Document Sample
					                                     HEALTH INSURANCE
NOTE: The following information is limited and is provided in an effort to educate members and assist 
with frequently asked questions.  The governing document for your health plan is the Cox HealthPlans 
Explanation of Coverage (EOC) booklet in conjunction with any updated Riders filed with the Missouri 
Department of Insurance and the current year’s prescription formulary guidelines.   
For COMPLETE information and verification of any benefits, please see your plan EOC, plan Schedule of 
Benefits, and the current year’s formulary available electronically at, or 
contact Cox HealthPlans Member Services at 417‐269‐2900 (toll free 1‐800‐205‐7665).  Members may 
view this information by creating a username/password under the “Member” section for access to 
their plan information. 

What is a Benefit Year?
January 1st – December 31st of each year.  This is the time frame in which your deductible and out of 
pocket maximums accumulate, therefore these amounts always begin every January despite the fact 
that the policy anniversary begins every July.  This is standard with every insurance company. 
What/When is our Policy Anniversary?
July 1st  ‐‐‐ This is the time that insurance premiums and health insurance benefits may change each 
What/When is Open Enrollment?
June 30th – July 31st each year (The school district may require Open Enrollment paperwork to be 
submitted prior to school letting out for the summer, which will be communicated to you by your 
Human Resources Department).  This is the time that you may change plan options, add eligible 
dependents to the coverage without a qualifying event, or delete dependents from the coverage.  
Open Enrollment changes are effective July 1st each year. 
When am I or my dependents eligible for health insurance coverage?
Employees – New employees are eligible the 1st of the month following date of hire.  Cox HealthPlans 
must receive Enrollment within 31 days of your eligibility date. 
Eligible employees who did not enroll as of their original eligibility date may enroll during any Open 
Enrollment period.  They may also enroll within 31 days of a Qualifying Event (involuntary loss of other 
group coverage) during the policy year. 
Eligible Employees: Must work at least 30 hours/week on a regular basis and exclude bus drivers, food 
service staff designated as Cafe/Kitchen Managers or Head Cooks, cashiers and cooks, 
paraprofessionals/aides and PAT Teachers (please see Human Resources for alternative options if you 
fall into these job classes). 
Dependents – At the same point of the employee’s initial eligibility, during any Open Enrollment, or 
first of the month following the date of a Qualifying Event during the year (as long as Cox HealthPlans 
receives Enrollment within 31 days of that event). 
When can I add dependents to my health insurance?
Dependents can be added when the employee first becomes eligible for health insurance or when 
there is a Qualifying Event that triggers eligibility on the health plan.   
There is a 31‐day window for you to notify the school district of the qualifying event for you or an 
eligible dependent AND for the district to have submitted either on paper or electronically to Cox 
HealthPlans.  If Cox HealthPlans does not have such notification by the 31st day from the event, the 
person(s) in question will not be eligible again until the following Open Enrollment. 
Coverage is effective on the first of the month following the date of the event unless the event is a 
birth or adoption, in which case coverage would fall on the date of birth or date of placement for 
adoption.  Also, if you already have other children covered under your insurance at the time of your 
baby’s birth, you have as long as 90 days to add your baby to your coverage back to the date of birth.  
 1) If the employee has any type of dependent coverage (spouse and/or children) at the time of the newborn's 
birth, the newborn is covered for the first 31 days.  Cox HealthPlans must receive the Enrollment/Change Form 
(completed by the employee) within the first 31 days from the child's birth to continue coverage past the first 31 

2) If the employee has single coverage at the time of the newborn's birth, Cox HealthPlans must receive the 
Enrollment/Change Form (completed by the employee) within the first 31 days from the child's birth for there to 
be any coverage from the date of birth moving forward.
1) Assuming the above, the newborn is covered under the employee's premium for the first 31 days.

2) Start date for premium charges is determined by the time in the month of the baby's birth using the wash 
method below:  

        Date of birth 1st ‐ 15th of the month: Premium for newborn is billed for the entire month of the first 
        billing cycle following date of birth.
             DOB = 6/6/09 
            31 days = 7/7/09
            Premium charges begin = month of July moving forward

        Date of birth 16th ‐ end of the month: Premium for newborn is NOT billed for that month.
             DOB = 6/20/09
            31 days = 7/21/09
            Premium charges begin = month of August moving forward
Examples of Qualifying Events and required documentation supporting proof of eligibility are (DO NOT 
wait for required documentation if it is not readily available.  Submit those pieces separately upon 
availability so as not to miss the 31‐day window): 
        Involuntary loss of other group coverage (including exhaustion of COBRA coverage through a 
        prior employer) ‐ must supply copy of Certificate of Prior Creditable Coverage that will come 
        from the prior insurance company along with the former employer’s name and phone number 
        *Marriage ‐ must submit copy of marriage certificate  
        Divorce – copy of divorce decree in order to add employer and/or dependent to the plan 
        Adoption – copy of adoption papers or legal guardianship papers 
        *Court Ordered Coverage – copy of the court/administrative order 
        Newborn – enrollment form (Social Security # can be submitted when issued); if the child’s last 
        name if different than the employee’s, a copy of the birth certificate must be submitted 
        reflecting the birth parents’ names. 
        *If adding step‐children, enrollment submission must be accompanied by a written statement 
        from the employee indicating financial responsibility for the child(ren). 
How long can my dependent child(ren) remain on my health insurance?
Dependent children are eligible for coverage as long as they are unmarried, do not have health 
coverage through an employer, are dependent upon the employee for support and maintenance, and 
are under age 25 (coverage automatically terminates as of midnight on their 25th birthday; at this 
point, the dependent would be eligible for COBRA).  Please contact Cox HealthPlans with questions 
regarding disabled dependents. 
How do I submit a Name / Address Change?
Name Changes: Complete an Enrollment/Change Form making sure to indicate the reason for the 
application in Section B, and sign/date.  Please also note your previous name and new name on the 
Address Changes: Either complete the same as the above, or logon to the Cox HealthPlans website 
( under the Member section.  If you do not have a username/password, you 
can simply do so once online in order to gain access to your information. 
When would my or my dependent(s)’ coverage terminate? 
Employee Terminations: End of the month following the date of termination of employment or the 
end of the month following the date of request for termination of coverage if still employed. 
Dependent Terminations: End of the month following the date of employee’s termination or the end 
of the month following the date Cox HealthPlans receives the request for termination. 
                              BENEFIT INFORMATION
What is happens if I use IN-NETWORK providers versus OUT-OF-NETWORK
In‐network providers/facilities are contracted with Cox HealthPlans.  Services provided by in‐network 
providers will be subject to your in‐network benefits, which means you will pay less and receive the 
highest level of benefit under the plan.   
Out‐of‐network providers/facilities are NOT contracted with Cox HealthPlans.  If you choose to seek 
care from out‐of‐network providers, charges for that care will be subject to your out‐of‐network 
benefits, which means you will pay more for those services.   

