ALL of the following

• Urgent & Emergency Care (see TOC entries for Ambulance Transportation, Emergency Room, Urgent Care)
• Preventive Services (ACA-required screenings and immunizations; frequency/age limits referenced)
• General Treatment Services (rehabilitation, DME, infusion, transplants) — details in benefit sections referenced in the schedule
• Pharmacy Prescription Benefit (including step therapy, specialty, mail order) — see pharmacy sections for formulary and prior authorization rules
• Vision and Hearing Benefits (pediatric/adult vision, hearing hardware limits) — network-specific authorization flow noted
• General Exclusions and Claims Administration (coordination of benefits, appeals, external review) — listed in TOC

ALL of the following

• Document includes sections on Benefits, Prior Authorization, When Benefits Are Available, Definitions, Continuity of Care, Coordination of Benefits and other administrative processes
• TOC shows sections for Appeals, External Review and Member Rights and contains references to detailed benefit descriptions in Section 7 (Benefit Description)
• Provider and member operational guidance (Find Care, Member Dashboard links) are referenced in TOC and supporting sections

ALL of the following

• Tier 1 medical network: Moda Select — use Tier 1 providers for highest benefit level
• Tier 2 medical network: First Choice (Alaska) — available when Tier 1 not accessible or per plan rules
• Dental network: Delta Dental Premier — pediatric dental and other dental benefits referenced
• Pharmacy network: Navitus — pharmacy benefit administration, specialty and mail order rules referenced
• Out-of-area network: Aetna PPO (Aetna Signature Administrators) for services outside Alaska
• Vision network: VSP — VSP handles benefit authorization for Tier 1/2 vision providers

ALL of the following

• Plan has no deductible or out-of-pocket maximum; covered services paid at 100% of Maximum Plan Allowance (MPA); Tier 3 providers may result in member responsibility for amounts above MPA
• Schedule of Benefits provides quick summary rows that reference detailed handbook sections for full conditions and limits (e.g., Section 7.x)
• Many services have frequency or lifetime limits (examples: 24 visits/year for some services; 10-visit lifetime maximum for certain services) — see schedule details for specifics

ALL of the following

• Acupuncture is covered up to an annual visit limit (24 visits per year) and requires prior authorization as medically necessary

ALL of the following

• Applied Behavior Analysis (ABA) for autism spectrum disorder is covered when medically necessary, prior authorized and provided/supervised by certified/licensed behavior analysts with an individualized treatment plan; services by family/household members, respite, certain therapies and services under an IEP are excluded
• Biofeedback is covered only to treat tension or migraine headaches and is subject to a lifetime visit limit (10-visit lifetime maximum referenced in schedule)

ALL of the following

• Pediatric dental care is covered through the end of the month you reach age 19, with specified frequency limits for diagnostic and preventive services (e.g., diagnostic exams twice/year, prophylaxis twice/year, full series x-ray once per 5 years, bitewings every 6 months)
• Minor restorative, endodontic, periodontic, oral surgery and prosthodontic services are described with per-tooth and per-period limits (e.g., crowns once per tooth per 5 years; dentures once per site every 5 years)
• Orthodontia is covered only when medically necessary for disabling malocclusion, cleft palate or severe craniofacial defects — payment arranged with initial 25% at placement and balance in monthly payments; plan obligation ends if treatment stops or eligibility ends

ALL of the following

• Biofeedback lifetime maximum: 10 visits (schedule references lifetime limit)
• Many services flagged 'Under age 19' carry frequency limits; orthodontia covered when medically necessary
• Diagnostic procedures include x-ray and lab; some diagnostic imaging requires prior authorization (see imaging rules)

ALL of the following

• Massage therapy: 24 visits per year; prior authorization required for some services
• Psychological/Neuropsychological testing: 12 hours per year (limits referenced)
• Outpatient rehabilitation: 45 sessions per year; inpatient rehab/habilitation limits and skilled nursing limits referenced
• Transplant travel/lodging/meals: covered up to specified maximum per transplant (e.g., $7,500) when criteria met; must use authorized transplant facility when available
• Hearing: hearing exam once/year; one hearing aid per ear every 3 years

ALL of the following

• Services and supplies are covered when medically necessary; many services require prior authorization and failure to obtain required prior authorization may result in denial of benefits or penalty (prior auth rules and penalties referenced)
• Emergency services worldwide are covered and paid at Tier 1 benefit level; prior authorization not needed for emergency screening/stabilization; if hospitalized at Tier 3 facility the treating physician will determine safe transfer timing
• Ambulance transportation covered to nearest equipped facility; Tier 3 ambulance providers may bill amounts above MPA
• Medical transportation (air) limited to two round-trips per member per year; prior authorization and written physician certification required; reimbursement limited to lowest commercial airfare

