Limited coverage criteria – varenicline

 

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Generic name	varenicline
Strength & form	0.5 mg, 1 mg, 0.5 (11)-1 tablet

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. Details below

Special notes

For smoking cessation:

• When prescribed 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®
• Prescription must indicate "dispense in 28-day supply"

Special Authority request form(s)

• Not applicable