Medications Requiring Precertification

Oxford Health Plans has a mission to help our Members maintain and improve their overall health through the appropriate use of medications. To this end, Oxford has established programs to encourage medication therapy that is appropriate and economical for our Members.

For most Members with pharmacy benefit coverage through Oxford, the medications on the following list (including generic equivalents, if available) generally require precertification based on Oxford's coverage criteria. Precertification, also known as prior authorization, requires your doctor to formally submit a request and receive approval for coverage of certain prescription medications. If you have any questions regarding the medications on this list or any additional medication, please call our Pharmacy Customer Service line at 800-905-0201.

This list is subject to change without notice. For the most up-to-date information, please call Pharmacy Customer Service at 1-800-905-0201.

Please note: Certain medications, and injectables covered under the Member's medical benefit require precertification through Oxford's Medical Management Department. Please view our List of Drugs Requiring Precertification through Oxford's Medical Management Department for details.

Dermatological medications	Endocrine medications
Avita2 Differin2 Elidel Protopic Raptiva Regranex Retin A2 Tazorac2	Somavert1 Zavesca1
Gastroenterology medications	Growth hormones
Lotronex Nexium Prevacid Capsule Prilosec Zelnorm	Serostim
Musculoskeletal and Rheumatological medications	Narcotic analgesics
Celebrex Enbrel Humira Kineret	Actiq
Obstetrics and Gynecology medications	Psychotherapeutic medications
Lupron Depot (3.75 mg and 11.25 mg)	Provigil Wellbutrin/Wellbutrin SR/Wellbutrin XL
Pulmonary medications	Urological medications
Revatio Tracleer Ventavis	Caverject Cialis Edex Levitra Muse Viagra
Miscellaneous products
Copegus Infergen Intron A Nutritional Therapies1 PEG-Intron Pegasys Rebetol Rebetron Restasis Roferon-A

¹For coverage information, Members should contact Oxford Customer Service at the number on the back of their ID card.
²Applies only to Members 40 years of age or older.