Currentmoda_health_plan_incPolicy ModaAKIndvCSV0bk 1-1-2026
2026 Alaska Individual Medical Plan — Table of Contents & Introductory Notice
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This document is the Moda Health 2026 Alaska Individual Medical Plan policy materials (Moda Select Alaska Standard Silver AI/AI Zero) including the welcome, refund/cancellation right, authorization signature, and an extensive table of contents outlining member resources, benefits, prior authorization, pharmacy, vision/hearing, claims, and other administrative sections; it applies to subscribers of the referenced 2026 Alaska Individual Medical Plan.
Policy Summary
Payermoda_health_plan_inc
Policy2026 Alaska Individual Medical Plan — Table of Contents & Introductory Notice
Policy CodePolicy ModaAKIndvCSV0bk 1-1-2026
Change TypeNo material changes indicated
Effective DateJan 1, 2026
Next Review Date
Key ActionCheck the Moda Health website or Member Dashboard to see if a service or supply requires prior authorization.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
15+TOC sections
10Referenced pages/sections
24/7Member Dashboard
2026-01-01Effective date on cover
50% up to $2,500Penalty for missing prior auth
Coverage Criteria & Benefit Summaries
Referenced benefit and administrative sections
Sections listed in the Table of Contents that in the full policy will contain coverage criteria include but are not limited to:
Primary Care (Table of Contents entries referencing primary care and PCP responsibilities).
Prior Authorization (PRIOR AUTHORIZATION; PRIOR AUTHORIZATION REQUIREMENTS; Services Requiring Prior Authorization; Prior Authorization Limitations).
Benefit Description and When Benefits Are Available (sections describing medical necessity, eligibility, and payment limits).
Urgent & Emergency Care, Ambulance, Medical Transportation, Emergency Room Care, Urgent Care (coverage, benefit level and prior authorization exceptions).
Preventive Services (ACA/USPSTF/ACIP/HRSA preventive benefits and frequency rules).
General Treatment Services (acupuncture, anticancer medications, ABA, behavioral health, biofeedback, clinical trials, cochlear implants).
Diagnostic Procedures and Advanced Imaging (including prior authorization requirements).
Pharmacy and Specialty Medications (covered meds, formulary exceptions, specialty pharmacy requirements).
Durable Medical Equipment (DME), Supplies & Appliances (coverage rules, rentals, prior authorization and exclusions).
Vision and Hearing Services (pediatric and adult vision, hearing aid frequency and exam rules).
Dental Benefits (pediatric dental schedule, orthodontia when medically necessary, dental injury).
Rehabilitation and Habilitation Services; Skilled Nursing Facility Care; Transplants; Hospice; Home Healthcare (coverage conditions and limits).
Surgery, TMJ, Therapeutic Injections, Therapeutic Radiology (surgical and procedural coverage and prior authorization).
Virtual Care Visits / Telehealth and Electronic Visits (coverage conditions and technology/licensure requirements).
Exclusions (cosmetic, custodial, experimental/investigational and other listed exclusions).
Administrative sections (TOC)
TOC entries referencing claims, prior authorizations, appeals, external review, coordination of benefits, and related administrative topics.
Claims submission and payment processes (Notice of Claim; How to Send Us Claims; Prescription Medication Claims; Vision Services Claims; Payment of Claims; Explanation of Benefits).
Time frames and inquiries (Time Frames for Processing Claims; Time Frames for Processing Prior Authorizations and Utilization Review; Claim Inquiries).
Appeals, Complaints & External Review (sections for member rights and appeal processes).
Coordination of Benefits/Third Party Liability (sections describing COB, Medicare coordination and related administrative rules).
Prior Authorization administration (locations of full list on Member Dashboard/website and customer service contact points).
Plan networks
Networks applicable to the plan and their associated vendors:
Medical network: Tier 1 Moda Select; Tier 2 First Choice in Alaska.
Dental network: Delta Dental Premier.
Pharmacy network: Navitus.
Out-of-area network: Aetna® PPO Network through Aetna Signature Administrators (for out-of-area coverage).
Vision network: VSP (VSP handles benefit authorization for Tier 1/2 vision providers).
Member support programs
Programs to support members with complex or behavioral health needs:
Care Coordination: Care Coordinators and Case Managers (nurses or behavioral health clinicians) coordinate access to services across levels of care for complex or catastrophic medical situations.
Disease Management & Health Coaching: Health Coaches provide education and support to help members follow provider care plans, self-manage chronic disease, and prevent complications; contact Disease Management and Health Coaching for more information.
Behavioral Health (Moda Behavioral Health): Specialty services for mental health and substance use disorder benefits; Behavioral Health Customer Service assists members in finding Tier 1 and Tier 2 providers and understanding benefits.
Summary coverage criteria and limits (partial)
Summary-level coverage and frequency limits; members must read Section 7 Benefit Description for limitations and requirements.
Preventive services under ACA: see Section 7.3 for age and frequency limits (examples: colonoscopy one per 10 years starting at age 45).
Medical transportation: limited to 2 round-trip tickets per member per year (see Section 7.2.3).
Acupuncture: covered up to 24 visits per year (see Section 7.4.1/7.4.2); prior authorization required when medically necessary.
Applied Behavior Analysis (ABA): 24 visits per year noted in schedule; ABA must be medically necessary and prior authorized with individualized treatment plan required (see Section 7.4.3/7.4.5).
Behavioral health: 24 visits per year shown in schedule; some behavioral services reference a 10-visit lifetime maximum in schedule fragments—see detailed Sections 7.4.x for exact application and limits.
Dental care for members under age 19: frequency limits and benefit specifics apply (see Schedule of Benefits and Section 7.4.8).
Prostate Specific Antigen (PSA) Test: one per year beginning at age 40 (earlier for certain high-risk individuals).
Plan-level cost sharing: plan has no deductible or out‑of‑pocket maximum; covered services are paid at 100% of the Maximum Plan Allowance (MPA) for Tier 1/2 providers; members may be responsible for amounts above MPA when using Tier 3 providers.
Prior authorization: may be required for some services (see Section 6.1). Failure to obtain required prior authorization may result in denial or penalty.
Schedule limits and conditional coverage
Coverage is conditional with explicit limits and cross-references to policy sections for full criteria.
Acupuncture: limited to 24 visits per year; see Section 7.4.1/7.4.2 for details and prior authorization requirements.
Applied Behavior Analysis / Biofeedback / Certain anticancer medication programs: schedule references a 10-visit lifetime maximum for some items—consult the detailed benefit sections for applicability and exceptions.
Dental care (under age 19): frequency limits apply; some minor restorative and orthodontia services covered only when medically necessary (see Section 7.4.8 and Schedule of Benefits).
General condition: frequency limits apply; coverage when medically necessary per the referenced Section 7.4.x; some supplies are covered under Pharmacy benefits (see Section 7.4.10/7.6).
Schedule fragment criteria
Benefit categories and brief constraints shown in the schedule fragment.
Dental Care: pediatric dental benefits apply through end of month member turns 19; frequency limits apply to diagnostic, preventive, minor restorative and other dental services (see Schedule details).
Orthodontia: covered only when medically necessary; payment structure and limits described in pediatric dental section (initial 25% then monthly payments).
Biofeedback: covered only for tension or migraine headaches and subject to a lifetime visit limit (see Section 7.4.5/7.4.x).
Diabetes Services: some supplies are covered under the Pharmacy benefit; insulin and diabetic supplies have pharmacy-specific rules and preferred manufacturer requirements (see Section 7.6).
Diagnostic and Supplemental Breast Exam/Biopsy/Consultation: listed in schedule with cross-reference to diagnostic procedures and breast services sections for full criteria and coverage rules.
Select Coverage Criteria & Limits
Select benefit limits and service-specific rules extracted from the Schedule of Benefits.
Massage Therapy: 24 visits per year (see Section 7.4.22).
Psychological/Neuropsychological Testing: 12 hours per year for testing and evaluation (see Section 7.4.30).
Outpatient Rehabilitation: 45 sessions per year (limits apply separately to rehabilitative and habilitative services).
Inpatient Rehabilitation/Habilitation: 30 days per year (see Section 7.4.31).
Skilled Nursing Facility Care: limited number of days as shown in Section 3 (examples in schedule: 30 or 60 days).
Transplants: must use an authorized transplant facility (Center of Excellence); donor costs and travel/lodging rules apply; travel/lodging capped (example $7,500 per transplant).
