State Medicaid Coverage of Cessation Counseling and Pharmacotherapy - 8/14/07

Q: Does your state Medicaid program cover tobacco cessation counseling and pharmacotherapy?  If yes, will you share the specific language?  Many thanks from Kentucky!

A:

  1. Arkansas – Arkansas Cessation Analyst, Sara Daniel, provided this information. If you have further questions, please visit the www.medicaid.state.ar.us website or email sara.daniel@arkansas.gov.  The information provided below is as of November 2004.
    • In recognition of both the need and ability to facilitate tobacco cessation, Arkansas Medicaid will begin covering generic Zyban (bupropion for tobacco cessation), nicotine gum or nicotine patches.  Participating providers must have prescriptive authority and the consultation must be in the scope of their practice.  Effective for claims with dates of service on or after October 1, 2004, coverage of tobacco cessation products will be available with prior authorization to eligible Medicaid recipients.
    • Medicaid providers who will be authorized to provide the counseling services defined in this notice are: Physicians, Nurse Practitioners, Certified Nurse-Midwives, Rural Health Clinics, Federally Qualified Health Centers, Dentist and Oral Surgeons.
    • The language then outlines coverage and limitations, procedure codes for counseling, etc.  Tobacco cessation products are not subject to co-pay and do not count towards the monthly prescription limit.  Arkansas Medicaid provider manuals are available for downloading from the Arkansas Medicaid website: www.medicaid.state.ar.us.
       
  2. Indiana – Attached is Indiana’s Medicaid bulletin that can be shared for specific language:

     
  3. Iowa – The legislative language that enabled cessation coverage under Iowa Medicaid is as follows:
    SMOKING CESSATION.  The department, in collaboration with Iowa department of public health programs relating to tobacco use prevention and cessation, shall implement a program with the goal of reducing smoking among recipients of medical assistance who are children to less than one percent and among recipients of medical assistance and expansion population members who are adults to less than ten percent, by July 1, 2007.

    The following is a description of the coverage provided by Iowa Medicaid (not in legislative language):

    4. A. Program Description
    • Effective January 1, 2007, the Iowa Medicaid Program expanded coverage to include select over-the-counter nicotine replacement patches and gum, and generic bupropion sustained-release products that are FDA-indicated for smoking cessation (generic Zyban®).
    • Bupropion 150mg sustained-release products that are FDA-indicated for smoking cessation (generic Zyban®) will be available without prior authorization (PA).
    • Over-the-counter nicotine replacement patches and gum will be covered with a prior authorization for members 18 years of age or older with a diagnosis of nicotine dependence and confirmation of enrollment in the Quitline Iowa program for counseling.
    • The maximum allowed duration of therapy is 12 weeks within a 12-month period. The initial dispensing limitations will be set at 14 units of nicotine replacement patches or 110 pieces of nicotine gum to assess patient tolerance of the medication delivery system (a two week supply).
    B. PA Process
    • Iowa Medicaid members who want assistance in quitting smoking will need to be referred to Quitline Iowa by their healthcare provider. Provider questions regarding the smoking cessation program should be directed to the IME Pharmacy Help Desk at 1-877-776-1567 or 515-725-1106 (local).  Provider questions regarding the smoking cessation counseling program may also be directed to Quitline Iowa at 1-866-822-6879 or visit their website, www.quitlineiowa.org.
    • If it is determined that the member would benefit from using over-the-counter nicotine replacement patches and/or gum, a Nicotine Replacement Therapy Prior Authorization form will need to be completed by the member and the prescriber before being faxed to Quitline Iowa at 319-384-4841.  The Prior Authorization form is available at www.iowamedicaidpdl.com. If the member would benefit from generic Zyban®; no prior authorization is required.  The prescriber would also need to write the appropriate prescriptions for the Iowa Medicaid member to present to the dispensing pharmacy.
    • Quitline Iowa will follow up with the member and assess the member’s smoking cessation counseling needs.
    • Following this initial consultation, Quitline Iowa will submit a prior authorization request to the Iowa Medicaid PA Unit for coverage of the necessary smoking cessation products.
    • In the event that the member chooses to disenroll from the Quitline Iowa program, all approved prior authorizations will be cancelled and notification will be faxed to the provider and pharmacy, while a letter will be mailed to the member.

    C. Prior Authorization Criteria for Nicotine Replacement Therapy
    Prior Authorization is required for over-the-counter nicotine replacement patches and nicotine gum. Requests for authorization must include:
    1) Diagnosis of nicotine dependence and referral to the Quitline Iowa program for counseling. 2) Confirmation of enrollment in the Quitline Iowa counseling program is required for approval. 3) Approvals will only be granted for patients eighteen years of age and older. 4) The maximum allowed duration of therapy is twelve weeks within a twelve-month period. 5) A maximum quantity of 14 nicotine replacement patches and/or 110 pieces of nicotine gum may be dispensed with the initial prescription. Subsequent prescription refills will be allowed to be dispensed as a 4-week supply at one unit per day of nicotine replacement patches and /or 330 pieces of nicotine gum. Following the first 28 days of nicotine replacement therapy, continuation is available only with documentation of ongoing participation in the Quitline Iowa program.

