Coverage may depend on previous use or trial of another drug. Step Therapy Medication Name Medication Class Preferred Products ANDRODERM Androgens Must try Androgel TESTIM Androgens Must try Androgel Axiron Androgens Must try Androgel Fortesta Androgens Must try Androgel Striant Androgens Must try Androgel Lamisil Antifungal If patient has HIV, Cancer, or Diabetes Tier 2, all other Tier 3 Sporanox Antifungal If patient has HIV, Cancer, or Diabetes Tier 2, all other Tier 3 ABILIFY Antipsychotics Must try 2 of the following: risperidone, Geodon, Seroquel/-XR, Zyprexa ABILIFY Antipsychotics Must try 2 of the following: risperidone, Geodon, Seroquel/-XR, Zyprexa FANAPT Antipsychotics Must try 2 of the following: risperidone, Geodon, Seroquel/-XR, Zyprexa INVEGA Antipsychotics Must try 2 of the following: risperidone, Geodon, Seroquel/-XR, Zyprexa SAPHRIS Antipsychotics Must try 2 of the following: risperidone, Geodon, Seroquel/-XR, Zyprexa Atacand/-HCT ARB Must try 2 of the following: generics, Diovan/-HCT, Micardis/-HCT, losartan/-HCT Benicar/-HCT ARB Must try 2 of the following: generics, Diovan/-HCT, Micardis/-HCT, losartan/-HCT Teveten/-HCT ARB Must try 2 of the following: generics, Diovan/-HCT, Micardis/-HCT, losartan/-HCT Edarbi/Edarbyclor ARB Must try 2 of the following: generics, Diovan/-HCT, Micardis/-HCT, losartan/-HCT Actonel Bisphosphonates Must try one of the following: alendronate or ibandronate Atelvia Bisphosphonates Must try one of the following: alendronate or ibandronate Altoprev Cholesterol Generic Statin and then Crestor Lescol XL Cholesterol Generic Statin and then Crestor Vytorin Cholesterol Generic Statin and then Crestor Byetta Diabetes Requires trial of metformin, sulfonylurea, or TZD prior to approval Symlin Diabetes Requires usage of another insulin Antara Fenofibrates Generic fenofibrates or gemfibrozil Fenoglide Fenofibrates Generic fenofibrates or gemfibrozil Fibricor Fenofibrates Generic fenofibrates or gemfibrozil Lipofen Fenofibrates Generic fenofibrates or gemfibrozil THINKING HEALTH FORWARD Pharmacy Benefit Limitations List Welcome to Cox HealthPlans! We appreciate the opportunity to provide health care coverage to the members of your plan. This list of medications is provided for your review and for review with your physician. These medications may require additional information or assistance from your physician prior to your first fill under your new benefits. Please review this list for any medications plan members are taking. These medications may require additional medical information, may require the use of a lower cost alternative before your current medication may be covered, or may be limited in quantity for coverage under your health plan. If you need assistance transitioning to a formulary medication, please contact your physician or complete the Self-Referral Case Management form for assistance from our medical staff in our Welcome Aboard program. Please note: Medications prescribed by your physician may be filled with the medication and dosage indicated. However, certain medications may not be covered in full or in part by your health insurance coverage. This medication list and the full formulary list do not imply all medications listed are covered benefits. Please consult your Schedule of Benefits for coverage information. Full formulary and additional information regarding each medication may be obtained at www.coxhealthplans.com or by contacting Catamaran at 888.341.8578.
