A telephone counseling helpline for tobacco-use cessation.

What is Quitline Iowa?

0101Free to all residents of the state of Iowa

Open Monday-Thursday 7:00am–12:00am / Friday 7:00am–9:00pm / Saturday–Sunday 8:00am–7:00pm

Fax referral program for healthcare providers

Assistance available in English and Spanish, with interpreter service for most other languages

Toll-free number: 1-800-QUIT NOW / 1-800-784-8669

TTY for the hearing impaired (TDD: 1-888-229-2182)

Web site available 24 hours a day: www.quitlineiowa.org

STAFFED BY TRAINED COACHES WHO PROVIDE:

Research-based information on the health consequences of tobacco use and cessation

Assistance in designing an individualized plan to quit

Support via proactive and reactive telephone calls

CONTENTS: ASK // ADVISE // REFER // QUITLINE IOWA // MEDICAID

What is Quitline Iowa?

0101askSMOKING IS THE MOST IMPORTANT PREVENTABLE CAUSE OF PREMATURE MORTALITY AND SMOKING IS THE MOST IMPORTANT PREVENTABLE CAUSE OF PREMATURE MORTALITY AND MORBIDITYMORBIDITY11. THE FIRST STEP TO EFFECTIVE COUNSELING IS IDENTIFYING TOBACCO USERS.. THE FIRST STEP TO EFFECTIVE COUNSELING IS IDENTIFYING TOBACCO USERS.

ASK ASK // ADVISE // REFER // QUITLINE IOWA // MEDICAID // ADVISE // REFER // QUITLINE IOWA // MEDICAID

HEALTH CARE PROVIDER’S STEPS FOR PATIENT’S SUCCESSFUL TOBACCO CESSATION.

Systematically ask every patient about tobacco use at every visit.Systematically ask every patient about tobacco use at every visit.

Determine if patient is a current tobacco user, a former user, or has never been a user.Determine if patient is a current tobacco user, a former user, or has never been a user.

Determine what form of tobacco is used.Determine what form of tobacco is used.

Determine frequency of use.Determine frequency of use.

Document tobacco-use status in the patient’s record.Document tobacco-use status in the patient’s record.

11 http://www.cdc.gov/tobacco/factsheets/Tobacco_Related_Mortality_factsheet.htmhttp://www.cdc.gov/tobacco/factsheets/Tobacco_Related_Mortality_factsheet.htm

Health Care Provider’s First StepHealth Care Provider’s First Step

ASK // ASK // ADVISEADVISE // REFER // QUITLINE IOWA // MEDICAID // REFER // QUITLINE IOWA // MEDICAID

0202adviseADVICE SHOULD BEADVICE SHOULD BE11::

CLEAR:CLEAR: “I think it is important for you to quit smoking now and I can help you. Cutting down while you are “I think it is important for you to quit smoking now and I can help you. Cutting down while you are ill is not enough.”ill is not enough.”STRONG:STRONG: “As your clinician, I need you to know that quitting smoking is the most important thing you can “As your clinician, I need you to know that quitting smoking is the most important thing you can do to protect your health now and in the future. The staff and I will help you.”do to protect your health now and in the future. The staff and I will help you.”PERSONALIZED:PERSONALIZED: Tie tobacco use to current health or illness, its societal and economic costs, and its Tie tobacco use to current health or illness, its societal and economic costs, and its impact on children and others in the household.impact on children and others in the household.

FOR PATIENTS RELUCTANT TO QUIT, YOU MAY OFFER THAT HEALTH BENEFITS BEGIN ALMOST FOR PATIENTS RELUCTANT TO QUIT, YOU MAY OFFER THAT HEALTH BENEFITS BEGIN ALMOST

IMMEDIATELY AFTER QUITTING.IMMEDIATELY AFTER QUITTING.

