- PA Required
- Prior Authorization: PA Applies
- Zero copay may apply. Must be 40-75. and have one or more cardiovascular risk factors (high cholesterol, diabetes, hypertension, or smoking), and a calculated 10-year risk of a cardiovascular event of 10% or greater.
- Quantity Limit: 8 patches per 28 day(s).
For FAX form click HERE
Our electronic prior authorization (ePA) process is the preferred method for submitting pharmacy prior authorization requests. Creating an account is free, easy and helps patients get their medications sooner. You can complete the process through your current electronic health record/electronic medical record (EHR/EMR) system or by using one of these ePA sites:
Log in to Surescripts
Log in to CoverMyMeds; For details on drug coverage click HERE;
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