Microsoft word - 668 smoking cessation iowacare providers1.doc

CHESTER J. CULVER, GOVERNOR
PATTY JUDGE, LT. GOVERNOR
INFORMATIONAL LETTER NO. 668
Iowa Department of Human Services, Iowa Medicaid Enterprise Subject:
Smoking Cessation Program for IowaCare Recipients Effective:
February 1, 2008

Effective February 1, 2008, the smoking cessation program that began January 1, 2007 for Iowa Medicaid
members will be expanded to include coverage for IowaCare members. IowaCare is a healthcare program that
covers limited inpatient and outpatient services. Prescriptions for smoking cessation products for IowaCare
members can be filled only at Broadlawns Medical Center and the University of Iowa Hospitals and Clinics, once
prior authorization criteria are met for the over-the-counter nicotine replacement patches and gum. Bupropion
150mg sustained-release products that are FDA-indicated for smoking cessation (generic Zyban®) will be
available without prior authorization (PA) and may also be filled only at by Broadlawns Medical Center and the
University of Iowa Hospitals and Clinics.

NOTE: When submitting a PA request form, please complete all the required fields down to the dotted line on the
fax referral form.

Smoking Cessation Program
A. Program Description

• Effective February 1, 2008, the IowaCare Program will cover select over-the-counter nicotine replacement patches and gum, and generic bupropion sustained-release products that are FDA-indicated for smoking cessation (generic Zyban®). • Bupropion 150mg sustained-release products that are FDA-indicated for smoking cessation (generic Zyban®) will be available without prior authorization (PA). • Over-the-counter nicotine replacement patches and gum will be covered with a prior authorization for members 18 years of age or older with a diagnosis of nicotine dependence and confirmation of enrollment in the Quitline Iowa program for counseling. • The maximum allowed duration of therapy is 12 weeks within a 12-month period. The initial dispensing limitations will be set at 14 units of nicotine replacement patches or 110 pieces of nicotine gum to assess patient tolerance of the medication delivery system (a two week supply). B. PA Process
• IowaCare members who want assistance in quitting smoking will need to be referred to Quitline Iowa by their healthcare provider. Provider questions regarding the smoking cessation program may also be directed to Quitline Iowa at 1-800-QUIT NOW (784-8669) or visit their website, www.quitlineiowa.org. • If it is determined that the member would benefit from using over-the-counter nicotine replacement patches and/or gum, a Nicotine Replacement Therapy Prior Authorization form will need to be completed by the member and the prescriber before being faxed to Quitline Iowa at 1-800-261-6259. If the member would benefit from generic Zyban®; no prior authorization is required. The prescriber would also need to write the appropriate prescriptions for the IowaCare member to present to the dispensing pharmacy. • Quitline Iowa will follow up with the member and assess the member’s smoking cessation needs. IOWA MEDICAID ENTERPRISE - 100 ARMY POST ROAD - DES MOINES, IA 50315 • Following this initial consultation, Quitline Iowa will submit a prior authorization request to the Iowa Medicaid PA Unit for coverage of the necessary smoking cessation products. • In the event that the member chooses to disenroll from the Quitline Iowa program, all approved prior authorizations will be cancelled and notification will be faxed to the provider and pharmacy, while a letter will be mailed to the member. C. Prior Authorization Criteria for Nicotine Replacement Therapy

Nicotine Replacement
Prior Authorization is required for over-the-counter nicotine replacement patches and nicotine gum. Requests for authorization must include: 1) Diagnosis of nicotine dependence and referral to the Quitline Iowa program for counseling. 2) Confirmation of enrollment in the Quitline Iowa counseling program is required for approval. 3) Approvals will only be granted for patients eighteen years of age and older. 4) The maximum allowed duration of therapy is twelve weeks within a twelve-month period. 5) A maximum quantity of 14 nicotine replacement patches and/or 110 pieces of nicotine gum may be dispensed with the initial prescription. Subsequent prescription refills will be allowed to be dispensed as a 4-week supply at one unit per day of nicotine replacement patches and /or 330 Use Nicotine Replacement pieces of nicotine gum. Following the first 28 days of nicotine replacement Therapy form therapy, continuation is available only with documentation of ongoing participation in the Quitline Iowa program.
D. Payable OTC Products

Drug Name
OTC MAC Rate
Nicoderm CQ 7mg/24h Patch 14.00 GlaxoSmithKline SM Nicotine Dis 7mg/24hr 14.00 Mckesson Valu-Rite Nicoderm CQ Clear 14mg/24h Patch 14.00 GlaxoSmithKline Nicoderm CQ 21mg/24h Patch 14.00 GlaxoSmithKline Nicoderm CQ Clear 21mg/24h Patch 14.00 GlaxoSmithKline Nicorelief Gum 2mg 110.00 Major Pharmaceuticals Nicorelief Gum 2mg 110.00 Major Pharmaceuticals Nicorette Gum 2mg 110.00 GlaxoSmithKline Nicorette Mint Gum 2mg 110.00 GlaxoSmithKline Nicotine Gum 2mg 110.00 Leader Brand Products Nicotine Pol Gum 2mg 110.00 Mckesson Valu-Rite Nicorette Gum 4mg 110.00 GlaxoSmithKline Nicorette Mint Gum 4mg 110.00 GlaxoSmithKline Nicorelief Gum 4mg 110.00 Major Pharmaceuticals Nicorelief Gum 4mg 110.00 Major Pharmaceuticals Nicotine Gum 4mg 110.00 Leader Brand Products Nicotine Pol Gum 4mg 110.00 Mckesson Valu-Rite Nicotine Pol Gum 4mg 110.00 Mckesson Valu-Rite
E. Payable Prescription Products
Drug Name
Buproban 150mg Tab Teva Pharmaceuticals 00093-5703-01
Important Contacts

Iowa Medicaid Website
www.iowamedicaidpdl.com
* To view the Nicotine Replacement Therapy PA Criteria and
PA Form.

Iowa Medicaid Member Services 1-800-338-8366
515-725-1003
* For questions or issues regarding Iowa Medicaid member
benefits.

Iowa Medicaid Providers
8:00 am to 5:00 pm (after hours on call available) * For provider questions regarding the Iowa Medicaid smoking cessation program, covered products, or PA form completion.
Quitline Iowa 1-800-QUIT
www.quitlineiowa.org * For information on the counseling hotline. The IME appreciates your partnership as we work together to serve the needs of Iowa Medicaid members within federal requirements. If you have any questions, please contact IME Provider Services at 1-800-338-7909, locally at 515-725-1004 or by e-mail at: imeproviderservices@dhs.state.ia.us

Source: http://www.ttac.org/tcn/peers/pdfs/11.19.10/IA_Smoking_Cessation.pdf