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 Brand 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 10/1/2017 through 4/1/2018. Product name Medication class Effective date Update ArmonAir RespiClick (fluticasone propionate) Respiratory Conditions Add quantity limit on ArmonAir RespiClick as follows: Limited to one inhaler per Add step therapy on ArmonAir RespiClick as follows: Arnuity Ellipta, Flovent Diskus, Flovent HFA, or Qvar. Asmanex, Asmanex HFA (mometasone furoate) Asthma and COPD Change Asmanex and Asmanex HFA from Value tier to non-preferred brand Avonex, Avonex Pen (interferon beta-1a) Change Avonex and Avonex Pen from preferred brand (Tier 2) to non-preferred brand Bethkis (tobramycin) Infectious Disease Change Bethkis from preferred brand (Tier Cayston (aztreonam lysine) Infectious Disease Bacterial Change Cayston from preferred brand (Tier Copaxone (glatiramer acetate) Change Copaxone from preferred brand (Tier Fiasp (insulin aspart (niacinamide)) Diabetes 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: Trial of Humalog Gilenya (fingolimod HCl) Change Gilenya from preferred brand (Tier Kitabis Pak (tobramycin/nebulizer) Infectious Disease - Change Kitabis Pak from preferred brand (Tier Lysodren (mitotane) Neoplastic Disease Change Lysodren from preferred brand (Tier Nexium 40mg capsule, packet (esomeprazole trihydrate) Gastrointestinal Change quantity limit on Nexium 40mg capsule/packet as follows: Limited to 60 capsules or packets per Plegridy, Plegridy Pen (peginterferon beta-1a) Change Plegridy and Plegridy Pen from preferred brand (Tier 2) to non-preferred brand Pulmicort Flexhaler (budesonide) Asthma and COPD Change Pulmicort Flexhaler from Value tier to non-preferred brand Rebif, Rebif Rebidose (interferon beta-1a/albumin) Change Rebif and Rebif Rebidose from preferred brand (Tier 2) to non-preferred brand

3 Shingrix (Varicella Zoster GE/AS01/PF) Zoster Vaccine 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 Sivextro (tedizolid) Infectious Disease 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. Tecfidera (dimethyl fumarate) Change Tecfidera from preferred brand (Tier Tobi (tobramycin in 0.225% sod chlor) Infectious Disease - Change Tobi from preferred brand (Tier 2) to non-preferred brand Xyzbac, Mebolic (multivit34/folic ac/nadh/coq10) Vitamins Add prior authorization requirements on Xyzbac and Mebolic. Yescarta (axicabtagene ciloleucel) CAR T Cell Therapies Add prior authorization requirements on Yescarta. Bevyxxa (betrixaban) Factor Xa Inhibitor Change Bevyxxa to non-preferred brand Add quantity limit on Bevyxxa of 43 capsules per 42 days. Tremfya (guselkumab) Immunomodulating Biologics for Psoriasis Tremfya. Anoro Ellipta (umeclidinium/vilanterol) LAMA/LABA Change step therapy on Anoro Ellipta to trial of Stiolto Respimat. Bevespi Aerosphere (glycopyrrolate/ formoterol) LAMA/LABA Change step therapy on Bevespi Aerosphere to trial of Stiolto Respimat. Utibron Neohaler (glycopyrrolate/ indacaterol) LAMA/LABA Change step therapy on Utibron Neohaler to trial of Stiolto Respimat. Asmanex, Asmanex HFA (mometasone furoate) ICS Add step therapy on Asmanex and Asmanex HFA for trial of QVAR, Arnuity Ellipta, or Flovent. Pulmicort Flexhaler (budesonide) ICS Change Pulmicort Flexhaler to non-preferred brand Add step therapy on Pulmicort Flexhaler for trial of QVAR, Arnuity Ellipta, or Flovent. Aerospan (flunisolide) ICS Change step therapy on Aerospan to trial of QVAR, Arnuity Ellipta, or Flovent. Alvesco (ciclesonide) ICS Change step therapy on Alvesco to trial of QVAR, Arnuity Ellipta, or Flovent.

4 Daliresp (roflumilast) PDE 4 Inhibitor Change step therapy on Daliresp to trial of preferred LAMA (Spiriva), LABA (Serevent), or ICS/LABA (Breo Ellipta or Advair Diskus). Vosevi (sofosbuvir/ velpatasvir/ voxilaprevir) Hepatitis C Vosevi. Mavyret (glecaprevir/ pibrentasvir) Hepatitis C Change Mavyret to Specialty Tier (Tier 4). Mavyret. Haegarda (C1 Esterase Inhibtor (SC)) Hereditary Angioedema Haegarda. Xatmep (methotrexate solution) Oncology Add quantity limit on Xatmep of 60mL per Add step therapy on Xatmep for trial of methotrexate tablets or injection solution if 12 years of age or older. Syndros (dronabinol solution) Oncology Add quantity limit on Syndros of 60mL per Add step therapy on Syndros for trial of generic dronabinol capsules. Marinol (dronabinol) Oncology Change step therapy on Marinol to trial of Emend, 5HT3 antagonist or dexamethasone. Abbott Test Strips Diabetic Test Strips Add quantity limit on Abbott Test Strips of 200 test strips per Non-Abbott Test Strips Diabetic Test Strips Add quantity limit on Non-Abbott Test Strips of 200 test strips per Donnatal tablets (phenobarb/hyoscy/ atropine/scop) Upper Gastrointestinal Disorders - Spastic Disease Add quantity limit on Donnatal tablets of 240 tablets per Add step therapy on Donnatal tablets of trial of dicyclomine capsules or tablets AND hyoscyamine. Change Donnatal Elixir to non-preferred Brand Donnatal Elixir (phenobarb/hyoscy/ atropine/scop) Upper Gastrointestinal Disorders - Spastic Disease Add quantity limit on Donnatal Elixir of 1200mL per Add step therapy on Donnatal Elixir of trial of dicyclomine capsules or tablets AND hyoscyamine. HP Acthar (corticotropin) Adrenocorticotrophic Hormones Change HP Acthar to Specialty Tier (Tier 4). Tivicay (dolutegravir) Infectious Disease - Viral Change quantity limit on Tivicay to 60 tablets per

