Currentmoda_health_plan_incPolicy 2026
Idaho Individual Medical Policy 2026
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This document is Moda Health Plan Inc's Idaho Individual Medical Policy (Idaho Individual Medical Policy 2026) describing plan terms, benefits, exclusions, network and prior authorization rules for members of the Moda Select Idaho Bronze 10000 individual plan.
Policy Summary
Payermoda_health_plan_inc
PolicyIdaho Individual Medical Policy 2026
Policy CodePolicy Policy 2026
Change TypeNo material changes
Effective DateJan 1, 2026
Last ReviewJan 1, 2026
Next Review Date
Key ActionCheck the Member Dashboard to determine whether a service or supply requires prior authorization before providing or ordering care.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
Bronze 10000Plan tier
Section 6Prior auth
$10,000Deductible
$10,000OOP max (in-network)
Section 7Benefit chapters
Covered Services, Benefits, and Limits
Benefit descriptions (Section 7)
Section 7 and its subsections enumerate benefit descriptions and when benefits are available across many service categories.
Benefits are payable only when coverage is in effect (eligibility met, enrolled, premiums paid) and only after the service or supply has been provided.
Covered services and supplies must be medically necessary to diagnose or treat a medical condition, or be preventive services as described in Section 7.
Many outpatient services and all nonemergency inpatient and residential care require prior authorization (see Section 6); failure to obtain required prior authorization may result in nonpayment or a penalty.
Payment for covered expenses is limited to the Maximum Plan Allowance (MPA); when using out-of-network providers members may be balance billed for amounts above the MPA when permitted by law.
Covered service categories
Detailed Table of Contents lists covered service categories.
Ambulatory and facility care including urgent care, emergency room, inpatient and outpatient hospital services
Preventive services (ACA-required) including screenings, immunizations and women's preventive care
Behavioral health services including outpatient therapy, intensive outpatient, partial hospitalization, residential and inpatient care
Applied Behavior Analysis (ABA) for autism spectrum disorder
Diagnostic procedures including standard and advanced imaging, labs, psychological testing
Durable Medical Equipment (DME), supplies and appliances
Diabetes services and supplies (pharmacy and DME distinctions)
Infusion therapy and provider-administered medications
Rehabilitation and habilitation services (PT/OT/SLP, cardiac/pulmonary)
Skilled nursing facility care
Surgery, reconstructive and cosmetic rules
Therapeutic injections, radiology and chemotherapy
Transplants and related travel/housing support
Virtual care visits (telemedicine)
Vision services (pediatric and adult) and VSP-administered benefits
Maternity care including prenatal, delivery, newborn nursery and breastfeeding support
Pharmacy prescription benefit including retail, mail order and specialty pharmacy
General exclusions and other non-covered services (Section 8)
Essential Health Benefits
Essential health benefits statement
This policy covers Essential Health Benefits as defined by HHS except pediatric dental; annual and lifetime dollar maximums are not applied to Essential Health Benefits.
Schedule of Benefits - selected items
Schedule of Benefits summary with cost-sharing and references to detailed Benefit Description and prior authorization sections.
Annual medical deductible (in‑network): $10,000 per member; out‑of‑network deductible: $20,000 per member.
Annual out‑of‑pocket maximum (in‑network): $10,000 per member; out‑of‑network: $125,000 per member.
Urgent care office visit in‑network: $125 per visit; out‑of‑network: 60% after deductible.
Ambulance transportation and emergency room facility (facility and ancillary) in‑network: 0% (deductible and OOP apply); details in Section 7.2.
Outpatient rehabilitation: in‑network coverage subject to limits (see Section 7.4.27); up to 20 outpatient sessions per year as noted in Schedule of Benefits.
Selected Benefit Cost-Sharing and Limits (excerpt)
Selected in‑network and out‑of‑network cost‑sharing highlights and limits (partial list).
Preventive services required under the ACA: in‑network 0% cost sharing; out‑of‑network: 60% after deductible.
Colonoscopy (age 45+, one per 10 years): in‑network 0% cost sharing; out‑of‑network: 60% after deductible.
Mammogram: in‑network 0%; one per year age 40+; out‑of‑network 60% after deductible.
PCP office visits example: $50 per visit in some Schedule rows; see Section 7.4.24 for details.
Infusion therapy (home or outpatient): in‑network 0% after deductible; prior authorization required for infusion services (see Section 6 and 7.4.18).
Pharmacy benefit criteria
Pharmacy benefit rules and criteria include tiered cost‑sharing, supply limits, and prior authorization requirements.
Retail pharmacy tier examples: Value Tier $2, Select Tier $20, Preferred Tier ~40% coinsurance, Nonpreferred Tier 50% after deductible (examples in Schedule of Benefits).
Mail order pharmacy examples: Value Tier $6, Select Tier $60; mail‑order and participating retail options may allow up to a 90‑day supply per prescription.
Members must use Moda‑designated mail‑order or specialty pharmacies where required; prior authorization is required for specialty medications and non‑Moda‑designated specialty or mail‑order pharmacies in some cases.
Some specialty medications may be limited to a 2‑week supply; eligible medications may have 90‑day supply options at participating retail pharmacies.
Pharmacy tiers & rules
Pharmacy coverage and cost‑sharing rules.
Tier definitions: Value, Select, Preferred, Nonpreferred, Specialty/Preferred Specialty as used in Schedule of Benefits.
Value Tier example copay: $6 (mail order), Select Tier example copay: $60 (mail order); Preferred Specialty typically 40% coinsurance; Nonpreferred 50% after deductible as shown in Schedule of Benefits.
Mail order and retail supply limits: up to 90‑day supply per prescription; one copay may cover a 30‑day supply depending on the drug and pharmacy option.
Prior authorization: required for many specialty medications and for use of non‑Moda‑designated specialty pharmacies; formulary exceptions and step therapy processes apply (see Section 7.6 and Section 6).
Payment & cost-sharing criteria
Payment, deductible, and out‑of‑pocket rules.
Deductible: members pay covered expenses until the applicable deductible is met; in‑network and out‑of‑network deductibles are separate; certain items (disallowed charges, copayments, prior authorization penalties, manufacturer discounts/copay assistance) do not count toward deductible.
Out‑of‑pocket maximum: once the member has paid the out‑of‑pocket maximum, Moda pays 100% of covered services for remainder of the year; prior authorization penalties and manufacturer discounts/copay assistance do not count toward the maximum; transplant costs not performed at a Center of Excellence may not count toward the maximum.
