Prescription benefit updates Large 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 888-361-1610. Value tier Select tier Preferred tier Brand 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 costeffective 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 brand 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.
Prescription coverage updates These expected Moda Health prescription tier and coverage updates go into effect for 2018. Product name Medication class Effective date Update Aciphex, Aciphex Sprinkle (rabeprazole sodium) Add age restriction on Aciphex and Aciphex Sprinkle as follows: Ages 18 years of age or older medication is excluded due to Analpram HC (hydrocortisone/pramoxine) Lower Disorders - Bowel Inflammat Changing from Analpram HC from preferred brand (Tier 2) to Anaspaz Changing from Anaspaz from preferred brand (Tier 2) to Anucort-HC, Anusol-HC (hydrocortisone acetate) Lower Disorders - Bowel Inflammat Changing Anucort-HC and Anusol-HC to excluded due to DESI Auvi-Q (epinephrine) Miscellaneous Agents Changing Auvi-Q from preferred brand (Tier 2) to nonpreferred brand (Tier 3). Beconase AQ (beclomethasone dipropionate) Nasal Steroid Add age restriction on Beconase AQ as follows: Ages 18 years of age or older medication is excluded due to Butrans (buprenorphine) Pain Management - Analgesics Changing Butrans from preferred brand (Tier 2) to Choline Mag Trisalicylate (choline salicyl/mag salicylate) Pain Management - Analgesics Changing Choline Mag Trisalicylate to excluded due to DESI Cortane-B (hydrocortisone/pramoxine/cxyl) Ear - General Disorders Changing Cortane-B to excluded due to DESI Covaryx, Covaryx H.S. (estrogen,ester/metestosterone) Hormonal Deficiency Changing Covaryx and Covaryx H.S. to excluded due to DESI Cytra-K (potassium citrate/citric acid) Urinary Tract - Functional Disorders Changing Cytra-K to excluded due to DESI Dexilant (dexlansoprazole) Add age restriction on Dexilant as follows: Ages 18 Disalcid (salsalate) Pain Management - Analgesics Changing Disalcid from preferred brand (Tier 2) to Donnatal (phenobarb/hyoscy/atropine/sc op) Changing Donnatal to excluded due to DESI
Product name Medication class Effective date Update Doxycycline Hyclate 100mg (tablet, capsule and tablet DR) Infectious - Bacterial Changing Doxycycline Hyclate 100mg tablet, capsule and tablet DR from preferred brand (Tier 2) to nonpreferred brand (Tier 3). EEMT, EEMT H.S. (estrogen,ester/metestosterone) Epiduo Forte (adapalene/benzoyl peroxide) Hormonal Deficiency Acne Agents, Topical Changing EEMT and EEMT H.S. to excluded due to DESI Add step therapy requirement on Epiduo Forte as follows: Must try/fail generic tretinoin or adapalene Epipen, Epipen JR (Epinephrine) Miscellaneous Agents Changing Epipen and Epipen JR from preferred brand (Tier 2) to Fenortho (fenoprofen calcium) Inflammatory Changing Fenortho from preferred brand (Tier 2) to Flonase (fluticasone propionate) Nasal Steroid Add age restriction on Flonase as follows: Ages 18 Flunisolide spray Nasal Steroid Add age restriction on Flunisolide spray as follows: Ages 18 years of age or older medication is excluded due to Fluoritab (fluoride (sodium)) Changing Fluoritab from preferred brand (Tier 2) to Fluvastatin, Fluvastatin ER Cardiovascular - Lipid Irregularity Add step therapy requirement on fluvastatin and fluvastatin ER for a trial of one of the following generics: atorvastatin, lovastatin, pravastatin, rosuvastatin, or simvastatin. Guaifenesin DAC (pseudoephed/codeine/guaifen) Cough And Cold Changing Guaifenesin DAC to excluded due to DESI Hemmorex-HC (hydrocortisone acetate) Antiinflammatory Changing Hemmorex-HC from preferred brand (Tier 2) to Hydrocortisone-Iodoquinol Acne Changing Hydrocortisone-Iodoquinol to excluded due to DESI Hydrocortisone-Pramoxine Lower Disorders - Bowel Inflammat Changing Hydrocortisone-Pramoxine to excluded due to DESI Hydrocortisone-Pramoxine HCl Miscellaneous Changing Hydrocortisone-Pramoxine HCl to excluded due to DESI Hyosyne Changing Hyosyne to excluded due to DESI Invokamet, Invokamet XR (canagliflozin/metformin hcl) Invokana (canagliflozin) Diabetes Diabetes Changing Invokamet and Invokamet XR from preferred brand (Tier 2) to non-preferred brand (Tier 3). Changing Invokana from preferred brand (Tier 2) to
