Currentmoda_health_plan_incPolicy 2026
Idaho Individual Medical Policy (Moda Select Bronze 7500 AI/AN Limited Plan)
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This document governs covered benefits, exclusions, network and prior authorization policies for the Moda Health Plan Inc Idaho individual medical product (Moda Select Bronze 7500 AI/AN Limited Plan) and related plan materials.
Policy Summary
Payermoda_health_plan_inc
PolicyIdaho Individual Medical Policy (Moda Select Bronze 7500 AI/AN Limited Plan)
Policy CodePolicy Policy 2026
Change TypeNo material change
Effective DateJan 1, 2026
Last ReviewJan 26, 2026
Next Review DateN/A
Key ActionProviders must obtain prior authorization for services listed in the plan's authorization list and follow timing/penalty rules for emergency and nonemergency admissions.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
Moda Select Bronze 7500Named plan variant
YesPrior auth present
CoveredEHB status
$7,500Deductible (IN)
$7,500OOP Max (IN)
$75,000Out-of-network OOP Max
Covered Benefits and Limits
inv-01: Enumerated benefit categories (detailed criteria not included in this excerpt)
Benefit categories enumerated in Table of Contents (section 7.4 and related subsections). Detailed clinical criteria are in the referenced Section 7.x entries.
ALL of the following
Examples
- Durable Medical Equipment & Supplies (Section 7.4.9).
- Behavioral Health (Section 7.4.3) and Applied Behavior Analysis (ABA) (Section 7.4.2).
- Maternity Care (Section 7.5).
- Infusion Therapy and Medication Administered by Provider/Infusion Center (Section 7.4.18 & 7.4.22).
- Rehabilitation & Habilitation (Section 7.4.27).
- Surgery and Transplants (Sections 7.4.30–7.4.33).
- Vision, Hearing and Cochlear services (Sections 7.4.35–7.4.13).
inv-02: Essential Health Benefits
Covered when meeting the Essential Health Benefits scope; pediatric dental is excluded.
Policy covers essential health benefits as defined by HHS except pediatric dental, which is not included and may be purchased as a stand-alone product (pediatric dental excluded).
inv-03: Schedule of Benefits
Schedule of Benefits summary and representative cost-sharing examples.
Schedule provides quick-reference benefit levels; in-network and out-of-network cost sharing differ and some services require prior authorization (see Section 6).
Deductibles and out-of-pocket maximums: In-network per-member deductible $7,500; Out-of-network per-member deductible $15,000; In-network OOP max $7,500; Out-of-network OOP max $75,000.
Example services
- Ambulance transportation: In-network 0% (deductible/OOP apply) (Section 7.2.1).
- Emergency room facility: In-network 0% (deductible/OOP apply) (Section 7.2.2).
- Urgent care office visit: In-network 0% after deductible; Out-of-network 60% after deductible (Section 7.2.3).
inv-04: Representative coverage nodes
Representative coverage stances and limits drawn from Schedule of Benefits with links to full Section 7 details.
Representative nodes
- Preventive services required by ACA: in-network 0% (out-of-network typically 60%); frequency and details in Section 7.3.
- Colorectal and cancer screening: colonoscopy age 45+ covered per intervals described; one follow-up colonoscopy covered under preventive benefit after positive screen (Section 7.3.1).
- Mammogram: one per year age 40+ in-network 0% (Section 7.3.8).
- Applied Behavior Analysis/Behavioral Health services: require prior authorization; in-network 0% after deductible (Section 7.4.2–7.4.3).
- Rehabilitation & Habilitation (PT/OT/ST): in-network after deductible; limits apply (e.g., up to 20 outpatient sessions/year) (Section 7.4.27).
- Skilled Nursing Facility Care: in-network 0% after deductible; limited number of days (typically 30 days/year) (Section 7.4.28–7.4.29).
inv-05: Extracted coverage rules (partial SECTION 3)
Key cost-share and payment rules extracted from Schedule of Benefits (partial Section 3).
Many in-network retail and mail-order pharmacy tiers show Value Tier copay $0 or cost-sharing reported as $0/0% for 30-day supply; Select/Preferred tiers often shown as 0% after deductible in the Schedule entries.
