Microsoft word - 703 il iowacare sc at any pharmacy _5_.doc

CHESTER J. CULVER, GOVERNOR
PATTY JUDGE, LT. GOVERNOR
INFORMATIONAL LETTER
All Iowa Medicaid Physician, Dentist, Podiatrist, Pharmacy, Home Health Agency, Rural Health Clinic, Clinic, Skilled Nursing Facility, Intermediate Care Facility, Community MH, Family Planning, Residential Care Facility, ICF MR State, Community Based ICF/MR Providers, Hospitals Iowa Department of Human Services, Iowa Medicaid Enterprise Subject:
Coverage of Drugs Used for Smoking Cessation for IowaCare Members Effective:
May 5, 2008
Purpose: The purpose of this letter is to inform you of the changes associated with coverage of smoking
cessation drugs by Iowa Medicaid Enterprise to allow IowaCare members to receive the smoking
cessation drugs at any pharmacy location. IowaCare members are required to meet the same requirements
to obtain smoking cessation drugs as Medicaid members. This includes prior authorization, duration and
quantity limits, and a copayment of $1.00 per smoking cessation prescription, including refills.
What is IowaCare?
IowaCare is limited health care for people ages 19 to 64. This program can give some inpatient and
outpatient services, physician and advanced registered nurse practitioner (ARNP) services, limited dental
services, limited prescription drug benefits, and transportation. IowaCare members can only get their
prescriptions filled at the University of Iowa Hospitals and Clinics, and IowaCare members who live in Polk
County may also get their prescriptions filled at Broadlawns Hospital. Beginning May 5, 2008, IowaCare
members may get prescriptions filled for smoking cessation products at any Iowa Medicaid participating
pharmacy.
A copy of the IowaCare card is below. The major difference between the IowaCare card and a regular
Medicaid card is the 3 stars located in the upper left hand corner.
Member Name
Member SID
IOWA MEDICAID ENTERPRISE - 100 ARMY POST ROAD - DES MOINES, IA 50315 A. Program Description
Effective January 1, 2007, the Iowa Medicaid Program began covering select over-the-counter nicotine
replacement patches and gum, and generic bupropion sustained-release products that are FDA-indicated
for smoking cessation (generic Zyban®). Effective February 18, 2008, the Iowa Medicaid Program
expanded coverage to include varenicline (Chantix™), which requires a prior authorization.
Over-the-counter nicotine replacement products and varenicline (Chantix™) 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 will be 12 weeks within a 12-month period for nicotine replacement products, and 24 weeks of therapy for varenicline (Chantix™). Bupropion sustained-release products that are FDA-indicated for smoking cessation (generic Zyban®) will be available without prior authorization. IowaCare members who want assistance in quitting smoking will need to be referred to Quitline Iowa by
their healthcare provider. We would encourage providers to go to the website at
www.iowamedicaidpdl.com to view the Nicotine Replacement Therapy and Varenicline (Chantix ™)
Prior Authorization Forms. If it is determined that the member would benefit from using over-the-counter
nicotine replacement patches and/or gum or varenicline (Chantix™), a Nicotine Replacement Therapy
Prior Authorization or Varenicline (Chantix™) Prior Authorization Form will need to be completed by
the member and the prescriber before being faxed to Quitline Iowa at 800-261-6259 for member
enrollment. At which time, Quitline Iowa will follow up with the member and assess the member’s
smoking cessation needs. Following this initial consultation, Quitline Iowa will submit prior authorization
requests to the Iowa Medicaid Enterprise for coverage of the necessary smoking cessation products. In the
event that the member chooses to dis-enroll 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. Prescriptions will also need to be issued by the prescriber for claims
processing and payment of the approved smoking cessation products. If it is determined by the provider
that the member would benefit from treatment with generic bupropion sustained-release products that are
FDA-indicated for smoking cessation (generic Zyban®), the provider needs to simply write a prescription
for generic Zyban®; no prior authorization is required.
B. Prior Authorization Criteria for Nicotine Replacement Patches, Gum and (Chantix™)
Smoking Cessation
Prior Authorization is required for over-the-counter nicotine replacement Products
patches and nicotine gum. Requests for authorization must include: 1) Diagnosis of nicotine dependence and referral to the Quitline 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 4) The maximum allowed duration of therapy is twelve weeks 5) Initial approvals will be granted for a quantity of 14 nicotine replacement patches and/or 110 pieces of nicotine gum. Subsequent approvals will be granted for 4 weeks at one unit per day of nicotine replacement patches and /or 330 pieces of nicotine gum. Following the first 28 days of therapy, approvals are available only with documentation of therapy success from 6) The 72-hour emergency supply rule does not apply for drugs used for the treatment of smoking cessation. Varenicline (Chantix®)
Prior Authorization is required for varenicline (Chantix™). Requests for 1) Diagnosis of nicotine dependence and referral to the Quitline 2) Confirmation of enrollment and ongoing participation in the Quitline Iowa counseling program is required for approval and 3) Approvals will only be granted for patients eighteen years of 4) The duration of therapy is initially limited to twelve weeks within a twelve-month period. For patients who have successfully stopped smoking at the end of 12 weeks, an additional course of 12 weeks treatment will be considered with a prior authorization request. The maximum duration of approvable therapy is 24 weeks within a twelve-month 5) Requests for varenicline to be used in combination with bupropion SR or nicotine replacement therapy will not be 6) The 72-hour emergency supply rule does not apply for drugs used for the treatment of smoking cessation. C. Payable Products