Payment basis: Moda pays based on the Maximum Plan Allowance (MPA); in‑network providers agree to look solely to Moda for compensation when Moda is the paying insurer.
Mail order/payment mechanics: mail order available up to 90‑day supply; must use Moda‑designated mail‑order pharmacies or pharmacies that agree to Moda terms for mail order; prior authorization required for some mail order/specialty situations.
Network criteria
Network and service area
Primary medical network: Moda Select; network service area counties are listed in the handbook and include a multi‑county service area in Idaho.
Pharmacy network: Navitus; vision network: VSP.
Using in‑network providers yields lower out‑of‑pocket costs; out‑of‑network providers may balance bill members for amounts over the MPA when permitted by law; use Find Care on Member Dashboard to locate in‑network providers.
Network, authorization, and benefit rules
General coverage stance and network rules
In‑network care results in lower member cost sharing; when receiving care at an in‑network facility members should seek related services from in‑network providers to receive in‑network cost sharing.
Authorizations are valid for a specified period and may limit number, amount, frequency, provider or specific services; services outside the authorization period may not be covered.
If required prior authorization for out‑of‑network services is not obtained in advance, a prior authorization penalty of 50% up to $2,500 per occurrence may apply (emergency admissions exempt).
Emergency services are covered at the in‑network benefit level worldwide; prior authorization is not required for emergency screening exams or stabilizing treatment.
Section 7 coverage criteria
Key coverage criteria and exclusions extracted from Section 7:
Eligibility & timing: coverage applies only when enrollment and premiums are current and benefits are requested for services provided while coverage is in effect; care outside the U.S. covered only for emergencies.
Emergency & Urgent Care: emergency services are covered at in‑network level worldwide; urgent care is covered for minor urgent conditions when patient is examined at an urgent care facility; prior authorization not required for emergency stabilization.
Preventive Services: ACA‑required preventive services are covered in‑network with no cost sharing; coverage frequency and specifics follow USPSTF/ACIP/HRSA guidance and may be updated periodically.
Diagnostic Procedures: diagnostic services (x‑ray, labs, standard and advanced imaging, psychological testing) are covered when for treatment of a condition; most advanced imaging requires prior authorization.
Anticancer Medications: prescribed anticancer medications covered; most require prior authorization and must be obtained from designated specialty pharmacy or prior authorization obtained to use a non‑designated specialty pharmacy.
General exclusions: custodial/respite care, services by family/household members, experimental/investigational procedures, many complementary therapies and other items listed in Section 8 are excluded unless an explicit exception applies.
ABA — Applied Behavior Analysis
Applied Behavior Analysis (ABA)
Coverage: ABA for autism spectrum disorder is covered.
Requirement: ABA services must be prior authorized (Section 6).
Exclusions: services provided by family/household members, custodial/respite care, equine/creative arts/wilderness/music therapy, neurofeedback, chelation, hyperbaric chamber, IEP services and services provided by Department of Health and Welfare are not covered under ABA benefits.
Behavioral Health
Behavioral Health and Mental Health Services
Coverage: behavioral health conditions (mental health and substance use disorders) are covered across levels of care including office/home visits, intensive outpatient, ACT, STAR, TMS, partial hospitalization, inpatient and residential care.
Requirements: Intensive outpatient mental health, ACT, STAR, and TMS must be prior authorized; residential programs must be state‑licensed to be covered.
Service levels and thresholds: mental health intensive outpatient = 3 or more hours/week; SUD intensive outpatient = adults 9–19 hrs/week and adolescents 6–19 hrs/week; partial hospital = >=4 hrs/day and >=20 hrs/week.
Diagnostic Procedures
Diagnostic Procedures
Coverage: diagnostic services are covered when used to diagnose or treat a medical or behavioral health condition, including x‑rays, labs, standard and advanced imaging, and psychological/neuropsychological testing.
Requirement: most advanced imaging services (MRI/MRA, CT, PET, nuclear medicine, cardiac imaging) require prior authorization; full list on Moda website.
DME
Durable Medical Equipment, supplies & appliances
Coverage: DME and related supplies that help manage a medical condition are covered when medically necessary; rental covered up to purchase price for most DME.
Examples: CPAP, certain glasses (aphakia/keratoconus), hospital beds, insulin pumps, intraocular lenses (within 90 days of cataract surgery), orthotics/braces, oxygen, prosthetics, wheelchairs, and related maintenance.
Limits/Replacement: wheelchair/scooter may be limited (one per year under age 19; one every 3 years age 19+ based on utilization review); replacement/repair covered only if equipment not abused and within specifications; provider may need to supply documentation for claim approval.
Exclusions: items primarily for comfort/convenience/cosmetic purposes, most therapeutic devices except TENS, dental appliances, incontinence supplies, certain supporting devices and testicular prostheses are excluded.
Diabetes
Diabetes Services
Coverage: insulin and diabetic supplies (syringes, needles, lancets, test strips, glucometers, CGMs) are covered under the pharmacy benefit when purchased from a pharmacy with a prescription and using a preferred manufacturer; insulin pumps may be covered under DME.
Examples: HbA1c testing, kidney disease checks, annual dilated eye exam/retinal imaging, diabetes self‑management programs, dietary/nutritional therapy and routine foot care (see Section 7.4.25 for foot care rules).
Clinical Trials
Clinical Trials
Coverage: usual care costs for approved clinical trial participants are covered with the same cost sharing as non‑trial care.
Exclusions: the policy does not cover items/services not covered outside the trial, items required only to provide/monitor the investigational therapy, or items provided solely for data collection not used for direct medical care.
Requirements: participation in a clinical trial must be prior authorized; approved trials are limited to certain government‑funded/cooperative groups or FDA pathways or federally exempt trials.
Hearing Services
Hearing and cochlear implant coverage
Coverage: hearing services for enrolled dependent children with congenital or acquired hearing loss that risks cognitive/speech deficits; includes hearing evaluations, one hearing aid per impaired ear every 3 years, bone conduction processors, ear molds and outpatient speech therapy up to 45 visits/year for hearing loss.
Cochlear implants: covered for members of all ages when medically necessary and prior authorized.
Requirements: hearing aids must be prescribed, fitted and supplied by an audiologist or hearing aid specialist and referred by a licensed physician.
Gender Affirming Services
Gender‑affirming services
Coverage: gender‑affirming treatment expenses are covered for members over age 18 when procedures are performed by a qualified professional and the treatment plan meets medical necessity criteria.