Cox HealthPlans services 26 counties in southwest Missouri.  The most current listings of providers are 
available through the Cox HealthPlans website ( either in Adobe format or 
you may also perform provider searches by Practice, Specialty or City.  Be sure to perform your 
searches under the PPO Directory.  You may also verify provider/facility participation in our network by 
contacting your specific provider or by calling the Cox HealthPlans Member Services line (this number 
has been provided on the back of your ID card). 
Cox HealthPlans also provides nationwide in‐network coverage if you use First Health PPO providers 
when outside of our 26‐county service area.  A link has to the First Health website/search has been 
provided for you on our website.  You may also verify provider/facility participation in the First Health 
network by calling the First Health toll free number listed on the back of your ID card, or by calling Cox 

What is my DEDUCTIBLE?
The deductible is the amount you pay for your medical services each calendar year BEFORE Cox 
HealthPlans begins sharing the costs for your medical services.   
If you are unsure of which deductible you are enrolled under, you can verify this by logging onto the 
Cox HealthPlans website under the Member area with your username/password (if you have never 
registered, you can do so while online and create your username/password at that time) to view your 
benefit information. 

Coinsurance is the percentage of cost‐sharing between you and Cox HealthPlans AFTER you have met 
your deductible. 
Your in‐network medical coinsurance responsibility after meeting your in‐network deductible is 20% of 
the remaining eligible expenses.  “Eligible” refers to the amount of a service charge for covered 
benefits that the insurance company will allow a contracted physician to bill a member.  If the 
contracted physician bills over this allowed amount, the member is not responsible for the additional 
cost above that allowed amount, and the physician is contractually required to “write off” that 
additional charge. 
Your out‐of‐network medical coinsurance responsibility after meeting your out‐of‐network deductible 
is 50% of “reasonable and customary” (R&C) or allowed charges.  Because out‐of‐network physicians 
are not contracted with the Cox Health Systems Insurance Company, they have the right to charge 
more than the allowed amounts recognized by the insurance company.  Therefore, a member could not 
only be responsible for 50% of the R&C charges, but also 100% of any remaining charges over the R&C 
*Ambulance services are subject to 20% coinsurance either in‐network or out‐of‐network on either 
plan, after you have met your plan deductible (in‐network / out‐of‐network deductibles respectively). 

The office visit co‐pay is the fee you pay for each visit to the doctor’s office.  This is the only payment 
you should be responsible for up‐front.  ALL OTHER PAYMENTS WILL BE BILLED TO YOU AFTER THE 
If you feel your physician has prematurely billed you before insurance has been filed, please contact 
Cox HealthPlans Member Services for verification.  You can also check the status of claims by logging 
onto the Cox HealthPlans website under the Member area with your username/password to view your 
benefit information.  If you have never registered, you can do so while online and create your 
username/password at that time. 
The in‐network Physician Office Visit co‐pays cover the physician consultation only.  ALL other services 
(for example, diagnostic X‐rays, lab work, etc.) provided in the doctor’s office will be subject to the in‐
network deductible and coinsurance.  Office visit co‐pays are applied to the coinsurance maximums 
(NOT to the plan deductibles).  Out‐of‐network office visits on either plan are subject to the out‐of‐
network deductible and coinsurance.   

How does my URGENT CARE co-pay work?
The Urgent Care co‐pay is $75 per visit if you seek care from an in‐network Urgent Care Facility, and 
covers all services provided at that facility.  It should be noted that some Urgent Care facilities bill 
separately from their physicians.  While this is rare in our area, if that is the facility’s practice, you 
would be billed two co‐pays instead of one. 
Typically, Urgent Care facilities are defined as facilities providing care without an appointment and 
with extended office hours, and are often named “XXX Urgent Care Center” (or something of that 
nature).  The most common local in‐network Urgent Care facilities would be Cox Health Urgent Care 
(located in the Turner Center on the south campus), Cox North Urgent Care, Family Medical Walk‐In 
Clinics, Skaggs Urgent Care, etc.   
NOTE 1:  Family Medical Walk‐In in OZARK is NOT currently an in‐network provider.  They may make 
special arrangements to only bill you your $75 co‐pay and not bill us the difference to offset the 
inconvenience.  If they do this, payment to them would not count towards your out‐of‐pocket 
maximum on the health plan because the claim is not submitted. 
NOTE 2:  The Clinics at Wal‐Mart provide services without an appointment and with extended office 
hours, but are processed under your Physician Office Visit benefits rather than Urgent Care benefits. 

How does my EMERGENCY ROOM co-pay work?
The Emergency Room co‐pay is $200 per visit and covers all services provided in the Emergency Room.  
Our Emergency Provision allows you to have this benefit whether or not you are at an in‐network ER.  
If you are admitted into the hospital, the co‐pay is waived and charges are rolled up into the inpatient 
costs you incur. 
NOTE: If you are admitted through an out‐of‐network ER into that hospital, hospital charges will fall 
under your out‐of‐network benefits UNLESS you or someone on your behalf contacts the health plan 
within 48 hours of being admitted.  These hospital charges would then apply to your in‐network 
benefits until you are deemed by the attending physician to be in stable condition.  At this point, if 
further care is necessary, you would be required to use in‐network providers to continue receiving 
in‐network benefits. 

