Prescription benefit updates Individual/small group

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1 Prescription benefit updates Individual/small group 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 brand 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 Value tier Select tier Preferred tier Non-Preferred tier Specialty 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. 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. Certain prescription medications are defined as specialty products. Specialty medications are often used to treat complex chronic health conditions. Specialty treatments often require special handling techniques, careful administration and a unique ordering process. You must access specialty medications through the exclusive specialty pharmacy.

2 Prescription coverage updates These expected Moda Health prescription tier and coverage updates go into effect for Product name Effective date Update Zenzedi 2.5mg, 7.5mg, 15mg, 20mg and 30mg (dextroamphetamine) Braftovi (encorafenib) Balcoltra (ethinyl estradiol/ levonorgestrel/iron) Imvexxy (estradiol) Intrarosa (prasterone) Siklos 100mg and 1000mg (hydroxyurea) Adrenaclick (epinephrine) Change Zenzedi from preferred (Tier 2) to non-preferred (Tier 3). Add step therapy on Zenzedi 15mg, 20mg, and 30mg as follows: Must try/fail dextroamphetamine sulfate ER/IR tablets or dextroamphetamine solution in the previous 120 days. Change quantity limit on Braftovi as follows: Limited to 180 capsules Add quantity limit on Balcoltra as follows: Limited to 28 tablets per 28 days. Add step therapy on Balcoltra as follows: Must try/fail generic oral contraceptive in the previous 120 days. Add quantity limit on Imvexxy as follows: Limited to 18 inserts per 28 days. Add quantity limit on Intrarosa as follows: Limited to 28 inserts per 28 days. Add quantity limit on Siklos (100mg strength only) as follows: Limited to 56 tablets per 28 days. Add step therapy on Siklos (1000mg strength only) as follows: Must try/fail generic hydroxyurea and Droxia in the previous 365 days. Add quantity limit on Adrenaclick as follows: Limited to 4 autoinjectors per fill. Move Augmentin 125/5mL (susp.) from preferred (Tier 2) to nonpreferred (Tier 3). Augmentin (susp.) (Amox/K Clav (125/5)) Add quantity limit on Augmentin 125/5mL (susp.) as follows: Limited to 150mL Carac (5 fluorouracil) Chenodal (chenodiol) Dibenzyline (phenoxybenzamine) Add step therapy on Augmentin 125/5mL (susp.) as follows: Trial of generic augmentin of different strength in previous 120 days. Add prior authorization guideline on Carac. Move Chenodal from Tier 3 (non-preferred brand) to Tier 4 (Specialty). Add prior authorization guidelines on Chenodal. Add prior authorization guidelines on Dibenzyline.

3 Duzallo (lesinurad/allopurinol) EpiPen (epinephrine) Krystexxa (pegloticase) Nicotine gum (nicotine) Nicotine lozenge (nicotine) Nilandron (nilutamide) Toradol (oral) (ketorolac) Toradol (injectable) (ketorolac) Trokendi XR (topiramate) Zurampic (lesinurad) Zyclara (imiquimod) Basaglar (insulin glargine) Adlyxin (lixisenatide) Bydureon/BCise (exenatide extended release) Byetta (exenatide) Ozempic (semaglutide) Tanzeum (albiglutide) Add step therapy on Duzallo as follows: Must try/fail allopurinol in previous 120 days. Add quantity limit on EpiPen as follows: Limited to 4 auto-injectors per fill. Move Krystexxa from Tier 3 (non-preferred brand) to Tier 4 (Specialty). Add prior authorization guidelines on Krystexxa. Change quantity limit on Nicotine gum as follows: Limited to 720 gum pieces Change quantity limit on Nicotine lozenge as follows: Limited to 600 lozenges Change quantity limit on Nilandron as follows: Limited to 60 tablets Add quantity limit on Toradol (oral) as follows: Limited to 20 tablets per 5 days. Add quantity limit on Toradol (injectable) as follows: Limited to 5 day supply at a time. Change quantity limit on Trokendi XR as followed: 25mg: 240 caps per 30 days 50mg: 120 caps per 30 days 100mg: 60 caps per 30 days Change step therapy on Zurampic as follows: Must try/fail allopurinol in the previous 120 days. Change step therapy on Zyclara as follows: Must try/fail imiquimod 5% cream packet, 5 FU generic 5%, or diclofenac 3% in previous 120 days. Change step therapy on Basaglar as follows: Must try/fail Lantus, Levemir, Toujeo, OR Tresiba in previous 120 days. Change step therapy on Adlyxin as follows: Must try/fail Bydureon, Bcise, Byetta, OR Trulicity AND metformin/metformin combination, OR formulary sulfonylurea OR pioglitazone/pioglitazone combination in previous 365 days. Change step therapy on Bydureon/BCise as follows: Must try/fail metformin/metformin combination or formulary sulfonylurea or pioglitazone/pioglitazone combination in previous 120 days. Change step therapy on Byetta as follows: Must try/fail metformin/metformin combination or formulary sulfonylurea or pioglitazone/pioglitazone combination in previous 120 days. Change step therapy on Ozempic as follows: Must try/fail metformin/metformin combination or formulary sulfonylurea or pioglitazone/pioglitazone combination in previous 365 days. Change step therapy on Tanzeum as follows: Must try/fail metformin/metformin combination or formulary sulfonylurea or pioglitazone/pioglitazone combination in previous 365 days.

