docCovered OTC Smoking Cessation
download 
Denúncia Transcrição
Covered OTC Smoking Cessation
Covered OTC Smoking Cessation Nicotine patches are covered for 180 days of therapy per calendar year; Nicotine lozenges and gum are covered for up to 180 days per calendar year with the second 90 days requiring a prior authorization. GCN Description NICOTINE POLACRILEX BUCCAL 2 MG GUM NICOTINE POLACRILEX BUCCAL 2 MG GUM NICOTINE POLACRILEX BUCCAL 2 MG GUM NICOTINE POLACRILEX BUCCAL 2 MG GUM NICOTINE POLACRILEX BUCCAL 2 MG GUM NICOTINE POLACRILEX BUCCAL 2 MG GUM NICOTINE POLACRILEX BUCCAL 2 MG GUM NICOTINE POLACRILEX BUCCAL 2 MG GUM NICOTINE POLACRILEX BUCCAL 2 MG GUM NICOTINE POLACRILEX BUCCAL 2 MG GUM NICOTINE POLACRILEX BUCCAL 2 MG GUM NICOTINE POLACRILEX BUCCAL 2 MG GUM NICOTINE POLACRILEX BUCCAL 2 MG GUM NICOTINE POLACRILEX BUCCAL 2 MG GUM NICOTINE POLACRILEX BUCCAL 2 MG GUM NICOTINE POLACRILEX BUCCAL 2 MG GUM NICOTINE POLACRILEX BUCCAL 2 MG GUM NICOTINE POLACRILEX BUCCAL 2 MG GUM NICOTINE POLACRILEX BUCCAL 2 MG GUM NICOTINE POLACRILEX BUCCAL 2 MG GUM NICOTINE POLACRILEX BUCCAL 2 MG GUM NICOTINE POLACRILEX BUCCAL 2 MG GUM NICOTINE POLACRILEX BUCCAL 2 MG GUM NICOTINE POLACRILEX BUCCAL 2 MG GUM NICOTINE POLACRILEX BUCCAL 2 MG GUM NICOTINE POLACRILEX BUCCAL 2 MG GUM NICOTINE POLACRILEX BUCCAL 2 MG GUM NICOTINE POLACRILEX BUCCAL 2 MG GUM NICOTINE POLACRILEX BUCCAL 2 MG GUM NICOTINE POLACRILEX BUCCAL 2 MG GUM NICOTINE POLACRILEX BUCCAL 2 MG GUM NICOTINE POLACRILEX BUCCAL 2 MG GUM NICOTINE POLACRILEX BUCCAL 2 MG GUM NICOTINE POLACRILEX BUCCAL 2 MG GUM NICOTINE POLACRILEX BUCCAL 2 MG GUM NICOTINE POLACRILEX BUCCAL 2 MG GUM NICOTINE POLACRILEX BUCCAL 2 MG GUM NICOTINE POLACRILEX BUCCAL 2 MG GUM NICOTINE POLACRILEX BUCCAL 2 MG GUM NICOTINE POLACRILEX BUCCAL 2 MG GUM NDC Description NICORELIEF NICORELIEF NICORELIEF NICORELIEF NICORETTE NICORETTE NICORETTE NICORETTE NICORETTE NICORETTE NICORETTE NICORETTE NICORETTE NICORETTE NICORETTE NICORETTE NICORETTE NICORETTE NICORETTE NICORETTE NICORETTE NICOTINE GUM NICOTINE GUM NICOTINE GUM NICOTINE GUM NICOTINE GUM NICOTINE GUM NICOTINE GUM NICOTINE GUM NICOTINE GUM NICOTINE GUM NICOTINE GUM NICOTINE GUM NICOTINE GUM NICOTINE GUM NICOTINE GUM NICOTINE GUM NICOTINE GUM NICOTINE GUM NICOTINE GUM NDC Code 00904-5734-11 00904-5734-51 00904-5736-11 00904-5736-51 00135-0157-07 00135-0157-10 00135-0157-11 00135-0225-02 