About Cialis

• Levitra®: for the treatment of erectile dysfunction, requires prior authorization.
If approved, quantity limit of six tablets every 30 days.
• Lumigan®: for use in the treatmentof glaucoma
• Namenda®: for the treatment of Alzheimer’s disease
• Nuvaring: for prevention of pregnancy
• Oxytrol: for the treatment of overactive bladder – requires prior authorization
• Restasis®: for the treatment of keratoconjunctivitis sicca (KCS, severe dry
eye), requires prior authorization and must be prescribed by either an ophthalmologist or rheumatologist
• Reyataz®: for the treatment of HIV infection in combination with other antiretroviral agents
• Stavelo®: for the treatment of Parkinson’s Disease.
• Vigamox®: for the treatment of bacterial conjunctivitis Drugs removed from the formulary:
• Viagra®: for the treatment of erectile dysfunction, will continue to require prior authorization, and if approved,
has a quantity limit of 6 tablets every 30 days at the higher non-formulary
copayment amount.
Formulary alternative:
•Levitra (requires prior authorization)
• Xalatan®: for the treatment of glaucoma.
Formulary alternatives: Azopt,® Cosopt,®Lumigan,® Travatan® and Trusopt.®
Other changes:
Drugs reviewed, not added to the formulary, requiring prior authorization.
Members are required to obtain prior authorization showing medical necessity for the following drugs:
• Alinia®: for the treatment of diarrhea caused by Cryptosporidium parvum and Giardia lablia in pediatric patients.
If approved, quantity limit of one bottle per prescription.
Formulary alternatives: metronidazole and Humatin®
• Cialis®: for the treatment of erectile dysfunction.
If approved, has a quantity limit of 6 tablets every 30 days at the higher
non-formulary copayment amount.
Formulary alternative: Levitra (requires prior authorization)
Drugs reviewed, not added to the formulary, having quantity limits.
• Emend®: for the prevention of acute and delayed nausea and vomiting
associated with highly emetogenic chemotherapy. Quantity limit of 3
capsules per fill.
Formulary alternatives: Kytril® and dexamethasone, Zofran® and dexamethasone,
and Anzemet® and dexamethasone
• Finacea®: for the topical treatment of inflammatory papules and pustules of
mild to moderate rosacea. Quantity limit of one tube per prescription.
Formulary alternatives: metronidazole, sodium sulfacetamide/sulfur and oral
antibiotics.
• Relpax®: For the acute treatment of migraine. Quantity limit of 6 tablets
per month.Formulary alternatives: Imitrex,®
Amerge® and Maxalt.®
• Strattera®: for the treatment of attention deficit hyperactivity disorder
(ADHD). Quantity limits will apply.
Formulary alternatives: Concerta,® Adderall,® Adderall XR, Metadate®
ER, methylphenidate (generic for Ritalin,® Ritalin SR), dextroamphetamine sustained release (generic for
Dexedrine® Spanules) and pemoline (generic for Cylert).
Other:
• Seasonale: for the prevention of pregnancy. Requires three non-formulary copayments at retail pharmacies for a 91-day supply. You can access the complete and updated Blue Shield Drug Formulary through our Web site at mylifepath.com. Click on the "Pharmacy" tab, then on the "drug database and formulary" button at the top of the page. You can then search by any portion of a drug name or by a drug category.
You can also download the Blue Shield Drug Formulary to your Palm OS
handheld device for free.

We are committed to covering safe and effective medications, so we continually review and update our drug formulary. Our Pharmacy and Therapeutics Committee meets four times a year to recommend changes based on the latest medical literature, consultation with physicians and information from the federal Food and Drug Administration. The committee includes practicing physicians and pharmacists from our provider network who have expertise in pharmacology and therapeutics. Here are changes made during their meetings in June, September and December 2003 and March 2004.