The “out‐of‐pocket maximum” noted on your benefit summary is the plan coinsurance maximum.  This 
is the cumulative of your coinsurance maximum (described above) and any medical co‐pays (Office 
Visit, Urgent Care, Emergency Room) you may incur throughout the calendar year.   
Once you have met your in‐network TOTAL out‐of‐pocket maximum within a calendar year, all services 
are covered at 100% by your insurance with the exception of your prescriptions for the remainder of 
that calendar year.   
If you were to meet your out‐of‐network out‐of‐pocket maximum within a calendar year, you could still 
be responsible for additional expenses because out‐of‐network providers are not required to write off 
charges above the “allowed” or “Reasonable & Customary” amounts. 
The total out‐of‐pocket maximums include both the coinsurance maximum and the plan deductible (if 
there are only two covered members, the deductible portion will be x2 rather than x3) on a calendar 
year basis are as follows: 
            Individual In‐Network:         $3,000 ($2,500 coinsurance max + $500 deductible) 
            Family In‐Network:             $6,500 (($2,500 x 2) + ($500 x 3)) 
            Individual Out‐of‐Network:     $7,250 ($6,250 coinsurance max + $1,000 deductible) 
            Family Out‐of‐Network:         $15,500 (($6,250 x 2) + ($1,000 x 3)) 
            Individual In‐Network:         $3,500 ($2,500 coinsurance max + $1,000 deductible) 
            Family In‐Network:             $8,000 (($2,500 x 2) + ($1,000 x 3)) 
            Individual Out‐of‐Network:     $8,250 ($6,250 coinsurance max + $2,000 deductible) 
            Family Out‐of‐Network:         $18,500 (($6,250 x 2) + ($2,000 x 3)) 
How does my PREVENTIVE BENEFIT work?
The average preventive costs in 2008 – 2009 were approximately $300 per person.  To encourage 
everyone to monitor their health on a regular basis, Cox HealthPlans covers the first $250 each 
calendar year of preventive/wellness services for each person covered under the plan, BEFORE you 
would pay towards your deductible and/or coinsurance.    
Preventive services include such things as Routine Physicals (school physicals are EXCLUDED from 
coverage under the plan), Well‐Woman visits, Mammograms, Well‐Child visits, and 
Prostate/PSA/colorectal exams.  Please note you will most likely be charged an office visit co‐pay by 
your doctor. 
It is important to verify with your physician that you have a preventive benefit under your health 
insurance, and that all services (including lab/X‐ray) should be coded as preventive in order for you 
to access this benefit to its fullest. 

How do my PRESCRIPTION DRUG benefits work?
To access your prescription drug benefits, you must show your health insurance ID card to the 
pharmacist each time you fill a prescription.  The Prescription Drug plan is separate from the medical 
plan in that none of what you pay for your prescriptions applies to the medical deductible/out‐of‐
pocket maximum.   
There is a Prescription Drug deductible of $100 per person per calendar year.  This deductible begins 
again every January 1st, just like your medical deductible.  Once this deductible is met, you then begin 
to receive the prescription drug co‐pay benefits under the plan.  As long as you fill your prescriptions at 
an in‐network pharmacy, you will not be subject to the out‐of‐network prescription drug benefits.   
The current prescription drug co‐pays are: 
Tier 1 (Most Generics) = $10 
Tier 2 (Preferred Brand) = $20 
Tier 3 (Non‐Preferred Brand) = $40 
Tier 4 (Specialty Medications) = $100 
For additional information and Frequently Asked Questions pertaining to prescription benefits, please 
the section labeled “2010 CatalystRx Prescription Drug Plan – FAQ”. 
For complete details regarding the prescription drug benefits, please see: 
    1) Your Cox HealthPlans Explanation of Coverage (EOC) booklet which can be viewed on the Cox 
       HealthPlans website ( when you login as a Member (hard copies are 
       available upon request), and  
    2) The 2010 Full Physicians’ Formulary List online at by selecting the 
       “Physicians” link, then selecting the “Cox HealthPlans 2010 Full Physicians’ Formulary”.  There is 
       also a link to the Catalyst Rx website from our website at  
                                    COX HEALTHPLANS - FIRST HEALTH PARTNERSHIP
          Cox HealthPlans is pleased to partner with First Health Network to provide Preferred Provider Organization
         (PPO) network services outside of Cox HealthPlans’ own network area. When seeking care outside of
        the Cox HealthPlans service area below, PPO members can lower their out-of-pocket expenses by taking
       advantage of this “wrap network”!

    First Health is one of the leading PPO networks in the United States. Today, their network consists of over
   490,000 providers, hospitals, and other health care providers in urban, suburban and rural areas throughout the
  United States including the District of Columbia.

It is easy to locate a provider in the First Health Network,
 • “Locate a Provider” on First Health’s web site at Select Locate a Provider/Search by
     Client - enter login ID: COXHP.
• Call First Health at 1-800-226-5116 Monday through Friday from 7 a.m. to 7 p.m. (CST)
• Call Cox HealthPlans Member Services Toll Free at 1-800-205-7665.

                                                              Members are not required to use the First Health
                                                              Network for unplanned or emergency treatment
                                                              while outside the service area, but doing so will help
                                                              to limit the out-of-pocket expenses and maximize
                                                              their benefit level.

                                                              Although a facility (hospital, clinic, etc.) is a contracted
                                                              provider with First Health Network, this does not ensure
                                                              that physicians or ancillary providers such as pa-
                                                              thologists, anesthesiologists, and radiologists
                                                                                     at this facility are contracted
                                                                                     with First Health. Services and
                                                                     26 County
                                                                                     items requiring pre-authorization,
                                                                                     including Inpatient, Outpatient,
                                                                                     and Emergency Services, will be
                                                                    Service Area
                                                                                     the covered person’s responsibility
                                                                                     to report to Cox HealthPlans.
                                                                                     For questions concerning the
                                                                                     procedures that require pre-
                                                                                     authorization, contact Member
                                                                                     Services at (417)269-2900 or

                               Please note: Cox HealthPlans will only utilize First Health Network outside of Cox
                                   HealthPlans’ service area. Providers in the First Health Network who are within
                                       the Cox HealthPlans service area will not be recognized as in-network providers.
                                     The Clinic at Walmart

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                                                                       When you need help for
 sinus infection                                                       minor illnesses and inju-
sprained ankle                                                         ries such as sinus infec-

    sports physical
                                                                          tions, cold and flu,
                                                                         strains and sprains,
CHOLESTEROL TEST               earache                                 health screenings or im-
                                                                       munizations, you don’t
                            sore throat                                      have to go far.