Pharmacy Rules: must use Moda-designated mail order and specialty pharmacies for certain medications; mail order up to 90-day supply; specialty meds typically require prior authorization and designated vendor (Section 7.6).
Vision Limits: pediatric vision — one exam and one pair of eyeglasses/contacts per year through age 19; adult vision — one exam annually, frames every 2 years, lenses annually (see Section 7.7).
Hearing Limits: hearing exam once per year; one hearing aid per ear once in a 3-year period; otological exam every 2 years (see Section 7.8).
Network/Tier Policy: Tier assignments determine benefit levels; when no Tier 1 within 50 miles, Tier 2 may be paid at Tier 1 level; Tier 3 may be paid at Tier 1 if no Tier 1/2 within 50 miles; balance billing rules for Tier 3 apply (MPA basis).
Extra-contractual Services: Moda may authorize services outside the policy after case evaluation and agreement with member/provider; such agreements are discretionary and not precedent setting.
Primary Care Provider (PCP): members are encouraged to choose Tier 1 PCP; PCP compositions and change rules referenced in network information.
Benefit availability and prior authorization impact
General benefit availability and prior authorization effect on coverage
Coverage available when services are medically necessary or preventive and performed while coverage is in effect; eligibility, enrollment and premium payment conditions apply.
Many services require prior authorization; a complete list is available on the Member Dashboard or website; failure to obtain required prior authorization may result in denial of benefits or a penalty (see Section 6.1).
Authorizations may be time-limited and limited by provider, number/amount/frequency; services outside authorization limits may be denied.
Transport and emergency care coverage
Urgent, emergency, ambulance and medical transportation coverage rules
Emergency services: covered worldwide at the Tier 1 benefit level; ER facility charges covered under ER benefit; professional fees may be billed separately under other benefits. Prior authorization not required for emergency medical screening or stabilization.
Ambulance transportation: licensed ground, water and air ambulance covered when medically necessary to nearest capable facility; balance billing may apply for Tier 3 ground ambulance providers.
Commercial transportation to obtain care: one-way commercial air or surface transport in Alaska to nearest hospital for sudden, life‑endangering condition covered at Tier 1 when trip begins where member became ill/injured (prior authorization rules apply as specified).
Medical transportation limits: round‑trip medical air transportation limited to member only, maximum 2 round-trip tickets per member per year; prior authorization and written physician certification required; reimbursement limited to lowest available commercial airfare and expenses beyond ticket not covered.
Emergency and urgent care coverage criteria
What is and is not covered under emergency and urgent care benefits
No prior authorization needed: emergency medical screening exams and treatment to stabilize an emergency medical condition are exempt from prior authorization requirements.
Non-emergency exclusions from Tier 1 emergency benefit: Tier 1 benefit not available for care at Tier 3 hospitals or hospitals outside Alaska for non‑emergency care; examples include urgent care visits, chronic condition care, preventive services, elective surgery and outpatient office visits.
Urgent care definition: urgent care covers short-term, minor but urgent medical conditions at facilities distinct from hospital ERs; members must be examined by a professional provider; many walk-in clinics bill as office visits and will be paid under office visit benefits unless billed as urgent care facilities.
Emergency care criteria
Emergency room care coverage and benefit level rules
Eligibility: medically necessary emergency room care for emergency medical conditions (defined in Section 11) is covered worldwide.
Benefit level: all emergency services are paid at the Tier 1 benefit level; using Tier 1/2 ER does not guarantee all providers are Tier 1/2 and balance billing rules for Tier 3 apply as permitted by law.
Prior authorization exception: no prior authorization required for emergency medical screening exams or treatment to stabilize an emergency medical condition.
Transfer and payment limit: if hospitalized in a Tier 3 or out-of-state facility, Tier 1 benefits stop after attending physician determines safe transfer date; Tier 1 benefit not available for non-emergency care at Tier 3 or out-of-state hospitals.
Urgent care criteria
Urgent care coverage rules
Definition: urgent care covers short-term, minor but urgent medical conditions at an urgent care facility (an office/clinic distinct from a hospital ER) when the member is actually examined by a professional provider.
Billing note: most walk-in/same-day clinics do not bill as urgent care; visits billed as office visits are paid under the office visit benefit rather than the urgent care benefit unless the facility bills as an urgent care facility.
Preventive services criteria
Preventive services covered at no cost-sharing when ACA/HRSA/USPSTF/ACIP criteria met
Coverage rule: USPSTF A/B-rated services, ACIP‑recommended immunizations, and HRSA‑recommended pediatric preventive services are covered at no cost sharing when performed by Tier 1 (Tier 2 also covered at no cost sharing); changes in recommendations may take up to one year to reflect no cost sharing.
Colorectal screening: start at age 45 for average risk with modalities and frequencies specified (FOBT/FIT annually; stool DNA every 3 years; CT colonography/sigmoid/ double contrast every 5 years; colonoscopy every 10 years); follow-up colonoscopy after positive screen covered as part of preventive benefit.
Pediatric screenings: newborn hearing within 30 days, routine vision screening ages 3–5, developmental and behavioral screenings per HRSA/USPSTF/state requirements.
Preventive exam frequency: newborn one hospital visit; age 2–4 three exams; age 5+ annual exam; PSA and prostate exam one per year age 40+ (earlier for high risk), mammography limits by age per schedule, and preventive women's visits annual with Pap and pelvic exams.
Treatment and therapy criteria
General treatment, specialty therapy, behavioral health, and other service coverage positions
Medical necessity: all services must be medically necessary; many outpatient services and all non-emergency inpatient/residential care require prior authorization and failure to obtain prior authorization may result in denial or penalty.
Acupuncture: covered up to an annual visit limit; acupuncture must be prior authorized as medically necessary; other services at acupuncture visit billed under standard benefits.
Anticancer medications: covered when prescribed; most require prior authorization and must be obtained from Moda‑designated specialty pharmacy; some require enrollment in assistance programs.
Applied Behavior Analysis (ABA): covered for ASD when medically necessary, provided/supervised by certified/licensed behavior analysts, prior authorized, individualized treatment plan required; specific exclusions apply (family-provided services, custodial/respite, services under IDEA or by state DHSS except employee plans).
Behavioral health levels: intensive outpatient, partial hospital and residential programs have defined intensity/hours; residential programs must be state‑licensed; TMS and intensive outpatient require prior authorization.
Biofeedback: covered only for tension or migraine headaches and subject to a lifetime visit limit; see detailed section for limit specifics.
Clinical trial criteria
Clinical trial coverage criteria
Eligibility: usual care costs for members enrolled in approved clinical trials for cancer or other life‑threatening conditions are covered when treating physician determines no clear superior non‑investigational alternative and available data provide reasonable expectation of benefit.
Covered costs: prevention, diagnosis, treatment, palliative care, investigational items/services necessary for care, diagnosis/treatment of complications, certain FDA‑approved drugs/devices not paid by manufacturer, administration services, and transportation essential to care; excludes nonclinical costs, unapproved trial drugs/devices, items for data collection only, items excluded elsewhere, and items paid by grants/funding.
Authorization: participation in a clinical trial must be prior authorized by Moda Health.
Biofeedback
Biofeedback coverage
Covered only to treat tension or migraine headaches; covered visits are subject to a lifetime visit limit (see Section 7.4.x for the exact limit).
Clinical Trials
Clinical trials coverage and limitations
Usual care costs for approved clinical trials covered subject to same cost sharing as non‑trial care when physician determines no clear superior non‑investigational alternative and reasonable expectation of benefit; participation must be prior authorized. Exclusions include unapproved trial drugs/devices, nonclinical costs, items for data collection only, items excluded in Section 8, and items paid by grants or other funding.
Cochlear Implants
Cochlear implants
Cochlear implants are covered when medically necessary and prior authorized.
Pediatric Dental Care
Pediatric dental coverage details, limits, and non‑covered items
Coverage period: dental care covered through the end of the month you reach age 19, including diagnostic, preventive, minor restorative, endodontic, periodontic, oral surgery, major restorative, prosthodontic and orthodontia (orthodontia only when medically necessary).
Frequency/limits examples: diagnostic exams twice per calendar year; prophylaxis twice per year; full series x‑ray once per 5 years; periodontal scaling once per quadrant in any 2‑year period; crowns/major restorative once per tooth in any 5‑year period; dentures once per tooth site in any 5‑year period.
