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

Oklahoma Health Care Authority

4345 N Lincoln Blvd

Oklahoma City, OK 73105

The Oklahoma Health Care Authority collects the personally identifiable data submitted and received in regard to applications for services, renewals, appeals, provision of health care and processing of claims. This data is treated as confidential and is stored securely in accordance with applicable law and regulations. OHCA may share this personally identifiable data with its authorized business associates, government agencies with jurisdiction over the OHCA, or as otherwise required or permitted by applicable law.