4 Move Victoza from preferred (Tier 2) to non-preferred (Tier 3). Victoza (liraglutide) Farxiga (dapagliflozin) Xigduo XR (dapagliflozin/metformin ER) Change step therapy on Victoza as follows: Must try/fail metformin/metformin combination or formulary sulfonylurea or pioglitazone/pioglitazone combination in previous 365 days. Change step therapy on Farxiga as follows: Must try/fail product containing any two of the three aforementioned agents. Change step therapy on Xigduo XR as follows: Must try/fail product containing any two of the three aforementioned agents. Move Invokana from preferred (Tier 2) to non-preferred (Tier 3). Invokana (canagliflozin) Change step therapy on Invokana as follows: Must try/fail product containing any two of the three aforementioned agents and Jardiance, Synjardy, Synjardy XR, Farxiga, or Xigduo XR. Move Invokamet from preferred (Tier 2) to non-preferred (Tier 3). Invokamet (canagliflozin/metformin) Invokamet XR (canagliflozin/metformin) Change step therapy on Invokamet as follows: Must try/fail product containing any two of the three aforementioned agents and Jardiance, Synjardy, Synjardy XR, Farxiga, or Xigduo XR. Move Invokamet XR from preferred (Tier 2) to non-preferred (Tier 3). Change step therapy on Invokamet XR as follows: Must try/fail product containing any two of the three aforementioned agents and Jardiance, Synjardy, Synjardy XR, Farxiga, or Xigduo XR. Move Steglatro from preferred (Tier 2) to non-preferred (Tier 3). Steglatro (ertugliflozin) Segluromet (ertugliflozin/metformin) Steglujan (ertugliflozin/sitagliptin) Qtern (dapagliflozin/saxagliptin) Change step therapy on Steglatro as follows: Must try/fail product containing any two of the three aforementioned agents and Jardiance, Synjardy, Synjardy XR, Farxiga, or Xigduo XR. Change step therapy on Segluromet as follows: Must try/fail product containing any two of the three aforementioned agents and Jardiance, Synjardy, Synjardy XR, Farxiga, or Xigduo XR. Change step therapy on Steglujan as follows: Must try/fail product containing any two of the three aforementioned agents and Jardiance, Synjardy, Synjardy XR, Farxiga, or Xigduo XR. Change step therapy on Qtern as follows: Must try/fail metformin IR/ER, sulfonylurea, pioglitazone or a combination product containing any two of the three aforementioned agents and Jardiance, Synjardy, Synjardy XR, Farxiga, or Xigduo XR.

