• How does Moda Health determine the coverage or tiering of a medication on the formulary?
• Who is on the Moda Health Pharmacy and Therapeutics (P&T) Committee?
• How do I determine the tiering on a specific medication for a member?
• How do I find out if a member’s medication requires a prior authorization or if it has any limitations?
• Why does a medication need prior authorization?
• What should I do if the member’s medication requires authorization?
• Are over-the-counter (OTC) products covered?
• If I prescribe a brand-name medication that has a generic equivalent available, what will the member be responsible for paying?
• Does Moda Health partner with a mail-order pharmacy?
• Is the member required to access specialty medications (e.g., self-injectables, biologics, etc.) through an exclusive specialty pharmacy?
• Does Moda Health offer any programs to support members in paying for the cost of their medication if they are uninsured or underinsured?

How does Moda Health determine the coverage or tiering of a medication on the formulary?

Moda Health uses an evidence-based formulary design to provide the best pharmaceutical care to our members. Medications are evaluated using scientific studies, clinical trials, peer reviews and comparisons integrated with clinical judgment to guide decision making. Unlike plans that offer a closed formulary, Moda Health offers an open formulary that provides members with choice.

At Moda Health, we take pride in actively managing our plan's pharmacy benefits to ensure the programs provide quality, comprehensive coverage, and remain current with industry standards and the changes occurring in the marketplace. The Moda Health clinical team reviews our formulary for updating throughout the benefit year. This approach allows Moda Health to actively evaluate and update our benefits when the FDA has approved new medications, generic alternatives become available or changes occur to existing drug profiles (e.g. dosing, patient safety and/or approved uses).

Who is on the Moda Health Pharmacy and Therapeutics (P&T) Committee?

The Moda Health P&T committee membership represents various clinical specialties that adequately represent the needs of our plans and members. Committee members include area practicing pharmacists, physicians and specialists in the care of elderly persons.

How do I determine the tiering on a specific medication for a member?

Moda Health provides our members with a Preferred Drug List, as well as an online formulary look-up and price quote tool. Members can access these resources by logging into the pharmacy section of their Member Dashboard account. The Moda Health Pharmacy Customer Service team is also available to answer any questions you or the member may have pertaining to the cost of a medication.

How do I find out if a member’s medication requires a prior authorization or if it has any limitations?

A listing of prescriptions requiring prior authorization is available under the benefits section of the member’s Member Dashboard account. You may also call the Moda Health Pharmacy Customer Service team for more information.

Why does a medication need prior authorization?

Prior authorizations for medications ensure our members are receiving the safest and most effective drug through a thorough review by our clinical team, using evidence based reviews of scientific studies, literature and best healthcare practices. To initiate the prior authorization process, please contact the Moda Health Pharmacy Customer Service team.

What should I do if the member’s medication requires authorization?

If a medication that is being prescribed requires authorization, you should call the Moda Health Pharmacy Customer Service team. Moda Health will then work with the prescribing physician to obtain the necessary information to review the requested medication.

Are over-the-counter (OTC) products covered?

Medications federally designated as OTC are, in general, not covered under the prescription benefits (select diabetic supplies and insulin are covered).

If I prescribe a brand-name medication that has a generic equivalent available, what will the member be responsible for paying?

If the member requests or the provider prescribes a brand-name drug when a generic equivalent is available, the member will be required to pay the non-preferred brand copay or coinsurance, plus the difference in cost between the generic and brand-name medication.

Does Moda Health partner with a mail-order pharmacy?

Yes, Moda Health partners with exclusive mail-order pharmacies to offer members a 90-day supply delivered directly to a U.S. address of their choice. The participating mail-order pharmacy will depend upon the pharmacy network that the plan's benefits are under. To determine a plan's mail-order pharmacy, the member should refer to the pharmacy section of their Member Dashboard account or you may contact the Moda Health Pharmacy Customer Service team.

Is the member required to access specialty medications (e.g., self-injectables, biologics, etc.) through an exclusive specialty pharmacy?

Yes, specialty medications must be accessed through the exclusive specialty pharmacy. The participating specialty pharmacy will depend upon the pharmacy network that the plan’s benefits are under. To determine a plan’s specialty pharmacy, the member should refer to the pharmacy section of their Member Dashboard account or you may contact the Moda Health Pharmacy Customer Service team.

Does Moda Health offer any programs to support members in paying for the cost of their medication if they are uninsured or underinsured?

Moda Health has partnered with the Northwest Prescription Drug Consortium to offer a free discount card to individuals living in the states of Oregon and Washington that are uninsured or feel that they are underinsured. Through the Northwest Prescription Drug Consortium individuals living in Oregon and Washington have access to The Oregon Prescription Drug Program (OPDP) and Washington Prescription Drug Program (WPDP).

Through the OPDP and WPDP free discount card individuals can receive a savings of up to 60 percent on generic medications and up to 20 percent on brand medications. To enroll, individuals can call 800-913-4146 or register online/print applications at www.opdp.org or www.rx.wa.gov.

Answers represent Moda Health standard benefits, for group specific details refer to the member's Member Handbook.