2026 Alaska Individual Medical Plan — Moda Select Alaska Standard Bronze AI/AI Zero Plan
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This document is the Moda Health 2026 Alaska Individual Medical Plan booklet describing member rights, coverage sections, benefits, prior authorization, claims, appeals, and administrative procedures for subscribers to the listed Alaska individual plans.
No material clinical or coverage changes in this revision.
Covered Benefits and Limits
Coverage topics (TOC)
The Table of Contents enumerates covered benefit categories and administrative topics included in this booklet.
Document sections (TOC)
The Table of Contents lists administrative sections and processes included in the booklet.
Schedule of Benefits excerpt
Summary items and key limits shown in the Schedule of Benefits excerpt.
See Schedule of Benefits introductory note.
Follow Benefit Description for full rules.
Partial coverage limits and references
Coverage categories with stated frequency or lifetime limits and cross-references.
Partial benefit limits and notes
Benefit categories with numeric limits and notes as provided in the excerpt.
Service-specific limits
Specific service limits and frequency rules listed in the Schedule of Benefits.
Prior authorization criteria and limits
Prior authorization requirements, limits and consequences summarized from the handbook.
Exceptions
- Emergency medical screening and treatment to stabilize do not require prior authorization.
Emergency and urgent care
Coverage stance for emergency and urgent care.
Medical transportation criteria
Medical transportation coverage and authorization requirements.
Preventive and screening coverage criteria
Preventive, screening and pediatric coverage rules and frequencies.
Preventive services criteria
Detailed preventive service frequencies and age-based screening rules.
Behavioral health and specialty treatment criteria
Behavioral health, specialty treatments and related medical necessity and authorization requirements.
Clinical trials, biofeedback, cochlear implants
Coverage stance for certain specialty or limited services.
Pediatric dental coverage criteria
Pediatric dental coverage scope, frequencies and typical exclusions.
Oral Surgery
Oral surgery coverage items and exclusions.
Major Restorative
Major restorative dental coverage rules and limits.
Prosthodontic
Prosthodontic coverage and limits.
Orthodontia
Orthodontia coverage conditions and payment schedule.
Other Dental Services
Other dental services and telehealth availability.
Dental Injury
Dental injury coverage criteria and timelines.
Diabetes Services
Diabetes services and routing between pharmacy and medical benefits.
Diagnostic Procedures
Diagnostic procedure coverage conditions and authorization requirements.
DME and Exclusions
Durable medical equipment examples, ordering rules and exclusions.
Electronic Visits
Electronic visit coverage condition.
Gender Affirming Services
Gender-affirming services coverage and authorization requirement.
Health Education
Health education services covered when related to a medical condition.
Home Healthcare
Home healthcare coverage conditions and visit limits.
Hospice and Respite Care
Hospice benefits, covered services and prior authorization for respite care.
Respite Care Coverage Criteria
Respite care coverage criteria and limitations.
Hospice Exclusions
Hospice exclusions summary.
Hospital Care Coverage
Hospital inpatient coverage and related limits.
Infusion Therapy Coverage
Infusion therapy coverage and authorization requirement.
Kidney Dialysis Coverage
Kidney dialysis coverage notes.
Massage Therapy Coverage
Massage therapy coverage and authorization.
Provider-Administered Medication Coverage
Provider-administered medication coverage and prior authorization requirement.
Enteral Formula Coverage
Nonprescription enteral formula coverage conditions.
Nutritional Therapy Coverage
Nutritional therapy coverage and exclusions.
Rehabilitation/Habilitation Coverage
Rehabilitative and habilitative services requirements and limits.
Skilled Nursing Facility Coverage
Skilled nursing facility coverage, definitions and exclusions.
Spinal Manipulation Coverage
Spinal manipulation coverage and requirements.
Skilled nursing exclusions
Skilled nursing facility exclusions referenced.
Spinal & other manipulations
Spinal manipulation coverage (cross-reference).
