Limited Coverage Drugs – Bupropion
|Strength||100 mg SR, 150 mg SR, 150 mg XL, 300 mg XL|
Special Authority Criteria
|Diagnosis indicating depression (GENERIC)||
|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|
- Bupropion (generic): Psychiatrists, when prescribed for depression only.
- Zyban® only: No Special Authority required when prescribed under the Smoking Cessation Program. See details below.
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.