MediCal Managed Care Plans by County and Coverage of Nicotine Replacement Therapy
(updated 3.28.16)
Straight Medi-Cal:
- Formulary here
- Patch, gum and lozenge all covered
County |
Health Plan & Link to Formulary |
Patch |
Gum/Lozenge |
Comments |
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Alameda |
Covers patch |
Covers gum & lozenge |
2 courses/year covered |
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Alameda |
Covers patch |
Covers gum & lozenge |
2 courses/year covered |
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Contra Costa |
Cover patch 28 patches for 28 days, approve 2 weeks at a time Max 6 mo treatment/year |
340 pieces every 30 days Lozenge: 324 pieces q 30 d.
|
Max 6 mo treatment/year |
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Contra Costa |
Covers patch |
Covers gum |
2 courses/year covered |
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Fresno |
generic on formulary 180 per 365 days limit |
need PA, generic on formulary |
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Fresno |
Covers patch |
Covers gum |
2 courses/year covered |
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Kern |
need PA, generic on formulary 180 per 365 days |
need PA, generic on formulary |
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Kern |
Covers patch |
Covers gum & lozenge |
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Kings |
Covers patch |
Covers gum |
2 courses/year covered |
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Kings |
180 each per 365 day, generic on formulary |
need PA, generic on formulary |
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LA |
180 each per 365 day, generic on formulary |
need PA, generic on formulary |
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LA |
Covers patch; age restrictions; |
Covers gum & lozenge with age restrictions |
Quantity limit |
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Madera |
Patch on formulary; limits: 180 patches within a year 1 strength per fill up to qty #42.
|
Gum on formulary; limit: Maximum of 810 pieces within a 1 year period.
|
No PA needed
|
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Marin |
Patch on formulary; limits: 180 patches within a year 1 strength per fill up to qty #42.
|
Gum on formulary; limit: Maximum of 810 pieces within a 1 year period.
|
No PA needed
|
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Mendocino |
Patch on formulary; limits: 180 patches within a year 1 strength per fill up to qty #42.
|
Gum on formulary; limit: Maximum of 810 pieces within a 1 year period.
|
No PA needed
|
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Merced |
Covered for 12 weeks/year and certificate required |
Covered for 12 weeks/year and certificate required |
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Monterey |
Covered for 12 weeks/year and certificate required |
Covered for 12 weeks/year and certificate required |
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Napa |
Patch on formulary; limits: 180 patches within a year 1 strength per fill up to qty #42.
|
Gum on formulary; limit: Maximum of 810 pieces within a 1 year period.
|
No PA needed
|
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Orange County |
|
Patch: 28 per 28 days Gum: 2, 4mg – limit 360/30 days Lozenge: limit 360/30 days |
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Placer | Anthem Blue Cross Partnership Plan | Covers patch | Covers gum | 2 courses/year covered | ||
Placer | California Health & Wellness | Generic covered; max 84/365 days for each strength | Generic covered; max 84/365 days for 2mg or 4mg gum Lozenge generic covered, 84/365 days |
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Riverside |
Patch covered, QL Gum, lozenge covered |
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Riverside |
OTC QL |
OTC QL |
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Sacramento |
Covers patch |
Covers gum, lozenge |
2 courses/year covered |
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Sacramento |
generic on formulary 180/365 days |
Gum, lozenge generic formulary |
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Sacramento |
Covered |
Gum & lozenge cCovered |
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San Bernadino |
Patch: on formulary, QL Gum: on formulary, QL Lozenge: on formulary, QL |
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San Bernadino |
Covered |
Gum, lozenge covered |
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San Diego |
PA & Certificate required |
PA & Certificate required |
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San Diego |
Community Health Group Partnership Plan
|
Covered with QL |
Gum covered with QL; lozenge needs PA |
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San Diego |
generic on formulary 180/365 |
generic on formulary |
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San Diego |
Covered with QL |
Gum, lozenge covered with QL |
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San Francisco |
Covers patch |
Covers gum |
2 courses/year covered |
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San Francisco |
Covered, 30/30 days |
Gum covered, 360/30d; lozenges covered 360/30 days |
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San Joaquin |
generic on formulary 180/365 |
generic on formulary |
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San Joaquin |
generic on formulary 180/365 |
generic on formulary |
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San Joaquin |
|
Limited to two 3-month courses of any smoking cessation agent per 365 days. |
Limited to two 3-month courses of any smoking cessation agent per 365 days.
|
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San Mateo:
|
|
Gum and patch on formulary; max 14 weeks per year |
Gum and lozenge on formulary; max 14 weeks per year |
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Santa Barbara:
|
Limited to 9 fills per 365 days |
Gum & lozenge: limited to 9 fills/year
|
no PA mentioned
|
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Santa Clara |
Covers patch |
Covers gum |
2 courses/year covered |
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Santa Clara |
Generic covered; 30/30d |
Generic gum/lozenge covered; limit 880/365 days |
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Santa Cruz |
certificate required |
certificate required |
Limited to 12 weeks/year |
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Santa Clara |
|
on formulary
|
on formulary
|
Limit 2-3 mo courses in 365 days |
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Solano/
Sonoma:
|
Patch on formulary; limits: 180 patches within a year 1 strength per fill up to qty #42. |
Gum, lozenge on formulary; limit: Maximum of 810 pieces within a 1 year period.
|
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Stanislaus
|
generic on formulary 180/365 d |
generic on formulary |
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Tulare |
Covers patch |
Covers lozenge, gum |
2 courses/year covered |
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Tulare |
generic on formulary 180/365 d |
generic on formulary |
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Yolo |
Patch on formulary; limits: 180 patches within a year 1 strength per fill up to qty #42.
|
Lozenge & gum on formulary; limit: Maximum of 810 pieces within a 1 year period.
|
No PA needed
|
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Ventura County |
on formulary, limit 12 weeks/lifetime |
Gum & lozenge on formulary, limit 12 weeks/lifetime |
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