Limited coverage drugs – bupropion

Generic name	bupropion
Strength & form	100 mg SR, 150 mg SR, 150 mg XL, 300 mg XL tablet

Special Authority criteria	Approval period
Diagnosis indicating depression (generic)	Indefinite
Smoking cessation (Zyban® only) for patients who want to stop smoking or using other tobacco products	12 weeks within a calendar year—no Special Authority required

Practitioner exemptions

• Bupropion (generic): Psychiatrists, when prescribed for depression only
• Zyban^® only: No Special Authority required when prescribed under the Smoking Cessation Program. See details below.

Special notes

Generic bupropion for depression

• Criteria applicable for all plans, including Plan G
• Generic bupropion is eligible for PharmaCare coverage only when prescribed for depression; coverage is not available when it is prescribed for any other indication

Zyban^® for smoking cessation

• For smoking cessation, PharmaCare covers only the Zyban brand; Wellbutrin^®, Wellbutrin XL^® and generic bupropion are not covered for this indication
• When prescribing Zyban under the Smoking Cessation Program, no Special Authority request is required
• Maximum amount covered per calendar year: one 12-week (84-day) course of bupropion (Zyban) or varenicline
• Written prescription must indicate:
  • the brand name "Zyban"
  • "smoking cessation"
  • "no substitutions"
  • "dispense in 28-day supply"

Special Authority request form

A Special Authority request must be submitted when generic bupropion is prescribed for depression by a physician other than a psychiatrist.

• Log in to eForms
• HLTH 5328 - Special Authority Request (PDF, 656KB)