Examples: covered services may include mental health, hormone therapy (including puberty suppression where indicated), and surgical procedures such as breast/chest surgery, gonadectomy, genital reconstruction and facial surgery.
Requirement: prior authorization is required for surgical gender‑affirming procedures.
Home Healthcare
Home healthcare
Coverage: home healthcare services and supplies from a licensed home healthcare agency are covered for homebound members when medically necessary and ordered by a treating practitioner; visits must be intermittent and provided by qualified professionals (RN/LPN, PT/OT/SLP/respiratory therapist, licensed social worker).
Exclusion: home health aides are not covered under home healthcare except as hospice employees when hospice benefits apply.
Note: if the member is in hospice, home healthcare services and supplies are covered under hospice provisions and DME sections as applicable.
Hospice Care
Hospice Care
Coverage: medically necessary or palliative care provided by a Medicare‑approved and nationally accredited hospice is covered when the member is terminally ill and not receiving curative treatment; services must be part of an approved hospice treatment plan certified by the treating provider.
Hospice home care: covered charges include services by RN/LPN, PT/OT/SLP, home health aide (as hospice employee), and licensed social worker; hospice treatment plan must certify terminal illness.
Respite and short‑term inpatient hospice care may be covered but often require prior authorization arranged by the attending provider.
Covered services and basic criteria
Covered services and baseline criteria (assorted items)
Home health, hospice, hospital inpatient, infusion therapy, rehabilitation, skilled nursing and related services are covered when medically necessary and meet program requirements and prior authorization rules where applicable.
Hospital inpatient care: covered when medically necessary and includes room, ICU, isolation, facility surgery charges and other hospital services; take‑home prescription drugs limited to 3‑day supply at hospitalization benefit level.
Infusion therapy: medically necessary infusion services and supplies covered; prior authorization required; some infusion meds may be covered under specialty pharmacy and preferred suppliers/providers may be required.
Rehabilitation & habilitation: PT/OT/SLP and cardiac/pulmonary rehab covered when medically necessary, part of a written treatment plan to improve/restore function; outpatient services have separate annual limits; only one session of each therapy type covered per day; maintenance therapy is not covered.
Skilled nursing facility care: covered for a limited number of days; covered expenses limited to the daily semi‑private room rate; facility must be licensed and provide rehabilitative services and 24‑hour RN care.
Rehabilitative/Habilitative Services
Rehabilitative and habilitative services
Requirements: services must be provided by licensed therapists or other licensed professionals, be medically necessary and part of a written treatment plan to improve or restore lost function.
Limit: only one session of each type of outpatient physical, occupational or speech therapy is covered per day; outpatient rehabilitative/habilitative services have separate annual limits (up to 20 sessions/year referenced in Schedule of Benefits).
Exclusions: maintenance therapy, recreational/educational therapy, animal therapy and non‑medical self‑help/training are not covered.
Skilled Nursing Facility Care
Skilled Nursing Facility (SNF) rules and exclusions
Definition: SNF provides inpatient care with rehabilitative services and 24‑hour nursing by registered nurses.
Limit: a limited number of SNF days are covered; covered expenses limited to the daily semi‑private room rate.
Exclusions: charges not covered if admission occurred before coverage effective date; care mainly for cognitive decline/dementia, routine nursing care, non‑medical self‑help/training and custodial care are not covered.
Surgery
Surgery coverage and reconstructive vs cosmetic rules
Coverage: surgical procedures including operating/recovery rooms, surgical supplies and standard surgical staff are covered when medically necessary.
Requirement: reconstructive procedures must be medically necessary and prior authorized; reconstructive surgery after mastectomy includes reconstruction, symmetry procedures, prostheses and treatment of complications.
Exclusion: cosmetic surgery is not covered unless medically necessary (e.g., gender dysphoria or post‑mastectomy); treatment of complications from cosmetic surgery is not covered except to stabilize an emergency.
Therapeutic Injections and Radiology/Chemotherapy
Therapeutic injections and radiology/chemotherapy
Therapeutic injections: administrative services for injections (e.g., allergy shots) in a provider's office are covered; when similar results can be achieved with self‑administered medications at home, the administrative services are not covered; vitamin/mineral injections not covered unless medically necessary.
Therapeutic radiology/chemotherapy: covered elements include treatment planning/simulation, professional services for administration and treatments, including therapist/facility/equipment charges.
Transplants
Transplants
Coverage: medically necessary transplants that follow standard medical practice and are not experimental/investigational are covered.
Requirement: providers should obtain prior authorization as soon as a transplant candidate is identified; donor costs rules depend on enrollment status.
Limit: transplants performed outside a Center of Excellence may not have deductible and coinsurance accumulate toward the out‑of‑pocket maximum; travel and housing expenses for recipient and one caregiver covered up to a maximum per transplant.
Exclusion: chemotherapy with autologous or allogeneic bone marrow transplant for cancers not approved for coverage is not paid.
Virtual Care Visits
Virtual care visits
Virtual care (live audio/video) visits are covered when services can be safely and effectively provided virtually and the technology meets privacy/security standards.
Virtual visits using the preferred vendor are covered at no cost sharing (see Section 3); see details for limitations and exceptions.
Vision Services
Vision Services
Pediatric vision (under 19): one complete well‑vision exam and one pair of eyeglasses or contacts per year; contact lens supply rules vary by lens type (minimum 3‑month supplies for contact lens types).
Adult vision (19+): one complete eye exam annually including refraction.
Authorization/Network: VSP administers in‑network vision benefits and may provide benefit authorization directly to in‑network providers; some vision services may require prior authorization.
Maternity Care
Maternity care
Coverage: pregnancy care, childbirth and related conditions are covered when provided by a professional provider (licensed midwives covered only if licensed/certified).
Hospital benefits: hospital room, facility charges (including birthing centers), nursery care (one in‑nursery physician visit for well‑newborn covered at no cost sharing in‑network), and take‑home prescription drugs limited to a 3‑day supply.
Special right upon childbirth: members may stay up to 48 hours after vaginal delivery and up to 96 hours after cesarean delivery without prior authorization per Newborns' and Mothers' Health Protection Act.
Breastfeeding support: counseling and breast pump purchase/rental and supplies covered; hospital‑grade pumps covered when medically necessary; MPA applies for retail purchases.
Diagnostic maternity procedures (labs, ultrasounds) are covered; some may require prior authorization and a full list is on Moda website.
