5.20 Smoking Cessation Program Policy

The Smoking Cessation Program covers two types of smoking cessation products:

• Prescription smoking cessation drugs—bupropion (brand name Zyban^®) and varenicline (generic brands)
• Specific non-prescription nicotine replacement therapy (NRT) products

Please see the specific NRTs covered in Products Covered.

Coverage is limited to a single continuous course of treatment lasting up to 12 weeks (84 days) of one eligible smoking cessation product (i.e., one course of a nicotine replacement therapy, or bupropion, or varenicline) each calendar year.

The 12 weeks (84 days) of coverage begins on the day of the first fill of the smoking cessation product.

All eligible fills of the product must be dispensed within 84 days of the first fill.

The Smoking Cessation Program coverage year runs from January 1 through December 31. Unused coverage from one calendar year cannot be carried over into the next calendar year.

Starting January 1 of every year,

• A new coverage year begins and each patient’s existing previous coverage is cancelled, even if the patient is only part way through the 12-week course of treatment; and
• Coverage is reset to 84 consecutive days (12 weeks) for the new year.

Patients who have not received all their eligible product fills for a course of treatment by December 31 may continue their treatment into the next year by accessing their new 84 days of coverage for the next year.

PharmaCare recognizes that the pack size of a particular product may result in minor overruns in treatment duration (e.g., six days over the course of treatment for blister-packed products in a 30-day supply pack size), and these small overruns are deemed acceptable.

Individuals who want to supplement the coverage available through the Smoking Cessation Program are expected to cover the costs themselves or through their extended health plans.

Under exceptional and compelling circumstances, PharmaCare may permit a change in the currently covered course of treatment (e.g., a change from a nicotine replacement therapy to one of the prescription smoking cessation drugs or vice versa).

To request a change in the currently covered course of treatment, the prescribing physician must submit a General Special Authority Request form (PDF, 656KB) requesting exceptional case-by-case consideration.

The request must include

• The patient’s diagnosis
• The current smoking cessation therapy
• Benefits that would accrue from changing the current course of treatment
• Reasons for the change
• Length of treatment needed
• Name and dosage of the alternate product, if applicable

Special Authority approval is not provided retroactively.

Plan B patients are eligible for a prescription smoking cessation drug or nicotine replacement therapy (NRT).

Since PharmaCare pays a monthly capitation fee to contracted pharmacies in addition to eligible drug costs for Plan B patients, no dispensing fees can be claimed for prescription smoking cessation drugs or non-prescription NRTs dispensed to Plan B patients.

Claims for bupropion (Zyban^®) and varenicline generics should be processed in the usual fashion for Plan B patients.

To ensure NRT claims for Plan B patients adjudicate to Plan S (under which they are a benefit) and not Plan B (under which they are not a benefit), the pharmacy must ensure that the long-term care facility code is not entered in NRT claims submitted on PharmaNet.

As with other prescription medications, PharmaCare is not the first payer for prescription smoking cessation drugs. However, federally insured patients with active Medical Services Plan coverage can choose PharmaCare coverage for NRTs, even if their federal insurer provides coverage. This includes individuals insured under

• Veterans Affairs Canada
• Non-Insured Health Benefits Program
• RCMP (non-retired members)
• Interim Federal Health Program (delivered through Immigration, Refugees and Citizenship Canada)

To process a Smoking Cessation Program claim for an individual covered under a federal drug plan, please see Procedures for Pharmacists.

Smoking cessation prescription drugs dispensed under the Smoking Cessation Program count as qualifying medications for purposes of determining a patient’s eligibility for medication review services.

>> See the Section 8.9—Medication Review Services for further information

If a pharmacy cannot provide a patient with the full amount of their prescription smoking cessation drug or nicotine replacement therapy, pharmacists should enter only one claim for the full amount, and ask the patient to return for the balance.

If a patient does not return to pick up the balance, pharmacists must adjust their claim to reflect the amount actually dispensed and picked up.

Pharmacies cannot substitute a non-benefit product for those listed as benefits under the Smoking Cessation Program.

Coverage is available to all smokers (and users of other tobacco products) of any age who are B.C. residents with active Medical Services Plan (MSP) coverage.

To enroll, both the individual and pharmacist must sign a BC Smoking Cessation Program Declaration and Notification form (HLTH 5464) (PDF, 560KB).

PharmaCare coverage of nicotine replacement therapies is limited to the products in the list of Eligible Smoking Cessation Products.

Claims for nicotine replacement therapies must be submitted with the applicable NPN.

Important: Please note that only the package sizes specified are eligible for coverage under the program. Claims for package sizes not specified in the list of Eligible Smoking Cessation Products above are subject to recovery upon audit.

Eligible individuals receive no-cost (100%) coverage of the designated nicotine replacement therapies (NRTs) purchased at a pharmacy in the same manner as prescription drugs.

Patients do not need a prescription for NRT coverage.

Both the patient and the pharmacist must sign a BC Smoking Cessation Program Declaration and Notification form (HLTH 5464) (PDF, 560KB).

