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Medicaid & Medicare

Medicaid covers the following FDA-approved prescription medications, for a 30-day supply only:

  • Bupropion SR (marketed as Zyban)
  • Nicotine inhaler (Nicotrol)
  • Nicotine nasal spray (Nicotrol)
  • Nicotine patch
  • Varenicline (Chantix)
  • Combination therapy: Nicotine replacement therapy and Zyban; or nicotine patch and other nicotine replacement therapy

Note: Repeated courses of treatment are allowable, as long as they are consistent with FDA-approved use of smoking cessation prescription medications. Health care providers must certify in their own handwriting on the prescription or attachment, “recipient is enrolled in a physician-supervised behavioral program for nicotine adhesive patches, gum and nasal spray.”

Know the Codes: Physicians and other Certified Medicaid Providers should use appropriate ICD-9 diagnostic code and select the appropriate billing code for services rendered.

Medicare Reimbursement

Health care providers should indicate ICD-9 diagnostic code 305.1 Tobacco Use Disorder.

The billing code for counseling treatment is: G0376 (over 10 minute counseling session) or G0375 (3-10 minute counseling session).

A cessation counseling attempt includes:
1. Up to 4 cessation counseling sessions (1 attempt = up to 4 sessions)
2. Two cessation counseling attempts (or up to 8 cessation counseling sessions) are allowed every 12 months.

A cessation counseling session refers to face-to-face patient contact of either:
1. Intermediate (greater than 3 minutes up to 10 minutes); or
2. Intensive (greater than 10 minutes)

Cessation counseling sessions may be performed “incident to” the services of a qualified practitioner. During a 12-month period, the practitioner and the beneficiary have flexibility to choose between intermediate or intensive counseling strategies for each session.

Covered Medications:
Every drug plan is required by Medicare to cover at least one of the following FDA-approved medications:

  • Bupropion SR (marketed as Zyban and Wellbutrin and also available generically)
  • Nicotine inhaler (Nicotrol)
  • Nicotine nasal spray (Nicotrol)
  • Nicotine patch (if prescription)
  • Varenicline (Chantix)

Please verify with Medicare Prescription Drug Plan or Medicare Advantage Prescription Drug Plan Formulary.

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