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 |
D
Smoking Cessation
Cost quoted for 12 weeks of stated dosing frequency
|
Nicotine Replacement Therapy |
Nicotine Gum | Nicorette | 2 mg | 12 pcs/d | $375 | BC - Restricted / IA - 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 | $375 | BC - Restricted / IA - 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 | $465 | BC - Restricted / IA - Covered |
Lifetime $ limit |
D
Smoking Cessation
Cost quoted for 12 weeks of stated dosing frequency
|
Nicotine Replacement Therapy |
Nortriptyline | Aventyl | 25 mg | 3 HS | $180 | BC / IA - 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 | 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 |
D
Smoking Cessation
Cost quoted for 12 weeks of stated dosing frequency
|
Smoking Cessation |
Bupropion | Wellbutrin SR | 150 mg | BID | $60 | BC / IA - Covered |
D
Smoking Cessation
Cost quoted for 12 weeks of stated dosing frequency
|
Smoking Cessation | |
Bupropion | Zyban | 150 mg | BID | $220 | BC / IA - Covered |
D
Smoking Cessation
Cost quoted for 12 weeks of stated dosing frequency
|
Smoking Cessation |