Janice K. Brewer, Governor Anthony D. Rodgers, Director 801 East Jefferson, Phoenix AZ 85034 phone 602 417 4000 Our first care is your health care
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
Prior Authorization Protocol Therapeutic Class: Smoking Cessation Aids Formulary Status: Medication Classes:
Nicotine Patch - Nicoderm CQ , Nicotrol , Habitrol
Bupropion - Wellbutrin , Wellbutrin XL , Zyban
FDA Approved Indications All products are FDA approved as aids for smoking cessation treatment and to help reduce withdrawal symptoms, including nicotine craving. Guidelines for Approval The following criteria apply to AHCCCS members choosing to receive a tobacco cessation product.
a. Members are encouraged to enroll in a tobacco cessation program through ADHS. To
enroll in an ADHS cessation program the member must call 1-800-55-66-222.
b. Members must contact their primary care provider (PCP) to obtain a prescription for a
tobacco cessation product. The PCP will identify an appropriate tobacco cessation product. In order to be covered by AHCCCS all tobacco use medications require a prescription. This includes all tobacco cessation products, including those that are available over-the-counter.
c. The maximum supply a member may receive of a tobacco cessation product is a 12-week
supply in a six month time period. The six month time period begins the date the first prescription is filled for the tobacco cessation product.
Draft Prepared 5.7.09 Approved by AHCCCS
Prior authorization will be required for the following: a. Members under the age of 18 years old b. Brand name medications when a generic product is available c. Bupropion 24 hour / Wellbutrin XL Coverage is Not Authorized For: a. Non-Title XIX Members b. Indications other than for as an aid for smoking cessation c. Doses greater than the FDA Maximum Allowable d. Combination treatment with more than one of the above agents e. Specific drug-disease condition contraindications Coverage for Dual Eligibles: a. Medications that are available by prescription only and bear the federal legend, “Federal Law
Prohibits Dispensing Without a Prescription” are to be obtained from and covered by the Medicare Part D Plan.
b. Medication that are available over-the-counter are to be covered by the AHCCCS Contracted
Health Plans and ordered in accordance with Section II- Guidelines for Approval.
Therapeutic Alternatives Smoking Cessation Dosing Regimen Maximum Daily Dose Product Nicotine Nasal Spray
(Zyban / Wellbutrin SR ) days, may increase to 150mg twice a
Draft Prepared 5.9.09 Approved by AHCCCS
General Information a. Nicotine (NRT)
i. Dependence has been recognized as a chronic, relapsing disease
ii. Any form is can be toxic and addictive
iii. Smoking-Drug interactions are costly to the health care system
b. Bupropion (Wellbutrin, Wellbutrin XL & Zyban)
ii. In comparative data trials, efficacy is superior to NRT
iii. Reduces weight gain after smoking cessation
iv. Has several contraindications, precautions and warnings
v. The study, A Controlled Trial of Sustained-Release Bupropion, a Nicotine Patch, or Both For Smoking Cessation. 1999, found that sustained release bupropion alone or in combination with a nicotine patch resulted in significantly higher long-term rates of smoking cessation as compared to the use of either the nicotine patch alone or placebo. Abstinence rates were higher with combination therapy than with bupropion alone but the difference was not statistically significant.
i. Represents a new class for smoking cessation therapy and acts as a nicotinic partial
ii. Dose dependent nausea has been reported in up to 40% of utilizing patients.
iv. Does not reduce weight gain after smoking cessation.
v. Efficacy of Verenicline as compared to NRT is currently unknown.
vi. In comparative trials following 12 weeks of treatment, bupropion naïve patients receiving
Verenicline were more likely to quit smoking than patients on bupropion.
vii. In one Verenicline study, an additional 12-week course of therapy was given to abstinent
patients immediately after the first 12-week course had elapsed. There is currently no data to support the efficacy of re-starting Verenicline after a lapse in therapy following the initial 12-week course.
viii. No contraindications (other than drug allergy)
ix. Extreme caution should be taken when evaluating a person with serious mental illness for
d. Abstinence rates were consistently higher with all products when combined with a behavioral
e. Based on the clinical trials of all of the products, an assumption can be drawn that Verenicline is
superior over Bupropion over NRT. References:
• AHCCCS Smoking Cessation Policy, October 2009 • Chantix Prescribing Information, Pfizer Labs, May 2006.
• Vernicline Monograph, Drug Facts and Comparisons, May 2009
• Bupropion Monograph, Drug Facts and Comparisons, May 2009 • Zyban Prescribing Information, GlaxoSmithKline, December 2008.
• Central Nervous system Agents, Smoking Deterrants, Nicotine, Drug Facts and Comparisons, May 2009 • Jorenby DE, Hays JT, Rigotti NA, et al. Efficacy of varenicline, an α4β2 nicotinic acetylcholine
receptor partial agonist, vs placebo or sustained-release bupropion for smoking cessation. JAMA. 2006;296:56-63.
Draft Prepared 5.9.09 Approved by AHCCCS
WHAT IS IT? Schizophrenia is a chronic, severe, and disabling brain disease. Approximately 1 percent of the population develops schizophrenia during their lifetime – more than 2 million Americans suffer from the illness in a given year. Although schizophrenia affects men and women with equal frequency, the disorder often appears earlier in men, usually in the late teens or early twenties, than i
One-Garden Offline Order Form To order offline, fill out your name, address, and payment information in the text boxes below, then print the entire form and write in the products you want. Or you may order by phone: 417-679-1003One-GardenBox 1, General DeliveryBrixey, MO 65618 You may fax your order to 1-240-266-8180 Zip Code: Country: Ship To (if different): Name: Zip Code:
Janice K. Brewer, Governor