Limited Use Note(s)
VARENICLINE TARTRATE
0.5mg & 1.0mg Tab (Starter Pack-53 Tabs)
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Reason For Use Code
Clinical Criteria
423
For smoking-cessation treatment in adults, in conjunction with smoking-cessation counseling. Network Note: Limited to 12 weeks (168 tablets) of reimbursement per 365 days per patient.
LU Authorization Period: 12 Weeks.
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