00135-0225-03 00135-0229-04 00135-0229-05 00135-0241-02 00135-0241-06 00135-0241-08 00135-0466-01 00135-0466-02 00135-0474-01 00135-0474-02 00135-0474-03 00135-0474-05 00135-0474-08 00113-0206-25 00113-0456-78 00536-1362-06 00536-1362-23 00536-1362-34 00536-3029-06 00536-3029-23 00536-3029-34 00536-3112-01 00536-3112-37 00536-3386-01 00536-3386-37 00536-3404-01 00536-3404-37 24385-0170-58 24385-0594-71 24385-0597-71 36800-0029-25 36800-0206-25 Covered OTC Smoking Cessation NICOTINE POLACRILEX BUCCAL 2 MG GUM NICOTINE POLACRILEX BUCCAL 2 MG GUM NICOTINE POLACRILEX BUCCAL 2 MG GUM NICOTINE POLACRILEX BUCCAL 2 MG GUM NICOTINE POLACRILEX BUCCAL 2 MG GUM NICOTINE POLACRILEX BUCCAL 2 MG GUM NICOTINE POLACRILEX BUCCAL 2 MG GUM NICOTINE POLACRILEX BUCCAL 2 MG GUM NICOTINE POLACRILEX BUCCAL 2 MG GUM NICOTINE POLACRILEX BUCCAL 2 MG GUM NICOTINE POLACRILEX BUCCAL 2 MG GUM NICOTINE POLACRILEX BUCCAL 2 MG GUM NICOTINE POLACRILEX BUCCAL 2 MG GUM NICOTINE POLACRILEX BUCCAL 2 MG GUM NICOTINE POLACRILEX BUCCAL 2 MG GUM NICOTINE POLACRILEX BUCCAL 2 MG GUM NICOTINE POLACRILEX BUCCAL 4 MG GUM NICOTINE POLACRILEX BUCCAL 4 MG GUM NICOTINE POLACRILEX BUCCAL 4 MG GUM NICOTINE POLACRILEX BUCCAL 4 MG GUM NICOTINE POLACRILEX BUCCAL 4 MG GUM NICOTINE POLACRILEX BUCCAL 4 MG GUM NICOTINE POLACRILEX BUCCAL 4 MG GUM NICOTINE POLACRILEX BUCCAL 4 MG GUM NICOTINE POLACRILEX BUCCAL 4 MG GUM NICOTINE POLACRILEX BUCCAL 4 MG GUM NICOTINE POLACRILEX BUCCAL 4 MG GUM NICOTINE POLACRILEX BUCCAL 4 MG GUM NICOTINE POLACRILEX BUCCAL 4 MG GUM NICOTINE POLACRILEX BUCCAL 4 MG GUM NICOTINE POLACRILEX BUCCAL 4 MG GUM NICOTINE POLACRILEX BUCCAL 4 MG GUM NICOTINE POLACRILEX BUCCAL 4 MG GUM NICOTINE POLACRILEX BUCCAL 4 MG GUM NICOTINE POLACRILEX BUCCAL 4 MG GUM NICOTINE POLACRILEX BUCCAL 4 MG GUM NICOTINE POLACRILEX BUCCAL 4 MG GUM NICOTINE POLACRILEX BUCCAL 4 MG GUM NICOTINE POLACRILEX BUCCAL 4 MG GUM NICOTINE POLACRILEX BUCCAL 4 MG GUM NICOTINE POLACRILEX BUCCAL 4 MG GUM NICOTINE POLACRILEX BUCCAL 4 MG GUM NICOTINE POLACRILEX BUCCAL 4 MG GUM NICOTINE POLACRILEX BUCCAL 4 MG GUM NICOTINE GUM NICOTINE GUM NICOTINE GUM NICOTINE GUM NICOTINE GUM NICOTINE GUM NICOTINE GUM NICOTINE GUM NICOTINE GUM NICOTINE GUM NICOTINE GUM NICOTINE GUM NICOTINE GUM NICOTINE GUM NICOTINE GUM NICOTINE GUM NICORELIEF NICORELIEF NICORELIEF NICORELIEF NICORETTE NICORETTE NICORETTE NICORETTE NICORETTE NICORETTE NICORETTE NICORETTE