Maternity and Pharmacy coverage criteria
Maternity and pharmacy‑related coverage and rules
Pharmacy scope: prescription medications during inpatient admission are covered under the medical plan; outpatient pharmacy benefit covers medically necessary prescriptions, compounded meds with a covered main ingredient, certain ACA preventive medications and tobacco dependence meds (prescription required).
Insulin & diabetic supplies: covered under pharmacy benefit when purchased from a pharmacy with prescription and preferred manufacturer; insulin pumps may be DME.
Formulary and exceptions: members/providers may request formulary exceptions for medical necessity; decision timelines 72 hours (standard) or 24 hours (urgent); step therapy applies and exceptions allowed when Step 1 is ineffective/harmful/not equivalent.
Supply/limits: 90‑day supply option at participating retail pharmacies and mail order up to 90 days where eligible; some specialty medications require prior authorization and Moda‑designated specialty pharmacy; some specialty meds may be limited to a 2‑week supply.
Exclusions: pharmacy exclusions include devices (see DME), excluded pharmacies, foreign medication claims, hair growth meds, travel immunizations (except ACA‑required), institutional meds, medication administration charges (limited exceptions), non‑FDA approved meds, OTC meds (except contraceptives/tobacco dependence), nutritional supplements/medical foods, replacement meds/supplies, most vitamins/minerals (except as required by law), and weight loss medications.
General Exclusions (selected items)
General exclusions (selected items)
Excluded unless exception noted
- Abortion (except to save mother's life or resulting from rape/incest).
- Acupuncture.
- Care outside the United States except for emergency medical conditions.
- Cosmetic procedures (excluded except reconstructive/gender‑confirming when medically necessary).
- Custodial care.
- Dental examinations/treatment and orthodontia except as described in Section 7.4.6.
- Experimental or investigational procedures.
- Homeopathic treatments and naturopathic supplies.
- Horse‑assisted/animal therapy.
Exclusions List - Part 14
Exclusions List - Part 14 (extended exclusions segment)
The following are excluded unless an explicit exception applies
- Horse‑assisted or animal therapy.
- Services for conditions caused by illegal acts.
- Infertility services and reversal of elective sterilization.
- Services while an inmate in custody.
- Massage or massage therapy.
- Missed appointments.
- Naturopathic supplies and nonprescription supplements.
- Never events and hospital‑acquired conditions.
- Non‑therapeutic counseling (legal, financial, vocational, spiritual).
- Nuclear radiation‑related medical conditions except as required by law.
Prior Authorization, Documentation, and Provider Responsibilities
Prior Authorization
Prior Authorization (Section 6) — program scope & emergency admissions
Section 6 describes Moda Health's prior authorization program and scope: prior authorization is used to ensure treatments are safe, medically necessary, and cost‑effective; authorizations are based on evidence‑based criteria and may require use of a preferred treatment center or provider. Emergency admissions must be authorized by the provider within 48 hours after admission (or as soon as reasonably possible). Prior authorization does not guarantee coverage; services excluded from benefits will be denied. Providers are instructed to contact Moda Health for prior authorization before the member receives services that require authorization.
Note
Discover PA requirement via Member Dashboard
Check the Member Dashboard to determine whether a planned service or supply requires prior authorization before scheduling or dispensing.
- Use Member Dashboard 'Find Care' and Prescription Price check tools to verify prior authorization requirements.
Note
Prior authorization may be required — see Sections 6 and 7
Prior authorization may be required for some services; refer to Section 6 and the Benefit Description (Section 7) for details and the list of services requiring authorization.
Note
Prior authorization reminder — review Section 6
Some services summarized elsewhere in the Schedule of Benefits note that prior authorization may be required; review Section 6 for full authorization rules.
Prior Authorization
PA required for specialty and non‑Moda mail‑order pharmacies
Most specialty medications and mail‑order prescriptions must come from Moda‑designated specialty or mail‑order pharmacies. If a non‑Moda‑designated specialty or mail‑order pharmacy is used, prior authorization is required in some cases.
- Ask Pharmacy Customer Service or check the Member Dashboard to confirm designated specialty/mail‑order pharmacies.
- Prior authorization is required for purchases at non‑Moda‑designated specialty pharmacies.
Prior Authorization
PA required when using non‑Moda‑designated specialty/mail‑order pharmacies
When using a non‑Moda‑designated specialty pharmacy or non‑Moda mail‑order pharmacy, obtain prior authorization as required; some specialty prescriptions purchased at non‑designated pharmacies will not be covered without PA.
Prior Authorization
Obtain PA for listed services — penalties & emergency admission timeline
Providers must obtain prior authorization for services listed by the plan. When out‑of‑network services requiring prior authorization are not authorized in advance, a penalty of 50% (up to $2,500 per occurrence) applies before regular benefits begin. Emergency admissions are exempt but must be authorized by the provider within 48 hours (or as soon as reasonably possible).
- Prior authorization penalty: 50% up to $2,500 per occurrence for unauthorized out‑of‑network services; penalty does not count toward deductible or OOP maximum.
- Emergency admissions: provider must authorize within 48 hours (or as soon as reasonably possible).
Documentation Required
Second opinion process — Moda‑requested reviews
Moda may require an independent second opinion for non‑emergency treatment; when Moda requires the second opinion the visit is provided at no charge to the member (paid under regular medical benefits).
Prior Authorization
Prior authorization required for many outpatient and all non‑emergency inpatient/residential services
Many outpatient services must be prior authorized; all nonemergency inpatient and residential care must be prior authorized. Charges may not be covered if the required prior authorization is not obtained.
- Some services may need a separate prior authorization.
- If required PA is not obtained, charges may be denied or penalties applied (see Section 6.1).
Prior Authorization
Anticancer medications — PA and designated specialty pharmacy requirement
Most anticancer medications require prior authorization and must be obtained from Moda's designated specialty pharmacy unless a prior authorization allows use of a non‑designated pharmacy.
- Some anticancer medications may require enrollment in manufacturer/provider programs.
Prior Authorization
ABA services require prior authorization
Applied behavior analysis (ABA) for autism spectrum disorder is covered but all ABA services must be prior authorized before delivery.
Prior Authorization
Behavioral health programs and advanced imaging require prior authorization
Intensive outpatient mental health treatment, ACT, STAR, TMS and most advanced imaging services require prior authorization. The full list of diagnostic procedures requiring PA is available on the Moda Health website.
