HOW THE IOWA MEDICAID TOBACCO-USE CESSATION PROGRAM WORKS.

Iowa Medicaid Program coverage includes select over-the-counter nicotine replacement patches and gum, generic bupropion sustained-release products that are FDA-indicated for smoking cessation (generic Zyban®), and varenicline (Chantix™).

Over-the-counter nicotine replacement patches, gum, 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. Medicaid will not authorize coverage of the nicotine replacement patches, gum, or varenicline (Chantix™) unless the patient is actively participating in the Quitline Iowa cessation counseling program.

Bupropion 150mg sustained-release products that are FDA-indicated for smoking cessation (generic Zyban®) will be available without prior authorization.

Generic bupropion sustained-release products that are FDA-indicated for smoking cessation (generic Zyban®), and varenicline (Chantix™), will not be available to Medicaid members over the age of eighteen years old that are dual eligible for Medicare Part D.

The maximum allowed duration of therapy for over-the-counter nicotine replacement patches and gum 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). The duration of therapy for varenicline (Chantix™) is initially limited to 12 weeks within a 12-month period. For patients who have successfully stopped smoking at the end of 12 weeks, an additional course of 12 weeks treatment with varenicline (Chantix™) will be considered with a prior authorization request. The maximum duration of approvable therapy is 24 weeks within a twelve-month period.

Provider questions regarding the tobacco-use cessation program should be directed to the IME Pharmacy Help Desk at 1-877-776-1567 or 515-725-1106 (local). Hours are 8 a.m. - 5 p.m. Monday through Friday.

Prescriber Billing for Smoking Cessation Counseling Office Visit
Iowa Medicaid will cover intensive smoking cessation counseling, lasting more than 10 minutes, in an office setting. Only Physicians, Advanced Registered Nurse Practitioners, Certified Nurse Midwives, Federally Qualified Health Centers, and Rural Health Clinics will be reimbursed for smoking cessation counseling.

Physicians, ARNPs, and nurse midwives should bill CPT code 99407 (Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes) for this service. CPT code 99407 will be reimbursed at $68.13. FQHCs and Rural Health Clinics must bill the appropriate encounter code for this service and include CPT code 99407 on the claim for tracking purposes. Reimbursement will be made to FQHCs and Rural Health Clinics for the encounter code only.

Smoking cessation counseling is payable once per year. Smoking cessation counseling will not be reimbursed in addition to other evaluation and management services performed and billed on the same day. All providers must include the ICD-9-CM diagnosis code 305.1 (tobacco use disorder) on the claim. Of the smoking cessation counseling service must be maintained in the medical record and available for any future review.

PRIOR AUTHORIZATION PROCESS.

Iowa Medicaid members who want assistance with tobacco-use cessation will need to be referred to Quitline Iowa by their healthcare provider. Active participation in the Quitline Iowa counseling program is required in order to receive authorization from Medicaid for coverage of nicotine replacement therapy or varenicline (Chantix™). Provider questions regarding the tobacco-use 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 tobacco-use cessation counseling program may also be directed to Quitline Iowa at 1-800-784-8669.

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 1-800-261-6259. If it is determined that the member would benefit from using varenicline (Chantix™), a Chantix Prior Authorization Form will need to be completed by the member and the prescriber before being faxed to Quitline Iowa at 1-800-261-6259. These Prior Authorization Forms are available at www.iowamedicaidpdl.com. The prescriber would also need to write a prescription for the appropriate nicotine replacement therapy or varenicline (Chantix™) for the Iowa Medicaid member to present to the dispensing pharmacy. If the member would benefit from generic Zyban®; no prior authorization is required.

Quitline Iowa will follow up with the member and assess the member's tobacco-use cessation counseling needs.

Following this initial consultation, Quitline Iowa will fax the prior authorization request back to the Iowa Medicaid Prior Authorization 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.

PRIOR AUTHORIZATION PROCESS.

Prior authorization is required for over-the-counter nicotine replacement patches, nicotine gum, and varenicline (Chantix™). Requests for authorization must include:

  1. Diagnosis of nicotine dependence and referral to the Quitline Iowa program for counseling.
  2. Approvals will only be granted for patients 18 years of age and older.
  3. The maximum allowed duration of therapy is for over-the-counter nicotine replacement patches and gum is12 weeks within a 12-month period. The duration of therapy for varenicline (Chantix™) 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 period.
  4. A maximum quantity of 14 nicotine replacement patches or 110 pieces of nicotine gum may be dispensed with the initial prescription.
  5. Requests for varenicline (Chantix™) to be used in combination with bupropion SR or nicotine replacement therapy will not be approved.
  6. The 72-hour emergency supply rule does not apply for drugs used for the treatment of smoking cessation.

Subsequent prescription refills for nicotine replacement patches and gum will be allowed to be dispensed as a four-week supply at one unit per day of nicotine replacement patches or 330 pieces of nicotine gum. Following the first 28 days of nicotine replacement therapy, continuation is available only with continued participation in cessation counseling with Quitline Iowa.

Providers should inform patients of the requirement to participate in the counseling program through Quitline Iowa in order to obtain nicotine replacement therapy through the Medicaid pharmacy program.

If the patient wishes to switch from one approved nicotine replacement therapy product to another or change the dosage, the physician must send an updated Prior Authorization Form requesting the new product.

When submitting a Prior Authorization Form, please complete all the required fields down to the dotted line on the form. Failure to document the patient's contact information as well as their signature for consent will result in the patient not receiving his/her requested medications.