Surgery and reconstructive surgery
Surgery coverage scope and reconstructive surgery rules.
Temporomandibular Joint Syndrome (TMJ)
TMJ coverage and authorization requirement.
Therapeutic injections
Therapeutic injection administrative coverage rule.
Therapeutic radiology
Therapeutic radiology covered components.
Transplants
Transplant coverage requirements and limits.
Virtual Care Visits (Telehealth)
Telehealth (virtual care) coverage conditions.
Maternity care
Maternity and childbirth coverage highlights and protections.
Abortion
Elective abortion coverage stance.
Breastfeeding support
Breastfeeding support coverage summary.
Circumcision
Circumcision coverage rule.
Pharmacy prescription benefit
Pharmacy prescription benefit overview and covered medication supply rules.
Benefit criteria and exclusions
Benefit routing, formulary and program rules plus vision and hearing limits.
Excluded Services (excerpt)
Excerpt of services and supplies listed as not covered under the plan.
Excerpt examples
- Animal therapy is not covered.
- Care outside the United States is not covered except for urgent or emergency care.
- Cosmetic procedures not medically necessary are excluded (reconstructive or gender-affirming surgery may be covered when medically necessary).
- Custodial care is excluded.
- Experimental or investigational procedures and medications are excluded.
- Hearing aids including implantable devices and implantation procedures are excluded unless covered elsewhere in the plan.
- Infertility services and supplies are excluded.
Exclusions (partial)
Partial list of exclusions from coverage unless an explicit exception is stated elsewhere in the policy.
Excluded items (partial)
- Services and supplies received while an inmate in custody are excluded.
- Treatment related to intellectual disability and learning disorders and institutional services for intellectually disabled are excluded.
- Herbal, naturopathic, homeopathic and other nonprescription supplements are excluded.
- Never events and hospital-acquired condition–related services and supplies are excluded.
- Non-therapeutic counseling (legal, financial, occupational, religious) excluded.
- Obesity/weight reduction services (including bariatric surgery and related meds) are excluded except services necessary to treat established medical conditions caused or worsened by obesity and ACA-required exceptions.
- Orthopedic shoes excluded except as described elsewhere.
- Orthognathic surgery and associated services excluded.
- Personal items and nonmedical conveniences excluded.
- Personality disorders listed as excluded.
- Physical exercise programs, videos and equipment excluded.
- Private nursing services excluded.
- Professional athletic activity related services excluded.
- Charges for reports and records (completing claim forms) excluded.
- Routine foot care excluded unless medically required (e.g., diabetes).
- Self-administered medications obtained outside the pharmacy benefit are excluded.
- Self-improvement programs and retreats excluded except as specifically covered.
- Service-related conditions from armed forces service excluded unless not covered by military/veterans coverage.
- Services for administrative or qualification purposes (employment, licensing, insurance exams) excluded.
- Services not actually provided (including missed appointments) excluded.
Codes, Limits and Billing Notes
| Prostate Specific Antigen (PSA) test: One per year, age 40+ (also annually for ages 35-40 if African American or family history) |
| No billing or procedure codes provided in these schedule entries (general treatment services, acupuncture, ABA, behavioral health entries) |
| (No specific CPT/HCPCS/ICD codes listed in this section of the document) |
| Medications and supplies that require prior authorization — full list maintained on the Moda Health website |
| Preventive exams and screenings (schedule and frequency described); no specific billing codes provided in this section |
| Comprehensive pediatric dental benefit descriptions and frequency limits (diagnostic, preventive, restorative, endodontic, periodontic, oral surgery) — no CPT/HCPCS codes specified in this extract |
| Major restorative and prosthodontic service descriptions with 5-year and 3-year frequency limits as specified; no billing codes provided |
| Assistant surgeon Maximum Plan Allowance (MPA) defined as 20% of physician's MPA (10% for PA/CRNA); eligible office surgery covered subject to prior authorization |
| Pharmacy and medication definitions and formulary rules described; no specific procedure or drug codes listed in this section of the extract |
| Hearing aids, including implantable hearing aids and the surgical procedure to implant them — excluded unless otherwise covered |
| Routine foot care (trimming/cutting corns, calluses, nails; removing dead tissue/foreign matter) excluded unless medically required (e.g., diabetes) |
Prior Authorization, Documentation & Provider Notices
Prior Authorization / Time Frames (TOC entries)
Prior Authorization requirements and time frames for processing prior authorizations and utilization review are listed in the plan's Table of Contents.