TWELVE HOURS AFTER QUITTING:TWELVE HOURS AFTER QUITTING: The carbon monoxide level in your blood drops to normal. The carbon monoxide level in your blood drops to normal.22

TWO WEEKS TO THREE MONTHS AFTER:TWO WEEKS TO THREE MONTHS AFTER: Your circulation improves and your lung function increases. Your circulation improves and your lung function increases.33

ONE TO NINE MONTHS:ONE TO NINE MONTHS: Coughing and shortness of breath decrease; cilia (tiny hair-like structures that Coughing and shortness of breath decrease; cilia (tiny hair-like structures that move mucus out of the lungs) regain normal function in the lungs, increasing the ability to handle mucus, move mucus out of the lungs) regain normal function in the lungs, increasing the ability to handle mucus, clean the lungs, and reduce the risk of infection.clean the lungs, and reduce the risk of infection.33

ONE YEAR:ONE YEAR: The excess risk of coronary heart disease is half that of a smoker’s. The excess risk of coronary heart disease is half that of a smoker’s.33

FIVE YEARS:FIVE YEARS: Your stroke risk is reduced to that of a nonsmoker. Your stroke risk is reduced to that of a nonsmoker.33

TEN YEARS:TEN YEARS: The lung cancer death rate is about half that of a continuing smoker’s. The lung cancer death rate is about half that of a continuing smoker’s.33

FIFTEEN YEARS:FIFTEEN YEARS: The risk of coronary heart disease is that of a nonsmoker’s. The risk of coronary heart disease is that of a nonsmoker’s.33

11 US Department of Health and Human Services Clinical Practice Guide, Treating Tobacco Use and Dependence, 2000. US Department of Health and Human Services Clinical Practice Guide, Treating Tobacco Use and Dependence, 2000.22 US Surgeon General’s Report, 1988. US Surgeon General’s Report, 1988.33 US Surgeon General’s Report, 1990. US Surgeon General’s Report, 1990.

THE SECOND STEP OF EFFECTIVE COUNSELING IS TO URGE EVERY THE SECOND STEP OF EFFECTIVE COUNSELING IS TO URGE EVERY TOBACCO USER TO QUIT IN A CLEAR, STRONG AND PERSONALIZED MANNER.TOBACCO USER TO QUIT IN A CLEAR, STRONG AND PERSONALIZED MANNER.

0303

THE QUITLINE HELPS THOUSANDS

OF IOWANS EVERY YEAR.

Health Care Provider’s Next StepHealth Care Provider’s Next Step

ASK // ADVISE // ASK // ADVISE // REFERREFER // QUITLINE IOWA // MEDICAID // QUITLINE IOWA // MEDICAID

0303referPeople who quit smoking by using telephone counseling are twice as likely to remain smoke-free as People who quit smoking by using telephone counseling are twice as likely to remain smoke-free as those who try to quit on their own.those who try to quit on their own.11

Quitline Iowa uses up-to-date, evidence-based practices to address tobacco cessation:Quitline Iowa uses up-to-date, evidence-based practices to address tobacco cessation:1.1. Quitline Iowa uses a variety of approaches, including Cognitive Behavioral Theory and Motivational Interviewing, to address Quitline Iowa uses a variety of approaches, including Cognitive Behavioral Theory and Motivational Interviewing, to address

both the cognitive both the cognitive and behavioral components of nicotine addiction for people who are just thinking about quitting, ready to quit, and behavioral components of nicotine addiction for people who are just thinking about quitting, ready to quit, or have quit already and want help staying smoke-free.or have quit already and want help staying smoke-free.

2.2. Quitline Iowa also addresses the physical component of nicotine addiction by assisting people in choosing a Quitline Iowa also addresses the physical component of nicotine addiction by assisting people in choosing a method for managing and coping with withdrawal.method for managing and coping with withdrawal.

Quitline Iowa coaches are paid professionals, trained in tobacco-cessation counseling.Quitline Iowa coaches are paid professionals, trained in tobacco-cessation counseling.

Quitline Iowa coaches also have information and resources designed specifi cally for teenagers and pregnant Quitline Iowa coaches also have information and resources designed specifi cally for teenagers and pregnant women who would like to quit tobacco use. Quitline Iowa can also provide information to family and friends women who would like to quit tobacco use. Quitline Iowa can also provide information to family and friends to help them support a person who is trying to quit or stay smoke-free.to help them support a person who is trying to quit or stay smoke-free.

