Clickable Table

Generic Name Brand Name Strength Dosing 90 Day Cost Coverage Comments Category 1 Category 2
Nicotine Patch Nicoderm 21 mg x 8 wks, 14 mg x 2 wks, 7 mg x 2 wks (patch daily) 21 mg x 8 wks, 14 mg x 2 wks, 7 mg x 2 wks (patch daily) $280 BC - RST / IA - Covered

Lifetime $ limit

Smoking Cessation
Cost quoted for 12 weeks of stated dosing frequency
Nicotine Replacement Therapy
Nicotine Gum Nicorette 2 mg 12 pcs/d $375 BC - RST / IA - Covered

Lifetime $ limit

Smoking Cessation
Cost quoted for 12 weeks of stated dosing frequency
Nicotine Replacement Therapy
Nicotine Gum Nicorette 4 mg 12 pcs/d $375 BC - RST / IA - Covered

Lifetime $ limit

Smoking Cessation
Cost quoted for 12 weeks of stated dosing frequency
Nicotine Replacement Therapy
Nicotine Inhaler Nicorette Cartridges 6 ctgs/d $465 BC - RST / IA - Covered

Lifetime $ limit

Smoking Cessation
Cost quoted for 12 weeks of stated dosing frequency
Nicotine Replacement Therapy
Nortriptyline Aventyl 25 mg 3 HS $170 BC / IA - Covered 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 0.5 mg QD x 3 days, 0.5 mg BID x 4 days, 1 mg BID thereafter $190 BC - SA / IA Covered

Quantity limits

Smoking Cessation
Cost quoted for 12 weeks of stated dosing frequency
Smoking Cessation
Bupropion Wellbutrin SR 150 mg BID $60 BC / IA - Covered Smoking Cessation
Cost quoted for 12 weeks of stated dosing frequency
Smoking Cessation
Bupropion Zyban 150 mg BID $215 BC / IA - Covered Smoking Cessation
Cost quoted for 12 weeks of stated dosing frequency
Smoking Cessation
Legend:
BC = Alberta Blue Cross, IA = Indian Affairs, NC = Not covered, SA = special authorization, SR = sustained release, OTC = over the counter, SQ = subcutaneous injection, SS=Social Services