Cost & Coverage

COST & PAYMENT FOR MEDS

To find the best prices and most convenient pharmacies for your patients, visit goodrx.com and type in the drug’s name.

You’ll even find online coupons and discounts for extra savings.

INSURANCE COVERAGE

There are a number of ways that you, as a healthcare provider, can assist your patients to quit using tobacco. And insurance can help, too. The Affordable Care Act provides helpful benefits for patients who want to quit.

VETERANS

Smoking and tobacco use remain some of the Veteran Affairs’ (VA) biggest public health challenges as many veterans began using tobacco while they were in the military. To help veterans quit, the VA offers:

  • Screening for tobacco use during primary care visits
  • Individual counseling
  • Prescriptions for nicotine replacement therapy (patch, gum or other medications)
  • Participation in evidence-based smoking cessation programs
  • Veterans can contact the nearest VA healthcare facility to schedule an appointment. Call toll-free, 1-877-222-8387.

Click here for a list of clinics where veterans can receive services in Utah.

1-855-QUIT-VET is a national, proactive, toll-free counseling quitline. 1-855-QUIT-VET is available at no cost to all Veterans receiving their health care through VA.

SmokefreeVET is a Veteran-focused text messaging program provides up to eight weeks of supportive and encouraging texts to Veterans attempting to quit smoking. Text messages are available in both English and Spanish.

Veterans can sign up for the program in English by texting the word VET to 47848 from their mobile phone or by visiting smokefree.gov/VET. For Spanish, they can text VETesp to 47848 or visit smokefree.gov/VETespanol.

1-855-QUIT-VET and SmokefreeVET are collaborations between VA and the National Cancer Institute.

Veterans can also receive intensive personal coaching to help them quit through the Utah Tobacco Quit Line (1.800.QUIT.NOW). Counseling and nicotine replacement therapy (patch or gum) are available to veterans, and services are provided free of charge to Utah residents up to twice per year.

Utah Quit Line Fax Referral Form

Utah Quit Line Online Referral Form

MEDICARE

Individuals aged 65 years and older as well as some disabled individuals are eligible to be covered by Medicare. Cessation medications that are required for Medicare to provide include nicotine nasal spray, nicotine inhaler, bupropion and varenicline. Part D plans may opt to cover other medications. Medicare-insured individuals also can receive up to four sessions of individual counseling and up to two quit attempts per year. There is no cost-sharing for patients not showing symptoms of a tobacco-caused disease.

Medicare patients may also receive intensive cessation coaching through the Utah Tobacco Quit Line (1.800.QUIT.NOW). Counseling and nicotine replacement therapy (patch or gum) are available and the services are provided free of charge to Utah residents up to twice per year.

Utah Quit Line Fax Referral Form

Utah Quit Line Online Referral Form

MEDICAID AND PRIMARY CARE NETWORK (PCN)

CESSATION COUNSELING AND SUPPORT

All Medicaid and PCN enrollees are eligible for intensive tobacco cessation counseling through the Utah Tobacco Quit Line (1.800.QUIT.NOW). Intensive counseling includes up to five sessions lasting 20 minutes each. In addition, up to eight weeks of nicotine replacement therapy (patch or gum) is available to those enrolled in the program. These services are provided free of charge to Utah residents up to twice per year.

Utah Quit Line Fax Referral Form

Utah Quit Line Online Referral Form

CESSATION MEDICATIONS

To view the medication benefits for Medicaid and PCN clients, go to Utah Medicaid Benefits.

UTILIZING MEDICAID

All Medicaid clients are eligible for a variety of free services through the Tobacco Quit Line. For those who are ready to quit, intensive cessation counseling and nicotine replacement (patch or gum) are available. For more information, call 1.800.QUIT.NOW.

UTILIZING THE PRIMARY CARE NETWORK

In Utah, the Primary Care Network is part of the Department of Health. PCN clients tend to have higher smoking rates than average, so the Tobacco Prevention and Control Program (TPCP) partners with the PCN to offer quitting services to their clients. The program offers services through the Utah Tobacco Quit Line and includes coverage of tobacco cessation medications, as well as additional help for pregnant women. To learn more, contact TPCP at 1-877-220-3466.

