2020.3 (7/1/2020). For prior effective dates, please contact Moda Health. modahealth.com

Prescription benefit updates

Moda Health’s prescription program is a pharmacy benefit that offers members a choice of safe

and effective medication treatments. The program also helps you save money on prescription

drugs. Periodically, medication coverage changes will occur. These changes allow us to maintain

a comprehensive benefit and provide you with an open formulary and choice, and support the

program’s ongoing stability.

Our prescription program uses a tiered copay/coinsurance system. You and your doctor can

choose between the value, select, preferred or non-preferred tier medications. What you pay for

a drug depends on your plan.

Please review the following expected pharmacy coverage updates. Please note, this information

could change and does not represent every potential update to your benefits. Refer to your

member handbook for specific tier and coverage information.

Questions? Call our Pharmacy Customer Service team toll-free at 888-361-1610.

Value tier Select tier Preferred tier Non-preferred tier

Value medications include commonly prescribed medications used to treat chronic medical conditions and preserve health.

Plans that do not include a value tier benefit will have medications categorized under this tier paid at the select or preferred tier copay/coinsurance levels.

Generic medications are considered by physicians and pharmacists to be therapeutically the same as brand name alternatives and at the most favorable cost. Generic medications must contain the same active ingredient as their brand name counterparts and be identical in strength, dosage and format.

This benefit level may also include select brand medications that have been identified as favorable from a clinical and cost effective perspective.

The preferred tier includes brand and specialty brand name medications that have been reviewed by Moda Health and found to be clinically effective at a favorable cost when compared with other medications in the same category. This tier may also include generic medications that have been found to have the same clinical outcomes as their more cost-effective generic counterparts in the same category. If your plan does not include a preferred tier, then those medications will be paid at the select or non-preferred tier copay/coinsurance level.

This tier includes brand name medications that have been reviewed by Moda Health and found not to have a significant therapeutic advantage over their preferred tier counterparts.

2020.3 (7/1/2020). For prior effective dates, please contact Moda Health. modahealth.com

Prescription coverage updates

These expected Moda Health prescription tier and coverage updates go into effect for 2020.

Product name Effective date Update

Captopril tablet

Captopril-Hydrochlorothiazide tablet 4/1/2020

Move Captopril from select (Tier 1) to preferred (Tier 2).

Add step therapy on Captopril as follows: Must try/fail at least 2 of the

following: ramipril, perindopril, enalapril, benazepril, moexipril,

fosinopril, Lisinopril, trandolapril, enalaprilat, or quinapril.

Desloratadine tab rapids 4/1/2020 Move Desloratadine to excluded.

Exelderm Cream (G)

Exelderm Solution 4/1/2020 Move Exelderm from preferred (Tier 2) to non-preferred (Tier 3).

Isotretinoin capsule 4/1/2020 Change quantity limits on Isotretinoin to 60 caps per 30 days.

Levocarnitine 4/1/2020 Move Levocarnitine to excluded.

Oxazepam capsule 4/1/2020

Move Oxazepam from select (Tier 1) to preferred (Tier 2).

Add step therapy on Oxazepam as follows: Must try/fail at least 2 of

the following: alprazolam IR, diazepam tab/sol, lorazepam tab/sol, or

chlordiazepoxide tab.

Ranolazine ER Tab ER 12h 4/1/2020 Move Ranolazine from select (Tier 1) to preferred (Tier 2).

Soolantra Cream (G) 4/1/2020 Move Soolantra from preferred (Tier 2) to non-preferred (Tier 3).

Duloxetine 40mg capsule 1/1/2020 Move Duloxetine from select (Tier 1) to preferred (Tier 2).

Evekeo 5mg, 10mg tablet 1/1/2020

Remove prior authorization on Evekeo.

Add step therapy on Eveko as follows: Must try/fail

dextroamphetamine IR AND amphetamine/dextroamphentamine IR.

Firvanq 25mg/ml Soln Recon 1/1/2020

Move from preferred (Tier 2) to non-preferred (Tier 3).

Change quantity limits on Fivanq to 140ml per 14 days.

Niaspan Tab ER 24h,

Niacin ER Tab ER 24h,

Niacin tablet,

Plain Niacin tablet

1/1/2020 Move Niacin to exclude due t o OTC alternatives available.

Pramipexole ER tablet 1/1/2020 Move Pramipexole ER from select (Tier 1) to preferred (Tier 2).

Testim 50mg (1%) Gel (Gram) 1/1/2020 Add quantity limits on Testim of 300 grams per 30 days.

Vogelxo 50mg (1%) Gel (Gram) 1/1/2020 Add quantity limits on Vogelxo of 300 grams per 30 days.

Zohydro ER 1/1/2020

Remove prior authorization on Zohydro ER.

Add step therapy on Zohydro ER as follows: Must try/fail morphine

sulfate ER tabs and fentanyl transderm patches.

This document is provided for informational purposes only, and is intended as a quick reference. For cost and further details of the coverage, including exclusions, prior authorization requirements, any reduction or limitations and the terms under which the policy may be continued in force, contact your producer or Moda Health. Copyright © 2014 Moda, Inc. All Rights Reserved. Health plans in Oregon and Alaska provided by Moda Health Plan, Inc.

2020.3 (7/1/2020). For prior effective dates, please contact Moda Health. modahealth.com

2020.3 (7/1/2020). For prior effective dates, please contact Moda Health. modahealth.com