Quitline Iowa is funded by a grant from the Iowa Department of Public Health (IDPH), Division of Tobacco Quitline Iowa is funded by a grant from the Iowa Department of Public Health (IDPH), Division of Tobacco Use Prevention and Control, so that all services provided by the Quitline are free to Iowans.Use Prevention and Control, so that all services provided by the Quitline are free to Iowans.

1 1 Journal of Consulting and Clinical Psychology, 1996. Journal of Consulting and Clinical Psychology, 1996.

THE THIRD STEP OF EFFECTIVE COUNSELING IS TO PROACTIVELY REFER YOUR THE THIRD STEP OF EFFECTIVE COUNSELING IS TO PROACTIVELY REFER YOUR CLIENT TO EFFECTIVE PROFESSIONAL COUNSELING LIKE QUITLINE IOWA.CLIENT TO EFFECTIVE PROFESSIONAL COUNSELING LIKE QUITLINE IOWA.

HOW OUR FAX REFERRAL PROGRAM WORKS.

Determine if your patient uses tobacco and is willing to make a quit attempt.

Ask your tobacco-using patients if they would like to receive Quitline Iowa’s free cessation services:1. If the patient would like assistance, ask him/her to fi ll in their personal information on the fax referral form and make

sure they sign the form.2. If the patient declines help at this time, give him/her Quitline Iowa’s phone number and encourage him/her to call

when ready to make a quit attempt.

On the fax referral form, enter your clinic information, including the clinic name, a contact person, your phone number and your fax number. Quitline Iowa will fax back referral outcome information including whether or not the patient enrolled in the cessation program and the date upon which cessation was achieved.

Verify that the form is completed correctly.

Fax it to Quitline Iowa at 1-800-261-6259.

For Medicaid members, refer to the Medicaid section for the Nicotine Replacement Therapy Prior Authorization Form process.

Health Care Provider’s Last StepHealth Care Provider’s Last Step

QUITLINE IOWA DEMONSTRATED A 6-MONTH QUIT RATE OF 31.4% IN 2006.1

1 During fiscal year 2006, based on 15,676 callers who received counseling and responded to a follow-up survery.

Once you refer your patientsto Quitline Iowa, we take itfrom there, helping themon their journey towardsa smoke-free future.

01The patient will be greeted by a Quitline Iowa coach who has been trained in evidence-based, best practices including Motivational Interviewing and the Stages of Change.

A coach will respond to your patient’s immediate questions and gather key information (tobacco-use history, results of past quit attempts, etc.) to assist the patient in tailoring the best course of action. Some demographic information must also be gathered for statistical and reporting purposes, and all information is kept in a confi dential database.

The coach will assess the patient’s current stage of change and help the patient set a quit date.

The coach will review the available service options and collaborate with the patient on an individualized plan of action that is tailored to his/her specifi c needs.

The coach will also mail printed support materials, based on the patient’s expressed interests.

WHAT HAPPENS WHEN WE CALL YOUR PATIENT.

QUITLINE IOWA’S STEPS FOR PATIENT’S SUCCESSFUL TOBACCO CESSATION.

ASK // ADVISE // REFER // QUITLINE IOWA // MEDICAID

Physicians Final Step

Quitline Iowa’s First Step01Quitline Iowa’s First Step01

02WE WORK WITH PATIENTS TO ARRANGE A PLAN THAT WORKS FOR THEM.

ASK // ADVISE // REFER // QUITLINE IOWA // MEDICAID

Quitline Iowa’s Next Step02Quitline Iowa’s Next Step02 COMPREHENSIVE PROGRAM

Education, support and written materials available for tobacco users at any stage of changeFree two-week course of nicotine patches or gum Comprehensive coaching program with up to 8 telephonic sessions, scheduled at participants’ convenienceCustomized protocols for pregnancy, adolescents and spit tobacco usersTobacco cessation coaches trained by national experts in Motivational Interventional and Addiction Counseling

PERSONALIZED ASSISTANCE

Coaches collaborate with each patient to: • develop personalized quit plan • facilitate problem solving for high risk situationsGuidance for correct use of nicotine patches or gum

HOW THE IOWA MEDICAID TOBACCO-USE CESSATION PROGRAM WORKS.HOW THE IOWA MEDICAID TOBACCO-USE CESSATION PROGRAM WORKS.