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Pharmacy Benefit limitations list - Cox Health Plans
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Coverage may depend on previous use or trial of another drug. Step TherapyMedication Name Medication Class Preferred ProductsANDRODERM Androgens Must try Androgel
TESTIM Androgens Must try Androgel
Axiron Androgens Must try Androgel
Fortesta Androgens Must try Androgel
Striant Androgens Must try Androgel
Lamisil Antifungal If patient has HIV, Cancer, or Diabetes Tier 2, all other Tier 3
Sporanox Antifungal If patient has HIV, Cancer, or Diabetes Tier 2, all other Tier 3
ABILIFY Antipsychotics Must try 2 of the following: risperidone, Geodon, Seroquel/-XR, Zyprexa
ABILIFY Antipsychotics Must try 2 of the following: risperidone, Geodon, Seroquel/-XR, Zyprexa
FANAPT Antipsychotics Must try 2 of the following: risperidone, Geodon, Seroquel/-XR, Zyprexa
INVEGA Antipsychotics Must try 2 of the following: risperidone, Geodon, Seroquel/-XR, Zyprexa
SAPHRIS Antipsychotics Must try 2 of the following: risperidone, Geodon, Seroquel/-XR, Zyprexa
Atacand/-HCT ARB Must try 2 of the following: generics, Diovan/-HCT, Micardis/-HCT, losartan/-HCT
Benicar/-HCT ARB Must try 2 of the following: generics, Diovan/-HCT, Micardis/-HCT, losartan/-HCT
Teveten/-HCT ARB Must try 2 of the following: generics, Diovan/-HCT, Micardis/-HCT, losartan/-HCT
Edarbi/Edarbyclor ARB Must try 2 of the following: generics, Diovan/-HCT, Micardis/-HCT, losartan/-HCT
Actonel Bisphosphonates Must try one of the following: alendronate or ibandronate
Atelvia Bisphosphonates Must try one of the following: alendronate or ibandronate
Altoprev Cholesterol Generic Statin and then Crestor
Lescol XL Cholesterol Generic Statin and then Crestor
Vytorin Cholesterol Generic Statin and then Crestor
Byetta Diabetes Requires trial of metformin, sulfonylurea, or TZD prior to approval
Symlin Diabetes Requires usage of another insulin
Antara Fenofibrates Generic fenofibrates or gemfibrozil
Fenoglide Fenofibrates Generic fenofibrates or gemfibrozil
Fibricor Fenofibrates Generic fenofibrates or gemfibrozil
Lipofen Fenofibrates Generic fenofibrates or gemfibrozil
THINKING HEALTH FORWARD
Pharmacy Benefit Limitations ListWelcome to Cox HealthPlans! We appreciate the opportunity to provide health care coverage to the members of your plan.
This list of medications is provided for your review and for review with your physician. These medications may require additional information or assistance from your physician prior to your first fill under your new benefits.
Please review this list for any medications plan members are taking. These medications may require additional medical information, may require the use of a lower cost alternative before your current medication may be covered, or may be limited in quantity for coverage under your health plan.
If you need assistance transitioning to a formulary medication, please contact your physician or complete the Self-Referral Case Management form for assistance from our medical staff in our Welcome Aboard program.
Please note: Medications prescribed by your physician may be filled with the medication and dosage indicated. However, certain medications may not be covered in full or in part by your health insurance coverage. This medication list and the full formulary list do not imply all medications listed are covered benefits. Please consult your Schedule of Benefits for coverage information. Full formulary and additional information regarding each medication may be obtained at www.coxhealthplans.com or by contacting Catamaran at 888.341.8578.