                                                                 Covered Services would apply to
                                                                  your plans Office Visit Copay

The Clinic at Walmart The Clinic at Walmart
2021 E. Independence 1150 U.S. Highway 60 East
Springfield, MO       Republic, MO

The Clinic at Walmart The Clinic at Walmart
2004 W. Marler Lane   3315 S. Campbell
Ozark, MO             Springfield, MO

The Clinic at Walmart
1101 Branson Hills Parkway            Monday—Saturday
Branson, MO                            10 a.m.-7 p.m.

                                          11 a.m.-4 p.m.

                    Each CoxHealth medical clinic located in a Walmart store is owned and operated by CoxHealth.
                  CoxHealth is unaffiliated with Wal-Mart. Wal-Mart does not employ any health care professionals or   Information as of
                  exercise any control over the provision of health care services at the CoxHealth clinics.               02/03/2010
Cox HealthPlans Member Online Access

                   Member Online Access 
                   provides our members 
                   access to their plan 24 
                   hours a day:
                     Benefit Information / Schedule of
                      Claims Status / Claims Payment
                      Identification card ordering &
                   temporary card generation
  John Doe
   - John Doe        Benefit accumulations to date
  Cox DirectCare
                   (Deductible/Coinsurance/Family totals)
                      Provider search by specialty or by
                     Pre-Authorization information
                     Secure messaging to/from CHP
                     Prescription Drug Information
 CatalystRx Member Online Access

                           Member Online Access 
                           provides our members 
                           access to their prescription 
                           drug plan 24 hours a day:
                             Benefit Information
                             Claims Payment Information
                             Retail Cost Comparisons
                             Prescription Drug Information / Cost
                           Saving Alternatives
                             Pharmacy Locator (including
                           Mapquest directions)
                             Pre-Authorization Information
                             Formulary Information

Customer/Pharmacy Support:
    • Staffed by nationally accredited Pharmacy Technicians
    • 24‐hour / 7 days‐a‐week / 365 days‐a‐year phone support
        • Exclusive Specialty Medication Pharmacy
            • 99.6% first call resolution rate
   Cox HealthPlans Provider Online Access
                                         Provider Online Access
                                         allows any provider to
                                         verify member eligibility
                                         and benefit information 24
                                         hours a day:
                                           Benefit Information
                                          Pre-Authorization Information
                                           Formulary Information

All Cox HealthPlans providers have been educated regarding the availability
of this access and how to register online. We have also provided First
Health's front line service people with the information to distribute to their
providers regarding online benefit verification.

 Finally, our ID cards direct providers to go to our website for benefit
   verification. Once online, all they have to do is register (VERY simple:
    required fields in the registration process are NPI # which verifies they are
      a provider, and create username/password) and they can immediately
         get into the system.
                              2010 Catalyst Rx Prescription Drug Plan - FAQ

Catalyst Rx is the contracted Pharmacy Benefits Manager for all Cox HealthPlans (CHP) members.  Catalyst Rx is 
based in Rockville, Maryland and currently serves over 4 million members nationwide and has an extensive 
(54,000) national network of pharmacies. 
This information is being provided regarding your prescription drug benefits in an effort to educate and assist 
with frequently asked questions.  For complete details regarding the prescription drug benefits, please see: 
    1) Your Cox HealthPlans Explanation of Coverage (EOC) booklet which can be viewed on the Cox 
        HealthPlans website ( when you login as a Member (hard copies are available 
        upon request), and  
   2) The 2010 Full Physicians’ Formulary List online at by selecting the “Physicians” link, 
      then selecting the “Cox HealthPlans 2010 Full Physicians’ Formulary”.  There is also a link to the Catalyst 
      Rx website from our website at  