Iowa Medicaid Program coverage includes select over-the-counter nicotine replacement patches and gum, Iowa Medicaid Program coverage includes select over-the-counter nicotine replacement patches and gum, generic bupropion sustained-release products that are FDA-indicated for smoking cessation (generic Zybangeneric bupropion sustained-release products that are FDA-indicated for smoking cessation (generic Zyban®®), ), and varenicline (Chantixand varenicline (ChantixTMTMand varenicline (Chantixand varenicline (ChantixTMand varenicline (Chantixand varenicline (Chantix ). ).

Over-the-counter nicotine replacement patches, gum, and varenicline (ChantixOver-the-counter nicotine replacement patches, gum, and varenicline (ChantixTMTMOver-the-counter nicotine replacement patches, gum, and varenicline (ChantixOver-the-counter nicotine replacement patches, gum, and varenicline (ChantixTMOver-the-counter nicotine replacement patches, gum, and varenicline (ChantixOver-the-counter nicotine replacement patches, gum, and varenicline (Chantix ) will be covered with a prior ) will be covered with a prior authorization for members 18 years of age or older with a diagnosis of nicotine dependence and confi rmation authorization for members 18 years of age or older with a diagnosis of nicotine dependence and confi rmation of enrollment in the Quitline Iowa program for counseling. Medicaid will not authorize coverage of the nicotine of enrollment in the Quitline Iowa program for counseling. Medicaid will not authorize coverage of the nicotine replacement patches, gum, or varenicline (Chantixreplacement patches, gum, or varenicline (ChantixTMTMreplacement patches, gum, or varenicline (Chantixreplacement patches, gum, or varenicline (ChantixTMreplacement patches, gum, or varenicline (Chantixreplacement patches, gum, or varenicline (Chantix ) unless the patient is actively participating in the Quitline ) unless the patient is actively participating in the Quitline Iowa cessation counseling program. Iowa cessation counseling program.

Bupropion 150mg sustained-release products that are FDA-indicated for smoking cessation (generic ZybanBupropion 150mg sustained-release products that are FDA-indicated for smoking cessation (generic Zyban®®) ) will be available without prior authorization. will be available without prior authorization.

Generic bupropion sustained-release products that are FDA-indicated for smoking cessation (generic ZybanGeneric bupropion sustained-release products that are FDA-indicated for smoking cessation (generic Zyban®®), ), and varenicline (Chantixand varenicline (ChantixTMTMand varenicline (Chantixand varenicline (ChantixTMand varenicline (Chantixand varenicline (Chantix ), will not be available to Medicaid members over the age of eighteen years old that are ), will not be available to Medicaid members over the age of eighteen years old that are dual eligibledual eligible for Medicare Part D. for Medicare Part D.

The maximum allowed duration of therapy for over-the-counter nicotine replacement patches and gum is 12 The maximum allowed duration of therapy for over-the-counter nicotine replacement patches and gum is 12 weeks within a 12-month period. The initial dispensing limitations will be set at 14 units of nicotine replacement weeks within a 12-month period. The initial dispensing limitations will be set at 14 units of nicotine replacement patches or 110 pieces of nicotine gum to assess patient tolerance of the medication delivery system (a two-patches or 110 pieces of nicotine gum to assess patient tolerance of the medication delivery system (a two-week supply). The duration of therapy for varenicline (Chantixweek supply). The duration of therapy for varenicline (ChantixTMTMweek supply). The duration of therapy for varenicline (Chantixweek supply). The duration of therapy for varenicline (ChantixTMweek supply). The duration of therapy for varenicline (Chantixweek supply). The duration of therapy for varenicline (Chantix ) is initially limited to 12 weeks within a 12-month ) is initially limited to 12 weeks within a 12-month period. For patients who have successfully stopped smoking at the end of 12 weeks, an additional course of 12 period. For patients who have successfully stopped smoking at the end of 12 weeks, an additional course of 12 weeks treatment with varenicline (Chantixweeks treatment with varenicline (ChantixTMTMweeks treatment with varenicline (Chantixweeks treatment with varenicline (ChantixTMweeks treatment with varenicline (Chantixweeks treatment with varenicline (Chantix ) will be considered with a prior authorization request. The maximum ) will be considered with a prior authorization request. The maximum duration of approvable therapy is 24 weeks within a twelve-month period. duration of approvable therapy is 24 weeks within a twelve-month period.