ALL of the following

• Emergency Room Care: medically necessary emergency care covered worldwide; paid at Tier 1 benefit level; prior auth not required for emergency screening/stabilization; Tier 3 providers cannot balance bill except when permitted by law
• Urgent Care: covered for minor but urgent conditions when billed as an urgent care facility and patient examined by a professional provider; many walk-in clinics bill as office visits and will be paid as such
• Preventive Services (ACA): USPSTF A/B, ACIP immunizations, HRSA-recommended services for infants/children/women covered at no cost when provided by Tier 1/2 providers; frequency and age limits apply
• Colorectal screening and other screening schedules defined with intervals (examples given) and follow-up colonoscopy covered under preventive benefit when appropriate
• Contraception: FDA-approved contraceptive methods and related office visits covered when prescribed; some methods covered with no cost sharing when provided by Tier 1/2 providers
• Acupuncture: covered up to annual visit limit; requires prior authorization as medically necessary
• Anticancer medications: covered but most require prior authorization and may require use of designated specialty pharmacy
• ABA: covered when medically necessary, prior authorized, with individualized treatment plan; many exclusions listed
• Behavioral Health: levels of care defined; intensive outpatient, partial hospital, residential program rules and prior authorization requirements documented
• Biofeedback: covered only to treat tension or migraine headaches and subject to lifetime visit limit
• Clinical Trials: usual care costs for approved clinical trials covered subject to specified conditions and prior authorization

ALL of the following

• Biofeedback services are covered only to treat tension or migraine headaches and are subject to a lifetime visit limit (schedule references 10-visit lifetime maximum)

ALL of the following

• Usual care costs for approved clinical trials for cancer or other life-threatening conditions are covered when treating physician determines no clear superior non-investigational alternative and data suggest reasonable expectation of at least equivalent effectiveness; participation must be prior authorized
• Covered items include prevention/diagnosis/treatment/palliative care, items/services necessary to provide investigational item, diagnosis/treatment of complications, certain FDA-approved drugs/devices not paid by manufacturer, services to administer investigational items, and transportation for patient and one caregiver; exclusions listed (non-FDA-approved trial drugs/devices, housing, data-collection-only items, items paid by grants)

ALL of the following

• Cochlear implants are covered when medically necessary and prior authorized

ALL of the following

• Dental care is covered through end of month you reach age 19 with detailed diagnostic, preventive, restorative, endodontic, periodontic, oral surgery, prosthodontic and orthodontic provisions
• Diagnostic limits: exams twice/year, full series x-ray once per 5 years, bitewings every 6 months, occlusal x-ray once per 2 years; many items limited by timeframes
• Preventive limits: prophylaxis twice/year (additional if pregnant or diabetic), topical fluoride twice/year, sealant once per 3 years on eligible teeth
• Orthodontia covered only when medically necessary for disabling malocclusion, cleft palate or severe craniofacial defects; payment schedule and treatment-end rules specified

ALL of the following

• Coverage for accidental injury to natural teeth requires: injury by foreign object or acute trauma (not biting/chewing), diagnosis within 6 months, treatment begins within 12 months, treatment medically necessary and provided while covered, and limited to restoration to functional state; implants and implant-related services are excluded

ALL of the following

• Insulin and diabetic supplies (syringes, needles, test strips, glucometers, CGMs) are covered under the pharmacy benefit when purchased from a pharmacy with a valid prescription and preferred manufacturer; insulin pumps may be covered under DME if not obtained via pharmacy
• Covered clinical services include HbA1c tests, kidney disease checks, annual dilated eye exam/retinal imaging, outpatient self-management training, and medical nutrition therapy when prescribed

ALL of the following

• Diagnostic procedures must be for treatment of a medical or behavioral condition; includes x-rays, laboratory tests, standard and advanced imaging, psychological/neuropsychological testing
• Most advanced imaging (MRI, MRA, CT, PET, nuclear medicine and cardiac imaging) must be prior authorized and full list of required prior authorization items is available on Moda Health website or Customer Service

ALL of the following

• DME includes items such as CPAP, insulin pumps, hospital beds, intraocular lens within 90 days of cataract surgery, orthotics/braces, oxygen, prosthetics, wheelchairs/scooters; diabetic supplies (other than pumps) covered via pharmacy with prescription and preferred manufacturer
• All DME must be medically necessary; some items require prior authorization; rental charges covered up to purchase price for most DME; replacement/repair covered only under specified conditions
• Exclusions include appliances used primarily for comfort/convenience/cosmetic purposes, wigs, dental appliances/braces, most therapeutic devices (except TENS), incontinence supplies, hearing aids/eyeglasses/contact lenses except as otherwise covered

ALL of the following

• E-visits are covered when you are an established patient of the provider (previously treated in their office) and the e-visit is medically necessary for a covered condition