Drug Name NDC
OTC SMAC Rate
Nicoderm CQ Dis 7mg/24hr 14.00 GlaxoSmithKline SM Nicotine Dis 7mg/24hr 14.00 Mckesson Valu-Rite Nicoderm CQ Dis 14mg/24hr 14.00 GlaxoSmithKline Nicoderm CQ Dis 21mg/24hr 14.00 GlaxoSmithKline Nicoderm CQ Dis 21mg/24hr 14.00 GlaxoSmithKline Nicorette Gum 2mg 110.00 GlaxoSmithKline Nicorette Gum 2mg 110.00 GlaxoSmithKline Nicotine Pol Gum 2mg 110.00 Watson Pharma, Inc. Nicotine Pol Gum 2mg 110.00 Watson Pharma, Inc. Nicorelief Gum 2mg 110.00 Major Pharmaceuticals Nicorelief Gum 2mg 110.00 Major Pharmaceuticals Nicotine Gum 2mg 110.00 Leader Brand Products Nicotine Pol Gum 2mg 110.00 Mckesson Valu-Rite Nicorette Gum 4mg 110.00 GlaxoSmithKline Nicorette Gum 4mg 110.00 GlaxoSmithKline Nicorelief Gum 4mg 110.00 Major Pharmaceuticals Nicorelief Gum 4mg 110.00 Major Pharmaceuticals Nicotine Gum 4mg 110.00 Leader Brand Products Nicotine Pol Gum 4mg 110.00 Mckesson Valu-Rite Nicotine Pol Gum 4mg 110.00 Mckesson Valu-Rite Nicotine Pol Gum 4mg 110.00 Watson Pharma, Inc. Nicotine Pol Gum 4mg 110.00 Watson Pharma, Inc. We would encourage providers to go to the website at www.iowamedicaidpdl.com to view the Nicotine
Replacement Therapy and Varenicline (Chantix™) Prior Authorization Criteria and Prior Authorization Forms. If you have any questions, please contact the Pharmacy Prior Authorization Provider Hotline at 877-776-1567 or 515-725-1106 (local in Des Moines) or e-mail [email protected].

Source: http://www.ihconline.org/UserDocs/Pages/IDPH_Legislation_Letter.pdf