                           For additional assistance, please contact Catalyst Rx toll free  
                       to speak with the licensed Pharmacy Technician at 1‐888‐341‐8578. 
1) How do my prescription drug benefits work? 
To access your prescription drug benefits, you must show your health insurance ID card to the pharmacist each 
time you fill a prescription.  The Prescription Drug plan is separate from the medical plan in that none of what you 
pay for your prescriptions applies to the medical deductible/out‐of‐pocket maximum.   
There is a Prescription Drug deductible of $100 per person per calendar year.  This deductible begins again every 
January 1st, just like your medical deductible.  Once this deductible is met, you then begin to receive the 
prescription drug co‐pay benefits under the plan.  As long as you fill your prescriptions at an in‐network pharmacy, 
you will not be subject to the out‐of‐network prescription drug benefits.   
The current prescription drug co‐pays are: 
Tier 1 (Most Generics) = $10                    Tier 3 (Non‐Preferred Brand) = $40 
Tier 2 (Preferred Brand) = $20                  Tier 4 (Specialty Medications) = $100 
Remember, Generic drugs meet the FDA standards of quality and contain same active ingredients as their Brand 
Name equivalent for a much lesser cost! 
2) How do I login to view my prescription drug information online? 
You can enter the Catalyst Rx website by going directly to or by selecting the link to Catalyst 
Rx on our website at  When entering the Catalyst Rx website, there will be a Member 
Login section on the home page.  Simply type in your Member ID number from your health insurance ID card and 
your birth date in the appropriate places and click “Login”.  (Remember to EXCLUDE the dash from your member 
number (i.e., instead of 000012345‐00, enter 00001234500) as well as using the proper format noted for the birth 
date.)  Finally, you must initially create a password by clicking on “create an account”.  The password will be 
required each time you login. 
3) How do I find an in‐network pharmacy? 
In‐Network pharmacies can be located by logging on as a “member” on the Catalyst Rx website 
( to perform a pharmacy search, by calling the Catalyst Rx toll free number (1‐888‐341‐8578), 
or by checking with your current pharmacist to verify that they accept Catalyst Rx at their place of business. 
4) What is the Mail Order Program and how does it work? 
The Mail Order Program allows members to obtain a 3‐month supply of certain maintenance prescriptions mailed 
to their home for 2 ½ times the applicable monthly co‐pay.  The maintenance prescription classes eligible for the 
Mail Order Program can be viewed on the Catalyst Rx website by selecting the “client” link, then selecting the 
“mail maintenance list”. 
Catalyst Rx partners with the IPS (Immediate Pharmaceutical Services) Mail Service for its members.  Mail Order 
Forms may be downloaded and printed from the Cox HealthPlans website at, under the 
“Member” link, selecting “Forms”, then selecting “Prescription Mail Order”.  Simply follow the instructions noted 
on the order form and submit with your prescription.  You can also obtain forms by logging on as a member on 
the Catalyst Rx website. 
Should you need to contact CatalystRx Mail Service, their toll free number is 1‐800‐233‐3872.  Remember to order 
your refill at least 7‐10 days before depleting your supply to allow ample time for shipping and delivery of your 
5) How do I know which drugs are covered and how much my prescription will cost? 
If you are unsure if your prescription is covered and how much it will cost, you can login on the Catalyst Rx 
website as described above.   
There are several helpful links in the Member section (including Mail Order information): 
        The “Co‐pay Information” link will tell you what the benefits are for your specific group plan.  
        The “What’s Covered” link will tell you what drugs are covered and notes any special requirements or 
        limitations (for more specific information, please see the “Cox HealthPlans 2010 Full Physician Formulary” 
        by selecting the “Physician” link on the Catalyst Rx homepage).   
        The “Drug Information” link will allow you to look up a specific drug or prescription to see how much it will 
        cost and any generic or less expensive alternatives to discuss with your provider if you wish to do so. 
        There are additional “Commonly Asked Questions” and answers. 
        The “Healthy Links” area can be an extremely useful tool with the following topics under “My Health 
             - Am I At Risk? Find out, and find solutions. 
             - Health Zones for in‐depth topic information. 
             - Medical Library to find quick answers. 
             - Tools and Activities to set goals, track progress. 
          “Other Healthy Links” provides links to sites regarding some of the most common diseases and health 
        conditions in our country 
          today, as well as links to several medical institutions and organizations. 
You can also call the Catalyst Rx toll free number (1‐888‐341‐8578) and a Pharmacy Technician can assist you. 
6) Why did some drugs from the previous formulary change co‐pay levels? 
Research shows that some prescriptions on the previous formulary were found to be under co‐pays that did not 
reflect the level of their retail costs (i.e., more expensive medications under a lower co‐pay, less expensive 
medications under a higher co‐pay).  Adjustments have been made to the new formulary to be more appropriate 
with these levels.  As research and cost changes in the pharmaceutical industry, the formulary is reviewed 
annually for these types of changes, and notification is always provided to all members at least 30 days prior to 
such changes as regulated by law.  Most changes typically take place every January. 
7) What if my doctor or I insist that I take a Brand Name prescription that has a Generic available? 
You can purchase any pharmaceutical drug with a prescription.  However, if a Generic equivalent is available, 
coverage under your health insurance plan would apply the Brand Name co‐pay plus the difference between the 
cost of the Brand and Generic drugs. 
8) Why aren’t certain medications covered under my prescription plan? 
Some medications are excluded from coverage because they are used to treat non‐covered conditions.  Other 
medications may be experimental, awaiting approval from the Food & Drug Administration or have effective 
alternatives at significantly lower cost. 
9) What do I do if my prescription claim is denied at the pharmacy? 
You can call the Catalyst Rx toll free number (1‐888‐341‐8578) for assistance or have your pharmacist call.  The 
first thing to remember is DON’T PANIC !  A claim denial at the pharmacy does not necessarily mean that you do 
not have coverage.  Many times the simplest of errors or corrections can be determined by speaking with Catalyst 
Rx Customer Service.  Catalyst Rx, Cox HealthPlans and your pharmacist will always work together to figure out 
the problem and assist our members. 
Some of the simplest solutions involve the pharmacist entering the correct claim information from your health 
insurance ID card or making sure you are using your most current ID card.  Other issues may involve Prior 
Authorization requirements from your doctor, Quantity Limitations, Step Therapy requirements for certain 
medications, or drug classes.  At times, your pharmacist may be able to provide a few days supply of the 
prescription while the necessary information or paperwork is being obtained. 
10) What are Prior Authorization requests and why are they required under our plan for certain drugs? 
Doctors are required to submit Prior Authorization Forms to Catalyst Rx to request coverage approval for certain 
medications or drug classes indicated on the Formulary listing (this includes requests to exceed any Quantity 
Limits).  Submission of these requests is not a guarantee of approval.  Prior Authorization Forms can be 
downloaded from the Catalyst Rx website ( under the “Physicians” link, and are located 
under the “Catalyst Rx” folder. 
Prior Authorization requirements are utilized to ensure the safety of our members, prohibit misuse, to verify that 
prescriptions are being used for covered conditions (many drugs are used for more than what they were originally 
developed which can include non‐covered conditions), and also in an attempt to control the increasing cost of 
health insurance to employers and employees.   
11) Why does my doctor have to submit a Prior Authorization request for a drug I’ve taken for years? 
Unfortunately when a new Formulary program is implemented, changes in protocols must apply to everyone in 
order to achieve the intended results of those protocols.  Generally, when the Prior Authorization request is 
approved, additional Prior Authorization requests will not be necessary.  If a Prior Authorization request is denied, 
you may either obtain the prescription at your own cost, or you can discuss other options or treatments with your 
12) What do I do if a Prior Authorization request for my prescription has been denied? 
Communication from Catalyst Rx to your doctor will include the reason for denial and any applicable recourses or 
alternatives to consider.  Your doctor will discuss this information with you. 
13) If a Prior Authorization request was approved under by my prior insurance company, does my doctor have 
to submit another one? 
         If the prescription was approved under your prior insurance company, your physician will still need to re‐
         submit a request for Prior Authorization through Catalyst Rx as neither Cox HealthPlans nor Catalyst Rx will 
         have record of this documentation, and guidelines under the Catalyst Rx Formulary may differ from that of 
         your prior insurance company. 
For assistance, your physician can contact the Catalyst Rx toll free number (1‐888‐341‐8578).   
14) Why are Quantity Limitations applied to certain drugs?   
Quantity Limitations on certain drugs simply limit the dosage covered and are based on the manufacturer’s 
recommended dosage as another method to ensure the safety of our members, prohibit misuse, and also in an 
attempt to control the increasing cost of health insurance to employers and employees. 
15) What if my doctor prescribes a dosage over the Quantity Limitation? 
Some drug classes, such as Sleep Aids and Erectile Disfunction (ED) drugs are not eligible for quantity limit 
overrides.  Other Prescriptions that exceed Quantity Limitations require the physician to submit a Prior 
Authorization request to Catalyst Rx to be reviewed for approval.   
16) Why are Sleep Aids (i.e, Ambien, Ambien CR, Lunesta, Rozerem, Sonata) limited to 15 pills per month? 
This limitation is based on the manufacturer’s recommended dosage for all of the reasons listed above under 
Quantity Limitations.  It should be noted that there are other prescriptions and methods of treatment that can aid 
with difficulty sleeping.  You can discuss these options with your doctor to determine what alternatives may be 
appropriate for you should you or your doctor feel that you need more than this monthly limit. 
17) What is Step Therapy and why is it used for certain drug classifications? 
Step Therapy entails requiring the member to try less expensive alternatives (with similar ingredients and efficacy) 
for certain drugs before using the highly marketed, more expensive prescriptions.  This is also another method to 
control the increasing cost of health insurance to employers and employees and is based on recommendations 
from health professionals.   
In order to be approved for a Step Therapy drug, your doctor needs to submit a Prior Authorization request to 
Catalyst Rx for approval along with a copy of your medical records showing that you have either tried the 
necessary alternative(s) without success, or that you have tried the other necessary alternative(s) and had severe 
adverse reaction to that medication.  This information will allow Catalyst Rx to determine whether you fit the 
criteria for approval of the Step Therapy drug. 
18) Why are some Proton Pump Inhibitors (i.e., Nexium, Aciphex, Prilosec 40 mg, Protonix) excluded and what 
can I do? 
Nexium is excluded from coverage due to its exorbitant cost ($3.70 per pill) and the fact that there are effective 
alternatives with virtually identical active ingredients at a fraction of that cost.   
The Step Therapy program for Proton Pump Inhibitors (PPI’s) requires that: 
    1) A member try Prilosec OTC (over‐the‐counter) or omeprazole first; this can be filled at the pharmacy under 
         the generic co‐pay with a doctor’s prescription, or 
    2) If the Prilosec OTC or omeprazole is ineffective, your doctor can submit a Prior Authorization request with 
         a copy of your records indicating this treatment process to request approval for coverage of Prevacid. 
19) Why are Brand Name Non‐Sedating Antihistamines (i.e., Allegra) excluded from coverage? 
This class of drug is considered to be a “lifestyle” drug by a majority of the insurance industry, and there are many 
over‐the‐counter alternatives proven to be as effective at a significantly lower cost.  Several insurance companies 
completely exclude coverage of these prescriptions and most of our competitors impose quantity and duration 
Cox HealthPlans has made these alternatives available to you so they are covered under your health insurance 
with a prescription!  Therefore, you can obtain the over‐the –counter medication at the applicable plan co‐pays 
designated under the formulary, which is then even less out‐of‐pocket for you than purchasing them at their retail 
                                                IMPORTANT COST SAVINGS OPPORTUNITY!