Orthodontia: covered only when medically necessary; Plan pays 25% at initial placement with balance in monthly payments; obligation ends if treatment stops or eligibility terminates.
Non‑covered examples: TMJ films, cone beam CT, certain behavior management, teledentistry billed separately not covered as separate benefit; implants have specific timing/necessity rules and some implant related services may be excluded.
Dental Injury
Dental injury coverage criteria
Accidental dental injury coverage conditions: accidental injury to natural teeth must be caused by a foreign object or acute trauma (not chewing food), diagnosis within 6 months, treatment begins within 12 months, treatment is medically necessary and provided while covered, and limited to restoring function; implants and implant‑related services are excluded.
Diabetes Services
Diabetes services
Insulin and diabetic supplies (syringes, needles, lancets, test strips, glucometers, CGMs) are covered under the pharmacy benefit when purchased from a pharmacy with a valid prescription and using a preferred manufacturer; insulin pumps may be covered under DME if not obtained from a pharmacy.
Covered diabetes services include HbA1c testing, kidney screening, annual dilated eye exam/retinal imaging, outpatient self‑management training/education, and medical nutrition therapy when prescribed.
Diagnostic Procedures
Diagnostic procedures
Diagnostic services must be for treatment of a medical or behavioral health condition; include x‑rays, lab tests, standard and advanced imaging (MRI/MRA, CT, PET, nuclear medicine), psychological testing and other diagnostic procedures. Most advanced imaging requires prior authorization and full list available on Moda Health website or Customer Service.
DME, Supplies & Appliances
Durable Medical Equipment (DME), supplies & appliances
DME and related supplies are covered when medically necessary; examples include CPAP, insulin pumps, hospital beds, prosthetics, wheelchairs; rental charges covered up to purchase price for most DME.
Diabetic supplies (other than pumps) covered only via pharmacy with prescription and preferred manufacturer; some DME require prior authorization; replacement/repair covered only if not abused and within specifications.
Exclusions: appliances used primarily for comfort/cosmetic, wigs, dental appliances/braces, hearing aids except where otherwise covered, incontinence supplies and certain supporting devices are excluded from DME coverage.
Electronic Visits
Electronic visits
E‑visits (electronic visits) are covered when you are an established patient of the provider and the e‑visit is medically necessary for a covered condition.
Gender Affirming Services
Gender affirming services
Gender‑affirming services are covered when procedures are performed by qualified professional providers, surgical procedures require prior authorization, and the treatment plan meets medical necessity criteria.
Covered examples include mental health services, hormone therapy (including puberty suppression for adolescents), and surgical procedures (breast/chest surgery, gonadectomy, genital reconstruction, gender‑affirming facial surgery) as specified in Section 7.4.35.
Health Education Services
Health education services
Outpatient health education services that manage a covered medical condition are covered (examples: tobacco cessation programs, diabetes education, asthma education, pain management, childbirth and newborn parenting training).
Gender-Affirming Services
Gender-affirming services are covered when conditions are met:
Procedures by qualified providers; surgical procedures require prior authorization; treatment plan must meet medical necessity criteria. Covered services may include mental health, hormone therapy (including puberty suppression), and specified surgical procedures. (See Section 7.4.35 for surgical details.)
Home Healthcare
Home healthcare coverage conditions and provider requirements:
Eligibility: home healthcare services and supplies from a licensed home healthcare agency are covered when you are homebound and services are medically necessary and ordered by your treating physician.
Provider requirements: visits must be intermittent and provided by registered/licensed practical nurse, physical/occupational/speech/respiratory therapist, or licensed social worker; home health aides do not qualify as home health service providers.
Limits: home health visits are subject to an annual limit for registered/licensed practical nurse services; other provider types limited to one visit per day; benefit excludes services provided as part of a hospice treatment plan (covered separately).
Hospice Care and Respite
Hospice services covered when included in a hospice treatment plan for terminally ill members; specifies covered hospice home and inpatient services and respite care rules and exclusions.
Coverage: hospice services and supplies are covered when included in a written hospice treatment plan for terminally ill members and certified by the attending physician; covers hospice home care providers (registered/licensed practical nurse, therapists, home health aide, licensed social worker).
Hospice inpatient care: short‑term hospice inpatient services and supplies for a limited number of days are covered (see section for limits).
Respite care: covered if arranged by attending professional provider, prior authorized, limited number of hours in appropriate setting; non‑professional provider services may be covered with prior approval; does not include caregiver return-to-work coverage.
Exclusions: hospice services provided to others than terminally ill member (e.g., bereavement counseling for family) and services/supplies not in the hospice treatment plan are not covered.
Hospital Care
Hospital inpatient and associated services are covered when medically necessary; includes specific support such as ICU, isolation, facility charges, and limits on take-home drugs.
Coverage: inpatient hospital care covered when medically necessary including hospital room, isolation care, ICU, facility charges for outpatient surgery, and other hospital services and supplies ordinarily provided by a hospital.
Take‑home prescriptions: limited to a 3‑day supply at the same benefit level as hospitalization; anesthesia for certain dental procedures covered when medically necessary and prior authorized for specified patient groups.
Special right upon childbirth: hospital length of stay not restricted to less than 48 hours after vaginal delivery or 96 hours after cesarean; no prior authorization needed to stay up to those limits.
Infusion / Provider-Administered Medications
Infusion and provider-administered medication coverage and billing notes:
Covered infusion services: solutions, medications, pharmacy compounding/dispensing, DME for infusion, ancillary supplies, nursing services, and lab monitoring required to monitor therapy.
Provider requirements: professional provider must obtain prior authorization for infusion therapy; some services/supplies may be included in other billed charges and not covered separately; preferred medication suppliers and preferred treatment centers may be used for cost savings.
Medication administered by provider: medications given in provider office, infusion center or home infusion are covered at the same benefit level as supplies/appliances; self‑administered injectables are not covered under this benefit (see pharmacy section).
Enteral Formula
Nonprescription elemental enteral formula coverage for home use when medically necessary and physician-ordered for severe intestinal malabsorption as sole or essential nutrition source.
Coverage: nonprescription elemental enteral formula for home use is covered when medically necessary and ordered by a physician to treat severe intestinal malabsorption and is sole or essential source of nutrition.
Nutritional Therapy
Nutritional therapy coverage includes assessment and individualized counseling; ACA preventive nutritional therapy covered under listed BMI/age/risk conditions.
Coverage: dietary/nutritional therapy including assessment and individualized counseling is covered; preventive nutritional therapy required by ACA covered at no cost for specified BMI/age/risk criteria (BMI ≥30, overweight with CVD risk factors, children age 6+ overweight/obese, females age 40–60 per specified guidance).
Exclusions: nutritional therapy does not include medical foods or nutritional supplements (see pharmacy/exclusions).
Podiatry Services
Podiatry services covered to diagnose and treat a specific current problem; routine podiatry not covered unless medically necessary due to condition (e.g., diabetes).
Coverage statement: podiatry services are covered to diagnose and treat specific current problems; routine podiatry is not covered unless medically necessary because of conditions such as diabetes.
Phenylketonuria
Phenylketonuria coverage
Coverage: formulas necessary for the treatment of phenylketonuria are covered.
Podiatry Services (duplicate)
Podiatry
Podiatry services are covered to diagnose and treat a specific current problem; routine podiatry is not covered unless medically required (e.g., diabetes).
Pre-admission Testing
Pre-admission testing
Preadmission testing is covered when ordered by a professional provider.
Psychological/Neuropsychological Testing
Psychological/Neuropsychological testing
Testing and evaluation (psychological and neuropsychological) are covered, including interpretation and report preparation necessary to prescribe an appropriate treatment plan; schedule limit example: 12 hours per year for neuropsychological testing as noted in Schedule of Benefits.
Inpatient and Outpatient Rehabilitation/Habilitation & Chronic Pain
Rehabilitative, habilitative and chronic pain care
Rehabilitative services must begin within 24 months of onset and be part of a physician's formal written program to improve and restore lost function; outpatient rehab limit example: 45 sessions/year; inpatient habilitation 30 days/year; limits apply separately to rehabilitative and habilitative services.
Coverage exception: for children under age 7 or those with autism spectrum disorders, neurodevelopmental therapy to restore/improve function and maintenance therapy to prevent significant deterioration are covered and may be excepted from annual limits.
Chronic pain services are subject to annual limits; benefits are not provided for both chronic pain care and neurodevelopmental therapy for the same condition.