Claims without a corresponding signed declaration are subject to recovery upon audit.

Pharmacies must submit a claim on PharmaNet at the time of purchase to access PharmaCare coverage for NRTs for their patients.

A new claim must be entered in PharmaNet for each NRT fill.

NRT coverage is not subject to, and does not contribute to, the Fair PharmaCare annual deductible or family maximum.

Nicotine patches

Eligible nicotine patches are to be dispensed in four-week (28-day) intervals.

PharmaCare limits coverage of eligible nicotine patches to a maximum 28-day supply.

Patients are covered for four boxes of patches (total 28 patches) every 28 days.

Over the total 12-week (84-day) course of treatment, patients are eligible for coverage of up to 84 NRT patches (supplied as 12 boxes with seven patches in each box). This quantity is based on the maximum dosing specified in the product monograph.

Nicotine gum

Over the total course of treatment, patients are eligible for up to 945 pieces of NRT gum (supplied as nine boxes with 105 pieces in each box). This quantity is based on the maximum dosing specified in the product monograph. On average, most patients need three boxes of NRT gum (total 315 pieces) every 28 days.

Nicotine lozenges

Over the total 12-week (84-day) course of treatment, patients are eligible for up to 800 pieces of NRT lozenge (supplied as 10 bottles with 80 lozenges in each bottle). This quantity is based on the dosing range specified in the product monograph. 

During a course of treatment, patients may switch between different types of nicotine replacement therapy—or from one dosage strength to another—only when picking up one of the three fills covered for the course of treatment. Such changes do not require Special Authority approval.

All Smoking Cessation Program policy limitations with respect to maximum days’ supply, dispensing intervals and dispensing fees continue to apply regardless of changes in product or strength.

Any changes in product or strength that may create a dispensing that is not in compliance with the Smoking Cessation Program policy limitations require prior Special Authority approval.

Community pharmacies are reimbursed for a dispensing fee up to the PharmaCare maximum for the dispensing of eligible nicotine replacement therapies (NRTs).

PharmaCare covers the dispensing fee for up to three dispenses per patient per course of treatment with one of the designated NRTs.

The Frequency of Dispensing Policy applies to NRTs.

PharmaNet cannot automatically reject NRT-related dispensing fees above the maximum allowable three dispensing fees. PharmaCare requires pharmacies to check a patient’s PharmaNet record to ascertain the number of previous NRT fills a patient has had and to ensure no more than three dispensing fees are claimed per patient per course of treatment.

Nicotine replacement therapies are not eligible for clinical services fees.

Nicotine replacement therapies are not eligible for special services fees.

The Full Payment Policy applies to all PharmaCare paid nicotine replacement therapy claims since they are covered 100% in all cases. Therefore, pharmacies may not charge individuals directly for any amount in excess of the PharmaCare paid amount for nicotine replacement therapy claims covered under the Smoking Cessation Program.

Nicotine replacement therapies (NRTs) and fees to dispense them are subject to 5% GST.

The GST must not be included as part of the claim for either the NRT product or the dispensing fee.

The GST must not be collected directly from either the patient or a third-party insurer.

The provincial government reimburses pharmacies for the GST associated with NRT claims paid under the Smoking Cessation Program. Pharmacies are reimbursed on a quarterly basis.

Each pharmacy’s NRT claims are reviewed and pharmacy payments are adjusted to reimburse 5% for the GST.

Patients cannot return any unused products for exchange, reimbursement or credit.

Coverage is available to all smokers (and users of other tobacco products) of any age who are B.C. residents and are registered for Fair PharmaCare or Plan B (Long-term Care), Plan C (Recipients of Income Assistance), Plan G (Psychiatric Medications) or Plan W (First Nations Health Benefits).

PharmaCare coverage of prescription smoking cessation drugs is limited to certain eligible products. (See list of Eligible Smoking Cessation Products).

Of the different versions of bupropion, PharmaCare covers only Zyban^® for smoking cessation. Wellbutrin^®, Wellbutrin XL^® and generic bupropion are not covered as smoking cessation drugs.

To ensure the prescription is for the version of bupropion eligible for Smoking Cessation Program coverage, prescribers are to indicate on the prescription

• The brand name Zyban^®
• The prescription is for “smoking cessation”
• “No substitutions”

PharmaCare only fully covers generic versions of varenicline. Brand name varenicline (Champix^®) is a partial benefit.

Coverage is subject to the applicable PharmaCare plan rules. Plans B, C, G and W provide 100% coverage. Fair PharmaCare provides partial, full or no coverage depending on whether an individual has met their annual deductible and family maximum.

Coverage does not require a request for Special Authority; however, Limited Coverage criteria should be used to assess patient eligibility for coverage.

>> See the Limited Coverage Drug Program Criteria Information for details.

Patients require a prescription to be eligible for coverage.

Individuals covered by Fair PharmaCare who receive eligible prescription smoking cessation drugs but who do not receive PharmaCare coverage in whole or part because they have not met their Fair PharmaCare deductible, are eligible for certain free eligible nicotine replacement therapies for that same calendar year.