5 Edex (alprostadil) Drugs To Treat Impotency Change quantity limit on Edex to 6 injections per Arymo ER (morphine sulfate extended release) Add quantity limit on Arymo ER of 90 tablets per Morphabond (morphine sulfate extended release) Add quantity limit on Morphabond of 60 tablets per Add quantity limit on APAP/caffeine/ Dihyrocodeine of 300 tablets per APAP/caffeine/ Dihyrocodeine (325/16/30 mg) Pain Management - Analgesics Add step therapy on APAP/caffeine/ Dihyrocodeine for trial of acetaminophen/codeine. Add age restriction on APAP/caffeine/ Dihyrocodeine as follows: Must be 12 years of age or older. Trezix (320.5/16/30 mg) (APAP/caffeine/ Dihyrocodeine) Pain Management - Analgesics Add step therapy on Trezix for trial of acetaminophen/codeine. Add age restriction on Trezix as follows: Must be 12 years of age or older. Soma (carisoprodol) Skeletal Muscle Relaxants Add quantity limit on Soma of 120 tablets per Veregen (sinecatechins 15% cream) Add step therapy on Veregen for trial of imiquimoid 5% cream and generic 0.5% condylox solution. Zyclara 2.5% & 3.75% (imiquimod cream) Add step therapy on Zyclara for trial of imiquimoid 5% cream Condylox (podofilox 0.5% gel) Change Condylox to non-preferred brand tier Add step therapy on Condylox for trial of Condylox 0.5% solution. Prudoxin (doxepin 5% cream) Add step therapy on Prudoxin for trial of a topical steroid. Zonalon (doxepin 5% cream) Add step therapy on Zonalon for trial of a topical steroid. Change Cordan to non-preferred brand tier Cordan (flurandrenolide tape) Add quantity limit on Cordan of 2 boxes per Add step therapy on Cordan for trial of a topical steroid.

6 Lidocaine 5% ointment Add quantity limit on Lidocaine 5% ointment of 240 grams per Add step therapy on Lidocaine 5% ointment for trial of Lidocaine 3%. Nexium (esomeprazole magnesium) Proton Pump Inhibitors Add quantity limit on Nexium of: 40mg capsules: 60 caps per 30 days 40mg packets: 60 packets per 30 days 20mg capsules: 30 caps per 30 days 2.5mg packets: 30 packets per 30 days 5mg packets: 30 packets per 30 days 10mg packets: 30 packets per 30 days 20mg packets: 30 packets per 30 days Codeine containing products Add age restriction on all codeine containing products as follows: Must be 12 years of age or older. Ultram (tramadol) Add age restriction on Ultram as follows: Must be 12 years of age or older. Ultram ER (tramadol ER) Add age restriction on Ultram ER as follows: Must be 12 years of age or older. Conzip (tramadol ER) Add age restriction on Conzip as follows: Must be 12 years of age or older. Ultracet (tramadol/acetaminophen) Add age restriction on Ultracet as follows: Must be 12 years of age or older. Exjade (deferasirox) Metallic Poison, To Treat Exjade. Jadenu (deferasirox) Metallic Poison, To Treat Jadenu. Ferriprox (deferiprone) Metallic Poison, To Treat Ferriprox. Desferal (deferoxamine) Metallic Poison, To Treat Desferal. Zyflo IR (zileuton) Asthma and COPD Add a quantity on Zyflo IR of 120 tablets per Add step therapy on Zyflo IR for trial of montelukast and zafirlukast. Zyflo CR (zileuton) Asthma and COPD Add a quantity on Zyflo CR of 60 tablets per Add step therapy on Zyflo CR for trial of montelukast and zafirlukast. Daxbia (cephalexin) Infectious Disease - Bacterial Add step therapy on Daxbia for trial of generic cephalexin tablets/capsules and suspension.

7 Ryvent (carbinoxamine) Allergy Add a quantity on Ryvent of 120 tablets per Add step therapy on Ryvent for trial of generic carbinoxamine 4mg tablets and carbinoxamine IR solution. Zonacort (dexamethasone) Inflammatory Disease Add step therapy on Zonacort for trial of generic dexamethasone 1.5mg tablets. Locort (dexamethasone) Inflammatory Disease Add step therapy on Locort for trial of generic dexamethasone 1.5mg tablets. Dexpak (dexamethasone) Inflammatory Disease Add step therapy on Dexpak for trial of generic dexamethasone 1.5mg tablets. Forteo (teriparatide) Osteoporosis Forteo. Nevanac (nepafenac 0.1%) Ophthalmic Change Nevanac to non-preferred brand tier Betoptic S (betaxolol HCl) Ophthalmic Change Betoptic S to non-preferred brand tier Betimol (timolol maleate) Ophthalmic Change Betimol to non-preferred brand tier Symproic (naldemidine) Gastrointestinal Add a quantity on Symproic of 30 capsules per Add step therapy on Symproic for trial of Movantik and Linzess. Soolantra (ivermectin 1% cream) Rosacea Derm Add step therapy on Soolantra for trial of Finacea gel or foam. Rasuvo (SC methotrexate) Inflammatory Disease Add step therapy on Rasuvo for trial of methotrexate tablet or solution. 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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