  1. Massachusetts – Attached are the rate sheet for the Massachusetts Medicaid smoking cessation benefit as well as one of the transmittal letters (for hospitals) detailing the specifics of the regulation.
     
  2. Montana – Medicaid coverage from the Pharmacy Provider manual section 5.6 (revised):
      Montana Smoking Cessation Drugs
      Nicotine-replacement products.
      Zyban (buproprion)
      Chantix
      Authorization given for 4-month course of therapy. Four nonconsecutivetrials of therapy are allowed per lifetime. (Working on increasing to 7 per recent studies).  Nicotine patches, bupropion, or Chantix are the preferred courses of therapy. The gum, lozenges and inhaler replacement therapies are only
      authorized for patients having allergies or intolerance to the patch
       
  3. New Hampshire – NH Medicaid does not cover smoking cessation educational services.  However, Medicaid members enrolled in the NH Medicaid Health Management Program receive educational services at no cost via our Disease Management Program administered by McKesson Health Solutions.  Members are also referred to the NH quit smoking line.  As far as pharmacotherapy I believe Chantix is a covered prescription although it is not listed on the NH Medicaid preferred drug list.  "Phantom prescriptions" were all covered during a trial period and discussions at the March Formulary Meeting indicated that Verenicline (Chanix by Pfizer) would be covered.
     
  4. North Carolina - North Carolina Medicaid covers all cessation pharmacotherapy including Chantix without need for prior authorization, no limits on number of refills.  Medicaid does not cover cessation counseling.
     
  5. North Dakota – North Dakota has the following coverage:
    • 40 psych visits/year without prior authorization 
    • Group counseling is also covered
    • Counseling must be done by a licensed clinical psychologist or LICSW
    • Gum: 1,164 pieces/person in a lifetime
      Patch: 1/day up to 90 days in a lifetime Buproprion: 1-2/day up to 90 days in a lifetime
  1. Oklahoma – SoonerCare, Oklahoma's Medicaid insurance program, offers a smoking cessation benefit. For the first 90 days, members may receive smoking cessation products such as Chantix, Zyban, or nicotine replacement through the pharmacy benefit without Prior Authorization (PA) and this does not count towards the monthly prescription limits.  After 90 days, a PA is required.  For approval, the member must submit proof of enrollment in a behavior modification program. For example, manufacturers of products such as Chantix and Zyban provide free counseling or the member may receive assistance from the Oklahoma Tobacco Helpline at (800) QUIT-NOW.  Product coverage includes Chantix, Zyban, and nicotine replacement products (gum, patches, lozenges, inhalers) with a valid prescription.  After the member has had 180 days of treatment in a 365 day period, there is a 180 day waiting period before smoking cessation treatment is covered again.  The Oklahoma Health Care Authority (Medicaid) rules on Smoking Cessation can be found in the following section of the rules:  OAC 317:30-5-2(a)(1)(FF) on page 79 of the pdf document: http://www.okhca.org/provider/policy/pdflib/chapter30.pdf
     
  2. Pennsylvania – Attached is our Medicaid bulletin outlining PA's coverage for counseling and Pharmacotherapy:
    PA_Medical Assistance Bulletin
     
  3. South Carolina – Please see attached.  SC Medicaid Program covers pharmacotherapy and SC DHEC (state health agency) covers cessation counseling through our Quitline.  A policy revision is under consideration to remove the current PA access restriction on Chantix (varenicline).
    SC_Tobacco Cessation and Quitline Nov 2006 Bulletin
     
  4. South Dakota – I am not able to send you the specific language from the Medicaid program by the 14, but I at least wanted to let you know that in SD Medicaid pays for Zyban (and the DOH pays for QL service) for Medicaid clients.  There is a $2 or $3 co-pay to the client for the prescription medication, but the rest is paid by Medicaid.
     
  5. Utah – Please see the link to follow for a summary of benefits available in Utah:http://www.tobaccofreeutah.org/healthcare-medicaid&pcnprograms.html
     
  6. West Virginia - The following is language from West Virginia's current RFP:
    1. Verify Medicaid eligibility status for each Medicaid member before entollment (Medicaid cannot reimburse for any service unless the person is a Medicaid member)
    2. Pharmacological therapy verified for eligibility with Medicaid's Pharmacy Vendor
    3. Counseling therapy verified for eligiblilty with Medicaid's Pharmacy Vendor.
    4. Vendor will follow Medicaid's policy for nrt.  (PLEASE SEE THIS WEBSITE FOR POLICY:  www.wvdhhr.org)

     
  7. Wyoming – WY Medicaid does cover counseling and pharmacotherapy services for smoking cessation.  This link is to the bulletin that address what smoking cessation drugs are covered by WY Medicaid. http://wyequalitycare.acs-inc.com/bulletins/smoking_cessation_061214.pdf
    We don't have any specific language to address counseling, but here is what WY Medicaid will cover:
    • G0375 - Smoking and Tobacco use cessation counseling visit - Intermediate, greater than 3 minutes up to 10 minutes.  This code pays $11.60/instance.
    • G0376 - Smoking and Tobacco use cessation counseling visit - Intensive, greater than 10 minutes.  This code pays $22.15/instance

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