Skilled Nursing Facility Care
Skilled nursing facility (SNF) care
Coverage statement: SNF provides rehabilitative and 24‑hour nursing care and a limited number of days are covered as shown in Section 3; covered expenses limited to daily semi‑private hospital room rate.
Exclusions: charges not covered include admissions before coverage start, care mainly for cognitive decline/dementia, routine nursing care, non‑medical self‑help or training, and personal hygiene/custodial care.
Spinal & Other Manipulations
Spinal & other manipulations
Spinal and other manipulations are covered up to an annual visit limit for treatment of a medical condition; other services at a spinal manipulation visit (office visits, lab, x‑ray, PT) are not covered under this benefit and are subject to standard plan benefits; spinal manipulations must be prior authorized.
Surgery
Surgery
Surgery and related facility and professional services are covered when medically necessary; includes primary surgeon, assistant surgeon (MPA for assistant surgeon is 20% of physician MPA or 10% for PA/CRNA), anesthesiologist/CRNA, surgical supplies and facility charges.
Requirements: certain procedures may be outpatient only; eligible office surgeries covered subject to prior authorization; reconstructive procedures must be medically necessary and prior authorized or benefits will not be paid.
Exclusions: cosmetic surgery is not covered except reconstructive/gender‑affirming when medically necessary as specified.
Temporomandibular Joint Syndrome (TMJ)
TMJ
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 services and dental disease/injury treatments are not covered under TMJ benefits.
Therapeutic Injections
Therapeutic injections
Administrative services for therapeutic injections (e.g., allergy shots) are covered when administered in a professional provider's office; when self‑administered meds at home can achieve results, provider administrative services are not covered. Vitamin and mineral injections not covered unless medically necessary. See referenced sections for more details.
Therapeutic Radiology
Therapeutic radiology
Therapeutic radiology covered expenses include treatment planning and simulation, professional services for administration/supervision, and treatments including therapist, facility and equipment charges.
Transplants
Transplants
Medically necessary transplants that follow standard practice and are not experimental are covered; prior authorization should be obtained as soon as possible and must be in writing to be valid.
Network/center requirement: transplants must be done at a Center of Excellence when available; if not available, Moda may prior authorize services at another transplant facility.
Donor costs, travel and housing: donor costs covered when you are recipient or self‑donor with limits and exclusions; travel and housing for recipient and caregiver covered up to a per‑transplant maximum when recipient lives >50 miles from Center of Excellence (e.g., $7,500 per transplant as shown in schedule).
Pharmacy split: immunosuppressives during hospital stay paid as medical supply; outpatient transplant medications paid under pharmacy benefit.
Virtual Care Visits (Telehealth Services)
Virtual care / telehealth
Virtual care (telehealth) is covered when services can be safely and effectively provided virtually, provided by or referred by a provider licensed in Alaska, and using technology that meets state and federal privacy and security standards (unless exempt during state emergency).
Maternity Care
Maternity care
Pregnancy care, childbirth and related conditions are covered when provided by a professional provider; maternity services billed as a global charge (prenatal, labor/delivery, post‑delivery) with some diagnostics reimbursed separately; home birth coverage limited to medically necessary supplies and provider fees only.
Hospital maternity services: nursery care covered under newborn coverage; take‑home prescription drugs limited to a 3‑day supply; minimum hospital stay protections (48 hours vaginal, 96 hours cesarean) apply without prior authorization up to those limits.
Abortion
Abortion
Elective abortions are covered under the plan.
Breastfeeding Support
Breastfeeding support
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) with MPA applying to retail purchases; hospital‑grade pumps covered when medically necessary; extra ice packs/coolers not covered.
Circumcision
Circumcision
Circumcision within 3 months of birth is covered without prior authorization; circumcision after 3 months of age requires medical necessity and prior authorization.
Breastfeeding Support (duplicate)
Breastfeeding and lactation support coverage details:
Lactation support and counseling covered during pregnancy and breastfeeding; breast pumps and supplies covered by purchase or rental (not exceeding purchase price) with MPA applying to retail purchases; hospital‑grade pumps covered when medically necessary.
Circumcision (duplicate)
Circumcision coverage rules:
ONE of: Circumcision within 3 months of birth: covered without prior authorization.
ONE of: Circumcision after 3 months of age: covered when medically necessary and prior authorized.
Maternity Hospital Services
Maternity diagnostic and hospital services:
Diagnostic services related to maternity care (labs, ultrasounds) are covered; some may require prior authorization; see website or Customer Service for full list.
Hospital maternity care (room, facility charges, nursery care) covered; nursery care covered under newborn's coverage; take‑home prescription drugs limited to 3‑day supply at hospitalization benefit level.
Hospital length of stay for childbirth: no prior authorization needed to stay up to 48 hours after vaginal delivery or 96 hours after cesarean (attending provider and member decide in consultation).
Pharmacy Benefits, Limits, and Exclusions
Pharmacy prescription benefit rules, limits, and exclusions:
Covered medications: medically necessary prescription meds, certain compounded meds, insulin and diabetic supplies (with prescription and preferred manufacturer), tobacco dependence meds (with prescription), certain preventive meds, contraceptives, and certain immunizations at in‑network retail pharmacies.
Formulary exception process: members/providers may request exceptions for non‑formulary meds based on medical necessity; decisions within 72 hours (24 hours if urgent); exceptions not used for plan limits/exclusions.
Specialty medications: most require prior authorization and must be obtained from Moda‑designated specialty pharmacy; if unavailable and delay threatens treatment, local fill may be authorized; some specialty scripts limited to <30 days while others eligible for 90‑day supply.
Step therapy & limitations: step therapy requires trial of Step 1 meds before Step 2 covered; new FDA approvals may have review periods and temporary limits; certain brand meds may be time‑limited pending generics; certain specialty meds may be limited to 15‑day supply.
Exclusions: a list of medication and supply exclusions apply (foreign meds, hair growth meds, travel immunizations except ACA, institutional meds, administration charges, meds covered under another benefit, non‑FDA approved meds, nutritional supplements, off‑label use unless supported, OTC except ACA tobacco dependence, repackaged/replacement meds, vitamins except as required, weight loss meds, pharmacies excluded for fraud).
Pediatric Vision Services
Pediatric vision coverage:
Pediatric vision: one complete well‑vision exam and one pair of eyeglasses and frames or contact lenses per year through the end of the month you reach age 19; contact lens supply minimums by replacement schedule apply; some vision services may require prior authorization and VSP handles Tier 1/2 authorizations.
Vision coverage criteria
Vision care coverage and limits
Pediatric vision: under age 19 — one complete well‑vision exam annually and one pair of eyeglasses & frames or contact lenses per year (contacts supply minimums specified); optional lens enhancements limited to listed coatings/types.
Adult vision: age 19+ — one complete eye exam annually, one pair of corrective lenses annually, one pair of frames every 2 years; elective contacts in lieu of eyeglasses covered per limits; low vision testing/aids per schedule.
Hearing coverage criteria
Hearing services coverage and limits
Hearing services: one audiological exam and evaluation annually; one hearing aid per ear once in a 3‑year period; otological exam every 2 years; hearing aid accessories and follow‑up covered as listed; exam by licensed physician required before obtaining hearing aid.
Exclusions
Exclusions (partial list shown here)
Vision exclusions: plano lenses under ±0.50 diopter, two pairs instead of bifocals, insurance/service agreements for contact lens coverage, artistically painted/non‑prescription contacts, extra office visits for contact lens pathology, contact lens modification/polishing/cleaning are not covered.
General exclusions: cosmetic procedures (unless reconstructive/gender‑affirming medically necessary), custodial care, experimental/investigational procedures and medications, services not stated as covered, care outside U.S. except urgent/emergency, charges over plan allowance, court‑ordered services unless medically necessary, educational/vocational/recreational services, faith healing, certain hearing aid implantable/surgical implantation are excluded among others listed in Section 8.
