value tier commercial
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*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.