CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Nicotrol Nasal Spray and Nicotrol Inhaler — Coverage Criteria

Covers medical necessity and prior authorization requirements for Nicotrol Nasal Spray and Nicotrol Inhaler used for tobacco cessation in adult members seeking pharmacologic tobacco dependence treatment.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyNicotrol Nasal Spray and Nicotrol Inhaler — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization confirming patient is ≥18, has received tobacco cessation counseling, has failed or is intolerant/contraindicated to nicotine patch/gum/lozenge and bupropion, and is not currently taking varenicline.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

18+min age

prior trialstep requirement

documentationcounseling required

vareniclinecontraindicated with

specifiedduration

Coverage Criteria

Initial Therapy

Covered when ALL of the following are met

Initial approval criteria: Patient is 18 years of age or older; treatment is requested for tobacco cessation; patient has received any form of tobacco cessation information or counseling (examples include prescriber-provided advice/information on importance of tobacco cessation, telephonic support, in-person counseling via support group or one-on-one with prescriber or prescriber representative, or pharmacist counseling); history of failure, contraindication, or intolerance to nicotine replacement patch, nicotine gum, and nicotine lozenge; history of failure, contraindication, or intolerance to bupropion (generic Zyban); patient is NOT currently taking varenicline (Chantix)all conditions required

From policy required medical information.

Use of Nicotrol Nasal Spray or Nicotrol Inhaler is excluded for patients under 18. The policy’s required medical information specifies that the patient must be 18 years of age or older for coverage to be considered.

Initial Therapy

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyNicotrol Nasal Spray and Nicotrol Inhaler — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

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Required trial/condition
Patient is 18 years of age or older
Treatment is requested for tobacco cessation
Patient has received tobacco cessation information or counseling (examples: prescriber-provided advice/information, telephonic support, in‑person counseling or pharmacist counseling)
History of failure, contraindication, or intolerance to nicotine replacement patches
History of failure, contraindication, or intolerance to nicotine gum
History of failure, contraindication, or intolerance to nicotine lozenge
History of failure, contraindication, or intolerance to bupropion (generic Zyban)
Patient is NOT currently taking varenicline (Chantix)

Provider Actions & Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required for Nicotrol Nasal Spray and Nicotrol Inhaler. Confirm the patient is age 18 or older, the request is for tobacco cessation, and that counseling or tobacco cessation information has been provided to the patient.

Patient age ≥ 18 years
Indication: tobacco cessation
Documentation that tobacco cessation counseling or information was provided (examples: prescriber advice, telephonic support, in‑person counseling, pharmacist counseling)

Step Therapy

Step Therapy Requirements

Step therapy: patient must have history of failure, contraindication, or intolerance to preferred first‑line nicotine replacement therapies and to bupropion before approval of Nicotrol Nasal Spray or Inhaler.

Trial/failure/intolerance to nicotine patch
Trial/failure/intolerance to nicotine gum
Trial/failure/intolerance to nicotine lozenge
Trial/failure/intolerance to bupropion (generic Zyban)

Documentation Required

Documentation Requirements

Required documentation must be submitted with the prior authorization request to support medical necessity.

Patient date of birth or age to confirm ≥ 18 years
Documentation of tobacco cessation counseling or information provided
Documentation of trials, failures, contraindications, or intolerance to nicotine patch, gum, lozenge, and to bupropion (as applicable)
Medication list showing patient is not currently taking varenicline (Chantix)

Denial Risk

Triggers for Denial

Requests may be denied if prerequisites are not met or documentation is incomplete.

Patient is under age 18
Missing documentation of tobacco cessation counseling/information
No documentation of required step‑therapy trials, failures, contraindications, or intolerance
Concurrent use of varenicline (Chantix) at time of request

Definitions

inv-08: Tobacco cessation counseling/information — definition and acceptable forms of counseling/documentation

DefinitionTobacco cessation information/counseling: prescriber-provided advice or information on the importance of tobacco cessation; telephonic support; in-person counseling (group or one-on-one) with the prescriber or prescriber's representative; or pharmacist counseling.

Acceptable forms — provider adviceDirect advice/information provided by the prescriber or prescriber's representative about quitting tobacco.

Acceptable forms — telephonic supportTelephone-based counseling or support services documented by the provider.

Acceptable forms — in-person counselingFace-to-face counseling in a support group or one-on-one session with the prescriber or prescriber's representative.

Acceptable forms — pharmacist counselingCounseling provided and documented by a pharmacist regarding tobacco cessation.

Most actionable requirementDocumentation that the patient has received any form of tobacco cessation information or counseling is required for prior authorization and coverage of Nicotrol products (patient must be age ≥18 and meet other criteria).

Background

Nicotrol Nasal Spray and Nicotrol Inhaler are nicotine replacement therapies indicated for tobacco cessation. Coverage is intended for adult patients pursuing pharmacologic treatment of tobacco dependence who meet the policy’s required criteria.

Prior authorization and coverage require confirmation that treatment is for tobacco cessation, that the member has received tobacco cessation information or counseling (examples include prescriber-provided advice, telephonic support, in-person counseling or pharmacist counseling), and that the member has a history of failure, contraindication, or intolerance to first-line nicotine replacement products (nicotine patch, nicotine gum, and nicotine lozenge) as well as to bupropion (generic Zyban). Requests will not be approved for members currently taking varenicline (Chantix).

OpenPayer

Nicotrol Nasal Spray and Nicotrol Inhaler — Coverage Criteria

Coverage Criteria

Initial Therapy

Continuation Therapy / Duration

Step Therapy Requirements

Provider Actions & Prior Authorization

Definitions

Background