Up to 90-day supply option available (retail and mail order) for eligible medications; one copay for a 30-day supply referenced and mail-order supply limits noted.
If member uses an out-of-network pharmacy, member must pay amounts charged above the Maximum Plan Allowance (MPA); pharmacy deductible applies (Section 3 notes).
inv-06: Pharmacy benefit criteria (section excerpts)
Pharmacy benefit fulfillment and tiered cost-sharing details from Schedule of Benefits and Section 7.6.
Up to 90-day supply per prescription allowed for eligible medications at participating retail pharmacies and via mail order (Sections 3 and 7.6.3–7.6.4).
Value Tier: $0 copay for a 30-day supply as shown in Schedule entries; Select/Preferred/Nonpreferred tiers appear with cost-sharing patterns shown as 0% after deductible in the Schedule excerpts.
Mail Order Pharmacy: up to 90-day supply; must use Moda-designated mail order pharmacy or pharmacies that agree to Moda's mail order terms for mail-order supply (Section 7.6.4 and Schedule notes).
Out-of-network pharmacy rule: member pays any amounts charged above the MPA when using an out-of-network pharmacy (Schedule notes).
inv-07: Pharmacy benefit criteria
Pharmacy coverage terms reflected in the Schedule of Benefits and pharmacy benefit sections.
Formulary tiers: Value, Select, Preferred, Nonpreferred and Specialty tiers are defined; Value Tier often shown with $0 copay for a 30-day supply; other tiers shown as 0% after deductible in Schedule excerpts (Sections 3 and 7.6.1–7.6.2).
Supply limits: up to 90-day supply per prescription for eligible medications; participating retail and mail-order supply options described (Section 7.6.3–7.6.4).
Prior authorization and specialty pharmacy: specialty medications generally require prior authorization and most specialty fills must come from a Moda-designated specialty pharmacy; non‑Moda‑designated specialty pharmacy use requires prior authorization (Section 7.6.5 and Schedule entries).
inv-08: Pharmacy schedule of benefits criteria
Schedule of Benefits statements regarding pharmacy tiers, mail-order rules, and specialty pharmacy prior authorization.
Mail-order pharmacy: up to 90-day supply per prescription; must use Moda-designated mail order pharmacy or other pharmacies that agree to Moda's mail-order terms (Sections 3 and 7.6.4).
Tier cost-sharing: Value Tier $0 copay; Select/Preferred/Nonpreferred tiers presented with cost-sharing frequently shown as 0% after deductible in the Schedule entries.
Specialty Pharmacy: Prior authorization required for non‑Moda‑designated specialty pharmacies; most specialty medications must be prior authorized and obtained from Moda-designated specialty pharmacy (Section 7.6.5 and Schedule notes).
inv-09: Payment and cost-sharing criteria
Payment and cost-sharing rules and definitions from Section 4.
Deductible rules: Member pays covered expenses until deductible is met; in-network and out-of-network deductibles are separate; some services may have no deductible (Section 4.1).
Out-of-pocket maximum: after member reaches OOP max, plan pays 100% of covered services for remainder of year; in-network and out-of-network maxima are separate; prior authorization penalty and manufacturer/copay assistance do not count toward OOP max (Section 4.2).
Payment basis: Moda pays based on Maximum Plan Allowance (MPA); in-network providers agree to look solely to Moda for compensation when Moda is paying (Section 4.3).
Extra-contractual services: Moda may cover services outside the contract after case evaluation and agreement; such payments are counted in benefit calculations but are not a precedent (Section 4.4).
inv-10: Network criteria
Network, service-area and out-of-network rules from Section 5.
In-network benefits: Using in-network providers yields higher benefits and lower out-of-pocket costs; find in-network providers via Member Dashboard 'Find Care' (Sections 5 and 5.1).
Service area and networks: Medical network is Moda Select for specified Idaho counties; out-of-area networks include Aetna® PPO and Affinity Limited when outside service area; pharmacy network is Navitus and vision is VSP (Section 5.1).
