NRT Coverage

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

(updated 3.28.16)

Straight Medi-Cal:

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 1st 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