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The excluded medications shown below are not covered on the Express Scripts drug list. Levitra, Staxyn, Stendra Cialis, Viagra.

This form is based on Express Scripts standard criteria and may not be.Pharmacy Benefit Clinical Appeal Process General Information.Erectile Dysfunction Agents: ONLY COMPLETED REQUESTS WILL BE REVIEWED.

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ESI Prior Authorization List. benefit plan will need prior authorization.

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The PA criteria for Cialis, Levitra, Viagra, Caverject, Edex, and Muse provide an approval.

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