Provider questions regarding the tobacco-use cessation program should be directed to the IME Pharmacy Provider questions regarding the tobacco-use cessation program should be directed to the IME Pharmacy Help Desk at 1-877-776-1567 or 515-725-1106 (local). Hours are 8 am - 5 pm Monday through Friday.Help Desk at 1-877-776-1567 or 515-725-1106 (local). Hours are 8 am - 5 pm Monday through Friday.

Medicaid

TOBACCO USERS WHO USE BOTH BEHAVIORAL THERAPY AND NICOTINE REPLACEMENT THERAPY ARE TWICE AS LIKELY TO QUIT.1

1 Treating Tobacco Use and Dependence, Clinical Practice Guideline, June 2000.

ASK // ADVISE // REFER // QUITLINE IOWA // MEDICAID ASK ASK // ADVISE // REFER // QUITLINE IOWA // // ADVISE // REFER // QUITLINE IOWA // MEDICAIDMEDICAID

Prescriber Bil l ing for Smoking Cessation Counseling Prescriber Bil l ing for Smoking Cessation Counseling Office VisitOffice Visit

Iowa Medicaid will cover intensive smoking cessation counseling, Iowa Medicaid will cover intensive smoking cessation counseling, lasting more than 10 minutes, in an offi ce setting. Only Physicians, lasting more than 10 minutes, in an offi ce setting. Only Physicians, Advanced Registered Nurse Practitioners, Certifi ed Nurse Midwives, Advanced Registered Nurse Practitioners, Certifi ed Nurse Midwives, Federally Qualifi ed Health Centers, and Rural Health Clinics will be Federally Qualifi ed Health Centers, and Rural Health Clinics will be reimbursed for smoking cessation counseling. reimbursed for smoking cessation counseling.

Physicians, ARNPs, and nurse midwives should bill CPT code Physicians, ARNPs, and nurse midwives should bill CPT code 9940799407 (Smoking and tobacco use cessation counseling visit; (Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes) for this service. CPT code 99407 intensive, greater than 10 minutes) for this service. CPT code 99407 will be reimbursed at $68.13. FQHCs and Rural Health Clinics must will be reimbursed at $68.13. FQHCs and Rural Health Clinics must bill the appropriate encounter code for this service and include CPT bill the appropriate encounter code for this service and include CPT code 99407 on the claim for tracking purposes. Reimbursement code 99407 on the claim for tracking purposes. Reimbursement will be made to FQHCs and Rural Health Clinics for the encounter will be made to FQHCs and Rural Health Clinics for the encounter code only. code only.

Smoking cessation counseling is payable once per year. Smoking Smoking cessation counseling is payable once per year. Smoking cessation counseling will not be reimbursed in addition to other cessation counseling will not be reimbursed in addition to other evaluation and management services performed and billed on the evaluation and management services performed and billed on the same day. All providers must include the ICD-9-CM diagnosis code same day. All providers must include the ICD-9-CM diagnosis code 305.1 (tobacco use disorder) on the claim. Of the smoking cessation 305.1 (tobacco use disorder) on the claim. Of the smoking cessation counseling service must be maintained in the medical record and counseling service must be maintained in the medical record and available for any future review.available for any future review.

PRIOR AUTHORIZATION PROCESS.PRIOR AUTHORIZATION PROCESS.