Out-of-network care: Benefits are lower and members may be balance billed for amounts above the MPA; when at an in-network facility, request related services be provided by in-network providers to avoid higher charges; out-of-area children rules apply for students (Sections 5.1.4 and 5.1.1).
inv-11: Pharmacy criteria
Pharmacy-specific operational rules and prior authorization requirements.
Mail-order pharmacy: must use Moda-designated mail order pharmacy or pharmacies agreeing to Moda's mail order terms; up to 90-day supply per prescription (Sections 3 and 7.6.4).
Specialty pharmacy: Specialty tiers defined; prior authorization required for use of non‑Moda‑designated specialty pharmacies; most specialty medications must be prior authorized (Section 7.6.5 and Schedule notes).
Tiering and cost sharing: Multiple pharmacy tiers (Value, Select, Preferred, Nonpreferred, Specialty) with cost sharing patterns shown in the Schedule (Sections 3 and 7.6.1).
inv-12: Coverage criteria and operational rules
Operational coverage rules, prior authorization timing, and emergency/urgent care rules.
Coverage conditionality: Benefits payable only when coverage is in effect (eligibility, enrollment, premiums paid) and after service provided; some services outside US covered only for emergency conditions (Sections 7.1 and 7.5).
Prior authorization: Many outpatient services and all nonemergency inpatient/residential care require prior authorization. Emergency admissions must be authorized within 48 hours after admission (or as soon as reasonably possible). Failure to obtain required prior authorization may lead to noncoverage or penalties up to 50% (max $2,500) (Sections 6 and 6.1).
Emergency and urgent care: Emergency services paid at in-network benefit level worldwide; prior authorization not needed for emergency screening/stabilization. Urgent care covered when facility bills as urgent care and member examined by professional provider (Sections 7.2 and 7.2.3).
Provider network guidance: When receiving care at in-network facilities, request related services be performed by in-network providers to avoid balance billing; find care via Member Dashboard (Sections 5.1.4 and 5.2).
inv-13: COVERAGE CRITERIA (summarizes what is covered, frequency limits, and special rules)
Summarizes covered services, frequency limits, and notable special rules across benefit sections.
Coverage summary items
- Preventive services: USPSTF A/B, ACIP immunizations and HRSA recommendations covered at no cost in-network; some updates may lag up to one year (Section 7.3).
- Colorectal cancer screening: multiple options covered for age 45+ with specified intervals; follow-up colonoscopy covered under preventive benefit after positive screen; high-risk individuals screened per provider recommendations (Section 7.3.1).
- Contraception: All FDA-approved methods covered; OTC contraceptives covered under pharmacy benefit; initial 3-month supply then up to 6-month supply thereafter with Customer Service guidance for 12-month supply (Sections 7.3.2 and 7.6.2).
- Diabetes services: insulin and diabetic supplies covered under pharmacy when purchased from pharmacy with prescription and preferred manufacturer; pumps may be DME (Section 7.4.7 and 7.6.2).
- Anticancer medications: covered but most require prior authorization and specialty pharmacy sourcing; some require program enrollment (Section 7.4.1 and 7.6.5).
- Clinical trials: usual care costs in approved trials covered with same cost-sharing as non-trial care; investigational items, monitoring-only items and data-collection-only items are not covered; participation must be prior authorized and limited to specified trial funders/regs (Sections 7.4.5 and 7.4.5–7.4.5c).
- ABA: covered for autism spectrum disorder with prior authorization; specified exclusions apply (Section 7.4.2).
- Therapeutic injections and oncology treatments: administrative services covered in office; injections not covered when equivalent self-administered; therapeutic radiology and chemotherapy covered including planning, professional services and treatment delivery (Sections 7.4.31–7.4.32).
- Transplants: medically necessary transplants covered when not experimental; provider should obtain prior authorization early; COE vs non-COE differences affect accumulation toward OOP maximum and travel/housing limits apply (Sections 7.4.33 and 7.4.33b–g).
- Rehabilitation & habilitation: covered when medically necessary as part of written treatment plan; outpatient limits apply and one session per therapy type per day; maintenance therapy not covered (Section 7.4.27).
inv-14: Clinical Trials
Clinical trial coverage and participation rules.