ALL of the following

• Gender-affirming treatment expenses are covered when procedures are performed by a qualified professional provider and the treatment plan meets medical necessity criteria; surgical procedures require prior authorization
• Covered services may include mental health, hormone therapy (including puberty suppression for adolescents) and surgical procedures such as breast/chest surgery, gonadectomy, genital reconstruction and facial surgery

ALL of the following

• Outpatient health education services are covered when managing a covered medical condition — examples include tobacco cessation, diabetes education, asthma education, pain management, and childbirth/newborn parenting training

ALL of the following

• Procedures must be performed by a qualified professional provider
• Prior authorization is required for surgical procedures
• Treatment plan must meet medical necessity criteria
• Covered services may include mental health, hormone therapy (including puberty suppression), and surgical procedures (breast/chest, gonadectomy, genital reconstruction, facial surgery)

ALL of the following

• Member must be homebound as defined by the plan; home healthcare must be medically necessary and ordered by treating physician
• Visits must be intermittent and provided by qualified professionals (RN/LPN, PT/OT/Speech/Respiratory therapists, licensed social worker); home health aides do not qualify
• Annual limit applies to RN/LPN services; other home healthcare providers limited to one visit per day

ALL of the following

• Hospice agency must be Medicare-approved or state licensed/certified; hospice treatment plan must be written, periodically reviewed and certify terminal illness by attending physician
• Covered hospice home care services include RN/LPN, therapists, certified respiratory therapist, home health aide and licensed social worker; short-term inpatient hospice covered for limited days
• Respite care covered when arranged by attending provider and prior authorized; non-professional provider services may be covered with prior approval; hospice services not for other than terminally ill member are excluded

ALL of the following

• Inpatient hospital care covered when medically necessary; covered expenses include hospital room, isolation care, ICU, facility charges for outpatient surgery and other medically necessary hospital services
• Take-home prescription drugs limited to a 3-day supply at hospitalization benefit level; general anesthesia for dental procedures in hospital/outpatient surgical center covered when medically necessary and prior authorized for specified groups

ALL of the following

• Covered infusion services include solutions/medications, pharmacy compounding/dispensing, DME for infusion, ancillary supplies, nursing services and lab testing for monitoring
• Professional provider must obtain prior authorization for infusion therapy; some medications/treatment centers require use of preferred suppliers; self-administered medications are not covered under provider-administered benefit

ALL of the following

• Nonprescription enteral formula for home use covered when medically necessary and sole/essential source of nutrition
• Formulas for phenylketonuria covered; preventive nutritional therapy covered per ACA in specified groups
• Podiatry services covered to diagnose/treat a specific current problem; routine podiatry not covered unless medically required (e.g., diabetes)
• Preadmission testing covered when ordered by a professional provider

ALL of the following

• Podiatry coverage applies to diagnosis and treatment of a specific current problem; routine podiatry not covered unless medically required (such as in diabetes)

ALL of the following

• Pre-admission testing is covered when ordered by a professional provider

ALL of the following

• Psychological and neuropsychological testing coverage includes interpretation and report preparation necessary to prescribe an appropriate treatment plan

ALL of the following

• Inpatient rehabilitative services must begin within 24 months of onset and be part of a physician's formal written program; annual limits apply except for autism spectrum disorders
• Outpatient rehabilitative and habilitative services are provided by licensed therapists/providers and are subject to annual visit limits, with separate limits for rehabilitative vs habilitative care; maintenance therapy without documented significant improvement is not covered

ALL of the following

• Skilled nursing facility care covered when facility licensed for inpatient care with RN supervision; limited number of days as shown in Section 3 and covered expenses limited to daily service rate for semi-private room
• Exclusions include admissions before coverage, care mainly for cognitive decline/dementia, routine nursing care, non-medical self-help, personal hygiene or custodial care

ALL of the following

• Spinal manipulations are covered up to an annual visit limit for treatment of a medical condition; spinal manipulations must be prior authorized and other services provided at the same visit are billed under standard benefits

ALL of the following

• Surgery (operations and cutting procedures) is covered when medically necessary; includes primary surgeon, assistant surgeon (assistant MPA rules apply), anesthesiologist, surgical supplies and facility charges
• Eligible office-based surgery is covered subject to appropriate prior authorization; reconstructive procedures must be medically necessary and prior authorized or benefits will not be paid; cosmetic surgery is not covered except specific exceptions

ALL of the following

• TMJ-related surgical procedures and splints require prior authorization and are covered only when medically necessary for problems such as pain, inability to chew properly, or severe acute trauma; orthodontia and related dental disease treatment are not covered under TMJ benefit

ALL of the following

• Administrative services for therapeutic injections (e.g., allergy shots) are covered when provided in a professional provider's office; when equivalent self-administered medications are available the provider administrative service is not covered; vitamin/mineral injections not covered unless medically necessary to treat a specific condition

