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    v1.0.31
    OpenPayerPolicy UpdatesPharmacy & Specialty DrugsAdvanced Health Tobacco PA Coverage | OpenPayer
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    CurrentAdvanced HealthPolicy N/A

    Tobacco Cessation Drug Criteria

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    This policy governs prior authorization and coverage criteria for nicotine inhalers and nicotine nasal sprays for Advanced Health members. It also identifies tobacco cessation medications available on formulary without prior authorization for up to two quit attempts per year.

    Policy Summary
    PayerAdvanced Health
    PolicyTobacco Cessation Drug Criteria
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateN/A
    Next Review DateN/A
    Key ActionBefore approval of nicotine inhaler or nasal spray, document tobacco cessation support and trials of listed formulary therapies or contraindications.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    2Formulary quit attempts without prior authorization per year
    3 monthsTobacco cessation course lookback
    12 monthsAlternative therapy trial lookback
    3 monthsApproved therapy duration

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Coverage Criteria

    Initial therapy

    Covered for nicotine inhaler or nicotine nasal spray when all of the following criteria are met.

    Initial authorization criteria

    • Tobacco cessation support

      • Qualifying support

        • The patient attended a tobacco cessation course within the past 3 months.Within the past 3 months
        • The patient is engaged with behavioral health therapy.
      • An exception to course attendance applies because no tobacco cessation course is offered in the member's area or a physical or mental health condition restricts participation, with provider documentation supporting the exception.

    • Alternative therapy requirement

      • Required formulary trials

        • The patient trialed nicotine patches within the past 12 months.Within the past 12 months
        • The patient trialed nicotine gum within the past 12 months.Within the past 12 months
        • The patient trialed nicotine lozenges within the past 12 months.Within the past 12 months
        • The patient trialed bupropion SR 150 mg tablets within the past 12 months.Within the past 12 months

    Provider Actions

    Prior Authorization

    Prior Authorization Required

    Prior authorization is required for Nicotine Inhaler and Nicotine Nasal Spray. Approval requires the patient to meet the tobacco cessation support requirement and to have trialed the listed formulary therapies or have a documented contraindication.

    • Affected therapies: Nicotine Inhaler and Nicotine Nasal Spray
    • Approval duration: 3 months, subject to the applicable quantity limits
    Step Therapy

    Trial Formulary Therapies First

    Before approval of Nicotine Inhaler or Nicotine Nasal Spray, the patient must have attended a tobacco cessation course within the past 3 months or be engaged in behavioral health therapy. The patient must also have trialed nicotine patches, nicotine gum, nicotine lozenges, bupropion SR 150 mg tablets, and varenicline within the past 12 months, unless a contraindication is documented.

    • This is a step-therapy requirement before approval
    • Formulary alternatives are available without prior authorization for up to two quit attempts per year
    Documentation Required

    Exception Documentation Required

    An exception to the tobacco cessation course requirement may be requested when no course is offered in the member’s area or when a physical or mental health condition restricts participation. The provider must submit documentation supporting the reason the course requirement cannot be met.

    • Document the lack of an available course or the condition restricting participation
    • Behavioral health therapy may satisfy the cessation support requirement
    Denial Risk

    Denial Risk: Criteria Not Met

    The request will be denied as Criteria Not Met if the patient has not attended a qualifying tobacco cessation course, is not engaged in behavioral health therapy, and does not meet a documented exception. It will also be denied if the patient has not trialed all listed formulary alternatives within the past 12 months and has no documented contraindication.

    • Providers must document qualifying cessation support, exceptions, trials, or contraindications
    • Formulary alternatives include nicotine patches, gum, lozenges, bupropion SR 150 mg tablets, and varenicline

    Policy Background

    This policy promotes use of cost-effective tobacco cessation medications and encourages participation in behavioral supports to improve cessation outcomes. Nicotine patches, nicotine gum, nicotine lozenges, bupropion SR 150 mg tablets, and varenicline tablets are available on the Advanced Health formulary without prior authorization for up to two quit attempts per year.

    Behavioral health support used with medication therapy is described as optimizing tobacco cessation outcomes. Coverage of nicotine inhalers and nicotine nasal sprays requires recent tobacco cessation support or behavioral health engagement, with documented exceptions permitted when a local cessation course is unavailable or a physical or mental health condition restricts participation.

    Initial Therapy Criteria

    Nicotine inhaler or nasal spray initial approval

    Nicotine inhaler or nicotine nasal spray may be approved when all listed criteria are met.

    Initial therapy

    • Tobacco cessation support

      • The patient attended a tobacco cessation course within the past 3 months.Within the past 3 months
      • The patient is engaged with behavioral health therapy.
      • An exception to course attendance applies because no tobacco cessation course is offered in the member's area or a physical or mental health condition restricts participation, with provider documentation supporting the exception.

        Documentation from the provider must support the exception.

    • Alternative therapy trial or contraindication

      • Required formulary trials

        • The patient trialed nicotine patches within the past 12 months.Within the past 12 months
        • The patient trialed nicotine gum within the past 12 months.Within the past 12 months
        • The patient trialed nicotine lozenges within the past 12 months.Within the past 12 months
        • The patient trialed bupropion SR 150 mg tablets within the past 12 months.Within the past 12 months

    Step Therapy Requirements

    StepRequirementDocumentation pathway
    1Before approval of nicotine inhaler or nicotine nasal spray, the patient must have trialed nicotine patches, nicotine gum, nicotine lozenges, bupropion SR 150 mg tablets, and varenicline within the past 12 months.If the patient has a contraindication to the listed therapies, document the contraindication instead of the trial history.

    Quantity Limits

    Quantity Limits
    Approved duration3 months of therapy
    Applies toNicotine inhaler or nicotine nasal spray
    Approval basisAfter required tobacco cessation support and formulary therapy trial or documented contraindication
    Quantity Limits
    Allowed attemptsUp to 2 quit attempts
    FrequencyPer year
    Covered therapiesNicotine patches, nicotine gum, nicotine lozenges, bupropion SR 150 mg tablets, and varenicline tablets
    Policy Summary
    PayerAdvanced Health
    PolicyTobacco Cessation Drug Criteria
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateN/A
    Next Review DateN/A
    Key ActionBefore approval of nicotine inhaler or nasal spray, document tobacco cessation support and trials of listed formulary therapies or contraindications.
    SourceLink
    On This Page
    Coverage CriteriaProvider ActionsPolicy BackgroundInitial Therapy CriteriaStep Therapy RequirementsQuantity Limits
    The patient trialed varenicline within the past 12 months.Within the past 12 months
  1. The patient has a contraindication to the listed alternative therapies.

    The contraindication must be documented.

  2. The patient trialed varenicline within the past 12 months.Within the past 12 months
  3. The patient has a contraindication to the listed therapies.

    The contraindication must be documented.