Usual care costs in approved clinical trials are covered with the same cost sharing as non-trial care; investigational trial-specific items and items provided only for data collection are not covered (Section 7.4.5).
Participation in a clinical trial must be prior authorized and is limited to trials funded or supported by specified federal agencies, FDA IND/IDE/BLA submissions, or trials exempt by federal law (Section 7.4.5).
inv-15: Dental Injury
Dental injury coverage conditions and limits.
Dental services not covered except for accidental injury to natural teeth when all conditions are met: injury by foreign object or acute trauma; diagnosis within 6 months; treatment completed within 12 months; medically necessary; provided while covered; limited to restoration to functional state. Implants and implant-related services are excluded (Section 7.4.6).
inv-16: Diabetes Services
Diabetes services and pharmacy benefit interaction.
Insulin and diabetic supplies (syringes, needles, lancets, test strips, glucometers, continuous glucose monitors) are covered under the pharmacy benefit when purchased from a pharmacy with a valid prescription and using a preferred manufacturer (Section 7.4.7 and 7.6.2).
Insulin pumps may be covered under the DME benefit (Section 7.4.9) if not obtained through pharmacy.
Examples of covered medical diabetes services include HbA1c testing, kidney disease checks, annual dilated eye exam/retinal imaging, diabetes self-management programs and routine foot care (Section 7.4.7).
inv-17: Diagnostic Procedures
Diagnostic procedures coverage and prior authorization requirements.
Diagnostic services must be for treatment of a medical or behavioral health condition; examples include x-rays, lab tests, standard and advanced imaging, psychological and neuropsychological testing (Section 7.4.8).
Provider must obtain prior authorization for most advanced imaging services (MRI, MRA, CT, PET, nuclear medicine, cardiac imaging); a full list of diagnostic procedures requiring prior authorization is on the Moda website (Section 7.4.8).
inv-18: DME Coverage and Exclusions
DME coverage examples, administrative rules, and exclusions.
DME covered when medically necessary for home use and repeated use; examples include CPAP, hospital beds, insulin pumps, orthotics, oxygen, prosthetics and wheelchairs/scooters with frequency limits (Section 7.4.9).
Administrative rules: rental charges covered up to purchase price for most DME; replacement/repair covered if not abused and within specifications; some DME may require prior authorization (Sections 7.4.9 and 7.4.9).
Exclusions: items primarily for comfort/convenience/cosmetic purposes, many therapeutic devices (except TENS), dental appliances/braces, incontinence supplies and certain supporting devices unless medically necessary are excluded (Section 7.4.9 and Exclusions list).
inv-19: Enterostomal Therapy
Enterostomal therapy coverage statement.
Enterostomal therapy for patients with stomas, complex wounds and incontinence is covered when medically necessary (Section 7.4.10).
inv-20: Gender Affirming Services
Gender-affirming services coverage and authorization requirements.
Gender-affirming treatment expenses covered for members over age 18 when performed by qualified professionals; surgical procedures require prior authorization and treatment plan must meet medical necessity criteria. Covered services may include mental health, hormone therapy (including puberty suppression) and specified surgical procedures (Section 7.4.11).
inv-21: Hearing and Cochlear
Hearing services coverage and cochlear implant prior authorization.
Hearing services covered for enrolled dependent children with congenital or acquired hearing loss that risks developmental deficits; includes evaluations, ear molds, bone conduction processors, and one hearing aid per impaired ear every 3 years; outpatient speech therapy up to 45 visits/year when billed for hearing loss (Section 7.4.12).
Cochlear implants are covered for members of all ages when medically necessary and prior authorized (Section 7.4.12 and Cochlear Implants note).
inv-22: Home Healthcare
Home healthcare eligibility and provider requirements.
Home healthcare services and supplies from a licensed home healthcare agency are covered if you are homebound, services are medically necessary, ordered by treating practitioner, visits are intermittent and provided by qualified professionals (RNs/LPNs, PT/OT/SLP/respiratory therapists, licensed social worker). Home health aides are not covered unless under hospice (Section 7.4.13).
inv-23: Hospice and Hospital Care
Hospice coverage, respite and hospital care rules including take-home drug limits.
