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.
Questions? Call our Pharmacy Customer Service team toll-free at 503-265-2911 or 866-923-0411.
Health condition
Asthma
Type of medication
Generic name
QVAR®
Beclomethasone
Flovent® (HFA & Diskus)
Fluticasone
Vasotec™*
Enalapril
Zestril™*
Lisinopril
Angiotension receptor
antagonist
Cozaar™*
Losartan Potassium
Lopressor™*
Metoprolol Tartrate
Beta-blockers
Toprol XL™*
Metoprolol Succinate
Tenormin™*
Atenolol
Coreg™*
Carvedilol
Norvasc™*
Amlodipine
Microzide™*, Ezide™*
Hydrochlorothiazide
Thalitone™*
Chlorthalidone
Lasix™*
Furosemide
Aldactone™*
Spironolactone
Ziac™*
Bisoprolol/HCTZ
Inderide™*
Propranolol/HCTZ
Vaseretic™*
Enalapril/HCTZ
Zestoretic™*
Lisinopril/HCTZ
Hyzaar™*
Losartan/HCTZ
Corticosteroids
ACE-inhibitors
Heart, cholesterol,
high blood pressure
Brand name
Calcium channel blocker
Diuretics
Combination hypertensive
Heart, cholesterol,
high blood pressure
*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 “Generic Substitution Policy” – Please refer to your Member Handbook for additional information.
2016.1 (1/1/2016). For prior effective dates, please contact Moda Health.
Health condition
(continued)
Type of medication
Depression
Osteoporosis
Generic name
Zocor™*
Simvastatin
Mevacor™*
Lovastatin
Glucophage™*
Metformin
Glucophage XR™*
Metformin ER
Amaryl™*
Glimepiride
Glucotrol™*
Glipizide
Glucotrol XL™*
Glipizide ER
DiaBeta™*
Glyburide
Combination anti-diabetics
Glucovance™*
Glyburide/Metformin
Selective serotonin reuptake
inhibitors (SSRIs)
Celexa™*
Citalopram
Prozac™*
Fluoxetine
Zoloft™*
Sertraline
Tricyclic antidepressants
Elavil™*
Amitriptyline
Bisphosphonates
Fosamax®*
Alendronate Sodium
Cholesterol lowering agents
Glucose production
inhibitors
Diabetes
Brand name
Insulin release stimulants
*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 “Generic 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 © 2014 Moda, Inc. All Rights Reserved. Health plans in Oregon p rovided by Moda Health Plan, Inc.
2016.1 (1/1/2016). For prior effective dates, please contact Moda Health.