NOw Available for california Medi-Cal Particpants

No-Cost Nicotine Replacement Therapy (NRT) Kit

Fully covered by Medi-Cal — includes nicotine gum or lozenges, vitamins, Tylenol, and more.

Reorder every month at no out-of-pocket cost.

Let’s Get You Started – It’s Quick & Secure

Takes Less Than 3 Minutes

(1/5)

First Name:

Last Name:

Female

Male

Prefer Not To Say

Email:

Where Should We Send Your Quit Kit?

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Medicaid ID Number (Optional):

Picture of Medicaid ID Card (Optional):

Qualification for NO-COST Smoking Cessation Products:

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Do you currently use any nicotine products, including cigarettes, e-cigarettes (vapes), or smokeless tobacco (chewing tobacco)?

Yes

No

How much tobacco/nicotine do you consume per day?

Would you like to quit or cut back your tobacco use?

Yes

No

Have you tried Nicotine Replacement Therapy (NRT) in the past?

Yes

No

If Yes, please describe your experience. Did you experience any success and/or negative symptoms?

Would you like to notify your primary care physician that you are being prescribed these medications? If so, please leave their name and contact information.

Helping You Get the Right Care:

(4/5)

List any conditions you have been diagnosed with:

Please provide a list of any allergies you have:

Last Step! Authorization:
(5/5)

Warning: Before taking any medications or over-the-counter drugs, consult a physician for a thorough evaluation. Always seek the advice of a physician or other qualified healthcare provider with any questions regarding a medical condition. Do not take medication if you have a known allergy to it.

I acknowledge I should seek medical advice from a provider before taking any medication, including over-the-counter medications.

Clear

I agree to Terms and Conditions. By signing this form, I authorize Stay Well US's Preferred Pharmacy to process and ship my No-Cost Nicotine Replacement Therapy (NRT) Kit. You will not be charged for this service.

How It Works

Step 1

Complete the quick eligibility request.

Step 2

Our team will review your request and verify eligibility.

Step 3

If eligible, your NRT kit will be shipped directly to you.

Checking your eligibility takes just a minute!

Your privacy is our priority.

We use a HIPAA-compliant form to securely collect your information, ensuring that your data is protected and handled with the highest standards.

Our No-Cost Nicotine Replacement Therapy (NRT) Kit includes:

Nicotine Gum or Lozenges – to help reduce cravings associated with quitting smoking, vaping, or using smokeless tobacco.

Vitamin C and Vitamin D Supplements – to support your body during the withdrawal process.

Magnesium Supplement – to promote better sleep while quitting.

Tylenol (Acetaminophen) – to relieve headaches and body aches.

COVID-19 Test Kit – included for added health support.

Refill available once per month — 100% covered by Medi-Cal

Why Choose Home Delivery?

Convenience:

No need to visit a store—your Stop Nicotine items come to you.

No Cost for Eligible Residents:

This program is available at no extra charge for qualified individuals.

Quick & Easy Process:

Check your eligibility in just a few minutes.

Click below to start your request:

Your health information is safe with us. Our HIPAA-compliant process ensures that your personal details are securely encrypted and used only to determine your eligibility.

STILL NOT SURE?

Frequently Asked Questions

We know you may have questions, and we’re here to help! Below are some of the most common questions about our program, how eligibility works, and what you can expect. If you need further assistance, feel free to reach out to our support team.

Who is eligible for this program?

Eligibility is based on residency and health coverage status. To determine if you qualify, simply complete our secure eligibility request form. It only takes a minute!

Does this program cost anything?

There is no out-of-pocket cost for eligible participants. Our stop smoking kits are available to qualified individuals through approved health program.

What’s included in the No-Cost Nicotine Replacement Therapy (NRT) Kit?

🟩 Nicotine Gum or Lozenge – helps reduce cravings💊 Vitamin C + Vitamin D – supports your body during withdrawal🌙 Magnesium Supplement – promotes better sleep while quitting💊 Tylenol (Acetaminophen) – relieves headaches and body aches🧪 COVID-19 Test Kit – included for added health support🌀 Refill available once per month — 100% covered by Medi-Cal

How do I check my eligibility?

Checking your eligibility is simple! Click the button below to complete our quick and secure HIPAA-compliant request form. Our team will review your information and notify you of the next steps.

How long does it take to receive my Stop Smoking Kit?

Once your eligibility is confirmed, we will process your request as quickly as possible. Delivery times may vary based on processing and shipping availability.

How is my information protected?

Your privacy is our priority. We use a HIPAA-compliant system to securely process your information, ensuring that it is encrypted and handled with the highest standards of privacy and security. Your details will never be shared without your consent.