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
- No Special Authority required when prescribed under the Smoking Cessation Program. See details below.
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