5 Amerge (naratriptan) Axert (almotriptan) Frova (frovatriptan) Imitrex (100mg) (sumatriptan) Imitrex (SC) (sumatriptan) Maxalt (rizatriptan) Relpax (eletriptan) Zomig (oral) (zolmitriptan) Synarel (nafarelin) Leuprolide (leuprolide) Megace ES (megestrol ES suspension) Dexcom Products (G4, G5, G6) (CGM monitor) Freestyle Libre Receiver (CGM monitor, Flash Glucose Reader and Sensor) Bonjesta (doxylamine/ pyridoxine) Erleada (apalutamide) Genvisc 850, Visco 3, Supartz FX (hyaluronate acid) Lonhala Magnair (glycopyrrolate nebulizer) Marinol (dronabinol) Noctiva (desmopressin) Syndros (dronabinol solution) Change quantity limit on Amerge as follows: Limited to 240 tablets Change quantity limit on Axert as follows: Limited to 240 tablets Change quantity limit on Frova as follows: Limited to 240 tablets Change quantity limit on Imitrex (100 mg) as follows: Limited to 240 tablets Change quantity limit on Imitrex (SC) as follows: (6mg/0.5mL): Limited to 5mL per 28 days. (4, 6 mg cartridge/pen): Limited to 4mL per 28 days Change quantity limit on Maxalt: as follows: Limited to 12 tablets Change quantity limit on Relpax as follows: Limited to 6 tablets per 30 days. Change quantity limit on Zomig (oral) as follows: Limited to 8 tablets Add prior authorization guidelines on Synarel. Add prior authorization guidelines on leuprolide. Change step therapy on Megace ES as follows: Must try/fail megestrol regular strength suspension. Add prior authorization guidelines on all continuous blood-glucose meters (CGM). Add prior authorization guidelines on Freestyle Libre Receiver. Change quantity limit on Bonjesta as follows: Limited to 60 tablets Add quantity limit on Erleada as follows: Limited to 120 tablets per 30 days. Add prior authorization guideline on Genvisc 850, Visco 3, and Supartz FX. Add quantity limit on Lonhala Magnair as follows: Limited to 1 unit Change step therapy on Marinol as follows: Must try/fail at least 1 of the following: Emend, Corticosteroid, 5HT3 antagonist OR megestrol regular strength suspension in the previous 120 days. Add quantity limit on Noctiva as follows: Limited to up to 3.8g (1 canister) Change step therapy on Syndros as follows: Must try/fail at least one of the following: generic dronabinol capsules OR megestrol regular strength suspension in the previous 120 days.

6 Vancomycin capsules Zypitamag (pitavastatin magnesium) Zytiga 250mg tablets (abiraterone) Benlysta IV (belimumab) Biktarvy (bictegravir/ emtricitabine/ tenofovir alafenamide) Bosulif (bosutinib) Carospir oral suspension (spironolactone) Chlorzoxazone 250mg, 375mg and 750mg tablets Cialis 10mg and 20mg tablets (tadalafil) Cleocin, intravaginal (clindamycin) Codeine/Phenylephrine/ Promethazine Cotempla XR ODT (methylphenidate ER) Change quantity limit on vancomycin capsules as follows: 125mg: 56 caps per 30 days 250mg: 112 caps per 30 days Add step therapy on Zypitamag as follows: Must try/fail Livalo (pitavastatin calcium) in the previous 120 days. Changing quantity limit on Zytiga as follows: Limited to 90 tablets Add prior authorization requirements on Benlysta IV. Add quantity limit on Biktarvy as follows: Limited to 30 tablets per 30 days. Change quantity limit on Bosulif as follows: 100mg tablets: 90 tabs per 30 days 400mg tablets: 30 tabs per 30 days 500mg tablets: 30 tabs per 30 days Add quantity limit on Carospir as follows: Limited to 600mL per 30 days. Add step therapy on Carospir as follows: Must try/fail spironolactone tablets in previous 120 days. Add quantity limit on Chlorzoxazone 250mg, 375mg and 750mg tablets as follows: Limited to 120 tablets Add step therapy on Chlorzoxazone 250mg, 375mg and 750mg tablets as follows: Must try/fail Chlorzoxazone 500mg tablets in previous 120 days. Add step therapy on Cialis 10mg and 20mg tablets as follows: Must try/fail sildenafil (Viagra) in previous 120 days. Add quantity limit on Cleocin as follows: Limited to 3 intravaginal ovules (1 box) Add step therapy on Cleocin as follows: Must try/fail at least 2 of the following: oral metronidazole, oral tinidazole, oral clindamycin; metronidazole gel (0.75%), or clindamycin cream (2%) in the previous 365 days. Change age restriction to Codeine/Phenylephrine/ Promethazine as follows: Must be 19 years of age or older. Add quantity limit on Cotempla XR-ODT as follows: 8.6mg tablets: 30 tabs per 30 days 17.3mg tablets: 30 tabs per 30 days 25.9mg tablets: 60 tabs per 30 days Add step therapy on Cotempla XR-ODT as follows: Must try/fail methylphenidate IR, long acting formulation of methylphenidate (ER, LA, CD), or generic/multisource mixed amphetamine salts (Adderall IR/XR) in previous 120 days.