Coding, Payment & Frequency Key Points
No specific medical codes listed in this excerptmixed
| No codes listed |
Not specified in this excerptmixed
| No codes listed |
not specifiedmixed
| No CPT/HCPCS/ICD codes listed in this document fragment. |
Payment basismixed
| MPA | Maximum Plan Allowance used to determine payment for Tier 1 and Tier 2 providers; Tier 3 MPA set by national database |
Services that may require prior authorizationmixed
| Inpatient services and residential programs; outpatient services; rehabilitation (OT/PT/ST); spinal manipulations, acupuncture, massage therapy; diagnostic services including imaging; infusion therapy; medications. Full list available on Moda Health website. |
Colorectal screeningmixedCovered
| FOBT/gFOBT/FIT annually; stool DNA (MT-sDNA/sDNA-FIT/FIT-DNA) every 3 years; CT colonography/flexible sigmoidoscopy/double contrast barium enema every 5 years; flexible sigmoidoscopy every 10 years plus FIT annually; colonoscopy including polyp removal every 10 years (start age 45+) |
Women's preventive servicesmixedCovered
| Annual pelvic and breast exam and Pap test; mammogram once between ages 35–39 and annually at age 40 and older; other Pap tests and breast imaging covered per clinical need or high risk |
Pediatric dental endodonticsmixedCovered
| Therapeutic pulpotomy; partial pulpotomy for apexogenesis; pulpal therapy (resorbable filling) for primary incisors up to age 6 and for primary molars/cuspids up to age 11 once per tooth per lifetime; root canal therapy; retreatment at least 2 years after original; apexification/recalcification; pulpal regeneration; apicoectomy and periradicular surgery; root amputation; hemisection |
Pediatric dental major restorativemixedCovered
| Inlays (limited to filling benefit); onlays and crowns once per tooth in any 5-year period; crown buildup once per tooth in any 5-year period; core buildup including pins with crown; prefabricated post and core once per tooth in any 5-year period; crown repair case-by-case |
Gender-affirming surgical categoriesmixedCovered
| Surgical procedures include breast/chest surgery; gonadectomy (hysterectomy/oophorectomy or orchiectomy); reconstruction of the genitalia; gender-affirming facial surgery. Prior authorization required and treatment plan must meet medical necessity; services by qualified providers. |
Surgical payment allocationmixed
| Maximum plan allowance (MPA) for an assistant surgeon is 20% of the physician's MPA (10% if the assistant is a PA or CRNA). |
Maternity and lactation servicesmixedCovered
| Comprehensive lactation support and counseling; purchase or rental of breast pump and supplies (rental not to exceed purchase price); MPA applies to retail breast pump purchases; hospital-grade pumps covered when medically necessary; hospital maternity services including room, facility charges, nursery care; take-home prescription drugs limited to a 3-day supply; minimum hospital stay 48 hours vaginal/96 hours cesarean without prior authorization. |
Pharmacy specialty and step therapymixedCovered
| Specialty medications often require prior authorization and must be obtained from a Moda-designated specialty pharmacy for coverage; when part of step therapy you must try required Step 1 meds before Step 2 will be covered; some specialty meds may require program enrollment; local fill may be authorized in urgent situations. |
Vision and hearing benefit itemsmixed
| No codes listed |
inv-75: N/A in this excerpt — placeholder key/value
N/A in excerptNo specific coding or threshold data available in this excerpt.
Use guidanceRefer to full policy sections and Member Dashboard for complete coding lists and thresholds.
Actionable noteNo codes provided here — do not rely on this excerpt for claim coding decisions.
inv-76: Colonoscopy frequency
Colonoscopy frequencyOne per 10 years for average-risk members starting at age 45.
Related modalitiesOther colorectal screening modalities and frequencies (FOBT/FIT yearly; stool DNA every 3 years; CT colonography/sigmoidoscopy every 5 years) are listed in preventive services.
High-risk exceptionScreening may start earlier or be more frequent if medically necessary for high-risk members.
inv-77: Mammogram frequency
Mammogram frequencyOne mammogram referenced in the schedule (age range shown as 35-40 in this excerpt); follow Section 7.3 for age-specific guidance.
Women's preventive servicesPreventive women's visits (annual pelvic/breast exam and Pap) and mammography limits are described in the women's preventive services section.
ActionConfirm exact age-based mammography intervals in Section 7.3 of the full policy before authorizing or billing.
inv-78: PSA test frequency
PSA test frequencyProstate Specific Antigen (PSA) test: one per year starting at age 40 (earlier at age 35–40 for African American or family history as noted).
Related examRectal (prostate) exam referenced alongside PSA testing in preventive services (see Section 7.3.6).
High-risk noteHigher-risk individuals may have different age thresholds; follow provider recommendation and Section 7.3.6.
inv-79: Visit and lifetime limits shown — examples
Example visit limitsExamples shown in the schedule include limits such as 24 visits per year for certain services and 10-visit lifetime maximums for others.
Where to find detailsFull visit and lifetime limits are described in the Schedule of Benefits and referenced Sections (e.g., 7.4.x) for each service.
Common services with limitsAcupuncture and many behavioral health services show 24 visits/year; some therapies and biofeedback show a 10-visit lifetime cap.
inv-80: biofeedback_lifetime_limit
Biofeedback lifetime limitBiofeedback is subject to a 10-visit lifetime maximum (covered only for tension or migraine headaches).
Clinical scopeCovered only to treat tension or migraine headaches and subject to lifetime visit limit per Schedule of Benefits.
ReferenceSee Schedule of Benefits and Section 7.4 for biofeedback details and medical necessity criteria.
inv-81: Balance billing responsibility
Balance billing responsibilityWhen you receive services from Tier 3 (out-of-network) providers, any amounts charged above the Maximum Plan Allowance (MPA) may be your responsibility (balance billing).
MPA basisMPA is the contracted fee for Tier 1/2; Tier 3 MPA is set by a national database (see Payment section).
Reimbursement processMembers may need to pay provider in full and file a claim for reimbursement limited to Tier 3 payment levels.
inv-82: Authorization validity limits
Authorization validity limitsAuthorizations are valid for a set period; authorized services received outside that period may not be covered.
Scope of limitsAuthorizations may limit provider, number/amount/frequency, and specific services covered; limits disclosed in the authorization letter.
Care coordinator helpCare Coordinators or Case Managers can assist members in understanding authorized treatment and limits.
inv-83: Medical transportation limit
Medical transportation limitMedical transportation benefit limited to a maximum of 2 round-trip commercial airline tickets per member per year (member only).
Prior authorization and certificationPrior authorization and written physician certification are required in advance; reimbursement limited to lowest commercial airfare available.
Covered trip examplesCovers initial and follow-up therapeutic visits, pre/postnatal visits and delivery, pre/post surgical visits, and certain allergic condition visits.
inv-84: Preventive exam frequency
Preventive exam frequencyPreventive exam schedule: Newborn – one hospital visit; Age 2–4 – three exams; Age 5 and above – one exam annually.
Well-baby timingWell-baby exams are scheduled during the first 24 months per the preventive schedule; see Section 7.3 for details.
ActionConfirm age-specific preventive services and any ACA-required items in Section 7.3 when authorizing or coding preventive visits.
inv-85: Colorectal screening age threshold
Colorectal screening start ageColorectal cancer screening begins at age 45 for average-risk members; earlier or more frequent screening covered if medically necessary for high-risk individuals.
Modalities coveredSupported screening options include FOBT/FIT annually, stool DNA every 3 years, CT colonography/sigmoidoscopy every 5 years, colonoscopy every 10 years.
Follow-up coverageFollow-up colonoscopy after a positive USPSTF-recommended screening is covered as part of the preventive benefit.
inv-86: Diagnostic exams frequency
Diagnostic exams frequencyCertain diagnostic exams (dental diagnostic exams in pediatric dental schedule) are covered up to twice per calendar year.
ScopeIncludes diagnostic exams and some re-evaluations as outlined in the pediatric dental section; see Section 7.4.36 for specifics.
Confirm in full policyVerify frequency for non-dental diagnostic procedures in the full diagnostic procedures section before authorization.
inv-87: Periodontal scaling frequency
Periodontal scaling frequencyPeriodontal scaling and root planing: once per quadrant in any 2-year period.
Dentures replacement frequencyComplete or partial dentures: once per tooth site in any 5-year period.
Prosthodontic limitsOther prosthodontic services have specific timing/limits (see pediatric dental prosthodontic section).
inv-88: Dentures replacement frequency
Dentures replacement frequencyComplete or partial dentures covered once per tooth site in any 5-year period.
Implant timingDental implants may be covered when dentally necessary at least 5 years after last cast restoration; implant-related items have separate rules.
Repair/adjustmentAdjustments, repairs, recementation or replacement of broken denture tooth are covered per limits described in the prosthodontic section.
inv-89: take-home prescription drug limit
Take-home prescription drug limitTake-home prescription drugs following hospitalization are limited to a 3-day supply at the same benefit level as hospitalization.