- Behavioral programs: intensive outpatient mental health = ≥3 hours/week; SUD intensive outpatient = 9–19 hrs/week (adults) or 6–19 hrs/week (adolescents).
- Most advanced imaging (MRI/MRA, CT, PET, nuclear medicine, cardiac imaging) requires PA.
Prior Authorization
Clinical trial participation requires prior authorization
Participation in an approved clinical trial must be prior authorized; covered trials are limited to specified government/cooperative group‑funded trials, FDA investigational pathways, or federally exempt trials.
Prior Authorization
PA required for surgical gender‑affirming procedures and cochlear implants
Surgical gender‑affirming procedures and cochlear implants require prior authorization before scheduling.
- Gender‑affirming surgical procedures require PA and must meet medical necessity criteria.
- Cochlear implants require medical necessity determination and prior authorization.
Prior Authorization
Infusion therapy, hospice respite and hospital dental require prior authorization
Prior authorization is required for infusion therapy and certain hospice, respite and dental procedures (e.g., hospital dental under general anesthesia); providers must obtain authorization for these services.
- Infusion therapy: prior authorization required for infusion services and supplies; authorization may be limited to preferred suppliers/providers/settings.
- Hospital dental/general anesthesia: must be prior authorized when medically necessary.
Prior Authorization
Respite and hospital dental/general anesthesia must be prior authorized by attending provider
Respite care and hospital dental/general anesthesia services must be arranged and prior authorized by the attending professional provider; prior approval is required before billing.
Prior Authorization
Seek prior authorization promptly when a transplant candidate is identified
If a member is identified as a possible transplant candidate, the provider should seek prior authorization as soon as possible after identification to ensure coverage and applicable limits are communicated.
- Transplant benefits may be limited and travel/housing rules and Center of Excellence requirements can affect cost‑sharing and OOP accumulation.
Prior Authorization
Diagnostic maternity procedures and some vision services may require PA (VSP handles in‑network vision authorization)
Some diagnostic procedures related to maternity care and certain vision services may require prior authorization. VSP will provide benefit authorization directly to in‑network vision providers; providers must identify members as VSP to facilitate authorization.
- A full list of diagnostic procedures that require PA is available on the Member Dashboard or via Customer Service.
Prior Authorization
Specialty medication prior authorization and formulary exception process
Most specialty medications require prior authorization; some prescriptions or quantities may also need PA. Formulary exceptions require provider documentation and will be decided within 72 hours (standard) or 24 hours (urgent).
- Specialty meds must come from Moda‑designated specialty pharmacy unless PA permits otherwise.
- Formulary exception requests must show prior trials or intolerance and will be processed within stated timelines.
Billing Rule
Brand vs. generic cost‑sharing — member may pay difference (not counted toward OOP max)
If a brand medication is dispensed when a generic equivalent is available, the member may be responsible for the cost difference; that difference does not count toward the out‑of‑pocket maximum.
Documentation Required
Exclusions listed here do not include PA rules — review exclusions separately
This portion of the exclusions section lists services with no associated prior authorization rules in these chunks; verify exclusions separately when planning services because exclusions may affect coverage regardless of prior authorization.
Documentation Required
Check third‑party liability before obtaining authorization
Determine whether another third party (e.g., government program or other payer) is responsible for payment; the plan excludes services and supplies when another third party is obligated to pay.
- This exclusion does not apply to certain state hospitals, approved community mental health/developmental disabilities programs, or the VA when care is not service‑related.
Documentation Required
Verify medical necessity for routine foot care (exclusion unless medically required)
Routine foot care (trimming corns/calluses, trimming nails, removing dead tissue) is excluded unless required by a medical condition such as diabetes; when routine foot care is clinically required due to a condition, verify medical necessity per the applicable benefit rules and obtain authorization if required.
- If foot care is medically necessary because of diabetes or another condition, document medical necessity and follow prior authorization rules as applicable.
Coding, Limits, and Quick Reference Values
Calendar-year accrual
Calendar-year accrualBenefits with annual or 'per year' limits accrue on a calendar year basis unless otherwise specified.
Reference for timingSee Schedule of Benefits (Section 3) and Benefit Description (Section 7) for specific limits and exceptions.
ApplicabilityApplies to benefits that state an annual or per‑year limit; exceptions will be noted where accrual is different.
Outpatient rehabilitation limit
Outpatient rehabilitation limitUp to 20 outpatient sessions per year (limits apply separately to rehabilitation and habilitation services).
ScopeIncludes outpatient physical, occupational and speech therapy; does not apply to cardiac/pulmonary rehab or behavioral health services.
Source tableListed in the Schedule of Benefits (Section 3) with reference to Section 7.4.27.
Skilled nursing facility limit
Skilled nursing facility (SNF) limitCovered for a limited number of days — Schedule of Benefits specifies a limit of 30 days per year.
Coverage basisCovered expenses limited to the daily service rate for a semi‑private room; facility must be licensed and provide rehabilitative services and 24‑hour RN care.
Reference sectionsSee Schedule of Benefits (Section 3) and Skilled Nursing Facility Care (Section 7.4.28).
Transplant inpatient travel/housing limit
Transplant travel & housing limitTravel and housing expenses for the recipient and one caregiver are covered up to 14 days per transplant.
Center of Excellence noteTransplant benefits and limits are detailed in Section 7.4.33; deductible/coinsurance and OOP treatment differ if performed outside a Center of Excellence.
Provider actionProviders should obtain prior authorization as soon as possible after identifying a transplant candidate.
Max supply per fill
Maximum supply per fillEligible prescriptions may be dispensed for up to a 90‑day supply per prescription (retail/mail order where permitted).
One copay ruleOne copay may apply for a 30‑day supply in some rows; mail order options and 90‑day retail eligibility are noted in Schedule of Benefits.
Mail/order requirementMail order fills must use a Moda‑designated mail order pharmacy or pharmacies that agree to Moda's mail‑order terms.
Out-of-pocket protection
Out‑of‑pocket protectionOnce a member has paid the annual out‑of‑pocket maximum, the plan pays 100% of covered services for the remainder of the calendar year.
What doesn't countPrior authorization penalties, manufacturer discounts and copay assistance do not count toward the out‑of‑pocket maximum.
Separate accumulatorsIn‑network and out‑of‑network out‑of‑pocket maximums accumulate separately and are not combined.
Authorization validity limits
Authorization validity limitsA prior authorization is valid for a set period; services provided outside that authorized time period may not be covered.
