Nicotrol Inhaler — United Healthcare
tobacco cessation
Preferred products
- Nicotine replacement patches OTC
- Nicotine gum OTC
- Nicotine lozenge or mini-lozenge OTC
- bupropion
Initial criteria
- For Varenicline (patients new to therapy, not currently on varenicline in the past 90 days):
- • age ≥ 18 years
- AND treatment is being requested for tobacco cessation
- AND 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)
- - Nicotine lozenge or mini-lozenge OTC (e.g. Nicorette lozenge-OTC)
- AND history of failure, contraindication, or intolerance to bupropion
- For Nicotrol NS or Nicotrol Inhaler:
- • age ≥ 18 years
- AND treatment is being requested for tobacco cessation
- AND 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)
- - Nicotine lozenge or mini-lozenge OTC (e.g. Nicorette lozenge-OTC)
- AND history of failure, contraindication, or intolerance to bupropion
Reauthorization criteria
- Patients established on therapy (on medication within past 90 days) for tobacco cessation are approved for continuation
Approval duration
3 months