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Effective 01/01/2025 Regence BlueCross BlueShield of Oregon is an Independent Licensee of the Blue Cross and Blue Shield Association Regence BlueCross BlueShield of Oregon 200 SW Market Street, 11th Floor I Portland, OR 97201 Regence complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-[PHONE REDACTED] (TTY: 711). 注意：如 果 您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-[PHONE REDACTED] (TTY: 711). © 2025 Regence BlueCross BlueShield of Oregon PHARMACY SERVICES Preventive Services: Covered Tobacco Cessation Products Are you ready to kick the habit? We recognize it is hard to quit, but studies from the United States Preventive Services Task Force show that a combination of interventions, including brief behavioral counseling sessions (less than 10 minutes) along with medication or nicotine replacement treatment are effective in increasing the success rate of people trying to quit and remain tobacco-free for one year. Treatment Combination therapy with counseling and medications is more effective at increasing success rates than either component alone. There are many different forms of medication treatment approved by the US Food and Drug Administration (FDA) that are effective for treating tobacco dependence in non- pregnant adults. As part of the Preventive Care Prescription Benefit, several FDA-approved tobacco cessation medications are covered at no cost to you. Treatments that are not FDA-approved medications are not covered under the prescription benefit (such as “e-cigarettes”). For information on coverage of tobacco cessation services under the Medical Benefit, please visit your health plan’s web page. ---PAGE BREAK--- Covered Prescription Medications Available at a pharmacy at no cost to you with a valid prescription from your doctor: varenicline bupropion (tobacco cessation formulation) Nicotrol® nasal spray/oral inhaler+* Covered Over-the-Counter Products A prescription from your doctor is required for the following products to be processed at no cost to you at a pharmacy: Transdermal nicotine skin patches – All generic and store-brand products; No name-brand coverage+ Nicotine chewing gum – All generic and store-brand products; No name- brand coverage+ Nicotine lozenges – All generic and store-brand products; No name-brand coverage+ Coverage Details All covered tobacco cessation therapies are subject to quantity limits: We will cover up to two quit attempts per 12-month period. Each quit attempt includes up to 90 days of therapy, based on FDA- approved length of therapy per quit attempt. Total annual maximum of 180 days of therapy (two 90-day attempts per 12- month period). If your doctor believes that our tobacco cessation medications are medically inappropriate for you, you may request a coverage exception for a different medication by contacting Customer Service. Questions? Call the Customer Service number on your member ID card. +Coverage is limited to no more than two nicotine replacement prescriptions at the same time. *For coverage of branded nicotine nasal spray and oral inhaler products, pre-authorization is required. To be authorized, documentation is required showing that at least two other nicotine replacement options (including gum, lozenges, and patches) have been ineffective, not tolerated, or contraindicated. To request pre-authorization, please use the form located on our web page or by contacting Member Services at the number listed on the back of your member ID card.