Potential limitationsAuthorizations may limit number, amount, frequency, provider, or specific services covered; details appear in the authorization letter.
Care coordinator supportCare Coordinators/Case Managers can help members understand and access authorized treatment within authorization limits.
Urgent care vs. emergency criteria
Emergency vs. urgent careEmergency services are covered and paid at the in‑network benefit level worldwide without prior authorization; urgent care covers minor, non‑life‑threatening conditions examined at an urgent care facility and requires an actual exam. Visits billed as walk‑in/same‑day clinics may be paid as office visits, not urgent care.
Billing noteTo receive urgent care benefits, the facility must bill as an urgent care facility; otherwise the visit is processed under office visit benefits.
Post‑emergency notificationNotify your PCP as soon as possible after receiving emergency care; emergency admissions must be authorized by provider within 48 hours when admitted.
Mental health intensive outpatient minimum hours
MH intensive outpatient minimum hoursMental health intensive outpatient treatment requires 3 or more hours per week of direct treatment.
Prior authorizationIntensive outpatient mental health programs must be prior authorized.
ContextIntensive outpatient services are more intensive than routine outpatient care and less intensive than a partial hospital program.
Substance use disorder intensive outpatient hours
SUD intensive outpatient hoursSubstance use disorder intensive outpatient: Adults 9–19 hours per week; Adolescents 6–19 hours per week.
Prior authorizationSUD intensive outpatient programs require prior authorization.
Relation to program levelsThese programs are more intensive than routine outpatient care and less intensive than partial hospitalization.
Partial hospital program weekly hours
Partial hospital program weekly hoursA partial hospital program provides 20 or more hours per week of direct treatment (and at least 4 hours per day); no overnight care is provided.
Licensure requirementProgram must be appropriately licensed to be covered.
No overnight carePartial hospital programs do not provide 24‑hour overnight care; residential programs provide overnight care and require state licensure.
take-home drug quantity limit
Hospital take‑home drug limitTake‑home prescription drugs from a hospital are limited to a 3‑day supply at the same benefit level as hospitalization.
Applies to maternity tooHospital maternity benefits explicitly state the same 3‑day take‑home prescription limit.
Benefit levelTake‑home drugs are paid at the medical/hospital benefit level when dispensed at discharge.
therapy sessions per day
Therapy sessions per dayOnly one session of each outpatient therapy type (physical, occupational, speech) is covered per day.
Session definitionA session is considered one visit; outpatient services have separate annual limits and must be part of a written treatment plan.
ExclusionsMaintenance therapy (to maintain function without documented improvement) is not covered.
Transplant travel/housing maximum
Transplant travel/housing maximumTravel and housing expenses for the recipient and one caregiver are covered up to a maximum per transplant (described as 'up to a maximum per transplant' in transplant benefits).
Center of Excellence impactIf transplant is performed outside a Center of Excellence, deductible/coinsurance may not accumulate toward the out‑of‑pocket maximum.
Prior authorizationProviders should seek prior authorization as soon as a transplant candidate is identified.
specialty supply limits
Specialty supply limitsSome specialty medications may be limited to a 2‑week supply while other eligible medications may be dispensed up to a 90‑day supply (per formulary and plan rules).
Supply examplesMost specialty medications must be obtained from a Moda‑designated specialty pharmacy; certain specialty meds may be limited to shorter day supplies.
Formulary & exceptionsFormulary exception and prior authorization processes apply; exception decisions are made within 72 hours (standard) or 24 hours (urgent).
Plan Terms and Definitions
Plan name
Plan nameModa Select Idaho Bronze 10000 Plan (Bronze 10000).
Document titleIdaho Individual Medical Policy 2026 — Policy 2026.
Subscriber rightSubscriber may return the policy within 10 days of delivery for a full premium refund (free look).
10-day free look / refund policy
10‑day free look / refundSubscriber may return the policy within 10 days of delivery for a full premium refund; policy is canceled from inception if returned.
How to exerciseReturn the policy within 10 days of delivery to obtain refund and cancel coverage from the start.
Document locationThis statement appears on the policy cover page (Policy 2026).
Policy nature & Medicare status
Policy nature & Medicare statusThis document describes individual health coverage and may be changed or replaced by Moda Health; it is not a Medicare Supplement policy.
Where to find current policyThe most current policy is available on the Member Dashboard at www.modahealth.com/idaho.
Governing relationshipPlan provisions are governed by this policy between the subscriber and Moda Health.
Child-only coverage
Child‑only coverage adjustmentsFor child‑only policies, references to dependents (including spouse/domestic partner/children) are deleted; siblings of the subscriber are eligible.
Policy text alterationLanguage throughout the policy will be interpreted with those deletions for child‑only coverage.
Eligibility noteContact Customer Service for details about child‑only enrollment and coverage specifics.
Member ID Card
Member ID CardMember ID cards are sent after enrollment and show the member ID number and provider network; show your card at each service visit.
ReplacementIf you lose your ID card, request a new one via Member Dashboard or Customer Service.
PurposeID card helps providers confirm in‑network status and applies correct benefits at point of service.
Care Coordinators and Case Managers
Care Coordinators & Case ManagersCare Coordinators and Case Managers are nurses or behavioral health clinicians who coordinate care for complex or catastrophic medical situations across levels of care.
FunctionsThey work with members and professional providers to coordinate access to services, help navigate authorization and treatment plans.
EngagementContact them via Care Coordination for assistance when eligible; they can help with authorized treatment access.
Health Coaches / Disease Management
Health Coaches / Disease ManagementHealth Coaches provide education and support to help members self‑manage chronic diseases, follow provider‑recommended care plans, and prevent complications.
ServicesHealth coaching helps members identify goals and self‑management strategies; contact Disease Management & Health Coaching for program details.
Target populationAvailable to members living with chronic disease or medical conditions who would benefit from coaching and disease management support.
Behavioral Health Services
Behavioral Health ServicesBehavioral health specialty services (mental health and substance use disorder benefits) are provided via Moda Behavioral Health; intensive outpatient, ACT, STAR and TMS require prior authorization.
Covered servicesIncludes psychotherapy, intensive outpatient programs, partial hospitalization, residential and inpatient care as specified under Section 7.4.
Access helpBehavioral Health Customer Service can assist with locating in‑network providers and understanding benefits.
Cost sharing
Cost sharing definitionCost sharing is the amount the member pays (see Section 4 for deductible and out‑of‑pocket maximum explanations).
