Update on smoking cessation options

by Cory Bradley, PharmD

One of the most important things a person can do to improve their health is stop smoking. Accordingly, the pharmacy benefit for drugs to support smoking cessation is one of the most frequently used and asked about on the entire formulary. CareOregon covers multiple options for first-line treatment. Other products that are higher cost are subject to quantity limits or prior authorization (PA) requirements. The table below recaps the current coverage information.

Table 1. CareOregon formulary coverage

Medication

OHP (Medicaid)

CareOregon Advantage (Medicare)

Nicotine gum/lozenge/patch

Each covered up to 180 days per year

Part D excluded

(may be covered by Medicaid)

Bupropion SR

180 days per year

Covered Part D

Chantix (varenicline)

90 days every six months

Covered Part D

168 days per 365 days

Nicotine inhaler

PA required

Covered Part D

Three months per 365 days

Nicotine nasal spray

PA required

Covered Part D

Three months per 365 days

Note: Additional quantity limits may be in place for all products based on typical FDA dosing per day.

Due to Part D OTC exclusion, some nicotine replacement products are only eligible if the member has OHP (Medicaid) coverage.

Chantix (varenicline) is one of the more popular products, but also has one of the more confusing quantity limits under our Medicaid line of business. While indicated for treatment up to 24 weeks at a time, CareOregon typically only covers 12-week treatment courses (one every six months) because there is limited evidence that using Chantix longer than 12 weeks improves long-term quit rates.

A 2006 JAMA article by Tonstad, et al, showed an additional 12 weeks of therapy benefited those who achieved smoking abstinence by the end of the original 12 weeks of therapy. However, this benefit decreases significantly the longer outcomes are tracked from the end of therapy (see Table 2). Nevertheless, CareOregon will approve 24-week courses for those with documented abstinence of seven days at the end of the original 12-week course. CareOregon Advantage (our Medicare Part D plan) does not limit the duration and allows for 24-week use without PA. This is based on a specific Part D rule on FDA indications.

Table 2. Quit rates of Chantix overtime for those who are abstinent at 12 weeks

 

12 weeks

24 weeks

52 weeks

Chantix x 24 weeks

100%- trial design only those abstinent at 12 weeks*

70.5%

43.6%

Chantix x 12 weeks

50%

36.9%

* Only 64% of patients were abstinent and qualified for follow-up study.             

Recently, the CareOregon Pharmacy and Therapeutics Committee agreed to allow a retreatment course every six months (previously only one course per year was covered without PA). This means 12 weeks of Chantix is eligible every six months without PA. For more frequent retreatment requests, prior authorization is required for exception. We anxiously await the generic varenicline expected later this year, which may allow expanded formulary access.