Iowa Medicaid members who want assistance with tobacco-Iowa Medicaid members who want assistance with tobacco-use cessation will need to be referred to Quitline Iowa by their use cessation will need to be referred to Quitline Iowa by their healthcare provider. Active participation in the Quitline Iowa healthcare provider. Active participation in the Quitline Iowa counseling program is required in order to receive authorization counseling program is required in order to receive authorization from Medicaid for coverage of nicotine replacement therapy or from Medicaid for coverage of nicotine replacement therapy or varenicline (Chantixvarenicline (ChantixTMTMvarenicline (Chantixvarenicline (ChantixTMvarenicline (Chantixvarenicline (Chantix ). Provider questions regarding the tobacco-). Provider questions regarding the tobacco-use cessation program should be directed to the IME Pharmacy Help use cessation program should be directed to the IME Pharmacy Help Desk at 1-877-776-1567 or 515-725-1106 (local). Provider questions Desk at 1-877-776-1567 or 515-725-1106 (local). Provider questions regarding the tobacco-use cessation counseling program may also regarding the tobacco-use cessation counseling program may also be directed to Quitline Iowa at 1-800-784-8669 or visit their Web site, be directed to Quitline Iowa at 1-800-784-8669 or visit their Web site, www.quitlineiowa.org.www.quitlineiowa.org.

If it is determined that the member would benefi t from using If it is determined that the member would benefi t from using over-the-counter nicotine replacement patches and/or gum, a over-the-counter nicotine replacement patches and/or gum, a Nicotine Replacement Therapy Prior Authorization Form will need Nicotine Replacement Therapy Prior Authorization Form will need to be completed by the member and the prescriber before being to be completed by the member and the prescriber before being faxed to Quitline Iowa at 1-800-261-6259. If it is determined that faxed to Quitline Iowa at 1-800-261-6259. If it is determined that the member would benefi t from using varenicline (Chantixthe member would benefi t from using varenicline (ChantixTMTMthe member would benefi t from using varenicline (Chantixthe member would benefi t from using varenicline (ChantixTMthe member would benefi t from using varenicline (Chantixthe member would benefi t from using varenicline (Chantix ), a ), a Chantix Prior Authorization Form will need to be completed by the Chantix Prior Authorization Form will need to be completed by the member and the prescriber before being faxed to Quitline Iowa at member and the prescriber before being faxed to Quitline Iowa at 1-800-261-6259. These Prior Authorization Forms are available at 1-800-261-6259. These Prior Authorization Forms are available at www.iowamedicaidpdl.com and copies are included in the back www.iowamedicaidpdl.com and copies are included in the back pocket. The prescriber would also need to write a prescription for pocket. The prescriber would also need to write a prescription for the appropriate nicotine replacement therapy or varenicline the appropriate nicotine replacement therapy or varenicline (Chantix(ChantixTMTM(Chantix(ChantixTM(Chantix(Chantix ) for the Iowa Medicaid member to present to the ) for the Iowa Medicaid member to present to the dispensing pharmacy. If the member would benefi t from dispensing pharmacy. If the member would benefi t from generic Zyban®; no prior authorization is required.generic Zyban®; no prior authorization is required.

Quitline Iowa will follow up with the member and assess the Quitline Iowa will follow up with the member and assess the member’s tobacco-use cessation counseling needs.member’s tobacco-use cessation counseling needs.

Medicaid (cont.)

Following this initial consultation, Quitline Iowa will fax the prior Following this initial consultation, Quitline Iowa will fax the prior authorization request back to the Iowa Medicaid Prior Authorization authorization request back to the Iowa Medicaid Prior Authorization Unit for coverage of the necessary smoking-cessation products.Unit for coverage of the necessary smoking-cessation products.

In the event that the member chooses to disenroll from the Quitline In the event that the member chooses to disenroll from the Quitline Iowa program, all approved prior authorizations will be cancelled Iowa program, all approved prior authorizations will be cancelled and notifi cation will be faxed to the provider and pharmacy, while a and notifi cation will be faxed to the provider and pharmacy, while a letter will be mailed to the member.letter will be mailed to the member.

PRIOR AUTHORIZATION CRITERIA FOR NICOPRIOR AUTHORIZATION CRITERIA FOR NICOTINE TINE REPLACEMENT THERAPY.REPLACEMENT THERAPY.

Prior authorization is required for over-the-counter nicotine Prior authorization is required for over-the-counter nicotine replacement patches and nicotine gum. Requests for authorization replacement patches and nicotine gum. Requests for authorization must include:must include:

1.1. Diagnosis of nicotine dependence and referral to the Quitline Iowa Diagnosis of nicotine dependence and referral to the Quitline Iowa program for counseling.program for counseling.