Inpatient medication billingInpatient medications are covered under the medical plan while hospitalized; outpatient prescription benefit does not apply during inpatient stay.
Maternity noteThis 3-day take-home supply limit is explicitly noted for maternity hospital services as well.
inv-90: home health nurse annual limit
Home health nurse annual limitHome health visits for a registered or licensed practical nurse are subject to an annual limit (limit specified in full policy Schedule of Benefits).
Other home healthcare limitsOther home healthcare provider types limited to one visit per day; homebound definition and prior physician order required.
ActionRefer to the Schedule of Benefits/Section 7.4 for the exact numeric annual limit when authorizing home health RN/LPN visits.
inv-91: massage therapy visit limit
Massage therapy visit limitMassage therapy is covered up to an annual visit limit (exact number specified in the full Schedule of Benefits) and requires prior authorization.
Benefit scopeMassage therapy does not include manual therapy and other services which are billed under standard benefits.
Prior authorizationMassage therapy must be prior authorized before services are rendered.
inv-92: Assistant surgeon MPA percentage
Assistant surgeon MPA percentageMaximum Plan Allowance (MPA) for an assistant surgeon is 20% of the physician's MPA; when the assistant is a PA or CRNA, the MPA is 10%.
Payment basisMPA is used to pay covered expenses for Tier 1/2 providers; Tier 3 MPA set by national database.
Billing implicationAssistant surgeon payments follow MPA percentages and are subject to standard MPA rules and balance-billing for Tier 3.
inv-93: hospital stay minimums
Hospital stay minimums after childbirthMinimum covered hospital stay: up to 48 hours after a normal vaginal delivery and up to 96 hours after a cesarean section; no prior authorization required to stay up to these limits.
Member choiceYou may go home earlier if you wish; attending provider will determine discharge timing in consultation with you.
Newborn coverageNursery care is covered under the newborn's own coverage while you are confined receiving maternity benefits.
inv-94: formulary exception decision timeframe
Formulary exception decision timeframeFormulary exception requests will be decided within 72 hours (or within 24 hours if the request is urgent).
Criteria for exceptionExceptions are considered when formulary meds were ineffective, not tolerated, or expected to be harmful; decision process involves contacting prescribing provider.
ScopeFormulary exception process is not used for denials based on plan limitations or exclusions unrelated to formulary status.
inv-95: frequency limits — pediatric and adult vision/hearing
Vision frequency limits (pediatric & adult)Pediatric vision: one complete well-vision exam and one pair of eyeglasses or contacts annually through end of month member turns 19. Adult vision: one exam annually, frames every 2 years, corrective lenses annually.
Hearing frequency limitsHearing: one audiological exam annually; one hearing aid per ear once every 3 years; otological exam every 2 years.
Contact lens supplyPediatric contact lenses require minimum supply depending on replacement schedule (standard one pair/year; monthly 6-month supply; bi-weekly 3-month; daily 3-month).
Provider Actions, Prior Authorization & Billing Alerts
Prior Authorization
Prior Authorization (TOC references)
Table of Contents entries show dedicated prior authorization sections: “PRIOR AUTHORIZATION,” “PRIOR AUTHORIZATION REQUIREMENTS,” “Services Requiring Prior Authorization,” and “Prior Authorization Limitations.” Providers should consult these sections for details on which services require authorization.
Prior Authorization
Prior authorizations timing (TOC reference)
The TOC references a section titled “Time Frames for Processing Prior Authorizations and Utilization Review” (see Table of Contents). Providers should expect specified timeframes for authorizations and utilization review in that section.
Prior Authorization
Prior authorization information access
Check Moda’s Member Dashboard and the referral page to verify whether a requested service or supply requires prior authorization: www.modahealth.com/medical/referral.
Documentation Required
Member ID card requirement
Ask members to present their Moda Health ID card at each visit; if a member loses their card, request a replacement via the Member Dashboard or Customer Service.
Prior Authorization
Prior authorization note
Some services in the Schedule of Benefits may require prior authorization; providers must review Section 6.1 for specifics before delivering those services.
Documentation Required
Medical necessity cross-reference
Coverage for services is contingent on medical necessity in referenced sections; providers should follow cross-references such as Section 7.4.9 for medical necessity criteria when requesting authorization.
Documentation Required
Section references present in schedule
The Schedule and related sections include numbered cross-references (for example Section 7.4.9, 7.4.10, 7.4.11) that indicate where detailed prior authorization and benefit rules are located; consult those sections for full criteria.
Prior Authorization
Extra‑contractual Services Authorization
Moda may approve extra‑contractual (outside-policy) services after case evaluation and agreement with the member and provider; such authorizations can be ended by any party with written notice.
Prior Authorization
Prior authorization initiation and emergency admission timing
Providers must contact Moda Health for prior authorization before services that require it. For emergency hospital admissions, the provider must authorize the admission with Moda within 48 hours after admission (or as soon as reasonably possible).
Denial Risk
Penalty for failure to obtain prior authorization
If required prior authorization is not obtained for inpatient, residential, urgent, outpatient or ambulatory services, a penalty of 50% (up to $2,500) will be applied to covered charges per occurrence; the penalty does not apply to emergency admissions.
Documentation Required
Prior authorization limitations and scope
Authorizations may be time‑limited, limited to specific providers, or limited by number/amount/frequency; any such limits will be described in the authorization letter and services outside those limits may be denied.
Note
Location of complete prior authorization list and contact points
A complete, up‑to‑date list of services and supplies that require prior authorization is available on the Moda Health website and Member Dashboard; providers may contact Customer Service or Behavioral Health Customer Service for mental health/substance use authorization details.
Prior Authorization
Prior authorization rules (excerpt)
Prior authorization is not required for emergency medical screening exams or treatment to stabilize an emergency medical condition; however, many non‑emergency inpatient/residential and outpatient services do require prior authorization.
Prior Authorization
Acupuncture prior authorization
Acupuncture services are covered up to an annual visit limit and must be prior authorized as medically necessary.
Prior Authorization
Anticancer medication prior authorization
Most anticancer medications require prior authorization and specific benefit limitations; many must be obtained from Moda’s designated specialty pharmacy and may require enrollment in manufacturer or provider programs.
Documentation Required
ABA prior authorization and documentation
Applied Behavior Analysis (ABA) services for autism spectrum disorder must be medically necessary, prior authorized, and accompanied by submission of an individualized treatment plan by the provider.
Prior Authorization
Behavioral health prior authorization and licensing
Behavioral health intensive outpatient programs and TMS require prior authorization; residential behavioral programs must be state‑licensed for coverage.
Prior Authorization
Clinical trial prior authorization
Participation in an approved clinical trial must be prior authorized by Moda Health before enrollment for coverage of usual care costs related to the trial.
Prior Authorization
Clinical Trials prior authorization
(See duplicate clinical trials entry.) Participation in a clinical trial requires prior authorization by Moda Health.
Prior Authorization
Cochlear implants prior authorization
Cochlear implants are covered when medically necessary and require prior authorization.
Prior Authorization
Advanced imaging prior authorization
Most advanced imaging and many diagnostic imaging services (MRI, MRA, CT, PET, nuclear medicine and cardiac imaging) must be prior authorized (see section 6.1.1).
Prior Authorization
Gender‑affirming surgery prior authorization
Surgical procedures for gender‑affirming care require prior authorization; providers must ensure surgical treatment plans meet medical necessity criteria.
Prior Authorization
DME prior authorization
Some durable medical equipment (DME) items require prior authorization; a full list of equipment requiring authorization is available on the Moda Health website or via Customer Service.
Prior Authorization
Gender‑affirming surgical prior authorization
(Duplicate) Prior authorization is required for surgical procedures related to gender‑affirming treatment.
Prior Authorization
Infusion therapy prior authorization
The professional provider must obtain prior authorization for infusion therapy; certain infusion treatment programs and related medications also require prior authorization.
Prior Authorization
Massage prior authorization
Massage therapy is covered up to an annual visit limit and must be prior authorized.
Prior Authorization
Respite care prior authorization
Respite care must be arranged by the attending professional provider and prior authorized; approval is required before services are provided.
Prior Authorization
Spinal Manipulation Prior Authorization
Spinal manipulations are covered up to an annual visit limit and must be prior authorized.
Prior Authorization
Transplant and Select Surgery Prior Authorization
For transplant candidates, obtain prior authorization as soon as possible after identification; written prior authorization from Moda Health is required for transplant coverage and associated network requirements apply.