Prior authorization lookup
See if a service or supply you need must be prior authorized at www.modahealth.com/medical/referral.
Member ID card use and replacement
Members receive ID cards after enrollment and should present them at each service; if lost, a replacement is available via the Member Dashboard or by calling Customer Service.
Prior authorization notice
Prior authorization may be required for some services; see Section 6.1 for details.
Medical necessity / cross-reference note
Services are covered when medically necessary; see the referenced handbook sections (for example Sections 7.4.3, 7.4.5, 7.4.8–7.4.10) for applicability and specifics.
Handbook cross-references and provider notice
See related handbook sections (for example Virtual Care Visits and Sections 7.4.21, 7.4.22, 7.4.26, 7.4.30–7.4.38) for service-specific details and requirements.
Prior authorization and penalties
Prior authorization is required for many services; providers should contact Moda Health before services are provided. Emergency admissions must be authorized by the provider within 48 hours after admission.
- Failure to obtain required prior authorization may trigger a penalty (50% up to $2,500 per occurrence) except for emergency admissions.
Services that may require authorization
Many types of services may require prior authorization, including inpatient/residential stays, outpatient services, rehabilitation (OT/PT/ST), spinal manipulation, acupuncture, massage therapy, and medically necessary non-emergency services outside Alaska.
Prior authorization requirements and limitations
Prior authorization may be required for a broad set of services (inpatient, outpatient, rehabilitation, spinal manipulation/acupuncture/massage, diagnostic imaging, infusion therapy, and medications); authorizations may limit time period, scope, provider, number/amount/frequency and must be followed to avoid denial or penalty.
- Any limits or requirements will be described in the authorization letter.
- Providers should check the full, up-to-date list on the Moda Health website or with Customer Service.
Consequences of not obtaining prior authorization
Failure to obtain required prior authorization may result in denial of benefits or a penalty; authorization letters describe applicable limits and requirements.
Authorization for medical transportation
Prior authorization is required for medical transportation benefits; the attending physician must submit written certification and travel must be approved in advance.
- Reimbursement limited to lowest available commercial airfare; maximum two round-trip tickets per member per year.
- Travel must be approved in advance and supported by written physician certification.
Prior Authorization general rule
Many outpatient services must be prior authorized and all nonemergency inpatient and residential care must be prior authorized; failure to obtain authorization may result in denial or penalty.
Acupuncture prior authorization
Acupuncture services are covered up to an annual visit limit and must be prior authorized as medically necessary.
Anticancer medication prior authorization and specialty pharmacy
Most anticancer medications need prior authorization, have specific benefit limitations, and specialty anticancer medications must be obtained from the designated specialty pharmacy.
- Some anticancer medications may require enrollment in manufacturer/provider programs.
ABA prior authorization and documentation
Applied Behavior Analysis (ABA) services must be medically necessary and prior authorized; providers must submit an individualized treatment plan.
- Coverage excludes services by family members, custodial/respite care, and services provided under an IEP or by certain state departments.
Behavioral health and TMS prior authorization
Intensive outpatient mental health treatment and transcranial magnetic stimulation (TMS) must be prior authorized.
Clinical trials prior authorization
Participation in a clinical trial must be prior authorized by Moda Health.
Cochlear implant prior authorization
Cochlear implants are covered when medically necessary and must be prior authorized.
