Prescription benefit updates - Moda Health (7/1/2018). modahealth.comFor prior effective dates,...

2018.3 (7/1/2018). For prior effective dates, please contact Moda Health. modahealth.com

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 888-361-1610.

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.


Prescription coverage updates

These expected Moda Health prescription tier and coverage updates go into effect for 2018.

Product name Effective date Update

Bonjesta

(doxylamine/ pyridoxine)

New starts: 7/1/2018

Existing users: 10/1/2018

Change quantity limit on Bonjesta as follows: Limited to 60

tablets per 30 days.

Erleada

(apalutamide)



Add quantity limit on Erleada as follows: Limited to 120 tablets

per 30 days.

Genvisc 850, Visco-3,

Supartz FX

(hyaluronate acid)



Add prior authorization guideline on Genvisc 850, Visco-3, and

Supartz FX.

Lonhala Magnair

(glycopyrrolate nebulizer)



Add quantity limit on Lonhala Magnair as follows: Limited to 1

unit per 30 days.

Marinol

(dronabinol)



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.

Noctiva

(desmopressin)



Add quantity limit on Noctiva as follows: Limited to up to 3.8g

(1 canister) per 30 days.

Syndros

(dronabinol solution)



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.

Vancomycin capsules New starts: 7/1/2018


Change quantity limit on vancomycin capsules as follows:

125mg: 56 caps per 30 days

250mg: 112 caps per 30 days

Zypitamag

(pitavastatin magnesium)



Add step therapy on Zypitamag as follows: Must try/fail Livalo

(pitavastatin calcium) in the previous 120 days.

Zytiga 250mg tablets

(abiraterone)



Changing quantity limit on Zytiga as follows: Limited to 90

tablets per 30 days.

Benlysta IV

(belimumab)


Existing users: 7/1/2018 Add prior authorization requirements on Benlysta IV.

Biktarvy

(bictegravir/ emtricitabine/

tenofovir alafenamide)



Add quantity limit on Biktarvy as follows: Limited to 30 tablets

per 30 days.

Bosulif

(bosutinib)



Change quantity limit on Bosulif as follows:

100mg tablets: 90 tabs per 30 days



Carospir oral suspension

(spironolactone)



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.



Chlorzoxazone 250mg, 375mg and

750mg tablets



Add quantity limit on Chlorzoxazone 250mg, 375mg and

750mg tablets as follows: Limited to 120 tablets per 30 days.

Add step therapy on Chlorzoxazone 250mg, 375mg and 750mg

tablets as follows: Must try/fail Chlorzoxazone 500mg tablets

in previous 120 days.

Cialis 10mg and 20mg tablets

(tadalafil)



Add step therapy on Cialis 10mg and 20mg tablets as follows:

Must try/fail sildenafil (Viagra) in previous 120 days.

Cleocin, intravaginal

(clindamycin)



Add quantity limit on Cleocin as follows: Limited to 3

intravaginal ovules (1 box) per 30 days.

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.

Codeine/ Phenylephrine/

Promethazine



Change age restriction to Codeine/

Phenylephrine/ Promethazine as follows: Must be 19 years of

age or older.

Cotempla XR-ODT

(methylphenidate ER)



Add quantity limit on Cotempla XR-ODT as follows:

8.6mg tablets: 30 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.

Doxycycline DR 200mg tablets New starts: 4/1/2018


Change quantity limit on doxycycline DR 200mg as follows:

Limited to 30 tablets per 30 days.

Duzallo

(allopurinol/ lesinurad)



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.

Fenortho, Profeno, Nalfon

(fenoprofen 200mg, 400mg, 600 mg)



Change Fenortho, Profeno, Nalfon from preferred (Tier 2) to

non-preferred (Tier 3).

Flolipid suspension

(simvastatin)


Existing users: 7/1/2018 Add prior authorization requirements on Flolipid.

FlowTuss, Obredon

(hydrocodone, guaifenesin)



Add age restriction on FlowTuss, Obredon as follows: Must be

19 years of age or older.

Forteo

(teriparatide SC)



Change quantity limit on Forteo as follows: Limited to 2.4mL

per 28 days with a max duration of 728 days per lifetime.

Gamunex-C 40G New starts: 4/1/2018


Add prior authorization requirements on Gamunex-C (40

Gram).

Gleostine

(lomustine)


Existing users: 7/1/2018 Add prior authorization requirements on Gleostine.



Glycopyrrolate 1.5mg tablets New starts: 4/1/2018


Add quantity limit on Glycopyrrolate 1.5mg tablets as follows:

Limited to 90 tablets per 30 days.

Add step therapy on Glycopyrrolate 1.5mg tablets as follows:

Must try/fail Glycopyrrolate 1mg tablets or Glycopyrrolate 2mg

tablets in previous 120 days.

Hycofenix

(hydrocodone, pseudoephedrine,

guaifenesin)



Add age restriction on Hycofenix as follows: Must be 19 years

of age or older.

Impoyz 0.025% cream

(clobetasol)



Add step therapy on Impoyz as follows: Must try/fail a topical

corticosteroid in the previous 120 days.

Indocin suppositories

(indomethacin)



Change Indocin from preferred (Tier 2) to non-preferred (Tier

3).

Add prior authorization requirements on Indocin.

Lupon Depot-Ped

(leuprolide)


Existing users: 7/1/2018 Add prior authorization requirements on Lupon Depot-Ped.

Lyrica CR

(pregabalin)



Add quantity limit on Lyrica CR as follows:




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.

