Montana Medicaid Program

Stop-Smoking Benefits and Products

How to Receive Services...

Medicaid Access: All Montana Medicaid clients have access to tobacco cessation counseling and products.

Passport referral: No Passport Referral (primary care provider referral) is needed to see a tobacco cessation counselor or get a prescription for cessation drugs.

Prior authorization: Prior authorization is needed for all tobacco cessation products. PA is not needed for counseling benefits. Providers will submit for PA.

Counselors: Qualified tobacco cessation counselors are physicians and mid-level practitioners at private practices, Rural Health Clinics, Federally Qualified Health Clinics, public health clinics, tribal health clinics, Indian Health Service facilities, outpatient hospitals, dentists, dental hygienists, psychologists, licensed clinical social workers, licensed professional counselors, and chemical dependency providers.

Counseling Benefits and Products...

Counseling Benefits

Up to three minutes: Medicaid coverage for up to three minutes of smoking and tobacco cessation counseling is considered to be included in reimbursement as part of a standard evaluation and management office visit.

More than three minutes: Counseling for more than three minutes is reimbursed as a separate service at two levels, intermediate and intensive.

• Intermediate coverage is for counseling sessions greater than three minutes up to ten minutes.
• Intensive coverage is for counseling sessions greater than ten minutes.

Counseling session limits: No limit on number of counseling sessions that can be reimbursed.

Cost sharing is a minimum of $1 per visit up to a maximum of the lesser of $5 per visit or 5% of the average Medicaid allowed amount (based on physician services).

Products

• Medicaid pays for two tobacco cessations trials a year of either generic  Zyban (buproprion), Chantix, or nicotine patches.
• Length and spacing of trials:

Six-month trials allowed for Chantix; prior authorization for 3 months initially, with an option for 3 more months upon verifying that the patient has quit using tobacco. If the patient has successfully quit for 6 months they would only be authorized for a second 6-month trial if they resumed using tobacco.

• If patient does not quit in the initial 3 months, then a one month minimum break is required before authorizing a second 6-month trial. The second 6-month trial is only approved after the patient has been off of Chantix for one month. For the second 6-month trial, Chantix is once again prior authorized for 3 months initially, with an option for 3 more months upon verifying that the patient has quit using tobacco.

Four-month trials are allowed for nicotine patches and Zyban, including concomitant therapy. There is no immediate re-authorization, i.e., one month minimum waiting period in effect.

Patients may switch treatment products for their second trial after the one month wait.

All tobacco cessation products are paid for on a monthly basis. Medicaid would not continue to provide cessation products if a patient’s eligibility ran out.

• Nicotine gum is only authorized when clients cannot use patches, due for example, to an allergy or intolerance to the patch adhesive.
• Inhalers are rarely authorized and would require a compelling reason.
• Dual eligibles, patients who have both Medicaid and Medicare, are not covered for Chantix or Zyban, as these products are covered under Medicare Part D prescription drug coverage.
• Dual eligibles are covered for nicotine patches, since they are an over-the-counter product that is not covered by Medicare Part D. Inhalers and gum are rarely covered.

Cost share for tobacco cessation products is 5% of the Medicaid allowed reimbursement, with a minimum of $1 and a maximum of $5 per prescription. The maximum cost sharing payment per patient shall not exceed $25 per month.