Nicotrol Inhaler (nicotine inhalation system) — United Healthcare
tobacco cessation
Preferred products
- nicotine replacement patches OTC
- nicotine gum OTC
- nicotine lozenge or mini-lozenge OTC
- bupropion
Initial criteria
- Patient is age ≥ 18 years (age ≥ 15 years if plan sitused in Oregon)
- Treatment is being requested for tobacco cessation
- History of failure, contraindication, or intolerance to ONE of the following: nicotine replacement patches OTC (e.g. Nicoderm CQ-OTC), nicotine gum OTC (e.g. Nicorette gum-OTC), OR nicotine lozenge or mini-lozenge OTC (e.g. Nicorette lozenge-OTC)
- History of failure, contraindication, or intolerance to bupropion
- Treatment duration has not exceeded a total of 2 (3 month) cycles of Tobacco Cessation Therapy per 12 month period
Approval duration
3 months per 12 month period; maximum 2 (3 month) cycles per 12 month period