Dear Valued Member:

Are you currently taking a brand-name prescription for high cholesterol, depression, allergies, sleep aide, or acid
reflux? If so, you may be able to save money at the pharmacy under the benefits of the 2009 prescription drug

        If your pharmacy plan has a prescription drug deductible, this deductible must be met prior to the copays
        being applied. The discount received through CatalystRx will apply to any prescriptions that go towards
        your prescription deductible. The deductible applies to each member on the plan.

        Any $0 copay prescriptions or over-the-counter (OTC) medications covered under your plan will still
        require a prescription from your physician.

                            TIER 1                   TIER 1                  TIER 2                   TIER 3
                        $0 Copayment                Generic            Preferred Brands       Non-Preferred Brands
                           (FREE)              ($8 - $10 Copay)        ($20 - $35 Copay)        ($40 - $75 Copay)

                                                   lovastatin                                       Altoprev®,
                          simvastatin         (generic Mevacor®),                                  Lescol-XL®,
     AGENTS                                                                 Crestor®
                       (generic Zocor®)           pravastatin                                        Lipitor®,
   (Step Therapy
                                             (generic Pravachol®)                                    Vytorin®
                                               bupropion SR/XL
                                              (Wellbutrin SR/XL),
                                               (generic Luvox®),
                                                                                                  Effexor XR®,
                                                                          Cymbalta®,                Pexeva®,
      ANTI-              citalopram           (generic Prozac®),
                                                                          Lexapro®,            Prozac Once Wkly®,
  DEPRESSANTS         (generic Celexa®)            paroxetine
                                                                           Pristiq®                Sarafem®,
                                                (generic Paxil®),
                                                                                                 venlafaxine XR
                                               (generic Zoloft®),
                                                 venlafaxine IR

                                                                         Alavert-D® OTC,
                                                                                                Cetirizine-D® OTC,
                                                 Alavert® OTC,           Cetirizine® OTC,
  NON-SEDATING                                                                                     fexofenadine
                                                 Claritin® OTC,          Claritin-D® OTC,
 ANTIHISTAMINES                                                                                 (generic Allegra®),
                                                loratadine OTC         loratadine-D® OTC,
                                                                                                  Zyrtec-D® OTC
                                                                           Zyrtec® OTC
   SLEEP AIDS                                                                                     Ambien-CR®,
     (Quantity                                                               None                  Lunesta®,
                                              (generic Ambien®)
   Limits Apply)                                                                                   Rozerem®,
                                             (generic Prilosec®),         lansoprazole
  (Step Therapy /                                                                                   Prevacid®
                                              omeprazole OTC           (generic Prevacid®)
   Quantity Limits
                                           (generic Prilosec® OTC)

All generic drugs must be reviewed and approved by the U.S. Food and Drug Administration (FDA) and are found to
be just as safe and effective as brand products. Although generics are just as effective as brand-name
medications, they are usually sold at substantial discounts.