Prior Authorization
Circumcision Prior Authorization
Circumcision performed within three months of birth is covered without prior authorization; circumcision after three months of age must be medically necessary and prior authorized.
Prior Authorization
Reconstructive Surgery Prior Authorization
Reconstructive procedures must be medically necessary and prior authorized; benefits will not be paid without required authorization.
Prior Authorization
Circumcision prior authorization (duplicate)
(Duplicate) Circumcision after three months of age requires prior authorization; circumcision within three months of birth does not require prior authorization.
Prior Authorization
Diagnostic prior authorization note
Some diagnostic procedures related to maternity care (labs, ultrasounds) may require prior authorization; providers should consult the full list on the Moda Health website or contact Customer Service.
Prior Authorization
Specialty medication prior authorization and network requirement
Most specialty medications must be prior authorized and must be obtained from a Moda‑designated specialty pharmacy to be covered; in urgent unavailability situations Moda may authorize a local fill.
Prior Authorization
Vision services prior authorization
Some vision services may require prior authorization; VSP provides benefit authorization directly to Tier 1 and Tier 2 providers and members must identify themselves as VSP members so authorization is obtained.
Documentation Required
Prior authorization and vendor routing
Vision and hearing vendor routing: VSP provides benefit authorization directly to Tier 1/2 vision providers; some vision and hearing services may require prior authorization and authorization or vendor routing rules determine payment levels.
Definitions & Subscriber Notices
inv-132: Subscriber refund/cancellation
Subscriber refund/cancellation rightThe subscriber may return this policy within 10 days of delivery for a refund of the premium; if returned, the policy is canceled from the beginning as if never issued.
Effect of returnCancellation is effective from the start date; subscriber must act within 10 days of delivery to exercise this right.
ReferencePolicy cover page and introductory notice include this 10-day right to return (refund/cancellation).
inv-133: Policy authorization/signature
Policy authorization/signatureThis policy is authorized by the signature of a Moda Health representative (Scott Loftin, Senior Vice President).
Legal effectThe signature on the policy authorizes the document as the contract description of coverage between the subscriber and Moda Health.
Document locationAuthorization appears on the policy cover page and introductory material.
inv-134: Definitions
Definitions sectionA Definitions section is included and listed in the Table of Contents (see TOC references).
PurposeContains defined terms used throughout the policy to interpret benefits, limits, and procedures.
LocationTOC indicates Definitions appear among administrative sections (e.g., Complaints, Appeals & External Review).
inv-135: Continuity of Care
Continuity of CareA Continuity of Care section is listed in the Table of Contents and addressed in the policy administrative sections.
FunctionProvides member protections and instructions when changing providers or transitioning care (details in full policy).
Where to findSee the Table of Contents and referenced sections for full continuity of care rules and procedures.
inv-136: Policy / Coverage
Policy / Coverage definitionThis policy is a description of your individual health coverage and may be changed or replaced without agreement of any member other than the subscriber.
Access to current policyThe most current policy is available on the Member Dashboard; plan provisions governed by the policy between subscriber and Moda Health.
Member resourcesMember Dashboard and Customer Service contacts are provided for questions and policy information.
inv-137: Child-only coverage
Child-only coverage noteIf this is a child-only policy, references to dependents (spouse, domestic partner or children) are deleted; siblings of the subscriber are eligible.
Effect on languagePolicy language will be interpreted with child-only adjustments where applicable.
ActionConfirm policy type (child-only or not) when applying dependent-related provisions.
inv-138: Care Coordinators and Case Managers
Care Coordinators and Case ManagersCare Coordinators and Case Managers are nurses or behavioral health clinicians who coordinate access to services across levels of care for members with complex or catastrophic needs.
ServicesThey work directly with members and providers to coordinate healthcare services and can assist with authorized treatment access.
ContactContact information and program details are available via Member Dashboard and Customer Service.
inv-139: Health Coach
Health Coach roleHealth Coaches provide education and support to help members follow provider care plans, self-manage chronic disease, and prevent complications.
Program scopePart of Disease Management & Health Coaching to improve health status, quality of life and productivity.
AccessContact Disease Management and Health Coaching via Member Dashboard for enrollment and information.
inv-140: Health Coach / Disease Management
Health Coach / Disease ManagementHealth Coaches help members identify healthcare goals, self-manage disease, and follow provider care plans as part of Disease Management and Health Coaching programs.
ServicesIncludes education, support, and assistance in chronic disease management; contact program for more information.
IntegrationWorks with Care Coordinators/Case Managers for members with complex needs.
inv-141: Behavioral Health (Moda Behavioral Health)
Behavioral Health (Moda Behavioral Health)Vendor provides specialty services for managing mental health and substance use disorder benefits and helps members locate Tier 1 and Tier 2 providers.
SupportBehavioral Health Customer Service assists members in understanding benefits and finding appropriate providers.
Prior authorizationMany behavioral health services (intensive outpatient, residential, TMS) require prior authorization per Schedule of Benefits.
inv-142: Frequency limits apply to some services
Frequency limits applyFrequency limits apply to some services; specific limits are listed in the Schedule of Benefits and referenced sections.
ExamplesExamples include acupuncture, rehab services, pediatric dental frequencies, and annual visit caps for various therapies.
ImplicationCheck the Schedule of Benefits or Section 7.4 for precise frequency limits before authorizing or billing.
inv-143: When medically necessary
When medically necessaryServices are covered when medically necessary per referenced sections (e.g., Section 7.4.9); medical necessity determines coverage for many services.
Cross-referencesSee the referenced benefit sections (7.3/7.4) for specific medical necessity criteria and documentation requirements.
Provider actionPrior authorization and supporting documentation may be required to demonstrate medical necessity.
inv-144: Biofeedback
Biofeedback definitionBiofeedback is covered only to treat tension or migraine headaches and is limited to a 10-visit lifetime maximum.
Limit referencedLifetime limit appears in the Schedule of Benefits; confirm service codes and authorization requirements in Section 7.4.
Medical necessityCoverage requires medical necessity determination and prior authorization if applicable.
inv-145: Dental Care / Orthodontia
Pediatric dental / OrthodontiaPediatric dental care covered through end of month member turns 19; orthodontia covered when medically necessary with specific payment terms.
Frequency & limitsDiagnostic exams twice per calendar year; prophylaxis twice per calendar year; periodontal scaling once per quadrant in any 2-year period; crowns and certain restorations limited to once per tooth in any 5-year period.
Orthodontia paymentOrthodontia covered only when medically necessary; Plan pays 25% at initial placement with balance paid monthly and obligations end if treatment stops or eligibility terminates.
inv-146: Moda Select network (Tier 1)
Moda Select network (Tier 1)Tier 1: Moda Select — provides the highest level of benefits in specified Alaska service areas.
Service areaTier 1 service area includes listed boroughs and census areas (e.g., Anchorage, Juneau, Fairbanks North Star, Kenai Peninsula, etc.).
Benefit implicationUsing Tier 1 providers yields highest benefit levels and reduced member financial responsibility.
inv-147: First Choice network (Tier 2)
First Choice network (Tier 2)Tier 2: First Choice — used in Alaska outside the Moda Select service area; Tier 2 providers may be paid at Tier 1 level when Tier 1 not reasonably accessible within 50 miles.
Access ruleWhen no Tier 1 within 50 miles of residence, a Tier 2 provider can be used at the Tier 1 benefit level.
Provider searchProviders searchable via the First Choice provider search link shown in the policy.
inv-148: Out-of-network providers (Tier 3)
Out-of-network providers (Tier 3)Tier 3: Out-of-network providers — members may be balance-billed for amounts charged above the MPA and often must pay provider and file for reimbursement limited to Tier 3 payment levels.
When Tier 3 paid at Tier 1 levelIf no reasonable access to Tier 1/2 within 50 miles, Tier 3 may be paid at Tier 1 benefit level; otherwise services billed by Tier 3 are paid at Tier 3 level.
Member actionMembers should confirm network status and consider member reimbursement process if using Tier 3 providers.
inv-149: Maximum Plan Allowance (MPA)
Maximum Plan Allowance (MPA)MPA is the contracted fee amount used to pay covered expenses for Tier 1 and Tier 2 providers; Tier 3 MPA is set by a national database.
Balance billing linkAmounts charged above the MPA by Tier 3 providers may be balance-billed to the member.
