Non-nicotine Combination Therapy Individual ... - Michigan

Michigan Medicaid Tobacco Cessation Benefits

6/27/2018

Health Plan

Patch OTC-

Gum

Lozenge

OTC-covered OTC-

Inhaler Nasal Spray RX product. RX product. Covered

Non-nicotine Prescription Medications

RX products. Chantix

Combination Therapy (i.e., Nicotine patch & inhaler)

Individual Counseling/ Coaching

MDHHS Approved Telephone

Resources on Plan Website

Quit Line

Covered

Covered

1-800-784-

Aetna Better covered with RX

covered with Covered with with QL of 40 per 30 covered with QL of 2

8669

mi

Health of MI

with RX

RX

a QL of 168 days

per day for two 12 week

Michigan chigan

1-866-316-3784

per 30 days

treatments per year.

Tobacco

Bupropion SR 150mg

Quitline

covered

Partner

OTC-

OTC-covered OTC-

Covered Covered

Covered

Covered

Covered/

1-800-784-

covered with RX

covered with with Rx

with Rx

with Rx

with Rx

Individual

8669



BlueCross

with RX

RX

couseling

MichiganTob your-health/health-

Complete

separate from acco Quitline resources-and-

1-800-228-8554

the 20

Partner

programs.html

outpatients

visits

Covered Covered QL Covered QL Covered QL Covered QL

RX covered for generic RX covered

Contact Health 1-800-784-

QL

Zyban and Wellbutrin

Plan for

8669

M

Harbor Health Plan 1-844-427-2671

individual counseling

1-800-QUIT- edia/Default/Docu

NOW

ments/Members/H

Michigan ealth%20and%20

Tobacco Wellness/Smoking-

Quitline

Program.pdf

Partner

McLaren Health Plan-Medicaid 1-888-327-0671

Per

Per Common

Common Formulary:

Formulary OTC covered

: OTC with RX - QL

Per Common Per Common Per Common Formulary Per Common Formulary Per Common Formulary

Formulary: Formulary covered with QL (FDA covered with QL (FDA covered with QL (FDA

OTC

covered with maximum)

maximum)

maximum)

covered with QL (FDA

Covered

1-800-784- mclarenhealt

8669



1-800-QUIT-

NOW

Medicaid Fee for RX

RX

RX

Rx

RX

RX

RX

Service

(Straight

Medicaid)

1-800-642-3195

Covered with 1-800-784-

codes: 99406 8669

or 99407

Michigan

Tobacco

Quitline

Partner

Not Available

OTC-

OTC- Covered OTC-

Covered with Covered with RX

Covered with RX

Any combination of

Covered

1-844-854-

Covered with RX

Covered with RX

consisten with Common consistent with

covered/formulary

Provider

5576

Meridian Health Plan 1-888-437-0606

with RX consistent with RX

consistent Common

consistent

with

Formulary

with

Common

Common

consistent with Common Formulary

Formulary

Common Formulary

tobacco cessation medications /replacement therapies as prescribed by a physician consistent

couseling separate from the 20 outpatients

Meridian "New Beginnings" Smoking

Formulary

Formulary

with Common Formulary visits

Cessation

Program

OTC-

OTC-Covered OTC-

RX - QL:168 RX - QL: 40 /30 days. Chantix covered with Covered with RX - QL Covered

1-800-784- midwesthealt

Covered with Rx

Covered with cartridges/30

RX.

8669

Formul

with RX QL (Gum) = Rx

days

Michigan ary.aspx

QL

2mg, 30

QL = 20

Zyban, Wellbutrin &

Tobacco

(patches) pieces/day pieces/day.

Bupropion covered RX -

Quitline

HAP Midwest = 30

4mg, 24

Concurrent

QL 60 tablets every 30

Partner

Health Plan

patches/3 pieces/day tx with

days

888-654-2200 0days. Concurrent tx transdermal

Concurren with

nicotine

t tx with transdermal encouraged

gum/loz nicotine

encourage encouraged

d

RX-OTC- RX-OTC-QL RX-OTC-QL RX-QL

RX-QL

RX-Zyban Generic QL Covered per individual Yes,

1-800-784- molinahealth

QL

RX-Chantix

product limits

telephonic 8669



counseling is Michigan

available

Tobacco

Molina

Quitline



Healthcare of

Partner

me

Michigan

mbers/common/en-

1-888-898-7969

US/healthy/styhlth

ytips/smoking/Pag

es/quitsmoking.as

px

Priority Health Choice 1-888-975-8102

OTC GenericCoveredQL (FDA max)

OTC GenericCovered-QL (FDA max)

OTC Generic-Covered Covered-QL QL (FDA max)

Covered - QL

RX generic Zyban and Covered per individual Chantix Covered - QL product limits

Total Health Care 1-800-826-2862

OTC Covered with RX QL

OTC Covered with RX - QL

OTC

Covered with Covered with RX - QL

Covered with RX - QL

RX - QL

Generic Zyban and Covered with RX - QL Chantix covered ? RX ? QL 60 of tablets per 30 days. Maximum 24 weeks of therapy per year.

RX-OTCQL United Healthcare Community Plan 1-800-903-5253

RX-OTC-QL

RX-OTC-QL RX-QL

RX-QL

RX-Zyban-Generic-QL Covered No PA RX-Chantix-Generic-QL QL applies to:

RX-Zyban-Generic-QL RX-Chantix-Generic-QL

OTC-

OTC QL

covered covered with

with RX. RX. QL of 24

QL of one or 30 pieces

Upper Peninsula patch per per day

Health Plan

day.

dependent on

1-800-835-2556

dose.

OTC QL RX-QL

covered with covered. QL

RX. QL of of one

20 lozenges inhaler per

per day.

30 days.

Concurrent

therapy with

other

nicotine

therapy

allowed.

RX-QL covered. QL of Zyban (Generic) RX-QL Combination therapy 1 package per 30 days. (QL of 60 per 30 days). allowed.

Chantix RX-QL (Maximum of two 12 week courses of treatment per year). Concurrent therapy with nicotine therapy allowed.

Available

1-800-784- priorityhealth

8669

.com

Michigan

Tobacco

Quitline

Partner

Unlimited

1-800-784- to

coaching calls 8669

bacco-cessation

with face to 1-(800-QUIT-

face coaching NOW)

sessions when Michigan

applicable Tobacco

Quitline

Partner

Covered

1-800-784-

8669

co

Michigan ntent/dam/commu

Tobacco nityplan/plandocu

Quitline

ments/linkshealthi

Partner

nformation/MI-Quit-

Smoking.pdf

PCP Covered Services

1-800-7848669 Michigan Tobacco Quitline Partner

om/members/medi caidmichild/healthylivinginformation/tobacc o-cessation/

RX= Prescription required for coverage

In some cases, the member may obtain the brand name drug, but may incur an additional charge (higher co-pay).

Benefits are subject to change at each insurer's discretion.

Check with your insurer to confirm coverage eligibility.

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