If you currently pay a higher copayment for a non-preferred drug, ask your physician if a lower-cost generic, over-
the-counter (OTC), or preferred brand-name drug may be an alternative that is right for you. Always ask your
doctor for preferred formulary alternatives whenever possible.

This is only a summary of information and the full formulary can be viewed at For any questions
regarding your pharmacy benefits, please call contact the CatalystRx Customer Service Department at 1-888-341-
8578. Representatives are available 24 hours a day, seven days a week to assist you.
                    For those qualified maintenance medications,
     you SAVE on prescription copays by participating in our Mail Service Program
       along with the added convenience of not having to go to the pharmacy!


       Go to: .
       Sign in with your member number (from Cox HealthPlans ID card) and date of birth.
       Select “Mail Service” on left; this will take you to the IPS (Immediate Pharmaceutical Services)
       At the IPS website you must first enroll using the "Enrolled with IPS" link.
       It takes 48 hours for them to process the enrollment so a member can register.


       48 hours later, you can go back to the same site and click on the "Register Here" link.
       Select your own ID and password.

   NOTE: When registering, you will be asked for your member ID. This is the first 9 digits of the
         member number on your Cox HealthPlans ID card.

   You will receive an e-mail confirmation of once registration complete. You can then access your
   online mail order information.

You will need to either obtain a prescription from your physician for those qualified maintenance
medications when initially setting each prescription up under the Mail Service Program, or your
physician can fax them to IPS using the faxable Prescription Mail Order form. All forms are available to
download at!

MEMBER COST: The cost for using the Mail Service Program is 2.5 x the plan copay for a 90-day
supply (after the annual prescription drug deductible, if applicable).

* See reverse side for list of qualified maintenance medications.

                        IPS Customer Service: 800-322-3872 (option 6)
                                     MAINTENANCE MEDICATIONS

Your prescription program allows you to obtain a 90-day supply of maintenance medications at Catalyst Rx
participating retail pharmacies or through Walgreens Mail Service. Maintenance medications are defined
as those medications that are almost exclusively used to treat chronic health conditions such as high blood
pressure, diabetes and asthma. Drugs used to treat these conditions are dosed and approved for long-
term use and can be taken on a daily basis. Although some people take medication chronically for
conditions like ulcers, allergies and arthritis, these medications are not truly considered “maintenance” as
some take these medications daily and others take them on an as needed basis. Please note that
specialty medications are not considered to be maintenance medications and are available only in a 30-
day supply.

The maintenance medication list is consistent with maintenance lists of other health plans nationwide. The
Catalyst Rx Pharmacy and Therapeutics (P&T) committee, made up of pharmacists and physicians,
develops this list to best support your prescription program.

The following drug classes are covered through your mail order program:
   • Alzheimer’s disease medication
   • Antidepressant medication
   • Anti-inflammatory / arthritis medication (does not include non-steroidal anti-inflammatory drugs
        or cyclooxygenase-2 inhibitors)
   • Antipsychotic medication
   • Antiviral medication for HIV / AIDS
   • Asthma and other respiratory medication
   • Benign Prostatic Hyperplasia (BPH) medication
   • Birth control medication
   • Blood pressure medication (e.g., beta blockers, calcium channel blockers, diuretics,
   • Blood thinners and other circulation medication
   • Cancer medication
   • Cholesterol-lowering medication
   • Diabetes mellitus medication
   • Hormone replacement medication
   • Glaucoma medication
   • Gout medication
   • Heart medication
   • Organ transplant medication
   • Osteoporosis medication
   • Parkinson’s disease medication
   • Potassium supplements
   • Seizure medication
   • Thyroid medication
   • Urinary antispasmodic medication

