Covering Quitting Aids
If your patient has Medi-Cal, Medicare, CMSP or private health insurance, they may be able to get products to help them quit smoking.
Here's how:
| Ask | if they smoke |
| Advise | them to quit |
| Refer | them to call 1-800-NO-BUTTS |
If applicable, arrange for prescription for one of the following:
- Patch & Zyban® - TAR not required (see below for details*)
- Spray, gum, inhaler, lozenge & Chantix® - TAR required with medical justification
Only 2 items are needed for Medi-Cal coverage of quitting aids:
1. Certificate of enrollment from an approved behavioral-modification program
- Available from the California Smokers' Helpline after first intervention call
- Once the first intervention call has been completed, California Smokers' Helpline will mail the certificate to the client or fax this direct to the client’s pharmacy
2. Prescription for quitting aid
The smoker presents the prescription and the certificate to the pharmacist, who then submits the request to Medi-Cal.
*For the Medi-Cal approved-treatment plan (no TAR needed):
- Nicoderm® CQ 21 mg, quantity 14 (with 2 refills).
- Nicoderm® 14 mg, quantity 14.
- Nicoderm® 7 mg, quantity 14.
- Nicoderm® CQ 14 mg, quantity 14 with 2 refills.
- Nicoderm® 7 mg, quantity 14.
- Write Zyban® (not the generic Wellbutrin®) for up to 12 weeks.
When writing a prescription for Nicoderm®:
If a patient smokes fewer than 10 cigarettes per day:
When writing a prescription for Zyban®:
Click here for the patients' Medi-Cal Checklist (Adobe Acrobat File)
In March 2005, Medicare Part B coverage was expanded to include two new levels of tobacco cessation counseling - intermediate and intensive. The new coverage is for patients who use tobacco and have a "disease or an adverse health effect that has been found by the U.S. Surgeon General to be linked to tobacco use, or who [are] taking a therapeutic agent whose metabolism or dosing is affected by tobacco use."
Medicare will pay for two quit attempts per year, both of which can include up to four intermediate or intensive sessions. Up to eight sessions in a 12-month period are covered.
Health care providers can be reimbursed for cessation counseling by using the newly created CPT codes (previously Medicare "G" codes) 99406 (3-10 minute intervention) and 99407 (>10 minute intervention).
Claims for tobacco cessation counseling should be submitted with the appropriate diagnosis code. Diagnosis codes should reflect the patient's condition that is adversely affected by the use of tobacco or the therapeutic agent that is affected by the use of tobacco.
Medicare drug plans also provide coverage for some tobacco dependence pharmocotherapy and will usually cover 2 quit attempts per year. Medicare will approve a quitting aid with a prescription and as long as the quitting aid is on the individual drug plan’s formulary. To search the Medicare formulary, click here or have your patient check with their pharmacist.
County Medical Services Program (CMSP) Coverage
CMSP covers some pharmacotherapy based on the CMSP coverage (depends on income level, county residence, etc) of the member.
The following items are needed for CMSP coverage of quitting aids for those members that meet coverage eligibility requirements:
1. Certificate of enrollment from an approved behavioral-modification program
- Available from the California Smokers' Helpline after first intervention call
- Once the first intervention call has been completed, California Smokers' Helpline will mail the certificate to the client or fax this direct to the client’s pharmacy
2. Prescription for quitting aid with TAR.
The patient presents the prescription and the certificate to the pharmacist, who then submits the request to CMSP along with a TAR from the clinic. Call 1-800-670-6133 for additional information on coverage of quitting aids.
Individual plans vary. Have the patient check with their carrier about procedures for coverage. Most carriers offer coverage with behavior-modification program enrollment, which includes utilization of the California Smokers' Helpline or by using programs within their own plan.