Hospice: medically necessary or palliative hospice care covered when terminally ill and not receiving curative treatment; must be provided by approved hospice with a hospice treatment plan certifying terminal illness (Section 7.4.14).
Respite care: covered with prior authorization and must be arranged by attending provider; short-term inpatient hospice also covered (Sections 7.4.13–7.4.15).
Hospital care: inpatient hospital care covered when medically necessary including room, ICU, facility charges and related services; take-home hospital prescription drugs limited to a 3-day supply at the same hospitalization benefit level (Section 7.4.15).
Dental anesthesia: general anesthesia for dental procedures in hospital/outpatient clinic covered when dental procedure risky or patient cannot be safely treated in dental office; prior authorization required (Section 7.4.15).
inv-24: Hospital care
Hospital inpatient coverage components and limits.
Covered hospital expenses include hospital room, intensive care unit, isolation care, facility charges for surgery in hospital outpatient department and other medically necessary hospital services and supplies; take-home prescription drugs limited to a 3-day supply (Section 7.4.15).
inv-25: Infusion therapy
Infusion therapy coverage, supplier and prior authorization rules.
Infusion therapy covered when medically necessary and requires prior authorization; covered items include solutions, meds, compounding/dispensing, DME for infusion, ancillary supplies, nursing services and lab testing for monitoring (Section 7.4.18).
Some medications may be limited to preferred medication suppliers, home infusion providers or specific settings; when authorization is limited to certain suppliers/settings, medications from other suppliers or settings may not be covered; some infusion meds may be covered under pharmacy specialty benefit (Section 7.4.18 and 7.6.5).
inv-26: Rehabilitation & Habilitation
Rehabilitation and habilitation coverage conditions and visit limits.
Rehabilitation & habilitation services (PT/OT/ST, cardiac/pulmonary rehab) are covered when medically necessary and part of a written treatment plan to improve function; maintenance therapy is not covered. Covered outpatient services have separate annual limits; typically up to 20 outpatient sessions per year and only one session of each therapy type per day (Section 7.4.27).
inv-27: Surgery
Surgery coverage rules, cost sharing and reconstructive surgery guidance.
Surgery and related facility services are covered when medically necessary; cost sharing applies to surgeon, assistant, anesthesiologist and surgical supplies. Some procedures may be outpatient only; cosmetic surgery is excluded while reconstructive surgery is covered when medically necessary and prior authorized (Sections 7.4.30).
Reconstructive surgery after mastectomy includes reconstruction, symmetry procedures, prostheses and treatment of complications; treatment of complications related to reconstructive surgery is covered when medically necessary (Section 7.4.30–7.4.30c).
inv-28: Skilled Nursing Facility Care
Skilled nursing facility coverage scope and exclusions.
Skilled nursing facility provides inpatient rehabilitative and 24-hour nursing care; coverage limited to a number of days (e.g., 30 days per year) and to daily semi-private room rate. Exclusions include admissions before coverage, care mainly for cognitive decline/dementia, routine nursing care and custodial care (Sections 7.4.28–7.4.29).
inv-29: Nutrition and Metabolic Disorders
Nutrition and metabolic disorder services and enteral formula rules.
Inborn errors of metabolism: treatment covered when medically standard diagnostic, treatment and monitoring methods exist; covered services include nutritional and medical care and medical foods (Section 7.4.17).
Nonprescription elemental enteral formula for home use covered when medically necessary, physician-ordered for severe intestinal malabsorption and is sole or essential source of nutrition (Section 7.4.22).
inv-30: Therapeutic Injections, Radiology & Chemotherapy
Therapeutic injection and oncology therapy components.
Therapeutic injections: administrative services for injections (e.g., allergy shots) covered in a professional provider's office; not covered when similar results can be achieved with self-administered meds; vitamin/mineral injections not covered unless medically necessary (Section 7.4.31).
Therapeutic radiology and chemotherapy: covered expenses include treatment planning and simulation, professional services for administration and supervision, and treatments including therapist, facility and equipment charges (Section 7.4.32).
inv-31: Office or Home Visits
Office or home visits definition and coverage guidance.