NICORETTE NICORETTE NICORETTE NICORETTE NICORETTE NICORETTE NICORETTE NICOTINE GUM NICOTINE GUM NICOTINE GUM NICOTINE GUM NICOTINE GUM NICOTINE GUM NICOTINE GUM NICOTINE GUM NICOTINE GUM 36800-0352-78 36800-0456-78 37205-0203-71 37205-0967-58 37205-0967-78 46122-0173-20 49348-0573-08 49348-0573-36 49348-0691-36 49348-0691-64 49348-0787-10 62011-0047-02 68016-0280-49 68016-0282-50 68016-0284-44 68016-0286-62 00904-5735-11 00904-5735-51 00904-5737-11 00904-5737-51 00135-0158-07 00135-0158-10 00135-0158-11 00135-0226-02 00135-0226-03 00135-0230-04 00135-0230-05 00135-0242-02 00135-0242-06 00135-0242-08 00135-0467-02 00135-0475-01 00135-0475-02 00135-0475-03 00135-0475-08 00113-0422-25 00113-0532-78 00536-1372-06 00536-1372-23 00536-1372-34 00536-3030-06 00536-3030-23 00536-3113-01 00536-3113-37 Covered OTC Smoking Cessation NICOTINE POLACRILEX BUCCAL 4 MG GUM NICOTINE POLACRILEX BUCCAL 4 MG GUM NICOTINE POLACRILEX BUCCAL 4 MG GUM NICOTINE POLACRILEX BUCCAL 4 MG GUM NICOTINE POLACRILEX BUCCAL 4 MG GUM NICOTINE POLACRILEX BUCCAL 4 MG GUM NICOTINE POLACRILEX BUCCAL 4 MG GUM NICOTINE POLACRILEX BUCCAL 4 MG GUM NICOTINE POLACRILEX BUCCAL 4 MG GUM NICOTINE POLACRILEX BUCCAL 4 MG GUM NICOTINE POLACRILEX BUCCAL 4 MG GUM NICOTINE POLACRILEX BUCCAL 4 MG GUM NICOTINE POLACRILEX BUCCAL 4 MG GUM NICOTINE POLACRILEX BUCCAL 4 MG GUM NICOTINE POLACRILEX BUCCAL 4 MG GUM NICOTINE POLACRILEX BUCCAL 4 MG GUM NICOTINE POLACRILEX BUCCAL 4 MG GUM NICOTINE POLACRILEX BUCCAL 4 MG GUM NICOTINE POLACRILEX BUCCAL 4 MG GUM NICOTINE POLACRILEX BUCCAL 4 MG GUM NICOTINE POLACRILEX BUCCAL 4 MG GUM NICOTINE POLACRILEX BUCCAL 4 MG GUM NICOTINE POLACRILEX BUCCAL 4 MG GUM NICOTINE POLACRILEX BUCCAL 4 MG GUM NICOTINE POLACRILEX BUCCAL 4 MG GUM NICOTINE TRANSDERM 7MG/24HR PATCH TD24 NICOTINE TRANSDERM 7MG/24HR PATCH TD24 NICOTINE TRANSDERM 7MG/24HR PATCH TD24 NICOTINE TRANSDERM 7MG/24HR PATCH TD24 NICOTINE TRANSDERM 7MG/24HR PATCH TD24 NICOTINE TRANSDERM 7MG/24HR PATCH TD24 NICOTINE TRANSDERM 7MG/24HR PATCH TD24 NICOTINE TRANSDERM 7MG/24HR PATCH TD24 NICOTINE TRANSDERM 7MG/24HR PATCH TD24 NICOTINE TRANSDERM 7MG/24HR PATCH TD24 NICOTINE TRANSDERM 7MG/24HR PATCH TD24 NICOTINE TRANSDERM 14MG/24HR PATCH TD24 NICOTINE TRANSDERM 14MG/24HR PATCH TD24 NICOTINE TRANSDERM 14MG/24HR PATCH TD24 NICOTINE TRANSDERM 14MG/24HR PATCH TD24 NICOTINE TRANSDERM 14MG/24HR PATCH TD24 NICOTINE TRANSDERM 14MG/24HR