Prior authorization for advanced imaging
Most advanced imaging services (MRI, MRA, CT, PET, nuclear medicine and cardiac imaging) must be prior authorized; a full list is available on the Moda Health website or via Customer Service.
Prior authorization and ordering for DME
Some durable medical equipment (DME) and supplies require prior authorization; a full list is on the Moda Health website or available via Customer Service. Rental charges are covered up to purchase price and replacement/repair conditions are specified.
- Providers must supply order information if requested to support claim payment.
Prior authorization for gender-affirming surgery
Prior authorization is required for surgical gender-affirming procedures.
- Procedures must be performed by a qualified provider and the treatment plan must meet medical necessity criteria.
Prior authorization for respite care
Respite care must be arranged by the attending provider and is covered only when prior authorized.
- A limited number of hours is covered; approval required for non-professional providers; care to allow a caregiver to return to work does not qualify.
Respite care prior authorization
Respite care must be arranged by the attending professional provider and prior authorized.
Infusion therapy prior authorization
Professional providers must obtain prior authorization for infusion therapy.
- Infusion therapy coverage includes solutions, compounding, DME, ancillary supplies, nursing services and required lab monitoring.
Massage prior authorization
Massage therapy is covered up to an annual visit limit and must be prior authorized.
- Massage therapy does not include other services such as manual therapy, which are subject to standard plan benefits.
Medication-administered treatment prior authorization
Treatment with medications administered in a provider office, treatment/infusion center, or via home infusion requires prior authorization.
- Preferred medication suppliers and preferred treatment centers may be available; self-administered medications are not covered under this benefit.
Spinal manipulation prior authorization
Spinal manipulations are covered up to an annual visit limit and must be prior authorized.
Spinal manipulation prior authorization
Spinal manipulations are covered up to an annual visit limit and must be prior authorized.
Surgery prior authorization for office procedures
Eligible surgery performed in a physician's office is covered, subject to the appropriate prior authorization.
TMJ prior authorization
TMJ-related surgical procedures and splints require prior authorization and are covered only when medically necessary.
Transplant prior authorization
Obtain prior authorization as soon as possible after a member is identified as a possible transplant candidate; prior authorization must be in writing from Moda Health.
- This requirement does not apply to corneal transplants and routine blood collection/transfusion.
Maternity diagnostic prior authorization
Some diagnostic procedures related to maternity care may require prior authorization; a full list is on the Moda Health website or available via Customer Service.
Pharmacy prior authorization and formulary exception process
Certain prescription medications and/or quantities may require prior authorization; formulary exception requests require provider documentation of medical necessity.
- Formulary exception requests must document trials of formulary meds, intolerance or harm, or lack of equivalent efficacy.
Prior authorization, specialty pharmacy, step therapy, and formulary exceptions
Prior authorization is required for certain medications and most specialty medications; specialty medications must be obtained from a Moda-designated specialty pharmacy or they will not be covered unless an urgent local fill is prior authorized. Step therapy requires trying Step 1 medications before Step 2 will be covered; formulary exception decisions are made within 72 hours (24 hours if urgent).
- Urgent local fills may be authorized if delay would threaten treatment.
- Some specialty prescriptions may be limited to less than 30 days; some medications may be eligible for a 90-day supply.
Experimental/Investigational Exclusion
Experimental or investigational procedures and medications are excluded from coverage.
Cosmetic Procedures Exclusion
Cosmetic procedures are excluded unless they are reconstructive or gender-affirming and medically necessary.
Obesity or Weight Reduction exclusion (with ACA exception)
Services and supplies directly treating obesity (including bariatric surgery, weight management programs, and related medications/formulas) are excluded, except services necessary to treat established medical conditions caused by or worsened by obesity; ACA-required exceptions may apply.
Never Events exclusion
Services and supplies related to never events and hospital-acquired conditions are excluded from coverage.
Defined Terms and Roles
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