NRT Coverage

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
Alameda	Anthem Blue Cross Partnership Plan	Covers patch		Covers gum & lozenge		2 courses/year covered
Alameda	Alameda Alliance	Covers patch		Covers gum & lozenge		2 courses/year covered
Contra Costa	Contra Costa Health Plan	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
Contra Costa	Anthem Blue Cross Partnership Plan	Covers patch		Covers gum		2 courses/year covered
Fresno	CalViva	generic on formulary 180 per 365 days limit		need PA, generic on formulary
Fresno	Anthem Blue Cross Partnership Plan	Covers patch		Covers gum		2 courses/year covered
Kern	Health Net Community Solutions	need PA, generic on formulary 180 per 365 days		need PA, generic on formulary
Kern	Kern Family Health Care	Covers patch		Covers gum & lozenge
Kings	Anthem Blue Cross Partnership Plan	Covers patch		Covers gum		2 courses/year covered
Kings	CalViva	180 each per 365 day, generic on formulary		need PA, generic on formulary
LA	Health Net Community Solutions	180 each per 365 day, generic on formulary		need PA, generic on formulary
LA	LA Care Health Plan	Covers patch; age restrictions;		Covers gum & lozenge with age restrictions		Quantity limit
Madera	Partnership Heath Plan	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
Marin	Partnership Heath Plan	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
Mendocino	Partnership Health Plan	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
Merced	Central CA Alliance for Health	Covered for 12 weeks/year and certificate required		Covered for 12 weeks/year and certificate required
Monterey	Central CA Alliance for Health	Covered for 12 weeks/year and certificate required		Covered for 12 weeks/year and certificate required
Napa	Partnership Heath Plan	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
Orange County	CalOptima	Patch: 28 per 28 days Gum: 2, 4mg – limit 360/30 days Lozenge: limit 360/30 days
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
Riverside	Inland Empire Health Plan	Patch covered, QL Gum, lozenge covered
Riverside	Molina HC of CA Partner Plan	OTC QL	OTC QL
Sacramento	Anthem Blue Cross Partnership Plan	Covers patch	Covers gum, lozenge		2 courses/year covered
Sacramento	Health Net Community Solutions	generic on formulary 180/365 days	Gum, lozenge generic formulary
Sacramento	Molina HC of CA Partner Plan	Covered	Gum & lozenge cCovered
San Bernadino	Inland Empire Health Plan	Patch: on formulary, QL Gum: on formulary, QL Lozenge: on formulary, QL
San Bernadino	Molina HC of CA Partner Plan	Covered	Gum, lozenge covered
San Diego	Care 1^st Partner Plan	PA & Certificate required	PA & Certificate required
San Diego	Community Health Group Partnership Plan	Covered with QL	Gum covered with QL; lozenge needs PA
San Diego	Health Net Community Solutions	generic on formulary 180/365	generic on formulary
San Diego	Molina HC of CA Partner Plan	Covered with QL	Gum, lozenge covered with QL
San Francisco	Anthem Blue Cross Partnership Plan	Covers patch	Covers gum		2 courses/year covered
San Francisco	SF Health Plan	Covered, 30/30 days	Gum covered, 360/30d; lozenges covered 360/30 days
San Joaquin	Health Net Community Solutions	generic on formulary 180/365	generic on formulary
San Joaquin	CalViva	generic on formulary 180/365	generic on formulary
San Joaquin	Health Plan of 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.
San Mateo:	Health Plan of San Mateo	Gum and patch on formulary; max 14 weeks per year	Gum and lozenge on formulary; max 14 weeks per year
Santa Barbara:	CenCal:	Limited to 9 fills per 365 days	Gum & lozenge: limited to 9 fills/year		no PA mentioned
Santa Clara	Anthem Blue Cross Partnership Plan	Covers patch	Covers gum		2 courses/year covered
Santa Clara	Santa Clara Family Health Plan	Generic covered; 30/30d	Generic gum/lozenge covered; limit 880/365 days
Santa Cruz	Central CA Alliance for Health	certificate required	certificate required		Limited to 12 weeks/year
Santa Clara	Health Plan of San Joaquin –	on formulary	on formulary		Limit 2-3 mo courses in 365 days
Solano/ Sonoma:	Partnership Heath Plan	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.
Stanislaus	Health Net Community Solutions	generic on formulary 180/365 d	generic on formulary
Tulare	Anthem Blue Cross Partnership Plan	Covers patch	Covers lozenge, gum		2 courses/year covered
Tulare	Health Net Community Solutions	generic on formulary 180/365 d	generic on formulary
Yolo	Partnership Heath Plan	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
Ventura County	Gold Coast Health Plan	on formulary, limit 12 weeks/lifetime	Gum & lozenge on formulary, limit 12 weeks/lifetime

Health Care Providers

MediCal Managed Care Plans by County and Coverage of Nicotine Replacement Therapy

Straight Medi-Cal: