Tobacco Cessation Treatment: What Is Covered?

Age 65+ or some disabled individuals

• Cessation medications: nicotine nasal spray, nicotine inhaler, bupropion and varenicline. Part D plans may opt to cover other medications.
• 4 sessions of individual counseling
• Up to 2 quit attempts per year
• No cost-sharing for counseling
• Annual prevention visit

Low-income or disabled individuals, eligibility varies by state

For pregnant women:

• Individual, group and phone counseling
• All FDA-approved smoking cessation medications

For all Medicaid enrollees:

• All FDA-approved smoking cessation medications

Low-income or disabled individuals, up to 138% of federal poverty level in states that expand Medicaid

• Tobacco cessation as a preventive service. Federal guidance defines this as:
  • 4 sessions of individual, group and phone counseling
  • 90 days of all FDA-approved smoking cessation medications
  • 2 quit attempts per year
  • No prior authorization for treatments
  • No cost-sharing

Individuals who buy plans through healthcare.gov or their state’s marketplace. Subsidies for these plans are available to those earning 100-400% of the federal poverty level.

• Tobacco cessation as a preventive service. Federal guidance defines this as:
  • 4 sessions of individual, group and phone counseling
  • 90 days of all FDA-approved smoking cessation medications
  • 2 quit attempts per year
  • No prior authorization for treatments
• No cost-sharing

Individuals who receive health insurance through their employer, association, union or other organization.

• Tobacco cessation as a preventive service. Federal guidance defines this as:
  • 4 sessions of individual, group and phone counseling
  • 90 days of all FDA-approved smoking cessation medications
  • 2 quit attempts per year
  • No prior authorization for treatments
• No cost-sharing

Individuals enrolled in a plan that was in existence before March 2010 and has not made significant changes since.

No requirements, but plans may opt to cover tobacco cessation treatment

Cost-sharing: money a patient must pay when receiving treatment/filling a prescription: copays, coinsurance, deductibles, etc.

These plans were designed to cover individuals to ill short gaps in health insurance coverage. They are plans sold on the individual market and have minimal federal regulations. These plans do not meet the Minimum Essential Coverage (MEC) standards as defined by the Affordable Care Act (ACA) and therefore are not legally considered to be health insurance plans. Short-term limited-duration plans do not satisfy the ACA’s individual mandate. Recently, the Department of Labor, Department of Treasury and the Department of Health and Human Services issued a new rule and starting October 2, 2018, short-term limited-duration plans can be sold for up to 364 days and can be renewable for up to three years.

No requirements, but plans may opt to cover tobacco cessation treatment

Cost-sharing: money a patient may be required pay when receiving treatment/filling a prescription: copays, coinsurance, deductibles, etc.

Federal Poverty Level: a measure of income level issued annually by the federal government. These levels are used to establish eligibility for certain programs and benefits, including Medicaid and eligibility for subsidies for health insurance. For more information, visit https://www.healthcare.gov/glossary/federal-poverty-level-FPL/