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Pharmacist-delivered tobacco cessation counseling and medication quantity limits
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Defines Alaska Medicaid coverage changes removing prior authorization for specified tobacco cessation medications, setting six-month quantity limits, and establishing reimbursement and billing requirements for pharmacist-delivered tobacco cessation counseling when ordered by an eligible prescriber.
The prior authorization requirement for listed tobacco cessation medications was replaced by a quantity limit.
Pharmacists may be reimbursed for providing tobacco cessation counseling when ordered by an eligible prescriber and provided at the time medication is dispensed.
Coverage Criteria for Tobacco Cessation
Tobacco cessation medication quantity limits and pharmacist counseling criteria
Covered when ALL of the following are met:
ALL of the following
- Pharmacist has an order from an eligible prescriber (physician, advanced nurse practitioner, or physician assistant) for the tobacco cessation medication.
- Pharmacist has an order from an eligible prescriber (physician, advanced nurse practitioner, or physician assistant) for tobacco cessation counseling.
- Pharmacist has participated in a continuing education presentation on tobacco cessation and maintains documentation of participation onsite at the pharmacy.
- Counseling is provided in person at the time the medication is dispensed, using the program guidance attachment for questions and counseling techniques.
- Pharmacist documents the counseling in a readily retrievable system using a SOAP note that at minimum includes recipient name, date of birth, date of counseling, and details of the counseling.
ALL of the following
- Submit diagnosis code 305.1 (tobacco use disorder) in the Diagnosis Code field with Diagnosis Code Qualifier = 01.
- Add the service fee of $19.40 in the Other Amount Claimed Submitted field with Other Amount Claimed Submitted Qualifier = 99.
- The Other Amount Claimed Submitted must be included in the Gross Amount Due (sum of all charges) to receive payment.
Coding and Quantities
| 305.1 | Tobacco use disorder |
Provider Actions and Billing Requirements
Prior Authorization Removed — Six‑Month Quantity Limits Established
Prior authorization for the listed tobacco cessation medications was removed effective 2011-04-13 and replaced with a six-month quantity limit to support a maximum 6-month course (3 months at maximum daily use plus up to a 3-month taper). The maximum six-month quantities are: Nicotine Gum — 2,079 units; Nicotine Lozenges — 2,520 units; Nicotine Patches — 180 patches; Chantix (varenicline) — 360 tablets. See the Department prior authorization website for updates.
- Nicotine Gum, Max Units (6 months) = 2,079 units
- Nicotine Lozenges, Max Units (6 months) = 2,520 units
- Nicotine Patches, Max Units (6 months) = 180 patches
- Chantix®, Max Units (6 months) = 360 tablets
- Prior authorization removed effective 2011-04-13; quantity limits established to cover up to six months
Prescriber Orders Required for Medication and Counseling
Pharmacists may provide and bill for tobacco cessation counseling only when they have received a prescriber order for both the tobacco cessation medication and for pharmacist-provided counseling. Eligible prescribers include physicians, advanced nurse practitioners, or physician assistants. Counseling must be provided in person at the time the medication is dispensed.
- Pharmacist must receive a medication order from a prescriber (physician, advanced nurse practitioner, or physician assistant)
- Pharmacist must receive a separate order from a prescriber for pharmacist-provided tobacco cessation counseling
- Counseling must be provided in person at point-of-dispense
Documentation and Training Requirements for Pharmacist Counseling
Documentation and pharmacist training are required before providing and billing for the counseling service. The pharmacist must complete continuing education on tobacco cessation and retain proof of participation at the pharmacy. Counseling encounters must be documented in a readily retrievable system using a SOAP note format that includes at minimum the recipient's name, date of birth, date of counseling, and details of the counseling.
- Pharmacist must participate in tobacco cessation continuing education and keep documentation on-site
- Document each counseling encounter in SOAP format (Subjective, Objective, Assessment, Plan)
- Minimum documentation: recipient name, date of birth, date of counseling, and counseling details
Definitions and Documentation Formats
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