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 ZYBAN TAB ER 12H Y    
BUPROPION HCL BUPROPION HCL SR TAB ER 12H Y    
NICOTINE NICOTROL CARTRIDGE Y PA Document  
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 NTS PATCH TD24 Y Quantity Limit  
NICOTINE NICOTINE PATCH PATCH TD24 Y Quantity Limit  
NICOTINE NICOTINE PATCH TD24 Y Quantity Limit  
NICOTINE NICODERM CQ PATCH TD24 Y Quantity Limit  
NICOTINE NICOTROL NS SPRAY Y PA Document  
NICOTINE POLACRILEX NICOTINE GUM GUM Y Quantity Limit  
NICOTINE POLACRILEX NICORELIEF GUM Y Quantity Limit  
NICOTINE POLACRILEX QUIT 2 GUM Y Quantity Limit  
NICOTINE POLACRILEX QUIT 4 GUM Y Quantity Limit  
NICOTINE POLACRILEX NICORETTE GUM Y Quantity Limit  
NICOTINE POLACRILEX NICORETTE GUM Y Quantity Limit  
NICOTINE POLACRILEX NICOTINE GUM GUM Y Quantity Limit  
NICOTINE POLACRILEX NICORETTE LOZENGE Y Quantity Limit  
NICOTINE POLACRILEX NICORETTE LOZENGE Y Quantity Limit  
NICOTINE POLACRILEX COMMIT 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 LOZENGE Y Quantity Limit  
NICOTINE POLACRILEX QUIT 2 LOZENGE Y Quantity Limit  
NICOTINE POLACRILEX NICOTINE LOZENGE LOZENGE 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  
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