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 www.coxhealthplans.com, 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.
ADMINISTRATIVE / ELIGIBILITY 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.
*IMPORTANT INFORMATION REGARDING NEWBORN COVERAGE:
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
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
(www.coxhealthplans.com) 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.
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.
How do I find IN-NETWORK PROVIDERS?
Cox HealthPlans services 26 counties in southwest Missouri. The most current listings of providers are
available through the Cox HealthPlans website (www.coxhealthplans.com) 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
HealthPlans Member Services. PLEASE SEE PAGE REGARDING FIRST HEALTH PROVIDERS AND
BENEFITS FOR ADDITIONAL IMPORTANT INFORMATION.
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
What is COINSURANCE?
Coinsurance is the percentage of cost‐sharing between you and Cox HealthPlans AFTER you have met
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
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).
What is my OFFICE VISIT CO-PAY?
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
CLAIM HAS BEEN SENT TO COX HEALTHPLANS AND PROCESSED.
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
What is the OUT-OF-POCKET MAXIMUM?
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:
$500 DEDUCTIBLE PLAN:
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))
$1,000 DEDUCTIBLE PLAN:
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
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‐
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 (www.coxhealthplans.com) when you login as a Member (hard copies are
available upon request), and
2) The 2010 Full Physicians’ Formulary List online at www.catalystrx.com 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 www.coxhealthplans.com.
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 www.ﬁrsthealth.com. 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
items requiring pre-authorization,
including Inpatient, Outpatient,
and Emergency Services, will be
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
Expert care in YOUR neighborhood
When you need help for
sinus infection minor illnesses and inju-
sprained ankle ries such as sinus infec-
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 Benefit accumulations to date
Provider search by specialty or by
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:
Claims Payment Information
Retail Cost Comparisons
Prescription Drug Information / Cost
Pharmacy Locator (including
• 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:
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 (www.coxhealthplans.com) when you login as a Member (hard copies are available
upon request), and
2) The 2010 Full Physicians’ Formulary List online at www.catalystrx.com 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 www.coxhealthplans.com.
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 www.catalystrx.com or by selecting the link to Catalyst
Rx on our website at www.coxhealthplans.com. 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
(www.catalystrx.com) 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 www.coxhealthplans.com, 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 (www.catalystrx.com) 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)
simvastatin (generic Mevacor®), Lescol-XL®,
(generic Zocor®) pravastatin Lipitor®,
(generic Pravachol®) Vytorin®
ANTI- citalopram (generic Prozac®),
Lexapro®, Prozac Once Wkly®,
DEPRESSANTS (generic Celexa®) paroxetine
Alavert® OTC, Cetirizine® OTC,
Claritin® OTC, Claritin-D® OTC,
ANTIHISTAMINES (generic Allegra®),
loratadine OTC loratadine-D® OTC,
SLEEP AIDS Ambien-CR®,
(Quantity None Lunesta®,
Limits Apply) Rozerem®,
(generic Prilosec®), lansoprazole
(Step Therapy / Prevacid®
omeprazole OTC (generic Prevacid®)
(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 www.catalystrx.com. 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!
TO SIGN UP:
Go to: www.catalystrx.com .
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.
THEN TO 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 www.coxhealthplans.com!
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)
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-
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:
• 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.
DRUGS AVAILABLE THROUGH THE SPECIALTY DRUG MANAGEMENT PROGRAM
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
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
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
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
GONAL-F/ RFF NEULASTA
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)
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