ALL of the following

• Therapeutic radiology covered expenses include treatment planning and simulation, professional services for administration and supervision, and treatments including therapist, facility and equipment charges

ALL of the following

• Medically necessary transplants that follow standard practice and are not experimental/investigational are covered; prior authorization required as soon as candidate identified and must be written to be valid
• Transplants must be performed at a Center of Excellence when available; donor costs, travel/housing (subject to limits when recipient >50 miles from Center), immunosuppressive drug payment rules, and specified exclusions are documented

ALL of the following

• Virtual care (telehealth) visits are covered when services can be safely and effectively provided virtually, provider is licensed in Alaska or referred by an Alaska-licensed provider, and the technology meets applicable privacy/security standards; exemptions may apply during a state emergency

ALL of the following

• Pregnancy care, childbirth and related conditions covered when provided by a professional provider; maternity services billed as a global charge (prenatal, labor/delivery, post-delivery) though some diagnostic services reimbursed separately
• Home births covered only for medically necessary supplies/fees; supportive services are not covered

ALL of the following

• Elective abortions are covered

ALL of the following

• Comprehensive lactation support and counseling covered during pregnancy and/or breastfeeding
• Purchase or rental of breast pump and supplies covered (rental not to exceed purchase price); MPA applies for retail purchases; hospital-grade pumps covered when medically necessary; extra ice packs/coolers not covered

ALL of the following

• Circumcision within 3 months of birth is covered without prior authorization; circumcision after 3 months must be medically necessary and prior authorized

ALL of the following

• Breastfeeding support includes lactation counseling and breast pump coverage subject to MPA and medical necessity rules
• Circumcision rules reiterated: covered within 3 months without prior authorization; after 3 months requires medical necessity and prior authorization

ALL of the following

• Diagnostic services related to maternity (labs, ultrasounds) are covered though some may need prior authorization
• Covered hospital maternity expenses include room, facility charges, nursery care and take-home prescriptions limited to a 3-day supply; Special Rights Upon Childbirth ensure minimum hospital stay of 48 hours for vaginal delivery and 96 hours for cesarean without prior authorization

ALL of the following

• Inpatient hospital prescription medications are covered under medical plan during admission; outpatient pharmacy benefits cover prescribed medications and supplies when medically necessary
• Insulin and diabetic supplies covered via pharmacy with valid prescription and preferred manufacturer; specialty medications generally require prior authorization and must be obtained from Moda-designated specialty pharmacy (with limited exceptions for urgent local fill)
• Formulary exception process requires provider justification and decision timelines (72 hours standard, 24 hours urgent)
• Step therapy enforces trial of Step 1 medications before Step 2; out-of-order submissions will not be covered
• Limitations and exclusions enumerated include items not covered (foreign meds, hair growth meds, OTCs with OTC options, non-FDA approved meds, nutritional supplements, weight loss meds, etc.) and other administrative limits

ALL of the following

• Annual pediatric vision coverage through end of month you reach age 19: one complete well-vision exam and one pair of eyeglasses and frames or contact lenses in lieu of eyeglasses; contact lens supply minimums by type specified
• Optional lens enhancements and certain services limited; VSP provides benefit authorization to Tier 1/2 doctors and some vision services may require prior authorization

ALL of the following

• Well-vision exam: one per year until age 19; eyeglasses or contact lenses: one pair per year until age 19 with contact lens supply minimums by lens type
• Certain pediatric vision supplies and services excluded (e.g., plano lenses < ±50 diopter, two pairs instead of bifocals, artistically painted contacts, contact lens modifications)

ALL of the following

• One complete eye exam annually for adults and one pair of corrective lenses annually; one pair of frames every 2 years; elective contacts in lieu of eyeglasses covered annually; some lens enhancements covered
• Exclusions mirror pediatric exclusions (e.g., plano lenses < ±50 diopter, artistically painted contacts, additional office visits for contact lens pathology)

ALL of the following

• One audiological hearing exam annually by certified/licensed audiologist or hearing aid specialist; one hearing aid per ear once every 3 years with related accessories and follow-up; otological exam once every 2 years
• To receive highest benefit, members should use Tier 1 audiologist/hearing aid provider; certain exclusions and replacement timing apply

ANY of the following

• Animal therapy is excluded
• Care outside the United States is excluded except for urgent/emergency medical conditions
• Cosmetic procedures are excluded unless medically necessary/reconstructive or gender-affirming when covered
• Custodial care is excluded
• Court-ordered services not medically necessary are excluded
• Experimental or investigational procedures and medications are excluded
• Food services (Meals on Wheels, guest hospital meals) are excluded
• Dental examinations and treatment generally excluded except as specified in pediatric dental sections and other specified dental benefits