Location of detailsSpecific deductible and out‑of‑pocket amounts are shown in Section 3 (Schedule of Benefits) and explained in Section 4.
ImplicationUsing out‑of‑network providers may result in additional amounts payable above the Maximum Plan Allowance (MPA).
Annual accrual
Annual accrual (repeat)When a benefit has an 'annual' or 'per year' limit, it accrues on a calendar year basis unless otherwise specified.
Where shownThis rule is noted in the Schedule of Benefits (Section 3) and applies unless a specific benefit states a different accrual period.
Practical effectLimits such as 'per year' reset at the start of the calendar year unless the benefit text states otherwise.
Mail-order requirement
Mail‑order requirementMembers must use a Moda‑designated mail‑order pharmacy or other pharmacies that agree to Moda's mail‑order terms for mail‑order fills.
Supply optionsMail order and participating retail pharmacies offer up to a 90‑day supply where eligible.
Prior authorization for non‑designatedPrior authorization may be required for use of non‑Moda‑designated mail‑order or specialty pharmacies.
Coinsurance levels
Coinsurance levelsPreferred Tier: approximately 40% after deductible; Nonpreferred Tier: approximately 50% after deductible.
ExamplesSchedule of Benefits shows example copays ($2, $20) and mail‑order copays ($6, $60) alongside coinsurance levels.
ApplicabilityCoinsurance applies after deductible where indicated; tiers and exact cost share can vary by medication and formulary placement.
MPA (Maximum Plan Allowance)
MPA (Maximum Plan Allowance)Moda Health pays covered expenses based on the Maximum Plan Allowance (MPA); in‑network providers agree to look solely to Moda for compensation when Moda is the paying insurer.
Balance billing implicationIf you use an out‑of‑network provider, you may have to pay amounts above the MPA when permitted by law (balance billing).
Where definedMPA is defined further in Section 11 of the policy.
Extra-contractual services
Extra‑contractual servicesModa may cover services outside the policy (extra‑contractual services) after case evaluation and agreement; such payments are discretionary and not precedent‑setting.
TerminationAny party can end extra‑contractual services by written notice; prior payments do not obligate future payments.
InclusionExtra‑contractual benefits are included in calculating benefits, limitations or cost sharing when paid.
Balance billing
Balance billingOut‑of‑network providers may bill members for amounts above the MPA when permitted by law; this is called balance billing.
Member actionAsk providers to send lab work or x‑rays to an in‑network facility to avoid unexpected out‑of‑network charges.
In‑network IDYour member ID card lists your network and helps providers apply in‑network rates.
Primary Care Provider (PCP)
Primary Care Provider (PCP)An in‑network clinician (family/general practitioner, internist, pediatrician, obstetrician/gynecologist, PA, ARNP in women's health, or certified nurse midwife) designated to coordinate member care; members are encouraged to select and may change their PCP at any time.
How to choose/changeUse Find Care on the Member Dashboard or contact Customer Service to select or change a PCP.
RolePCP coordinates referrals, preventive care and overall management of member's care and access to specialists.
Prior authorization
Prior authorization definitionPrior authorization is the plan's process to evaluate and authorize services, supplies or medications in advance to ensure medical necessity and cost‑effective treatment; required for many inpatient, outpatient, rehab, diagnostic, infusion therapy and medication services.
Provider responsibilityAsk your provider to contact Moda Health for prior authorization before receiving services that require it; emergency admissions must be authorized within 48 hours after admission (or as soon as reasonably possible).
Limitations and effectsAuthorizations may limit number, amount, frequency, provider or specific services; services not authorized may not be covered and may incur a prior authorization penalty for out‑of‑network care.
Emergency services
Emergency servicesEmergency services are care for emergency medical conditions and are covered at the in‑network benefit level worldwide; prior authorization is not required for emergency medical screening exams or stabilizing treatment.
Post‑emergency admissionIf admitted, emergency admissions must be authorized by your provider within 48 hours after admission (or as soon as reasonably possible).
Balance billing protectionsYou cannot be balance billed for amounts beyond applicable cost sharing for emergency care in many circumstances; out‑of‑network ER providers may be out‑of‑network but balance billing is restricted as described.
Urgent care facility
Urgent care facilityAn office or clinic distinct from a hospital ER that diagnoses and treats illness/injury for patients without an appointment seeking immediate attention; facility must bill as urgent care to be paid under urgent care benefits.
Exam requirementMember must be actually examined by a professional provider to qualify for urgent care benefits.
Billing cautionMost walk‑in or same‑day clinics do not bill as urgent care and may be processed under office visit benefits instead.
Partial hospital program
Partial hospital programA licensed behavioral health facility providing no less than 4 hours of direct, structured treatment services per day and 20 or more hours of direct treatment per week; no overnight care.
Coverage notePartial hospital programs are covered when appropriately licensed; they are distinct from residential programs which provide overnight care.
Relation to virtual careVirtual care visits are live, interactive audio/video visits and are covered when services can safely and effectively be provided virtually; preferred vendor visits may have no cost sharing.
Residential program
Residential programA program providing organized full‑day or part‑day treatment with overnight 24‑hour care; must be state‑licensed for services to be covered.
Licensing requirementResidential programs must be state‑licensed to be covered under the policy.
Coverage distinctionResidential programs include overnight care; partial hospital programs do not provide overnight care.
Pharmacy vs DME coverage for diabetes supplies
Pharmacy vs DME for diabetes suppliesInsulin and diabetic supplies (syringes, needles, lancets, test strips, glucometers, CGMs) are covered under the pharmacy benefit when purchased from a pharmacy with a prescription and using a preferred manufacturer; insulin pumps may be covered under DME if not obtained from a pharmacy.
Where to checkPreferred manufacturer list and formulary available on the Member Dashboard.
Examples of covered medical servicesHbA1c testing, kidney disease checks, annual dilated eye exams, diabetes self‑management programs and routine foot care (see specific sections).
DME exclusions
DME exclusionsItems used primarily for comfort, convenience or cosmetic purposes; therapeutic devices except TENS units; dental appliances and braces; incontinence supplies; certain supporting devices unless medically necessary; testicular prostheses are excluded.
Replacement/repair ruleReplacement or repair covered only if equipment not abused and within warranty/repair rules; provider may need to supply information for approval.
Rental to purchaseDME rental is covered up to purchase price for most equipment per Section 7.4.9 (see DME section for details).
homebound
Homebound definitionHomebound means you generally cannot leave home because of your condition; if you do leave, it must be infrequent, for short times, and mainly to get medical treatment.