7 Doxycycline DR 200mg tablets Duzallo (allopurinol/ lesinurad) Fenortho, Profeno, Nalfon (fenoprofen 200mg, 400mg, 600 mg) Flolipid suspension (simvastatin) FlowTuss, Obredon (hydrocodone, guaifenesin) Forteo (teriparatide SC) Gamunex C 40G Gleostine (lomustine) Glycopyrrolate 1.5mg tablets Hycofenix (hydrocodone, pseudoephedrine, guaifenesin) Impoyz 0.025% cream (clobetasol) Indocin suppositories (indomethacin) Lupon Depot Ped (leuprolide) Lyrica CR (pregabalin) Change quantity limit on doxycycline DR 200mg as follows: Limited to 30 tablets Add quantity limit on Duzallo as follows: Limited to 30 tablets per 30 days. Add step therapy on Duzallo as follows: Must try/fail allopurinol or Uloric (feuxostat) in previous 120 days. Change Fenortho, Profeno, Nalfon from preferred (Tier 2) to nonpreferred (Tier 3). Add prior authorization requirements on Flolipid. Add age restriction on FlowTuss, Obredon as follows: Must be 19 years of age or older. Change quantity limit on Forteo as follows: Limited to 2.4mL per 28 days with a max duration of 728 days per lifetime. Add prior authorization requirements on Gamunex C (40 Gram). Add prior authorization requirements on Gleostine. Add quantity limit on Glycopyrrolate 1.5mg tablets as follows: Limited to 90 tablets Add step therapy on Glycopyrrolate 1.5mg tablets as follows: Must try/fail Glycopyrrolate 1mg tablets or Glycopyrrolate 2mg tablets in previous 120 days. Add age restriction on Hycofenix as follows: Must be 19 years of age or older. Add step therapy on Impoyz as follows: Must try/fail a topical corticosteroid in the previous 120 days. Change Indocin from preferred (Tier 2) to non-preferred (Tier 3). Add prior authorization requirements on Indocin. Add prior authorization requirements on Lupon Depot Ped. Add quantity limit on Lyrica CR as follows: 82.5mg tablets: 90 tabs per 30 days 165mg tablets: 90 tabs per 30 days 330mg tablets: 60 tabs per 30 days Add step therapy on Lyrica CR as follows: Must try/fail at least 2 of the following: gabapentin, tricyclic antidepressants (amitripyline, nortriptyline/ notriptyline solution, desipramine, doxepin capsules/solution, imipramine, maprotilene), duloxetine, venlafaxine, or valproic acid/ divalproex in the previous 365 days.

8 Promethazine/Codeine Renagel (sevelamer HCL) Sensipar (cinacalcet) Silenor (doxepin) Solosec (secnidazole) Sprix (ketorolac) Supprelin LA (histrelin) Taytulla (ethnityl estradiol/ noethindrone/fe) Tussicaps (hydrocodone, chlorpheniramine ER) Tussigon (tablet), Hydromet (syrup) (hydrocodone/homatropine) Tussionex (hydrocodone, chlorpheniramine ER 12H suspension) Tuzistra XR (codeine/chlorpheniramine) Vemlidy (tenofovir alafenamide) Vituz (hydrocodone, chlorpheniramine) Xhance (fluticasone propionate) Add age restriction on Promethazine/ Codeine as follows: Must be 19 years of age or older. Change Renagel from preferred (Tier 2) to non-preferred (Tier 3). Add quantity limit on Sensipar as follows: 30mg tablets: 60 tabs per 30 days 60mg tablets: 60 tabs per 30 days 90mg tablets: 120 tabs per 30 days Change step therapy on Silenor as follows: Must try/fail at least 1 of the following: zolpidem IR, zaleplon, eszopiclone, doxepin 10mg/mL solution, or doxepin 10mg capsule in the previous 120 days. Add quantity limit on Solosec as follows: Limited to 30 single dose packets Add step therapy on Solosec as follows: Must try/fail at least 2 of the following: oral metronidazole, oral tinidazole, oral clindamycin; metronidazole gel (0.75%), clindamycin cream (2%) in the previous 365 days. Add step therapy on Sprix as follows: Must try/fail 1 generic NSAID in previous 120 days. Add prior authorization requirements on Supprelin LA. Add step therapy on Taytulla as follows: Must try/fail at least 2 generic contraceptives in previous 365 days. Add age restriction on Tussicaps as follows: Must be 19 years of age or older. Add age restriction on Tussigon (tablet) and Hydromet (syrup) as follows: Must be 19 years of age or older. Add age restriction on Tussionex as follows: Must be 19 years of age or older. Add age restriction on Tuzistra XR as follows: Must be 19 years of age or older. Add step therapy to Vemlidy as follows: Must try/fail tenofovir 300mg (Viread) in previous 120 days. Add age restriction on Vituz as follows: Must be 19 years of age or older. Add quantity limit on Xhance as follows: Limited to 32mL (2 inhalation devices) Add step therapy on Xhance as follows: Must try/fail at least 2 of the following inhaled nasal corticosteriods: mometasone, fluticasone propionate/furoate, flunisolide, or beclomethasone (Qnasl) in the previous 365 days.