2.2. Approvals will only be granted for patients 18 years of age and older. Approvals will only be granted for patients 18 years of age and older.

3.3. The maximum allowed duration of therapy is for over-the-counter The maximum allowed duration of therapy is for over-the-counter nicotine replacement patches and gum is12 weeks within a 12-month nicotine replacement patches and gum is12 weeks within a 12-month period. The duration of therapy for varenicline (Chantixperiod. The duration of therapy for varenicline (ChantixTMTM) is initially ) is initially limited to twelve weeks within a twelve-month period. For patients limited to twelve weeks within a twelve-month period. For patients who have successfully stopped smoking at the end of 12 weeks, who have successfully stopped smoking at the end of 12 weeks, an additional course of 12 weeks treatment will be considered with an additional course of 12 weeks treatment will be considered with a prior authorization request. The maximum duration of approvable a prior authorization request. The maximum duration of approvable therapy is 24 weeks within a twelve-month period.therapy is 24 weeks within a twelve-month period.

4.4.A maximum quantity of 14 nicotine replacement patches or 110 pieces A maximum quantity of 14 nicotine replacement patches or 110 pieces of nicotine gum may be dispensed with the initial prescription. of nicotine gum may be dispensed with the initial prescription.

5.5.Requests for varenicline (ChantixRequests for varenicline (ChantixTMTM) to be used in combination with ) to be used in combination with bupropion SR or nicotine replacement therapy will not be approved.bupropion SR or nicotine replacement therapy will not be approved.

6.6. The 72-hour emergency supply rule does not apply for drugs used for The 72-hour emergency supply rule does not apply for drugs used for the treatment of smoking cessation.the treatment of smoking cessation.

Subsequent prescription refi lls for nicotine replacement patches Subsequent prescription refi lls for nicotine replacement patches and gum will be allowed to be dispensed as a four-week supply at and gum will be allowed to be dispensed as a four-week supply at one unit per day of nicotine replacement patches or 330 pieces of one unit per day of nicotine replacement patches or 330 pieces of nicotine gum. Following the fi rst 28 days of nicotine replacement nicotine gum. Following the fi rst 28 days of nicotine replacement therapy, continuation is available only with continued participation in therapy, continuation is available only with continued participation in cessation counseling with Quitline Iowa.cessation counseling with Quitline Iowa.

Providers should inform patients of the requirement to participate Providers should inform patients of the requirement to participate in the counseling program through Quitline Iowa in order to obtain in the counseling program through Quitline Iowa in order to obtain nicotine replacement therapy through the Medicaid pharmacy nicotine replacement therapy through the Medicaid pharmacy program.program.

If the patient wishes to switch from one approved nicotine If the patient wishes to switch from one approved nicotine replacement therapy product to another or change the dosage, replacement therapy product to another or change the dosage, the physician must send an updated Prior Authorization Form the physician must send an updated Prior Authorization Form requesting the new product. requesting the new product.

When submitting a Prior Authorization Form, please complete all When submitting a Prior Authorization Form, please complete all the required fi elds down to the dotted line on the form. Failure the required fi elds down to the dotted line on the form. Failure to document the patient’s contact information as well as their to document the patient’s contact information as well as their signature for consent will result in the patient not receiving his/her signature for consent will result in the patient not receiving his/her requested medications.requested medications.

ASK ASK // ADVISE // REFER // QUITLINE IOWA // // ADVISE // REFER // QUITLINE IOWA // MEDICAIDMEDICAID

THIS PACKET CONTAINS THE FOLLOWING:

Quitl ine Iowa Fax Referral Form

Quitl ine Iowa Fax Referral Form– Spanish Language

Iowa Medicaid Prior Authorization Form– Nicotine Replacement Therapy

Iowa Medicaid Prior Authorization Form – Chantix™

For more Fax Referral Forms visit www.idph.state.ia.us/tobacco

For more Medicaid Nicotine Replacement Therapy Prior Authorization Forms visit www.iowamedicaidpdl.com and click on “PA Forms”

Photocopy additional forms as needed