*The generic forms of these medications qualify as “value tier” medications and are available at a lower copayment. Their brand-name equivalents

are covered as “Brand” and may be subject to the “Brand Substitution Policy” – Please refer to your Member Handbook for additional information.

2021.1 (1/1/2021). For prior effective dates, please contact Moda Health. modahealth.com

Value tier medication list

Value medications include select commonly prescribed products used to treat chronic medical

conditions and preserve health. The table below shows medications included in the value tier.

When a medication from this list has a generic equivalent, the generic form of the medication

qualifies for the value benefit, while the brand form is covered at the brand tier benefit level.

Health condition Type of medication Brand name Generic name

Asthma Corticosteroids Arnuity® Ellipta® Fluticasone furoate

Asmanex® Inhaler Mometasone Furoate

Flovent® (HFA & Diskus) Fluticasone

Pulmicort®* Budesonide

Heart, cholesterol, high blood pressure

ACE-inhibitors Vasotec™* Enalapril

Zestril™* Lisinopril

Angiotension receptor antagonist Cozaar™* Losartan Potassium

Beta-blockers Lopressor™* Metoprolol Tartrate

Toprol XL™* Metoprolol Succinate

Tenormin™* Atenolol

Coreg™* Carvedilol

Calcium channel blocker Norvasc™* Amlodipine

Diuretics Microzide™*, Ezide™* Hydrochlorothiazide

Thalitone™* Chlorthalidone

Lasix™* Furosemide

Aldactone™* Spironolactone

2021.1 (1/1/2021). For prior effective dates, please contact Moda Health. modahealth.com

Health condition Type of medication Brand name Generic name

Heart, cholesterol, high blood pressure (continued)

Combination hypertensive Ziac™* Bisoprolol/HCTZ

Vaseretic™* Enalapril/HCTZ

Zestoretic™* Lisinopril/HCTZ

Hyzaar™* Losartan/HCTZ

Cholesterol lowering agents Zocor™* Simvastatin1

Lipitor®* Atorvastatin1

Mevacor™* Lovastatin1

Diabetes Glucose production inhibitors Glucophage™* Metformin

Glucophage XR™* Metformin ER

Insulin release stimulants Amaryl™* Glimepiride

Glucotrol™* Glipizide

Glucotrol XL™* Glipizide ER

DiaBeta™* Glyburide

Combination anti-diabetics Glucovance™* Glyburide/Metformin

Depression Selective serotonin reuptake inhibitors (SSRIs)

Celexa™* Citalopram

Prozac™* Fluoxetine

Zoloft™* Sertraline

Lexapro®* Escitalopram

Osteoporosis Bisphosphonates Fosamax®* Alendronate Sodium

1Simvastatin, Atorvastatin, and Lovastatin qualify as “preventative care” medications for members 40 years of age and older. Medications covered under

preventative care are considered preventative medications and may be covered at little or no cost to you.

*The generic forms of these medications qualify as “value tier” medications and are available at a lower copayment. Their brand-name equivalents are

covered as “Brand” and may be subject to the “Brand Substitution Policy” – Please refer to your Member Handbook for additional information.

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, any reduction or limitations and the terms under which the policy may be continued in force, contact your producer or Moda Health. Copyright © 2020 Moda, Inc. All Rights Reserved. Health plans in Oregon, Alaska and Washington provided by Moda Health Plan, Inc.

Effective 4/1/2013

Effective 4/1/2013