Wellbutrin®, Wellbutrin XL® and generic bupropion are not covered for this indication.
  • When prescribing Zyban® under the Smoking Cessation Program, no Special Authority request is required.
  • Maximum amount covered per calendar year: One 12-week (84 day) course of bupropion (Zyban®) or varenicline.
  • Written prescription must indicate:
    • the brand name "Zyban®"
    • "smoking cessation"
    • "no substitutions"
    • "dispense in 28-day supply"

Special Authority Request Form(s)

A Special Authority request must be submitted when generic bupropion is prescribed for depression by a physician other than a psychiatrist.