9 Xigduo XR (dapagliflozin/metformin) Change quantity limit on Xigduo XR as follows: 2.5/1000mg tablets: 60 tabs per 30 days 5/1000mg tablets: 60 tabs per 30 days 5/500mg tablets: 30 tabs per 30 days 10/500mg tablets: 30 tabs per 30 days 10/1000mg tablets: 30 tabs per 30 days Add quantity limit on Ximino as follows: Limited to 30 capsules per 30 days. Ximino (minocycline ER cap) Add step therapy on Ximino as follows: Must try/fail generic IR Minocycline tablets or generic IR Minocycline capsules in the previous 120 days. Zodex/Locort/ ZonaCort/Dexpack (dexamethasone 1.5 mg blister pack) Zurampic (lesinurad) Zutripro (hydrocodone, chlorpheniramine, pseudophedrine) ArmonAir RespiClick (fluticasone propionate) Asmanex, Asmanex HFA (mometasone furoate) Avonex, Avonex Pen (interferon beta-1a) Bethkis (tobramycin) Cayston (aztreonam lysine) Copaxone (glatiramer acetate) Fiasp (insulin aspart (niacinamide)) Gilenya (fingolimod HCl) Kitabis Pak (tobramycin/nebulizer) Add age restriction on Ximino as follows: Must be 12 years of age or older. Change step therapy on Zodex/Locort/Zonacort/Dexpack (dexamethasone 1.5 mg tablet taper packs) as follows: Must try/fail dexamethasone 1.5 mg tablets. Change Zurampic from preferred (Tier 2) to non-preferred (Tier 3). Add age restriction on Zutripro as follows: Must be 19 years of age or older. Add quantity limit on ArmonAir RespiClick as follows: Limited to one inhaler Add step therapy on ArmonAir RespiClick as follows: Must try/fail Arnuity Ellipta, Flovent Diskus, Flovent HFA, or Qvar. Change Asmanex and Asmanex HFA from Value tier to nonpreferred (Tier 3). Change Avonex and Avonex Pen from preferred (Tier 2) to nonpreferred (Tier 3). Change Bethkis from preferred (Tier 2) to non-preferred (Tier 3). Change Cayston from preferred (Tier 2) to non-preferred (Tier 3). Change Copaxone from preferred (Tier 2) to non-preferred (Tier 3). Add quantity limit on Fiasp as follows: Vial: 40mL (4 vials) per 28 days Pen: 30mL (10 vials) per 28 days Add step therapy on Fiasp as follows: Must try/fail Humalog. Change Gilenya from preferred (Tier 2) to non-preferred (Tier 3). Change Kitabis Pak from preferred (Tier 2) to non-preferred (Tier 3).

10 Lysodren (mitotane) Nexium 40mg capsule, packet (esomeprazole trihydrate) Plegridy, Plegridy Pen (peginterferon beta-1a) Pulmicort Flexhaler (budesonide) Rebif, Rebif Rebidose (interferon beta-1a/albumin) Shingrix (Varicella Zoster GE/AS01/PF) Sivextro (tedizolid) Tecfidera (dimethyl fumarate) Tobi (tobramycin in 0.225% sod chlor) Xyzbac, Mebolic (multivit34/folic ac/nadh/coq10) Yescarta (axicabtagene ciloleucel) Change Lysodren from preferred (Tier 2) to non-preferred (Tier 3). Change quantity limit on Nexium 40mg capsule/packet as follows: Limited to 60 capsules or packets Change Plegridy and Plegridy Pen from preferred (Tier 2) to nonpreferred (Tier 3). Change Pulmicort Flexhaler from Value tier to non-preferred (Tier 3). Change Rebif and Rebif Rebidose from preferred (Tier 2) to nonpreferred (Tier 3). Add quantity limit to Shingrix as follows: Limit to 2 doses per 365 days Add age restriction to Shingrix as follows: Must be 50 years of age or older Add quantity limit on Sivextro as follows: 1 tablet per day for a duration of 6 days. Add step therapy on Sivextro as follows: Must try/fail linezolid 600mg tablets. Change Tecfidera from preferred (Tier 2) to non-preferred (Tier 3). Change Tobi from preferred (Tier 2) to non-preferred (Tier 3). Add prior authorization requirements on Xyzbac and Mebolic. Add prior authorization requirements on Yescarta. 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

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