Limited Coverage Drugs - Varenicline

Generic Name / Strength / Form

varenicline

Special Authority Criteria

Approval Period

Smoking cessation for patients who want to stop smoking or using other tobacco products.

12 weeks within a calendar year—No Special Authority required

Practitioner Exemptions

Special Notes

  • Criteria applicable for all plans, including Plan G

For smoking cessation

  • When prescribing under the Smoking Cessation Program, no Special Authority request is required.
  • Maximum amount covered per calendar year: One 12-week (84 day) course of varenicline or Zyban®
  • Written prescription must indicate:
    • "dispense in 28-day supply"

Special Authority Request Form(s)

  • Not applicable