PATCH TD24 NICOTINE TRANSDERM 14MG/24HR PATCH TD24 NICOTINE TRANSDERM 14MG/24HR PATCH TD24 NICOTINE GUM NICOTINE GUM NICOTINE GUM NICOTINE GUM NICOTINE GUM NICOTINE GUM NICOTINE GUM NICOTINE GUM NICOTINE GUM NICOTINE GUM NICOTINE GUM NICOTINE GUM NICOTINE GUM NICOTINE GUM NICOTINE GUM NICOTINE GUM NICOTINE GUM NICOTINE GUM NICOTINE GUM NICOTINE GUM NICOTINE GUM NICOTINE GUM NICOTINE GUM NICOTINE GUM NICOTINE GUM NICODERM CQ NICODERM CQ NICOTINE NICOTINE PATCH NICOTINE PATCH NICOTINE PATCH NICOTINE PATCH NICOTINE PATCH NICOTINE PATCH NICOTINE PATCH NICOTINE PATCH NICODERM CQ NICODERM CQ NICOTINE PATCH NICOTINE PATCH NICOTINE PATCH NICOTINE PATCH NICOTINE PATCH NICOTINE PATCH 00536-3387-01 00536-3387-37 00536-3405-01 00536-3405-37 24385-0171-58 24385-0598-71 24385-0599-71 36800-0170-25 36800-0170-71 36800-0422-71 36800-0532-78 36800-0854-78 37205-0204-71 37205-0968-58 37205-0968-78 49348-0572-08 49348-0572-36 49348-0692-36 49348-0692-64 49348-0788-10 62011-0170-01 68016-0281-49 68016-0283-50 68016-0285-44 68016-0287-62 00135-0147-02 00135-0196-02 68016-0290-88 00067-0213-07 00067-0213-14 00067-5124-07 00067-5124-14 00067-6141-14 00536-5894-88 37205-0363-74 62011-0050-01 00135-0195-02 00135-0195-03 00067-0214-07 00067-5125-07 00067-5125-14 00067-6140-14 00536-5895-88 37205-0361-74 Covered OTC Smoking Cessation NICOTINE TRANSDERM 14MG/24HR PATCH TD24 NICOTINE TRANSDERM 14MG/24HR PATCH TD24 NICOTINE TRANSDERM 21 MG/24HR PATCH TD24 NICOTINE TRANSDERM 21 MG/24HR PATCH TD24 NICOTINE TRANSDERM 21 MG/24HR PATCH TD24 NICOTINE TRANSDERM 21 MG/24HR PATCH TD24 NICOTINE TRANSDERM 21 MG/24HR PATCH TD24 NICOTINE TRANSDERM 21 MG/24HR PATCH TD24 NICOTINE TRANSDERM 21 MG/24HR PATCH TD24 NICOTINE TRANSDERM 21 MG/24HR PATCH TD24 NICOTINE TRANSDERM 21 MG/24HR PATCH TD24 NICOTINE TRANSDERM 21 MG/24HR PATCH TD24 NICOTINE TRANSDERM 21 MG/24HR PATCH TD24 NICOTINE TRANSDERM 21 MG/24HR PATCH TD24 NICOTINE TRANSDERM 21 MG/24HR PATCH TD24 NICOTINE POLACRILEX BUCCAL 4 MG LOZENGE NICOTINE POLACRILEX BUCCAL 4 MG LOZENGE NICOTINE POLACRILEX BUCCAL 4 MG LOZENGE NICOTINE POLACRILEX BUCCAL 4 MG LOZENGE NICOTINE POLACRILEX BUCCAL 4 MG LOZENGE NICOTINE POLACRILEX BUCCAL 4 MG LOZENGE NICOTINE POLACRILEX BUCCAL 4 MG LOZENGE NICOTINE POLACRILEX BUCCAL 4 MG LOZENGE NICOTINE POLACRILEX BUCCAL 4 MG LOZENGE NICOTINE POLACRILEX BUCCAL 4 MG LOZENGE NICOTINE POLACRILEX BUCCAL 4 MG LOZENGE