New TeamstersCare Smoking Cessation Medication Coverage
Effective May 1, 2007

The TeamstersCare Board of Trustees has appoved coverage for Chantix®, a prescription medication used to treat smoking addiction, for members and their eligible dependents who want to quit smoking.
Coverage for Chantix® works as follows:

• The patient fills the initial prescription for 12 weeks of Chantix® at a retail pharmacy and enrolls in any smoking cessation program. GetQuit, TrytoStop, and programs sponsored by the American Cancer Society, are some examples.
• He/She submits prescription receipts, and a certificate of completion of a smoking cessation program to TeamstersCare Member Services for reimbursement. TeamstersCare will reimburse the total cost of the prescription minus a $25.00 co-pay per prescription.
• If needed, the patient may fill a prescription for an additional 12 weeks of Chantix® only at a TeamstersCare pharmacy with a $15 co-pay.
• The maximum reimbursement for Chantix® will be for a total of up to 24 weeks in a 12 month period.

To obtain reimbursement:

1. Complete all sections on the reverse side of this form. Be sure to sign and date as indicated.
2. Attach legible copies of your prescription receipts (cancelled checks, cash register receipts or charge card receipts are not valid). Keep your original receipts and proofs of payment for your records.
3. The prescription receipts must include:
   • Name of person receiving the prescription,
   • Name of medication,
   • Name of prescribing physician,
   • Date of purchase,
   • Prescription number; and
   • Total charge for the prescription (amount for which you are requesting reimbursement)
4. Send the completed form with a copy of proof of completion of a Smoking Cessation Program to TeamstersCare Member Services at 16 Sever Street, Charlestown, MA 02129-1309. You may want to keep a copy of the form for your records.

Click here for a link to the Chantix Smoking Cessation Program Reimbursement Claim Form.

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