Office or home visit means actual examination by a professional provider; consultations with written reports and second opinion surgery consultations are covered; naturopathic MD office visits are specialist visits unless credentialed as primary care (Section 7.4.25 and related notes).
inv-32: Spinal Manipulation
Spinal manipulation visit limits and payment rules.
Spinal manipulation: a limited number of visits covered annually; other services at the same visit are billed under standard plan benefits; if copayments differ, member pays highest copay at a visit with same provider; chiropractor office visits are specialist visits (Section 7.4.29–7.4.31).
inv-33: Supplier/Setting Limitations
Supplier and setting limitations for infusion and administered medications.
Some infusion medications may be covered only when obtained from preferred medication suppliers or administered at preferred providers or settings; when authorization limited to certain supplier/provider/setting, items from other suppliers or settings may not be covered; some infusion meds are covered under pharmacy specialty benefit (Section 7.4.18).
inv-34: Therapeutic injections
Therapeutic injection administrative coverage rules.
Administrative services for therapeutic injections performed in a professional provider's office are covered; such services are not covered when similar results can be achieved with self-administered meds at home; vitamin/mineral injections not covered unless medically necessary (Section 7.4.31).
inv-35: Therapeutic radiology and chemotherapy
Therapeutic radiology and chemotherapy covered components.
Covered components include treatment planning and simulation; professional services for administration and supervision; and treatments including therapist, facility and equipment charges (Section 7.4.32).
inv-36: Transplants
Transplant coverage requirements, limits and donor/travel rules.
Medically necessary transplants that follow standard practice and are not experimental are covered; provider should obtain prior authorization as soon as possible after identifying potential transplant candidate (Section 7.4.33).
If transplant performed at non-Center of Excellence, deductible and coinsurance will not accumulate toward OOP maximum; donor costs covered in defined circumstances; travel and housing expenses for recipient and one caregiver covered up to a maximum per transplant (Section 7.4.33).
inv-37: Virtual care visits
Virtual care visit coverage conditions.
Virtual care visits (live audio/video) are covered if services can be safely and effectively provided virtually and technology meets privacy/security standards; virtual visits using preferred vendor are covered with no cost sharing (Section 7.4.34).
inv-38: Pediatric vision services
Pediatric vision services coverage and exclusions (under age 19).
For members under 19, one complete well-vision exam and one pair of eyeglasses and frames or contact lenses once per year are covered; contact lenses require minimum supply amounts depending on lens type; optional lenses and treatments limited as specified (Section 7.4.35).
Exclusions include plano lenses with refractive correction < ±0.50 diopter, two pairs of glasses instead of bifocals, insurance policies for contact lens coverage, artistically painted/non-prescription contact lenses, additional office visits for contact lens pathology and certain contact lens services (Section 7.4.35–7.4.35 exclusions).
inv-39: Adult vision exam
Adult vision exam coverage (age 19+).
For members age 19 and older, one complete eye exam annually including refraction charge is covered; VSP handles benefit authorization for eligible members and failure to identify as VSP member or obtaining out-of-network care may result in member financial responsibility (Section 7.4.36).
inv-40: Maternity care
Maternity care elements, frequency limits and hospital stay protections.
Pregnancy care, childbirth and related conditions covered when provided by a professional provider; midwives covered only if licensed and certified (Section 7.5).
Maternity services typically billed as a global charge; some diagnostics (e.g., amniocentesis, fetal stress test) may be reimbursed separately and may require prior authorization (Sections 7.5 and 7.5.3).
Breastfeeding support and breast pump coverage: purchase or rental of pumps and supplies covered; MPA applies for retail purchases; hospital-grade pumps covered when medically necessary (Section 7.5.1).
Circumcision: within 3 months of birth covered without prior authorization; after 3 months requires medical necessity and prior authorization (Section 7.5.2).
Take-home prescription drugs after hospitalization limited to a 3-day supply at same hospitalization benefit level (Section 7.5.6).
Hospital length-of-stay protections: benefits not restricted to less than 48 hours after normal vaginal delivery or 96 hours after cesarean; no prior authorization needed to stay up to these limits (Section 7.5 Special Right Upon Childbirth).
inv-41: Pharmacy prescription benefit
Pharmacy prescription benefit definitions and coverage scope.