Medication Name Medication Class Preferred ProductsTricor Fenofibrates Generic fenofibrates or gemfibrozil
Triglide Fenofibrates Generic fenofibrates or gemfibrozil
Trilipix Fenofibrates Generic fenofibrates or gemfibrozil
Edluar Hypnotics Must try one of the following: estazolam, zaleplon, zolpidem, temazepam, flurazepam, triazolam
Intermezzo Hypnotics Must try one of the following: estazolam, zaleplon, zolpidem, temazepam, flurazepam, triazolam
Rozerem Hypnotics Must try one of the following: estazolam, zaleplon, zolpidem, temazepam, flurazepam, triazolam
Silenor Hypnotics Must try one of the following: estazolam, zaleplon, zolpidem, temazepam, flurazepam, triazolam
Zolpimist Hypnotics Must try one of the following: estazolam, zaleplon, zolpidem, temazepam, flurazepam, triazolam
Beconase AQ Nasal Steroids Must try one of the following: flunisolide, fluticasone, Nasonex
Dymista Nasal Steroids Must try one of the following: flunisolide, fluticasone, Nasonex
Qnasl Nasal Steroids Must try one of the following: flunisolide, fluticasone, Nasonex
NASACORT AQ Nasal Steroids Must try one of the following: flunisolide, fluticasone, Nasonex
OMNARIS Nasal Steroids Must try one of the following: flunisolide, fluticasone, Nasonex
RHINOCORT AQUA Nasal Steroids Must try one of the following: flunisolide, fluticasone, Nasonex
Zetonna Nasal Steroids Must try one of the following: flunisolide, fluticasone, Nasonex
VERAMYST Nasal Steroids Must try one of the following: flunisolide, fluticasone, Nasonex
Aciphex PPI Excluded, must try omeprazole product then Prevacid
Lansoprazole (Prevacid) PPI Must try Prilosec OTC or omeprazole
Nexium PPI Excluded, must try omeprazole product then Prevacid
Pantoprazole (Protonix) PPI Excluded, must try omeprazole product then Prevacid
Zegerid PPI Excluded, must try omeprazole product then Prevacid
Chantix Smoking Cessation Must try Nicotrol Inhaler/Spray or Nicotine Gum/Lozenge/Transdermal or Bupropion
LEXAPRO SSRI Must try Citalopram and one of the following: paroxetine, fluvoxamine, fluoxetine, sertraline
LUVOX CR SSRI Must try Citalopram and one of the following: paroxetine, fluvoxamine, fluoxetine, sertraline
PEXEVA SSRI Must try Citalopram and one of the following: paroxetine, fluvoxamine, fluoxetine, sertraline
AXERT Triptans Must try one of the following: naratriptan, sumatriptan, rizatriptan, zolmitriptan, Relpax
FROVA Triptans Must try one of the following: naratriptan, sumatriptan, rizatriptan, zolmitriptan, Relpax
SUMAVEL Triptans Must try one of the following: naratriptan, sumatriptan, rizatriptan, zolmitriptan, Relpax
TREXIMET Triptans Must try one of the following: naratriptan, sumatriptan, rizatriptan, zolmitriptan, Relpax
ZOMIG Triptans Must try one of the following: naratriptan, sumatriptan, rizatriptan, zolmitriptan, Relpax
Alsumat Triptans Must try one of the following: naratriptan, sumatriptan, rizatriptan, zolmitriptan, Relpax
PRISTIQ SNRI Must try a generic SSRI and venlafaxine ER
Victoza GLP Must try Byetta or Bydureon
Humalog/Humulin Insulin Must try Novolin or Novolog
Levemir Insulin Must try Lantus
Ascensia Test Strip Mus try Accucheck or One Touch
Breeze Test Strip Mus try Accucheck or One Touch
Contour Test Strip Mus try Accucheck or One Touch
Freestyle Test Strip Mus try Accucheck or One Touch
Precision Test Strip Mus try Accucheck or One Touch