PRIVATE

To determine what benefits are offered by Utah health insurance companies, please see below:

Aetna

For more information, patients can call the number on the back of their card.

Cigna

For more information, patients can call 1-800-244-6224.

Humana

For more information, patients can call the number on their card.

National Health Insurance Company

For more information, patients can call the number on their card.

PEHP

For more information, patients can call 1-800-765-7347.

Medications:*

  • Patch
  • Gum
  • Lozenge
  • Nasal Spray
  • Inhaler
  • Bupropion
  • Varenicline

*Counseling required for medications

Counseling:

  • Phone counseling through PEHP Quit Line
  • Individual counseling

Regence BlueCross BlueShield

For more information, patients can call 1-866-QUIT-4-LIFE.

SelectHealth

For more information, patients can call the number on their card.

University of Utah Health Plans

For more information, patients can call 801-587-6480.

Other

For more information, patients can call the number on their card.

This web page is for informational purposes only. The accuracy, reliability or completeness of any of the information cannot be guaranteed. If you wish to obtain information about your benefits, contact your health plan directly.

Insured patients may receive one phone call and two weeks of nicotine replacement therapy through the Utah Tobacco Quit Line (1.800.QUIT.NOW).

UNINSURED

Uninsured patients may receive intensive cessation counseling through the Utah Tobacco Quit Line (1.800.QUIT.NOW). Intensive personal coaching up to five sessions lasting 20 minutes each. In addition, up to eight weeks of nicotine replacement therapy (patch or gum) is available to those enrolled in this intensive counseling program and services are provided free of charge to Utah residents up to twice per year.

Utah Quit Line Fax Referral Form

Utah Quit Line Online Referral Form

ASSOCIATION FOR UTAH COMMUNITY HEALTH (AUCH)

Uninsured community health center clients can receive up to 12 weeks of Zyban or 24 weeks of Chantix per year, free of charge, through participating Associations for Utah Community Health (AUCH). Patients receiving cessation medications through the program are referred to the Utah Tobacco Quit Line for counseling.

Click here for a list of community health centers.

BILLING & REIMBURSEMENTS

CODING REFERENCE

As of January 2014, the Affordable Care Act (ACA) requires insurance plans to cover many clinical preventive
services. Some of the covered preventive services include:

  1. Tobacco use screening for all adults
  2. Tobacco cessation counseling for adults who use tobacco, and expanded counseling for pregnant women

Medicare

Medicare Part B covers both intermediate and intensive levels of tobacco cessation counseling for symptomatic and
asymptomatic patients.

Two cessation attempts are covered per year, and both coinsurance and deductibles are waived. Each attempt may
include a maximum of four intermediate or intensive counseling sessions. The total annual benefit covers up to eight
smoking cessation counseling sessions in a 12-month period. The patient may receive another eight counseling sessions
during a second or subsequent year after 11 months have passed since the first Medicare-covered cessation counseling
session.

To qualify for payment from Medicare, the following criteria must be met at the time of service:

  • Patients must be competent and alert.
  • Counseling must be provided by a physician or other Medicare-recognized practitioner.

SYMPTOMATIC PATIENTS

Symptomatic patients are those who use tobacco and:

  • Have been diagnosed with a disease or an adverse health effect that has been found by the U.S. Surgeon General
    to be linked to tobacco use.
  • Take a therapeutic agent for which the metabolism or dosing is affected by tobacco use, based on information
    approved by the U.S. Food and Drug Administration (FDA).

Use the following CPT codes for symptomatic patients.

CODE Type of Counseling Description
99406 Intermediate Smoking and tobacco-use cessation counseling visit greater than three minutes but not more than 10 minutes.
99407 Intensive Smoking and tobacco-use cessation counseling visit greater than 10 minutes.

 

Asymptomatic Patients

Asymptomatic patients are those who use tobacco but do not have symptoms of a tobacco-related disease. Use the
following CPT codes for asymptomatic patients.

CODE Type of Counseling Description
G0436 Intermediate Smoking and tobacco use cessation counseling visit greater than 3 minutes but not more than 10 minutes.
G0437 Intensive Smoking and tobacco use cessation counseling visit greater than 10 minutes.

