|
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 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 |
|
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 |
|
Placer |
California Health & Wellness |
Generic covered; max 84/365 days for each strength |
Generic covered; max 84/365 days for 2mg or 4mg gum |
|
|
Riverside |
Molina HC of CA Partner Plan |
OTC QL |
OTC QL |
|
|
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 |
Community Health Group Partnership Plan |
Covered with QL |
Gum covered with QL; lozenge needs PA |
|
|
San Diego |
Molina HC of CA Partner Plan |
Covered with QL |
Gum, lozenge covered with QL |
|
|
San Francisco |
SF Health Plan |
Covered, 30/30 days |
Gum covered, 360/30d; lozenges covered 360/30 days |
|
|
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. |
|
|
Santa Barbara: |
CenCal: |
Limited to 9 fills per 365 days |
Gum & lozenge: limited to 9 fills/year |
no PA mentioned |
|
Santa Clara |
Santa Clara Family Health Plan |
Generic covered; 30/30d |
Generic gum/lozenge covered; limit 880/365 days |
|
|
Stanislaus |
Health Net Community Solutions |
generic on formulary 180/365 d |
generic on formulary |
|
|
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 |