Lumigan Ophtalmic Must try latanoprost, travapost, Travatan Z
Rescula Ophtalmic Must try latanoprost, travapost, Travatan Z
Zioptan Ophtalmic Must try latanoprost, travapost, Travatan Z
Flovent Asthma Must try Asmanex, Pulmicort, Qvar
Proventil Asthma Must try ProAir
Ventolin Asthma Must try ProAir
(Continued)Step Therapy
Medication Name Medication Class Quantity Limit Time FrameBupropion (Wellbutrin 100mg) Antidepressant 90 Every 30 days
Bupropion (Wellbutrin 75mg) Antidepressant 120 Every 30 days
Bupropion (Wellbutrin SR) Antidepressant 60 Every 30 days
Bupropion (Wellbutrin XL) Antidepressant 30 Every 30 days
Citalopram (Celexa) Antidepressant 30 Every 30 days
Cymbalta Antidepressant 60 Every 30 days
Fluoxetine (Sarafem) Antidepressant 30 Every 30 days
Lexapro Antidepressant 30 Every 30 days
Paroxetine (Paxil) Antidepressant 30 Every 30 days
Paroxetine CR (Paxil CR) Antidepressant 30 Every 30 days
Sertraline (Zoloft) Antidepressant 30 Every 30 days
fluconazole (Diflucan) Antifungal 4 Every 30 days
Actonel 35mg Bisphosphonate 4 Every 30 days
Actonel 5/30mg Bisphosphonate 30 Every 30 days
Actonel with Calcium Bisphosphonate 28 Every 30 days
Boniva 150mg Bisphosphonate 1 Every 30 days
Boniva 2.5mg Bisphosphonate 30 Every 30 days
Fosamax 35/70mg Bisphosphonate 4 Every 30 days
Fosamax 5/10/40mg Bisphosphonate 30 Every 30 days
Fosamax Plus D Bisphosphonate 4 Every 30 days
Fosamax Solution Bisphosphonate 300 Every 30 days
Advicor Cholesterol 30 Every 30 days
Altocor Cholesterol 30 Every 30 days
Crestor Cholesterol 30 Every 30 days
Lescol Cholesterol 30 Every 30 days
Lescol XL Cholesterol 30 Every 30 days
Lipitor Cholesterol 30 Every 30 days
lovastatin (Mevacor) Cholesterol 30 Every 30 days
pravastatin (Pravachol) Cholesterol 30 Every 30 days
simvastatin (Zocor) Cholesterol 30 Every 30 days
Vytorin Cholesterol 30 Every 30 days
Zetia Cholesterol 30 Every 30 days
Tussionex Cough and Cold 120 Every 30 days
Glucagon, Glucagen Diabetes 2 Every 365 days
Insulin Injecting Devices Diabetes 2 Every 365 days
Cialis Eryctile Dysfunction 6 Every 30 days
Levitra Eryctile Dysfunction 6 Every 30 days
Muse/Edex/Caverject Eryctile Dysfunction 6 Every 30 days
Viagra Eryctile Dysfunction 6 Every 30 days
Depo Provera Family Planning/Hormone Replacement 1 Every 90 days
Estring Family Planning/Hormone Replacement 1 Every 90 days
Femring Family Planning/Hormone Replacement 1 Every 90 days
Lunelle Family Planning/Hormone Replacement 1 Every 30 days
Nuvaring Family Planning/Hormone Replacement 1 Every 30 days
Amerge Migraine 18 Per month (Whole Class)
Axert Migraine 18 Per month (Whole Class)
Frova Migraine 18 Per month (Whole Class)
Maxalt/-MLT Migraine 18 Per month (Whole Class)
Relpax Migraine 18 Per month (Whole Class)
Sumatriptan (Imitrex) Migraine 18 Per month (Whole Class)
Zomig/-ZMT Migraine 18 Per month (Whole Class)
Coverage may be limited to specific quantities per prescription and for time period. Quantity Limited
Medication Name Medication Class Quantity Limit Time FrameAllegra D 12hr Non Sedating Antihistamines 60 Every 30 days
Allegra D 24 hr Non Sedating Antihistamines 30 Every 30 days
Cetirizine (Zyrtec) Non Sedating Antihistamines 30 Every 30 days
Cetirizine /-D (Zyrtec/-D) Non Sedating Antihistamines 60 Every 30 days
Clarinex/-D Non Sedating Antihistamines 30 Every 30 days