Payment principleExcept for plan limitations, Tier 1 and Tier 2 providers agree to look only to Moda Health for compensation when Moda is the paying insurer.
inv-150: Emergency services
Emergency services coverageEmergency medical conditions are covered worldwide and emergency services are paid at the Tier 1 benefit level; prior authorization not required for emergency screening or stabilization.
ScopeER facility charges covered under ER benefit; separate professional fees are paid under inpatient/outpatient benefits.
Transfer ruleIf hospitalized in a Tier 3 or out-of-state facility, Tier 1 benefits stop after treating physician determines safe transfer date.
inv-151: Urgent care facility
Urgent care facility definitionAn urgent care facility is an office or clinic distinct from a hospital emergency room providing short-term care for minor but urgent conditions; member must be examined by a professional provider.
Billing distinctionMany walk-in or same-day clinics bill as office visits; such visits will be paid under the office visit benefit unless facility bills as an urgent care facility.
Coverage noteUrgent care is covered when billed by an urgent care facility and member is examined by a professional provider.
inv-152: Urgent care facility (duplicate definition)
Urgent care definition (alternate)An office or clinic distinct from a hospital ER that diagnoses and treats illness/injury for patients without an appointment seeking immediate medical attention.
Coverage implicationConfirm facility billing designation to determine whether visit is paid under urgent care or office visit benefit.
Member actionAsk facility whether they bill as urgent care to ensure correct benefit application.
inv-153: Applied Behavior Analysis (ABA)
Applied Behavior Analysis (ABA)ABA is a structured treatment program for autism spectrum disorder provided or supervised by certified/licensed behavior analysts; services must be medically necessary, prior authorized, and require an individualized treatment plan.
SettingCovered in approved settings including home, licensed health care facility, or other Moda-approved settings.
ExclusionsServices by family/household members, respite/custodial care, certain therapies and services under IDEA or provided by state DHSS are excluded.
inv-154: Intensive outpatient and partial hospital program definitions
Intensive outpatient & partial hospital definitionsIntensive outpatient: mental health = 3+ hours/week; SUD = 9-19 hours/week (adults) or 6-19 hours/week (adolescents). Partial hospital: >=4 hours/day and >=20 hours/week of direct structured treatment.
Licensing requirementResidential programs must be state-licensed for coverage; partial hospital programs are licensed facilities providing structured treatment.
Prior authorizationIntensive outpatient and TMS require prior authorization as noted in behavioral health rules.
inv-155: Electronic visit (e-visit)
Electronic visit (e-visit)An e-visit is a structured, secure online consultation covered when you are an established patient and the e-visit is medically necessary for a covered condition.
Provider requirementE-visits must be with your professional provider and meet medical necessity to be covered.
Use caseAppropriate for follow-up/triage and certain minor conditions per provider discretion.
inv-156: Natural teeth / Dental injury
Natural teeth / Dental injuryDental injury coverage applies to accidental injury to natural teeth when diagnosis within 6 months, treatment begins within 12 months, treatment is medically necessary and restores function; implants and implant-related services are not covered.
RequirementsAccidental injury must be caused by a foreign object or acute trauma; treatments must be provided while covered by the policy.
ExclusionsImplants and implant-related services excluded from dental injury coverage.
inv-157: Homebound
Homebound definitionHomebound means you generally cannot leave home because of your condition; if you do leave, it must be infrequent, short, and mainly for medical treatment.
Home healthcare providersCovered home healthcare visits must be ordered by treating physician and provided by RN/LPN, physical/occupational/speech/respiratory therapists, or licensed social worker; home health aides do not qualify.
Visit limitsHome health RN/LPN visits subject to an annual limit; other home healthcare providers limited to one visit per day.
inv-158: Hospice treatment plan
Hospice treatment planA hospice treatment plan is a written plan of care established and periodically reviewed by the attending physician certifying terminal illness and describing services and supplies for palliative care.
Coverage conditionServices and supplies are covered when included in the hospice treatment plan and are medically necessary for intermittent or palliative care.
Provider requirementHospice must be Medicare-approved or state-licensed/certified agency to provide covered hospice services.
inv-159: Hospital
Hospital definitionA hospital is a licensed facility providing surgical, medical and psychiatric care with 24-hour nursing and physician supervision; certain federal facilities covered when legally required.
Included servicesCovered hospital services include room, ICU, isolation, facility charges for outpatient surgery, and other medically necessary supplies/services ordinarily provided by a hospital.
Take-home drug limitTake-home prescription drugs after hospitalization limited to a 3-day supply at hospitalization benefit level.
inv-160: Virtual Care Visits (Telehealth Services)
Virtual Care Visits (Telehealth Services)Virtual care (telehealth) is live, interactive audio/visual/data communication visits covered when generally accepted practice supports safe/effective virtual care and provider is licensed in Alaska or referred by such a provider.
Technology standardsProvider must use technology meeting state and federal privacy/security standards unless exempt during a state emergency.
ScopeIncludes diagnosis and treatment of chronic or minor medical conditions when appropriate.
inv-161: Transplant
Transplant definitionTransplant: procedures where tissue is removed from one person and implanted in another, or removed and later reimplanted into the same body; covered when medically necessary and not experimental.
Prior authorizationPrior authorization should be obtained as soon as possible and must be in writing from Moda Health to be valid.
Coverage limitsTransplant benefits subject to specified limitations and Center of Excellence/network requirements detailed in transplant section.
inv-162: Habilitative services
Habilitative servicesHabilitative services are those necessary for development of bodily or cognitive functions not developed appropriately for chronological age; includes medically necessary therapy to retain skills and prevent regression.
ExclusionsHabilitative services exclude respite, day habilitation, chore, educational, vocational, recreational or custodial services.
Coverage noteHabilitative services for eligible children may be subject to annual visit limits except for certain autism-related services.
inv-163: Rehabilitative services
Rehabilitative servicesRehabilitative services are those necessary to restore bodily or cognitive functions lost due to a medical condition; maintenance therapy without improvement is not considered rehabilitative.
LimitsRehabilitative services are subject to annual visit limits; therapy must be part of a physician's formal written program to improve and restore function.
Visit countingEach session or therapy by a different professional counts as one visit; multiple sessions by same provider in one day count as one visit.
inv-164: Breastfeeding Support
Breastfeeding SupportComprehensive lactation support and counseling covered during pregnancy and/or breastfeeding; purchase or rental of a breast pump and supplies covered (rental not to exceed purchase price); MPA applies to retail purchases.
Hospital-grade pumpHospital-grade pumps covered when medically necessary; extra items like ice packs/coolers not covered.
Payment noteMPA applies for retail purchases; rental not to exceed purchase price.
inv-165: Specialty Medications
Specialty MedicationsSpecialty medications treat complex chronic conditions, often require prior authorization and must generally be obtained from a Moda-designated specialty pharmacy.
Local fill exceptionIf specialty medication unavailable and delay threatens treatment efficacy or life, Moda may prior authorize a local fill.
Program requirementsSome specialty meds may require enrollment in manufacturer/provider programs and may have supply limits (some limited to <30 days, some eligible for 90-day supply).
inv-166: Pediatric Vision Services
Pediatric Vision ServicesOne complete well-vision exam and one pair of eyeglasses/frames or contact lenses covered annually through the end of the month you turn 19.
Contact suppliesContact lenses require specified minimum supplies depending on replacement schedule (standard one pair/year; monthly 6-month supply; bi-weekly 3-month; daily 3-month).
Authorization routingVSP provides benefit authorization directly to Tier 1 or Tier 2 providers; members should identify as VSP when scheduling to ensure authorization flow.
inv-167: Tier provider / benefit authorization
Tier provider / benefit authorizationVSP provides benefit authorization directly to Tier 1 or Tier 2 vision providers; Tier 3 providers may be reimbursed at limited levels and members may need to pay in full and request reimbursement.
Member actionIdentify yourself as a VSP member when contacting a Tier 1/2 doctor so the doctor will obtain benefit authorization from VSP.
Payment implicationIf services obtained from non-Tier 1/2 provider without authorization, member responsible for payment and reimbursement limited to Tier 3 levels.
Policy Summary
Payermoda_health_plan_inc
Policy2026 Alaska Individual Medical Plan — Table of Contents & Introductory Notice
Policy CodePolicy ModaAKIndvCSV0bk 1-1-2026
Change TypeNo material changes indicated
Effective DateJan 1, 2026
Next Review Date
Key ActionCheck the Moda Health website or Member Dashboard to see if a service or supply requires prior authorization.
SourceLink
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