Request For Prior Authorization Form - Highmark Blue Cross Blue Shield Delaware - Health Options
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1Request for Prior Authorization – Nicotine Replacement Therapy
Website Form –
Submit request via: Fax - 1-855-476-4158
Client name _________________________________________ DOB: ________________________________________________
Medicaid ID Number: __________________________________ Date of Request:_______________________________________
Practitioner Name:____________________________________ NPI:__________________________________________________
Office Phone Number: _________________________________ Office Fax Number: ____________________________________
(Patches, gum, nasal spray, inhalers, tablets, lozenges)
New products with this classification will automatically require the same documentation.
Nicotine replacement products aim to replace nicotine of cigarettes in order to reduce withdrawal symptoms associated with smoking
cessation.
Covered Conditions
Aid in cessation of tobacco usage
General Requirements
FDA approved dosage and duration
Must be > 18 years of age
Must be enrolled in a cessation program or have access to counseling with enrollment occurring at least 2 weeks prior to “quit date”
Limit to three quit attempts per 12 months
Limit of one treatment modality per quit attempt. Concurrent use of products will not be covered.
Coverage of inhaler requires documented prior attempts with gum, patches, and nasal spray, and lozenges
Coverage of Varenicline (Chantix) tablets will require the failure of a nicotine agonist. Chantix requests with no documented failure
of a first line agent will be approved with a relevant co-morbid diagnosis or medical rationale for avoiding first line therapies.
Approvals will be in a two-fold duration, initially for 3 months, then a reevaluation form will be needed for an additional 3 month
approval.
Max
Annual
Daily Max Dose
Duration per attempt
attempt
Treatment Modalities
Nicotine Gum
<24 pieces
12 Weeks
3
Nicotine Patch
1 patch
12 Weeks
3
Nicotine Nasal Spray
< 40 sprays
6 months
2
Nicotine Lozenges
< 12 lozenges
12 Weeks
3
Nicotine Inhaler
< 16 cartridges
6 months
2
Varenicline
2 tablets
3-6 months
2
Authorization:
Diagnosis________________________________ Co-morbid Diagnosis____________________________
Proposed Regimen: Gum____ Patch____ Nasal Spray____ Lozenges____ Inhaler_____ Tablet_____
Date of Last Quit Attempt (if applicable) _________________Product______
Cessation Program Information_____________________________________________________________
Date_______________ Additional Comments:___________________________________________________________________________
The purpose of this record is for payment purposes. The patient’s medical record must substantiate the information provided on this form and compare
for consistency. Medicaid reserves the right to request chart records to confirm the information provided above
Practitioner Signature: _____________________________________________________________________________________
Date: _____________________________________________________________________________________________________
Revised 11/07/2014
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