Inpatient medications administered during a hospital admission are covered by the medical plan as part of inpatient expense; outpatient pharmacy benefit does not apply to inpatient meds (Section 7.6).
Medications must be medically necessary to be covered; formulary, tier definitions (Value, Select, Preferred, Nonpreferred, Specialty), and brand/generic rules are defined (Sections 7.6.1 and 7.6.2).
Covered medication supplies include prescription meds, certain compounded meds, ACA preventive meds, tobacco dependence meds with prescription covered with no cost sharing at in-network retail, contraceptives with multi-month supply options, and certain immunizations at in-network retail pharmacies (Section 7.6.2–7.6.3).
Formulary and tier placement may change; members should use Member Dashboard price check tool or Customer Service for current coverage and cost-sharing details (Section 7.6.1–7.6.2).
inv-42: Covered medication types, supply rules, and limitations/exclusions
Covered medication types, supply rules, limitations and exclusions under the pharmacy benefit.
Covered items: medically necessary prescription medications, compounded meds with a covered main ingredient, certain ACA preventive meds, tobacco dependence meds with prescription covered with no cost sharing at in-network retail, contraceptives with multi-month supply options, and certain immunizations at in-network retail pharmacies (Section 7.6.2).
Diabetes supplies: insulin and diabetic supplies (syringes, needles, lancets, test strips, glucometers, CGMs) covered with prescription and use of preferred manufacturer (Sections 7.4.7 and 7.6.2–7.6.3).
Supply options: 90-day supply available at participating retail pharmacies for eligible meds; mail order via Moda-designated or equivalent mail order pharmacies; not all meds eligible for 90-day supply (Sections 7.6.3–7.6.4).
Specialty requirements: most specialty medications require prior authorization and must come from Moda-designated specialty pharmacy or have prior authorization to use non-designated; some specialty prescriptions limited to <30 days or 2-week supply (Section 7.6.5 and 7.6.8).
Self-administered rules and step therapy: self-administered medications follow prescription requirements; step therapy requires trial of Step 1 before Step 2 unless exception applies (Sections 7.6.6–7.6.7).
Formulary exception and limitations: formulary exception requests require provider-supplied medical necessity documentation; decision within 72 hours (24 hours if urgent); new FDA approvals reviewed and may have coverage limits; brand/generic substitution cost differences may not count toward OOP max (Sections 7.6.4–7.6.9).
Exclusions: devices, excluded-network pharmacies, foreign medication claims, hair growth meds, travel immunizations (except ACA-required), institutional medications, administration fees (except immunizations/contraceptives at retail), non-FDA approved meds, off-label uses unless supported, OTC meds (except contraceptives/tobacco dependence), repackaged meds, replacement meds/supplies, vitamins/minerals (except required by law), weight loss meds (Section 7.6.9).
Coding, Tiers and Key Quantities
No explicit billing/coding lists in this excerptmixed
Pharmacy tiers (retail & mail-order)mixed
| Value Tier | Value Tier $0 copay for a 30-day supply (retail/mail-order) |
| Select Tier | Select Tier: 0% after deductible (retail/mail-order) |
| Preferred Tier | Preferred Tier: 0% after deductible (retail/mail-order) |
| Nonpreferred Tier | Nonpreferred Tier: 0% after deductible (retail/mail-order) |
Benefit tier references (schedule footnotes)mixed
| No codes listed |
Pharmacy tiers / cost sharingmixed
| No codes listed |
Pharmacy tiers (mail-order requirement & supply)mixed
| No codes listed |
Schedule footnote codesmixed
| 1 | In-network: 0% after deductible (per Schedule footnote) |
| 2 | Out-of-network: 0% after deductible (per Schedule footnote) |
| 3 | Section 7.4.1: Prior authorization required for non-Moda-designated pharmacies (per Schedule footnote) |
External prior-authorization list referencemixed
| No codes listed |
Preventive screening timeframesmixed
| No codes listed |
Prior-auth diagnostics and DMEmixed
| Most advanced imaging (MRI, MRA, CT, PET, nuclear medicine, cardiac imaging) and some diagnostic procedures require prior authorization; some DME items may require prior authorization (see Moda Health website for full list). |
Surgery-related services (cost sharing applies)mixed
| No codes listed |
Therapeutic radiology and chemotherapy (covered components)mixedCovered
| rad-1 | Treatment planning and simulation |
| rad-2 | Professional services for administration and supervision |
| rad-3 | Treatments including therapist, facility and equipment charges |
Service categories mentioned (no CPT/HCPCS codes provided)mixed
| No codes listed |
Pharmacy coding (not specified)mixed
| No specific billing CPT/HCPCS/NDC codes provided in this excerpt for pharmacy items; tiers and definitions are described (Value, Select, Preferred, Nonpreferred, Specialty). |
Deductible referenced
Referenced deductible (in‑network, per member)$7,500
Referenced deductible (out‑of‑network, per member)$15,000
Maximum annual family deductible (in‑network)$15,000
Calendar year accrual
Accrual basis for annual/per‑year limitsWhen a benefit has an 'annual' or 'per year' limit, it will accrue on a calendar year basis unless otherwise specified.
