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Quitline Iowa
FAX Completed Form To
Iowa Department of Public Health/Quitline Iowa
Smoking Cessation Therapy- Oral
(PLEASE PRINT - ACCURACY IS IMPORTANT) Member ID #: |___|___|___|___|___|___|___|___|___| Patient Name: ___________________________________ DOB: _________________ Patient Address:__________________________________________________________________________________________________
Provider NPI: |___|___|___|___|___|___|___|___|___|___| Prescriber Name:_______________________________ Phone:_________________

Prescriber Address:_______________________________________________________________________ Fax:____________________

Pharmacy Name:_____________________________ Address:_______________________________________ Phone:_________________
Prescriber must fill all information above. It must be legible, correct and complete or form will be returned.

NPI: |___|___|___|___|___|___|___|___|___|___| Pharmacy Fax: _____________________ NDC : |___|___|___|___|___|___|___|___|___|___|___|

Prior Authorization is required for varenicline (Chantix™) or bupropion SR that is FDA approved for smoking cessation. Requests
for authorization must include: 1) Diagnosis of nicotine dependence and referral to the Quitline Iowa program for counseling.
2) Confirmation of enrollment and ongoing participation in the Quitline Iowa counseling program is required for approval and
continued coverage. 3) Approvals will only be granted for patients eighteen years of age and older. 4) The duration of therapy
is initially limited to twelve weeks within a twelve-month period. For patients who have successfully stopped smoking at the end of 12
weeks, an additional course of 12 weeks treatment will be considered with a prior authorization request. The maximum duration
of approvable therapy is 24 weeks within a twelve-month period. 5) Requests for varenicline to be used in combination with
bupropion SR or nicotine replacement therapy will not be approved. 6) The 72-hour emergency supply rule does not apply for drugs
used for the treatment of
smoking cessation

 Chantix™ Starter Pak  Chantix™ 1mg BID  Other: _______________________ (**May check more than one box**)

 Bupropion SR Strength_____________ Dosing Instructions:__________________________________________________
PA Renewal Prescriber signature on this line indicates medical documentation that the member has stopped smoking
after the initial 12 weeks of therapy. _______________________________

 The patient has agreed to the following:
1) Volunteered to participate with Quitline Iowa 2) Quitline Iowa may contact the patient about quitting smoking, local programs, and/or counseling 3) Quitline Iowa may discuss the patient’s use of Quitline with the patient’s health care provider and/or Iowa Medicaid 4) All the patient’s information will be kept private ________________________________________ ________________ _________________ _____________ Patient’s Signature Patient’s Phone Number Preferred Language Hearing Impaired/Need TDD Best times and days for Quitline to call:  8:00 a.m. to noon  Best days to call:_________________________  The counselor may leave a message saying
Prescriber Signature: _________________________________________ Date of Submission: ______________________

Prescriber: Please fax completed portion above to Quitline Iowa: 1-866-688-7577.
Outcome (to be completed by Quitline Iowa and faxed to the Iowa Medicaid PA Department at 1-800-574-2515):

 Member enrolled in Quitline Iowa Counseling Program
IMPORTANT NOTE: In evaluating requests for prior authorization the consultant will consider the treatment from the standpoint of medical necessity only. If
approval of this request is granted, this does not indicate that the member continues to be eligible for Medicaid. It is the responsibility of the provider who initiates
the request for prior authorization to establish by inspection of the member’s Medicaid eligibility card and, if necessary by contact with the county Department of
Human Services, that the member continues to be eligible for Medicaid.

Source: https://www.quitnow.net/_assets/cms_uploads/Smoking_Cessation_PA_Form.pdf

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