Tobacco Smoking Cessation

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PDL Status Values

Y = preferred
N = non-preferred. Non-preferred drugs listed as N but without clinical drug use criteria are subject to the Non-Preferred Drugs in Select PDL Classes prior authorization criteria. New drugs will be listed as N until reviewed by the P&T Committee and are subject to the New Drug Policy.
V = voluntary non-preferred. Non-preferred mental health drugs are listed as V and prior authorization is not required but eligible patients will encounter a co-pay at the pharmacy.
Null (i.e. blank) = indicates the class or specific drug has not been reviewed for PDL placement.

To request a Prior Authorization, please use this form.

Generic Name Brand Name Form PDL
Status
Current Drug Use Criteria New Drug Evaluation
bupropion HCl BUPROPION HCL SR TAB ER 12H Y    
bupropion HCl ZYBAN TAB ER 12H Y    
nicotine NICOTINE PATCH PATCH DYSQ Y Quantity Limit  
nicotine NICOTINE PATCH PATCH DYSQ Y Quantity Limit  
nicotine NICODERM CQ PATCH TD24 Y Quantity Limit  
nicotine NICOTINE PATCH PATCH TD24 Y Quantity Limit  
nicotine NICODERM CQ PATCH TD24 Y Quantity Limit  
nicotine NICOTINE PATCH TD24 Y Quantity Limit  
nicotine NICOTINE PATCH PATCH TD24 Y Quantity Limit  
nicotine NTS PATCH TD24 Y Quantity Limit  
nicotine HABITROL PATCH TD24 Y Quantity Limit  
nicotine polacrilex NICOTINE GUM GUM Y Quantity Limit  
nicotine polacrilex NICORELIEF GUM Y Quantity Limit  
nicotine polacrilex NICORETTE GUM Y Quantity Limit  
nicotine polacrilex EQUATE NICOTINE GUM GUM Y Quantity Limit  
nicotine polacrilex NICORELIEF GUM Y Quantity Limit  
nicotine polacrilex NICOTINE GUM GUM Y Quantity Limit  
nicotine polacrilex QUIT 2 GUM Y Quantity Limit  
nicotine polacrilex QUIT 4 GUM Y Quantity Limit  
nicotine polacrilex STOP SMOKING AID GUM Y Quantity Limit  
nicotine polacrilex THRIVE NICOTINE GUM Y Quantity Limit  
nicotine polacrilex NICORETTE GUM Y Quantity Limit  
nicotine polacrilex NICORETTE LOZENGE Y Quantity Limit  
nicotine polacrilex NICOTINE LOZENGE LOZENGE Y Quantity Limit  
nicotine polacrilex COMMIT LOZENGE Y Quantity Limit  
nicotine polacrilex NICORETTE LOZENGE Y Quantity Limit  
nicotine polacrilex NICOTINE LOZENGE LOZENGE Y Quantity Limit  
nicotine polacrilex QUIT 2 LOZENGE Y Quantity Limit  
nicotine polacrilex QUIT 4 LOZENGE Y Quantity Limit  
nicotine polacrilex STOP SMOKING AID LOZENGE Y Quantity Limit  
nicotine polacrilex NICOTINE LOZENGE LOZNG MINI Y Quantity Limit  
nicotine polacrilex NICORETTE LOZNG MINI Y Quantity Limit  
nicotine polacrilex NICORETTE LOZNG MINI Y Quantity Limit  
nicotine polacrilex NICOTINE LOZENGE LOZNG MINI Y Quantity Limit  
varenicline tartrate CHANTIX TAB DS PK Y Quantity Limit  
varenicline tartrate CHANTIX TABLET Y Quantity Limit  
nicotine NICOTROL CARTRIDGE N PA Document  
nicotine NICOTROL NS SPRAY N PA Document