Fexofenadine 180mg (Allegra) Non Sedating Antihistamines 30 Every 30 days
Fexofenadine 30mg/60mg (Allegra) Non Sedating Antihistamines 60 Every 30 days
Xyzal Non Sedating Antihistamines 30 Every 30 days
Celebrex 100/200mg NSAID 60 Every 30 days
Celebrex 400mg NSAID 30 Every 30 days
Lansoprazole (Prevacid) PPI 30 Every 30 days
Omeprazole 40mg (Prilosec) PPI 30 Every 30 days
Adcirca Pulmonary Arterial Hypertension 90 Every 30 days
Revatio Pulmonary Arterial Hypertension 90 Every 30 days
Advair Respiratory 60 Every 30 days
Aerobid Respiratory 14 Every 30 days
Aerochamber, Inspirease Respiratory 1 Every 365 days
Alupent Respiratory 28 Every 30 days
Atrovent Respiratory 30 Every 30 days
Atrovent HFA Respiratory 26 Every 30 days
Azmacort Respiratory 41 Every 30 days
Combivent Respiratory 30 Every 30 days
Epi-Pen, Epi-Pen JR Respiratory 2 Every 365 days
Flovent HFA Respiratory 26 Every 30 days
Flovent Rotadisk Respiratory 120 Every 30 days
Intal Respiratory 30 Every 30 days
Maxair Autohaler Respiratory 28 Every 30 days
Proventil HFA/Ventolin HFA Respiratory 18 Every 30 days
Proventil/Ventolin Respiratory 51 Every 30 days
Pulmicort Respules Respiratory 140 Every 30 days
Pulmicort Turbohaler Respiratory 2 Every 30 days
Qvar Respiratory 16 Every 30 days
Serevent Diskus Respiratory 120 Every 30 days
Tilade Respiratory 34 Every 30 days
Twinject Respiratory 2 Every 365 days
Ambien CR Sleep Aid 15 Every 30 days for all sleep aids combined
Lunesta Sleep Aid 15 Every 30 days for all sleep aids combined
Rozerem Sleep Aid 15 Every 30 days for all sleep aids combined
Zaleplon (Sonata) Sleep Aid 15 Every 30 days for all sleep aids combined
Zolpidem (Ambien) Sleep Aid 15 Every 30 days for all sleep aids combined
Chantix Smoking Cessation 2 Cycles 6 months total
(Continued)Quantity Limited
Medication Name Medication Class RationaleADHD Stimulant Class (Ritalin, Adderall, etc) ADHD Stimulant Class Require PA for members 19 and older
Bupropion (Wellbutrin) Antidepression Not for use in smoking cessation or weight loss
Nuvigil Antinarcolepsy Approved for FDA Indications of: Narcolepsy, Idiopathic Hypersomnia, OSAHS, SWSD, Fatigue due to MS.
Provigil/Modafanil AntinarcolepsyApproved for FDA Indications of: Narcolepsy, Idiopathic Hypersomnia, OSAHS, SWSD, Fatigue due to MS. Also requires trial of Nuvigil prior to approval.
Abilify Antipsychotic Requires trial of 2 antidepressants prior to approval for depression. For use in Autisim, requires trial of risperidone.
ARANESP ALBUMIN FREE Specialty BUSULFEX Specialty COLISTIMETHATE SODIUM Specialty
Requires specific physician request process.
Requiring prior authorization.
Prior Authorization
Specialty Medications
Medication Name Medication Class Medication Name Medication Class Medication Name Medication ClassCOLISTIN METHANESULFONATE Specialty ETHYLPARABEN Specialty GLASSIA Specialty
COLY-MYCIN M Specialty ETHYOL Specialty GLEEVEC Specialty
Medication Name Medication Class Medication Name Medication Class Medication Name Medication ClassKINERET Specialty NEULASTA Specialty PEGASYS PROCLICK Specialty
Medication Name Medication Class Medication Name Medication Class Medication Name Medication ClassREPRONEX Specialty SYNVISC Specialty VENTAVIS Specialty
RESORCINOL MONOACETATE Specialty SYNVISC ONE Specialty VEPESID Specialty