This policy applies to those members whose prescription drug benefits exclude or require prior authorization of smoking cessation therapy.

Background:

Bupropion is an oral antidepressant agent. It is available in both immediate-release (Wellbutrin), sustained-release (Wellbutrin SR) and extended release (Wellbutrin XL)dosage forms. Wellbutrin, Wellbutrin SR, and Wellbutrin XLare indicatedfor the treatment of depression.

Bupropion is also available under the proprietary name Zyban. Zyban is an oral sustained-release dosage form containing bupropion 150 mg. Zyban is indicated as an aid to smoking cessation treatment; it is not indicated in the treatment of depression.

Many groups do not include smoking cessation therapy as part of their prescription drug benefit. However, Wellbutrin SR,Wellbutrin XL, and Zyban are available as 150 mg sustained-release tablets. Thus, the opportunity exists to obtain coverage for Wellbutrin SR or Wellbutrin XLand to then utilize this medication as an aid in smoking cessation treatment for those members who do not have coverage for smoking cessation therapy. Therefore, Wellbutrin, Wellbutrin SR, and Wellbutrin XLrequire prior authorization.

Approval Criteria: For groups that exclude coverage for smoking cessation, the following indication will be applied for the coverage of Wellbutrin, Wellbutrin SR, and Wellbutrin XL therapy:

1.Any medical condition with the exception of smoking cessation therapy.

Use of Wellbutrin, Wellbutrin SR, or Wellbutrin XL for smoking cessation treatment will be denied to prevent the circumvention of established benefit exclusions.

Duration of Authorization:

If approved, authorization should be granted for a period of one year.