Implication for home healthcareHome healthcare services and supplies from a licensed home healthcare agency are covered when member is homebound, medically necessary and ordered by a treating practitioner.
Provider typesVisits must be provided by qualified professionals (RN/LPN, PT/OT/SLP/respiratory therapist, licensed social worker); home health aides are not covered except as hospice employees.
hospice
Hospice definition & accreditationHospice is a private or public hospice agency approved by Medicare and accredited by a nationally recognized entity; hospice care is for terminally ill members receiving palliative rather than curative treatment and services must be part of an approved hospice treatment plan.
Certification requirementThe treating provider must certify in the hospice treatment plan that the member is terminally ill; plan must describe services and supplies to be provided.
Coverage scopeHospice home care includes services by RNs, LPNs, therapists and licensed social workers per the hospice treatment plan.
skilled nursing facility
Skilled nursing facility definitionA skilled nursing facility is licensed to provide inpatient care with rehabilitative services and 24‑hour‑a‑day nursing by registered nurses; coverage is limited to a number of days with expenses limited to the daily semi‑private room rate.
Coverage limitsA limited number of SNF days are covered (Schedule of Benefits specifies 30 days per year).
ExclusionsCharges not covered if admission occurred before coverage effective date or for care mainly for cognitive decline/dementia; routine custodial care is excluded.
Rehabilitative services
Rehabilitative services definitionRehabilitative services restore or improve an ability you have lost because of a medical condition; services must be medically necessary and part of a written treatment plan.
Therapies includedPhysical therapy, occupational therapy, speech therapy, cardiac and pulmonary rehab are included when meeting criteria.
LimitsOutpatient rehabilitative services have separate annual limits; maintenance therapy is not covered.
Habilitative services
Habilitative services definitionHabilitative services are used to form skills that you never developed due to a medical condition.
PurposeIntended to help develop skills and functions not previously acquired because of a medical condition.
Coverage noteHabilitative services share similar provider and medical necessity requirements as rehabilitative services and may have separate limits.
Virtual care visit
Virtual care visitA virtual care visit is a live, interactive audio and video visit with a provider where services can be safely and effectively provided virtually; preferred vendor virtual visits may be covered at no cost sharing.
Technology standardsTechnology used must meet state and federal privacy and security standards for protected health information.
Covered servicesIncludes diagnosis and treatment of chronic or minor medical conditions when safely deliverable via virtual visit.
Formulary and tier definitions
Formulary & tier definitionsFormulary is the plan's list of prescription medications and how they are covered; tiers include Value, Select, Preferred, Nonpreferred, Specialty, etc., and tier placement may change over time.
Where to viewUse the Member Dashboard prescription price check tool to view current formulary and tier placement.
Tier roleTier determines copay/coinsurance and prior authorization/step therapy requirements for medications.
Nursery care (well-newborn)
Nursery care (well‑newborn)One in‑nursery physician visit for a well‑newborn is covered at no cost sharing when the provider is in‑network; there is no deductible for routine nursery care.
Coverage scopeNursery care is covered under the newborn's own coverage while you are in the hospital receiving maternity benefits.
Related maternity benefitHospital maternity benefits include room, facility charges and other medically necessary hospital services.
Special Right Upon Childbirth
Special Right Upon ChildbirthNewborns' and Mothers' Health Protection Act protections: hospital length of stay will not be restricted to less than 48 hours after vaginal delivery or 96 hours after cesarean delivery without prior authorization.
No prior auth neededYou do not need prior authorization to stay in the hospital up to these limits; you may go home earlier if you and your provider decide.
Decision authorityAttending professional provider for you and your baby will make the discharge decision with you.
Custodial Care
Custodial CareCustodial care is routine care that helps with everyday life activities (bathing, dressing, feeding, medication assistance) and is excluded from coverage when it can be provided by persons without medical or paramedical skills.
ExamplesIncludes assistance with mobility, meal prep and similar non‑medical daily activities.
Exception noteServices that are medically necessary and require qualified professionals may be covered under other benefits (e.g., home healthcare, hospice).
Cosmetic Procedures
Cosmetic proceduresCosmetic procedures are those intended to change or maintain appearance without significant improvement in body function and are excluded unless reconstructive or gender‑confirming surgery is medically necessary.
ExamplesRhinoplasty, breast enhancement, liposuction and hair removal are cited as examples of cosmetic procedures.
Reconstructive exceptionReconstructive or gender‑confirming surgery is covered if medically necessary and not specifically excluded.
Experimental/Investigational
Experimental/InvestigationalExperimental or investigational procedures and related expenses are excluded from coverage (see definition in Section 11).
ScopeExclusion applies even if the procedure would otherwise be covered in non‑experimental situations.
ReferenceSee Section 11 for the policy's definition and further details on experimental/investigational criteria.
Never Events
Never EventsNever events are serious preventable events (e.g., wrong surgery, surgery on wrong body part) and services/supplies related to never events are excluded from coverage.
CMS alignmentThis aligns with CMS definitions of hospital‑acquired conditions and serious preventable events.
ImplicationClaims related to never events will be denied per the exclusion.
Obesity/Weight Reduction
Obesity/Weight reduction exclusionObesity and weight‑reduction services (including gastric restrictive procedures, weight management programs and related medications) are excluded except when necessary to treat established medical conditions caused or worsened by obesity or as required by the Affordable Care Act.
Examples excludedGastric restrictive procedures, weight loss programs, counseling, related medications and formulas are listed as excluded items.
ExceptionServices to treat established medical conditions caused or worsened by obesity may be covered; ACA‑required services are also covered as applicable.
Family member
Family member definitionFor exclusions involving services provided or ordered by a family member, 'family member' includes you or your spouse, domestic partner, child, sibling or parent of you or your spouse/domestic partner.
Effect on coverageServices provided or ordered by a family member (other than dental providers) are excluded under the policy.
Reference sectionSee Exclusions list for full context of family‑member‑provided services exclusion.
Policy Summary
Payermoda_health_plan_inc
PolicyIdaho Individual Medical Policy 2026
Policy CodePolicy Policy 2026
Change TypeNo material changes
Effective DateJan 1, 2026
Last ReviewJan 1, 2026
Next Review Date
Key ActionCheck the Member Dashboard to determine whether a service or supply requires prior authorization before providing or ordering care.
SourceLink
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