NICOTINE POLACRILEX BUCCAL 4 MG LOZENGE NICOTINE POLACRILEX BUCCAL 4 MG LOZENGE NICOTINE POLACRILEX BUCCAL 4 MG LOZENGE NICOTINE POLACRILEX BUCCAL 4 MG LOZENGE NICOTINE POLACRILEX BUCCAL 4 MG LOZENGE NICOTINE POLACRILEX BUCCAL 2 MG LOZENGE NICOTINE POLACRILEX BUCCAL 2 MG LOZENGE NICOTINE POLACRILEX BUCCAL 2 MG LOZENGE NICOTINE POLACRILEX BUCCAL 2 MG LOZENGE NICOTINE POLACRILEX BUCCAL 2 MG LOZENGE NICOTINE POLACRILEX BUCCAL 2 MG LOZENGE NICOTINE POLACRILEX BUCCAL 2 MG LOZENGE NICOTINE POLACRILEX BUCCAL 2 MG LOZENGE NICOTINE POLACRILEX BUCCAL 2 MG LOZENGE NICOTINE POLACRILEX BUCCAL 2 MG LOZENGE NICOTINE POLACRILEX BUCCAL 2 MG LOZENGE NICOTINE POLACRILEX BUCCAL 2 MG LOZENGE NICOTINE POLACRILEX BUCCAL 2 MG LOZENGE NICOTINE PATCH NICOTINE PATCH NICODERM CQ NICODERM CQ NICODERM CQ NICODERM CQ NICOTINE NICOTINE PATCH NICOTINE PATCH NICOTINE PATCH NICOTINE PATCH NICOTINE PATCH NICOTINE PATCH NICOTINE PATCH NICOTINE PATCH NICORELIEF NICORETTE NICORETTE NICORETTE NICORETTE NICORETTE NICORETTE NICORETTE NICORETTE NICOTINE LOZENGE NICOTINE LOZENGE NICOTINE LOZENGE NICOTINE LOZENGE NICOTINE LOZENGE NICOTINE LOZENGE NICOTINE LOZENGE NICORELIEF NICORETTE NICORETTE NICORETTE NICORETTE NICORETTE NICORETTE NICORETTE NICORETTE NICORETTE NICOTINE LOZENGE NICOTINE LOZENGE NICOTINE LOZENGE 62011-0172-01 68016-0289-88 00135-0145-02 00135-0194-01 00135-0194-02 00135-0194-03 68016-0288-88 00067-0215-07 00067-5126-07 00067-5126-14 00067-6130-14 00067-6139-14 00536-5896-88 37205-0358-74 62011-0173-01 00904-6258-62 00135-0509-02 00135-0509-03 00135-0511-01 00135-0511-02 00135-0511-05 00135-0513-01 00135-0513-05 00135-0515-03 00113-0873-05 24385-0976-67 36800-0873-05 37205-0988-69 49348-0853-16 62011-0171-01 62011-0171-02 00904-6257-62 00135-0508-02 00135-0508-03 00135-0510-01 00135-0510-02 00135-0510-05 00135-0512-01 00135-0512-05 00135-0514-03 00135-0514-04 00113-0344-05 24385-0975-67 36800-0344-05 Covered OTC Smoking Cessation NICOTINE POLACRILEX BUCCAL 2 MG LOZENGE NICOTINE POLACRILEX BUCCAL 2 MG LOZENGE NICOTINE TRANSDERM 21-14-7MG PATCH DYSQ NICOTINE LOZENGE NICOTINE LOZENGE NICOTINE PATCH 37205-0987-69 49348-0852-16 00067-6045-56
Documentos relacionados
diapositivos em pdf
In patients with relapsing-remitting multiple sclerosis(MS),
does interferon-1a reduce the rate and severity of
relapse?
Design
Randomized, double-blind, placebo-controlled trial with 2year follow-...