Some common drug classes excluded from the mail order program include:
  • Antibiotics
  • Antihistamines / decongestants
  • Controlled substances (e.g., pain medication, ADD / ADHD medication)
  • Non-steroidal anti-inflammatory drugs
  • Cyclooxygenase-2 (COX-2) inhibitor medication
  • Prenatal vitamins
  • Ulcer / reflux medication
                                                                     SPECIALTY DRUG MANAGEMENT PROGRAM: Drug List
Specialty drugs are those that may have the following characteristics: expensive, limited access, complicated treatment regimens, compliance issues, special storage requirements and/or
manufacturer reporting requirements. Many medications listed below are biotech medications. Biotech products are manufactured using DNA recombinant technology (genetic replication)
as opposed to chemical processes.
Listed below are drugs managed in the Catalyst Rx Specialty Drug Management Program. Most of these drugs are available through our preferred specialty vendor, Walgreens Specialty
Pharmacy. Limited distribution drugs are only available through select specialty providers as determined by the drug manufacturer. Access to limited distribution drugs is available through
other specialty providers in the Catalyst Rx Specialty Drug Management Program.
* Asterisk denotes products that can be administered in a physician’s office and should not be restricted to pharmacy benefit coverage, i.e., blocked from medical billing.
Arthritis                              Hematologics                           Hepatitis C                             Infertility (cont.)                     Oncology and Related (cont.)
ENBREL                                 ARANESP                                ALFERON N*                              LUVERIS                                 NEUPOGEN
EUFLEXXA*                              ARIXTRA                                COPEGUS                                 MENOPUR                                 NOVANTRONE*
HUMIRA                                 EPOGEN                                 INFERGEN                                NOVAREL                                 OCTREOTIDE
HYALGAN*                               FRAGMIN                                INTRON A                                OVIDREL                                 ondansetron (generic)
KINERET                                INNOHEP                                PEGASYS                                 PREGNYL                                 PROLEUKIN*
ORTHOVISC*                             LOVENOX                                PEG-INTRON                              REPRONEX                                SANDOSTATIN
REMICADE*                              NPLATE                                 REBETOL                                 Multiple Sclerosis                      SANDOSTATIN LAR*
SIMPONI                                PROCRIT                                ribasphere (generic)                    AVONEX                                  SYNAREL
SUPARTZ*                               Hemophilia                             ribavirin (generic)                     BETASERON                               THYROGEN*
SYNVISC*                               ADVATE*                                ROFERON-A                               COPAXONE                                TRELSTAR LA/ DEPOT*
Cardiovascular                         ALPHANATE*                             HIV/AIDS                                EXTAVIA                                 TREANDA*
ADCIRCA                                ALPHANINE SD*                          FUZEON                                  mitoxantrone* (generic)                 VIADUR*
REVATIO                                AUTOPLEX T*                                                                    NOVANTRONE*                             ZOLADEX*
                                                                              Immune Deficiency                                                               ZOMETA*
Crohn’s Disease                        BEBULIN VH*                            BAYGAM*                                 REBIF
HUMIRA                                 BENEFIX*                               BAYRHO-D*                               Oncology (Oral)                         Osteoporosis
REMICADE*                              FEIBA VH IMMUNO*                       CARIMUNE NF*                            AFINITOR                                BONIVA I.V.*
                                       GENARC*                                FLEBOGAMMA/ DIF*                        GLEEVEC                                 FORTEO
Enzyme Replacement                     HELIXATE FS*                                                                                                           RECLAST*
ALDURAZYME*                                                                   GAMMAGARD S/D*                          SPRYCEL
                                       HEMOFIL-M*                             GAMMAR-P I.V. *                         SUTENT                                  Psoriasis
FABRAZYME*                             HUMATE-P*
MYOZYME*                                                                      GAMASTAN S/D*                           TARCEVA                                 AMEVIVE*
                                       HYATE C*                               GAMUNEX*                                TARGRETIN                               ENBREL
Gaucher’s Disease                      KOATE-DVI*                             HYPERRHO S/D                            TASIGNA                                 REMICADE*
CEREDASE*                              KOGENATE FS*                           MICRHOGAM*                              TEMODAR
CEREZYME*                              MONARC-M*                                                                                                              Pulmonary Cystic Fibrosis
                                                                              OCTAGAM*                                THALOMID                                PULMOZYME
Growth Hormone                         MONOCLATE-P*                           PANGLOBULIN*                            VOTRIENT
                                       MONONINE*                                                                                                              TOBI
GENOTROPIN                                                                    PRIVIGEN*                               XELODA
GENOTROPIN MINIQUICK                   NOVOSEVEN/ RT*                         POLYGAM S/D*                            ZOLINZA                                 Ulcerative Colitis
HUMATROPE                              PROFILNINE SD*                         RHOGAM*                                                                         REMICADE*
                                       PROPLEX T*                                                                     Oncology and Related
NORDITROPIN                                                                   RHOPHYLAC*                              ELIGARD                                 Miscellaneous
NUTROPIN                               RECOMBINATE*                           VENOGLOBULIN-S*                                                                 ACTIMMUNE
                                       REFACTO*                                                                       FIRMAGON
NUTROPIN AQ                                                                   Infertility                             LEUKINE*                                BOTOX
NUTROPIN DEPOT*                        THROMBATE III*                                                                                                         colistimethate (generic)*
                                       XYNTHA*                                BRAVELLE                                leuprolide acetate* (generic)
OMNITROPE                                                                     CETROTIDE                               LUPRON*                                 COLY-MYCIN M*
SAIZEN                                 Hepatitis B                                                                                                            MYOBLOC
                                                                              CHORIONIC GONADOTROPIN                  LUPRON DEPOT*
SEROSTIM                               BARACLUDE                                                                                                              SOLIRIS*
                                                                              FOLLISTIM AQ                            LUPRON DEPOT PED*
SOMATULINE DEPOT*                      BAYGAM*                                                                                                                SUPPRELIN LA*
                                                                              GANIRELIX ACETATE                       MOZOBIL
TEV-TROPIN                             HEPSERA
                                                                              GONAL-F/ RFF                            NEULASTA
                                       INTRON A
                                                                              leuprolide acetate* (generic)           NEUMEGA
LIMITED DISTRIBUTION DRUGS ( ) A representative specialty provider is noted in parenthesis for the respective drug. Additional specialty providers may be available.
Asthma                                 Enzyme Replacement                     Immune Globin                           Oncology                                Rheumatoid Arthritis
XOLAIR (Medmark/Walgreens)             ELAPRASE* (Accredo)                    VIVAGLOBIN (Medmark/Walgreens)          DACOGEN (Medmark/Walgreens)             ORENCIA* (Medmark/Walgreens)
Cardiovascular                         NAGLAZYME* (Accredo)                   Macular Degeneration                    IRESSA (Iressa Access Program)          RSV
FLOLAN* (Accredo)                      Gaucher’s Disease                      LUCENTIS* (Walgreens/Besse Medical)     NEXAVAR (Medmark/Walgreens)             SYNAGIS* (Medmark/Walgreens)
LETAIRIS (Medmark/Walgreens)           ZAVESCA (Medmark/Walgreens)            MACUGEN* (Walgreens/Besse Medical)      REVLIMID (Medmark/Walgreens)
                                                                                                                      TYKERB (Medmark/Walgreens)              Trypsin Deficiency
PROMACTA (Medmark/Walgreens)           Growth Hormone                         VISUDYNE* (Walgreens/Besse Medical)                                             ARALAST* (Accredo)
REMODULIN (Accredo)                                                                                                   VANTAS* (Priority Healthcare)
                                       INCRELEX (Curascript/Walgreens)        Multiple Sclerosis                                                              PROLASTIN* (Express Scripts)
TRACLEER (Accredo)                     SOMAVERT (Express Scripts)             ACTHAR HP (Medmark/Walgreens)           Parkinson’s Disease                     ZEMAIRA* (Accredo)
TYVASO (Accredo/Caremark)              ZORBITIVE (Medmark/Walgreens)          TYSABRI* (Medmark/Walgreens)            APOKYN (Accredo)
VENTAVIS (Accredo)                                                                                                                                            Miscellaneous
                                       Huntington’s Disease                   Narcolepsy                              Renal Disease                           ARCALYST (Accredo)
Crohn’s Disease                        XENAZINE (Accredo)                     XYREM (Express Scripts)                 CYSTAGON (PharmaCare)                   KUVAN (Biomarin Program)
CIMZIA* (Medmark/Walgreens)
         Specialty medications may require prior authorization to ensure appropriate usage. Coverage for these medications may vary with respect to benefit design.
                  This list is subject to change without notice to accommodate the introduction, removal and availability of new drugs and clinical information.                   DL 01 992 0110

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