 

Use the following CPT codes for patients who use tobacco but do not have symptoms of tobacco-related disease:

CODE Description
F17.200 Nicotine dependence, unspecified, uncomplicated
F17.201 Nicotine dependence, unspecified, in remission.
F17.210 Nicotine dependence, cigarettes, uncomplicated
F17.211 Nicotine dependence, cigarettes, in remission
F17.220 Nicotine dependence, chewing tobacco, uncomplicated
F17.221 Nicotine dependence, chewing tobacco, in remission
F17.290 Nicotine dependence, other tobacco product, uncomplicated
F17.291 Nicotine dependence, other tobacco product, in remission
Z87.891* Personal history of nicotine dependence
    *For use with asymptomatic patients only

*For each patient receiving smoking and tobacco-use cessation counseling or counseling to prevent tobacco use,
medical record documentation must show and include standard information along with sufficient patient history to
adequately demonstrate that Medicare coverage conditions were met.

Medications

Medicare Part D covers FDA-approved cessation drug therapies. However, over-the-counter therapies are typically
excluded.

MEDICAID

 

Counseling

Many states offer some payment for individual tobacco cessation and treatment counseling for Medicaid patients.
However, providers are encouraged to contact their state Medicaid office for coverage information in their specific
state.

Medications

As of January 1, 2014, all state Medicaid programs are required to support all FDA-approved smoking cessation
medications without requiring co-pays or other financial barriers.

PRIVATE / COMMERCIAL INSURANCE CARRIERS

Private insurers are required to provide evidence-based tobacco cessation counseling and interventions to all adults
and pregnant women. Private payer benefits are subject to specific plan policies. Providers need to check with
insurance plans to determine what specific interventions are included and the extent to which they are covered.

CODE Type of Counseling Description
99406 Intermediate Smoking and tobacco-use cessation counseling visit greater than three minutes but not more than 10 minutes
(Short Descriptor: Smoke/tobacco counseling 3-10).
99407 Intensive Smoking and tobacco-use cessation counseling visit greater than 10 minutes (Short Descriptor: Smoke/tobacco
counseling greater than 10).
S9075 Smoking Cessation Treatment
S9453 Smoking Cessation Classes Non-physician provider, per session
99381-99397 Preventive Medicine Services Comprehensive, preventive evaluation based on age and gender to include appropriate history, examination,
counseling/anticipatory guidance, risk factor reduction interventions, and related plan of care
99078 Physician Educational Services Group Setting (e.g., Prenatal, Obesity, Diabetes)

 

Various E/M services (associated with acute or chronic care) may be coded. When providing an E/M service, if greater
than 50 percent of face-to-face time with patient is spent on counseling, time may be used as a basis for selection
of level of service.

ICD-10 DIAGNOSIS CODE Description
305.1 Tobacco-use disorder
649.0x Tobacco-use disorder complicating pregnancy, childbirth or puerperium
989.84 Other substances, chiefly nonmedicinal as to source, tobacco*

 

  • List additional code to specify nature of toxic effect. Excludes localized toxic effects classified elsewhere
    and respiratory conditions due to external agents and, if applicable, any diagnosis code(s) for condition(s)
    evaluated and managed in the same encounter.*
  • All codes with .x or .xx require fourth or fifth digits. See the ICD-9 manual for complete descriptions.

*This list was formulated based on the 2004 Surgeon General’s Report on the Health Consequences of Smoking. It is not
an all-inclusive list and may be subject to different interpretation of the report.

For a more comprehensive list of billing codes and information on how to use them, please see the American Lung
Association’s Billing Guide for Tobacco Screening and Cessation here.

SELF-PAY PATIENTS AND UNINSURED PATIENTS

Resources for patients who do not have insurance coverage or who have limited coverage from their insurance carrier
include the following:

  • Quit lines (1-800-QUIT-NOW)
  • Online cessation resources (Online Coaching)
  • Flexible spending accounts if smoking cessation is an allowable expense
  • Employee Assistance Programs (EAP); tobacco cessation may be covered by EAPs in some cases.
  • Community resources and support groups
  • Out-of-pocket spending

Last updated: 08/23/2018