Promethazine/Codeine New starts: 4/1/2018


Add age restriction on Promethazine/ Codeine as follows: Must

be 19 years of age or older.

Renagel

(sevelamer HCL)



Change Renagel from preferred (Tier 2) to non-preferred (Tier

3).

Sensipar

(cinacalcet)



Add quantity limit on Sensipar as follows:




Silenor

(doxepin)



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.

Solosec

(secnidazole)



Add quantity limit on Solosec as follows: Limited to 30 single

dose packets per 30 days.

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.



Sprix

(ketorolac)



Add step therapy on Sprix as follows: Must try/fail 1 generic

NSAID in previous 120 days.

Supprelin LA

(histrelin)


Existing users: 7/1/2018 Add prior authorization requirements on Supprelin LA.

Taytulla

(ethnityl estradiol/ noethindrone/Fe)



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

generic contraceptives in previous 365 days.

Tussicaps

(hydrocodone, chlorpheniramine ER)



Add age restriction on Tussicaps as follows: Must be 19 years

of age or older.

Tussigon (tablet),

Hydromet (syrup)

(hydrocodone/homatropine)



Add age restriction on Tussigon (tablet) and Hydromet (syrup)

as follows: Must be 19 years of age or older.

Tussionex

(hydrocodone, chlorpheniramine ER

12H suspension)



Add age restriction on Tussionex as follows: Must be 19 years

of age or older.

Tuzistra XR

(codeine/chlorpheniramine)



Add age restriction on Tuzistra XR as follows: Must be 19 years

of age or older.

Vemlidy

(tenofovir alafenamide)



Add step therapy to Vemlidy as follows: Must try/fail tenofovir

300mg (Viread) in previous 120 days.

Vituz

(hydrocodone, chlorpheniramine)



Add age restriction on Vituz as follows: Must be 19 years of

age or older.

Xhance

(fluticasone propionate)



Add quantity limit on Xhance as follows: Limited to 32mL (2

inhalation devices) per 30 days.

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.

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




Ximino

(minocycline ER cap)



Add quantity limit on Ximino as follows: Limited to 30 capsules

per 30 days.

Add step therapy on Ximino as follows: Must try/fail generic IR

Minocycline tablets or generic IR Minocycline capsules in the

previous 120 days.

Add age restriction on Ximino as follows: Must be 12 years of

age or older.

Zodex/Locort/

ZonaCort/Dexpack

(dexamethasone 1.5 mg blister pack)



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.

Zurampic

(lesinurad)



Change Zurampic from preferred (Tier 2) to non-preferred (Tier

3).



Zutripro

(hydrocodone, chlorpheniramine,

pseudophedrine)



Add age restriction on Zutripro as follows: Must be 19 years of

age or older.

ArmonAir RespiClick

(fluticasone propionate)



Add quantity limit on ArmonAir RespiClick as follows: Limited

to one inhaler per 30 days.

Add step therapy on ArmonAir RespiClick as follows: Must

try/fail Arnuity Ellipta, Flovent Diskus, Flovent HFA, or Qvar.

Asmanex, Asmanex HFA

(mometasone furoate)



Change Asmanex and Asmanex HFA from Value tier to non-

preferred (Tier 3).

Avonex, Avonex Pen

(interferon beta-1a)



Change Avonex and Avonex Pen from preferred (Tier 2) to


Bethkis

(tobramycin)



Change Bethkis from preferred (Tier 2) to non-preferred (Tier

3).

Cayston

(aztreonam lysine)



Change Cayston from preferred (Tier 2) to non-preferred (Tier

3).

Copaxone

(glatiramer acetate)



Change Copaxone from preferred (Tier 2) to non-preferred

(Tier 3).

Fiasp

(insulin aspart (niacinamide))



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.

Gilenya

(fingolimod HCl)



Change Gilenya from preferred (Tier 2) to non-preferred (Tier

3).

Kitabis Pak

(tobramycin/nebulizer)



Change Kitabis Pak from preferred (Tier 2) to non-preferred

(Tier 3).

Lysodren

(mitotane)



Change Lysodren from preferred (Tier 2) to non-preferred (Tier

3).

Nexium 40mg capsule, packet

(esomeprazole trihydrate)



Change quantity limit on Nexium 40mg capsule/packet as

follows: Limited to 60 capsules or packets per 30 days.

Plegridy, Plegridy Pen

(peginterferon beta-1a)



Change Plegridy and Plegridy Pen from preferred (Tier 2) to


Pulmicort Flexhaler

(budesonide)



Change Pulmicort Flexhaler from Value tier to non-preferred

(Tier 3).

Rebif, Rebif Rebidose

(interferon beta-1a/albumin)



Change Rebif and Rebif Rebidose from preferred (Tier 2) to


Shingrix

(Varicella-Zoster

GE/AS01/PF)



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)



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 (Tier 2) to non-preferred

(Tier 3).

Tobi

(tobramycin in 0.225% sod chlor)


Existing users: 4/1/2018 Change Tobi from preferred (Tier 2) to non-preferred (Tier 3).

Xyzbac, Mebolic

(multivit34/folic

ac/nadh/coq10)


Existing users: 4/1/2018 Add prior authorization requirements on Xyzbac and Mebolic.

Yescarta

(axicabtagene ciloleucel)


Existing users: 4/1/2018 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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Prescription benefit updates - Moda Health (7/1/2018). modahealth.comFor prior effective dates,...

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