Limited Coverage Drugs - Special Authority Criteria

Generic Name / Strength / Form
varenicline
Criteria Approval Period

Smoking cessation where the patient wishes to stop smoking or using other tobacco products

12 weeks

Practitioner Exemptions

  • None

Special Notes

  • No Special Authority form is required.
  • Criteria applicable for all plans including Plan G
  • When writing prescriptions for varenicline, please prescribe up to a 12-week supply and note that “dispensing limited to a 28-day maximum supply per dispense” 
  • Coverage available once in a calendar year