Product name Medication class Effective date Update Isopto Atropine (atropine sulfate) Eye - Glaucoma Changing Isopto Atropine from preferred brand (Tier 2) to Isopto Carpine (pilocarpine hcl) Eye - Glaucoma Changing Isopto Carpine from preferred brand (Tier 2) to Ketorolac Tromethamine 0.4% Drops Eye - General Disorders Changing Ketorolac Tromethamine 0.4% Drops from Select (Tier 1) to preferred brand (Tier 2). Klor-Con (Packet) (potassium chloride) Electrolyte Regulation Changing Klor-Con packets from preferred brand (Tier 2) to Klor-Con-Ef (potassium bicarbonate/cit ac) Electrolyte Regulation Changing Klor-Con-Ef from preferred brand (Tier 2) to Levbid Changing Levbid from preferred brand (Tier 2) to Levsin, Levsin-SL Changing Levsin and Levsin-SL from preferred brand (Tier 2) to Lodine (etodolac) Inflammatory Changing Lodine from preferred brand (Tier 2) to Ludent Fluoride (fluoride (sodium)) Changing Ludent Fluoride from preferred brand (Tier 2) to Nasonex (mometasone furoate) Nasal Steroid Add age restriction on Nasonex as follows: Ages 18 Nexium (esomeprazole magnesium) Add age restriction on Nexium as follows: Ages 18 Nodolor (isomethept/dichlphn/acetamin op) Pain Management - Analgesics Changing Nodolor to excluded due to DESI Nulev Changing Nulev from preferred brand (Tier 2) to nonpreferred brand (Tier 3). Omeppi (omeprazole/sodium bicarbonate) Add age restriction on Omeppi as follows: Ages 18 Omnaris (ciclesonide) Nasal Steroid Add age restriction on Omnaris as follows: Ages 18 Phenergan (promethazine hcl) Antiemesis/ Antivertigo Changing Phenergan from preferred brand (Tier 2) to PNV-DHA (prenatal 47/iron/folate 1/dha) Changing PNV-DHA to excluded due to DESI
Product name Medication class Effective date Update PNV-Select (prenatal,calc.40/iron/folate 1) Changing PNV-Select to excluded due to DESI Potaba (potassium aminobenzoate) Changing Potaba to excluded due to DESI Pramosone (hydrocortisone/pramoxine) Miscellaneous Changing Pramosone from preferred brand (Tier 2) to Prevacid (lansoprazole) Add age restriction on Prevacid as follows: Ages 18 Prilosec (omeprazole magnesium) Add age restriction on Prilosec as follows: Ages 18 Proctocort (Supp. Rect) (hydrocortisone acetate) Lower Disorders - Bowel Inflammat Changing Proctocort rectal suppositories to excluded due to DESI Proctocort (Cream) (hydrocortisone) Antiinflammatory Changing Proctocort cream from preferred brand (Tier 2) to Protonix (pantoprazole sodium) Add age restriction on Protonix as follows: Ages 18 Pyridium (phenazopyridine hcl) Urinary Tract - Functional Disorders Changing Pyridium from preferred brand (Tier 2) to Rectacort-HC (hydrocortisone acetate) Antiinflammatory Changing Rectacort-HC from preferred brand (Tier 2) to Revatio (sildenafil citrate) Cardiovascular - Hypertension Changing Revatio from preferred brand (Tier 2) to Scalacort (hydrocortisone) Antiinflammatory Changing Scalacort from preferred brand (Tier 2) to Symax Changing Symax from preferred brand (Tier 2) to Symax-SL Changing Symax-SL to excluded due to DESI Symax-SR Changing Symax-SR from preferred brand (Tier 2) to Terconazole 0.04% Cream/Appl Vaginal Antifungals Terconazole 0.08% Cream/Appl Vaginal Antifungals Change quantity limit on Terconazole 0.04% to 45 gm per 30 days. Change quantity limit on Terconazole 0.08% to 20 gm per 30 days.
Product name Medication class Effective date Update Terconazole 80mg Supp.Vag Vaginal Antifungals Change quantity limit on Terconazole 80mg suppositories to 3 suppositories per 30 days. Tretinoin Microsphere Acne Add step therapy requirement on Tretinoin Microsphere for a trial of generic tretinoin or adapalene. Tretin-X (tretinoin) Acne Add step therapy requirement on Tretin-X for a trial of generic tretinoin or adapalene. Urelle (meth/meblue/sod phos/ psal/hyos) Infectious - Bacterial Changing Urelle to excluded due to DESI classification as less-than-effective. Valcyte (valganciclovir hcl) Infectious - Viral Changing Valcyte from preferred brand (Tier 2) to Xyzbac (multivit34/folic ac/nadh/coq10) Changing Xyzbac to excluded due to vitamin exclusion (see member handbook). Zegerid (omeprazole/sodium bicarbonate) Add age restriction on Zegerid as follows: Ages 18 Zithromax (azithromycin) Infectious - Bacterial Changing Zithromax from preferred brand (Tier 2) to 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.