Individuals covered by Fair PharmaCare who receive PharmaCare coverage in whole or part for an eligible prescription smoking cessation drug are not eligible for coverage of nicotine replacement therapies in that same calendar year.

Eligible prescription smoking cessation drugs are to be dispensed in four-week (28-day) intervals.

PharmaCare covers a maximum 28-day supply of eligible prescription smoking cessation drugs.

Except as noted below, PharmaCare covers the dispensing fee for up to three dispenses per patient (not per pharmacy) per course of treatment with an eligible prescription smoking cessation drug.

When a 14-day starter pack of varenicline (generics) is dispensed patients may receive four fills of medication (two in the first 28 days, followed by two additional fills of 28 days each) and pharmacies may claim up to a maximum of four dispensing fees per patient per course of treatment.

If specified on the prescription, PharmaCare may cover more frequent dispenses over the course of treatment up to a maximum specified in Section 8.3—Frequency of Dispensing Policy.

Prescription smoking cessation drugs are eligible for clinical services fees for dose and regimen changes but not for prescription renewals or therapeutic substitutions.

Prescription smoking cessation drugs are eligible for Special Services Fees.

The Full Payment Policy applies to prescription smoking cessation drug claims in the same manner as any other prescription drug claim.

1. Confirm in PharmaNet that the patient has received PharmaCare coverage for no more than two previous nicotine replacement therapy (NRT) fills in the current calendar year, with respect to the 84-day course of treatment. If the patient has had three fills in the current calendar year, explain to them that they have used up their coverage for the current year.
   
   Check PharmaNet not your local pharmacy system since a patient may have had NRTs dispensed through a different pharmacy.
    
2. Ensure that the Declaration and Notification form (HLTH 5464) (PDF, 560KB) is fully completed; that is, ensure all required fields are completed and that both you and the patient have signed the form.
   A declaration form must be signed for each NRT fill or refill.
3. In separate yearly files, file the declaration form by patient name, then chronologically. Claims without a corresponding signed declaration form or with only one signature are subject to recovery upon audit.
4. Enter the fill as a new prescription (not a refill).
5. Enter the appropriate product NPN.
6. Enter your pharmacist College ID in the Practitioner ID field.
7. Enter the number of units dispensed in the Dispensed Quantity field (i.e., the number of pieces of gum, lozenges or patches).
8. Enter the drug cost and dispensing fee. Do not add GST to either the drug cost or the dispensing fee.

Advising the patient about subsequent fills

If a patient has refills remaining, remind them to wait at least two weeks before refilling. This ensures their refill is within the limits of the Refilling Prescriptions Too Soon policy.

1. Confirm that the prescribed drug is eligible for Smoking Cessation Program coverage.
   
   Prescriptions for varenicline (Champix^® and generics) can be written in the usual fashion.
   Prescriptions for bupropion must specify the Zyban^® brand of bupropion and indicate the prescription is for smoking cessation.
    
2. Review the patient’s medication history in PharmaNet to determine if the patient has already received prior PharmaCare coverage for a course of treatment with a smoking cessation product (nicotine replacement therapy, bupropion or varenicline) in the current calendar year or has used up their coverage for a current course of treatment.
   
   Note that you must use PharmaNet rather than your local system as a patient may have had smoking cessation products dispensed by another pharmacy. These fills count towards the total allowable for the patient.
    
3. Submit the claim. 
   
   If a patient has refills remaining, remind them that, to receive PharmaCare coverage, they cannot refill their prescription until they have a remaining supply of 14 days or less.

Patients with federal drug coverage may request coverage under the Smoking Cessation Program even if they have existing smoking cessation aid coverage under their federal plan.

Individuals choosing coverage under the Smoking Cessation Program are subject to all policies and procedures of the program.

Submit the claim as described in the Claims for Prescription Smoking Cessation Drugs and Claims for Nicotine Replacement Therapies sections above.

When a patient covered by a federal drug plan requests NRTs or presents a prescription for one of the smoking cessation drugs covered by the program:

1. Submit the claim to the patient's federal plan first.
2. If the federal plan indicates it will not cover the product for the patient, then

• ​Remove the federal coverage in your local system.
• Call the PharmaNet Help Desk to have the federal coverage flag removed, so that
  • the NRT claim can adjudicate as PharmaCare pays 100%, or
  • the prescription smoking cessation drug claim can adjudicate according to the rules of the patient's PharmaCare plan.

    3. If the federal plan claim indicates it will cover the product, the patient can choose PharmaCare coverage instead.

• Ensure the patient understands that, while NRTs will be free of charge, the prescription drugs may not (depending on the rules of the patient's primary PharmaCare plan, including any deductible requirements).
• For example, patients covered by Fair PharmaCare, due to annual deductibles, receive more coverage under their federal plan for a prescription smoking cessation drug.

    4. If the patient chooses PharmaCare coverage, remove federal coverage as established in Step 2 above.