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Smoking Cessation

PHARM-13 Statement of Medical Necessity for Quantity Limits Override.

Smoking Cessation

Drugs

Quantity Limits

Chantix (Varenicline Tartrate) Dose-Pack Tablets

53 Tablets per 28 Days

Chantix (Varenicline Tartrate) 0.5mg and 1mg Tablets 

60 Tablets per 30 Days

Zyban (Bupropion HCL) 150mg SA Tablets 

100 Tablets per 50 Days

 

Last Modified on Nov 10, 2020
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