Clickable Table
Generic Name | Brand Name | Strength | Dosing | 90 Day Cost | Coverage | Comments | Category 1 | Category 2 |
---|---|---|---|---|---|---|---|---|
Nicotine Gum | Nicorette | 2 mg | 12 pcs/d | $390 | BC - Restricted / NIHB - Covered |
Lifetime $ limit |
D
Smoking Cessation
Cost quoted for 12 weeks of stated dosing frequency
|
Nicotine Replacement Therapy |
Nicotine Gum | Nicorette | 4 mg | 12 pcs/d | $390 | BC - Restricted / NIHB - Covered |
Lifetime $ limit |
D
Smoking Cessation
Cost quoted for 12 weeks of stated dosing frequency
|
Nicotine Replacement Therapy |
Nicotine Inhaler | Nicorette | Cartridges | 6 ctgs/d | $485 | BC - Restricted / NIHB - Covered |
Lifetime $ limit |
D
Smoking Cessation
Cost quoted for 12 weeks of stated dosing frequency
|
Nicotine Replacement Therapy |
Nortriptyline | Aventyl | 25 mg | 3 HS | $205 | BC / NIHB - Covered |
D
Smoking Cessation
Cost quoted for 12 weeks of stated dosing frequency
|
Smoking Cessation | |
Varenicline | Champix | 0.5 mg QD x 3 days, 0.5 mg BID x 4 days, 1 mg BID thereafter | $100 | BC - Restricted / NIHB - Covered |
Quantity limits |
D
Smoking Cessation
Cost quoted for 12 weeks of stated dosing frequency
|
Smoking Cessation | |
Bupropion | Wellbutrin SR | 150 mg | BID | $195 | BC / NIHB - Covered |
D
Smoking Cessation
Cost quoted for 12 weeks of stated dosing frequency
|
Smoking Cessation | |
Bupropion | Zyban | 150 mg | BID | $240 | BC / NIHB - Covered |
D
Smoking Cessation
Cost quoted for 12 weeks of stated dosing frequency
|
Smoking Cessation | |
Nicotine Patch | Nicoderm | 21 mg x 8 wks, 14 mg x 2 wks, 7 mg x 2 wks (patch daily) | $280 | BC - Restricted/ NIHB - Covered |
Lifetime $ limit |
D
Smoking Cessation
Cost quoted for 12 weeks of stated dosing frequency
|
Nicotine Replacement Therapy |