Member Dashboard referenceSee Section 3 and Member Dashboard for details and links to benefit specifics.
American Indian/Alaska Native exceptionSpecial coverage rules (no cost when services received via IHS/Tribal/Urban Indian Clinic or referred by them).
Calendar-year accrual for annual limits
Calendar‑year accrual rule for annual limitsAnnual or 'per year' limits accrue on a calendar year basis unless otherwise specified.
Where statedSection 3 (Schedule of Benefits) — cross‑references Section 7 for details.
Effect on family vs member limitsPer‑member and family limits described in Schedule of Benefits; accrual follows calendar year rules above.
Maximum days supply
Maximum days' supply (general)Up to 90‑day supply per prescription (retail and mail order where eligible).
Participating retail 90‑day optionYou may buy a 90‑day supply from participating retail pharmacies (see Member Dashboard for participating pharmacies).
Not all meds eligibleNot all medications are eligible for a 90‑day supply; administrative rules apply.
Calendar-year accrual for annual limits
Maximum supply per prescriptionUp to 90‑day supply per prescription (retail and mail order where eligible).
One copay basisSchedule notes reference one copay for a 30‑day supply as pricing basis for multi‑day fills.
Mail‑order alignmentMail order entries also indicate up to 90‑day supply per prescription with same tiering rules.
Maximum supply
Max supply per prescription (explicit)Up to 90‑day supply per prescription.
Applies to retail and mail order where eligibleBoth retail and mail‑order entries list up to 90‑day supply per prescription when medication eligible.
Eligibility noteSome specialty medications and other medications may be excluded from 90‑day supply (see Section 7.6).
Maximum supply per prescription
Maximum supply per prescription (numeric)Up to 90‑day supply per prescription
Mail order / retail paritySchedule shows same 90‑day per prescription limit for retail and mail order where eligible.
Value Tier copay referenceValue Tier examples (30‑day $0) provided alongside supply limits for tier pricing context.
max_supply_days
Maximum supply (days) — max_supply_days90
Applies to eligible medications90‑day maximum applies only to medications eligible for 90‑day fills at participating pharmacies or mail order.
Mail order requirementMail‑order fills up to 90 days must use Moda‑designated mail order pharmacy or pharmacies agreeing to Moda terms.
Mail-order supply limit
Mail‑order supply limitUp to 90‑day supply per prescription via mail order (when eligible).
Mail‑order pharmacy requirementMust use Moda‑designated mail order pharmacy or other pharmacies that agree to follow Moda's mail order terms.
Tiering appliesTier cost‑sharing (Value/Select/Preferred/Nonpreferred) applies to mail‑order supplies as shown in Schedule of Benefits.
prior authorization penalty cap
Prior authorization penalty cap (per occurrence)Penalty up to $2,500 per occurrence (also described as 50% up to $2,500).
Penalty effectPenalty applied if required prior authorization for out‑of‑network provider services is not obtained in advance; does not count toward deductible/OOP max.
Emergency admission exceptionPrior authorization penalty does not apply to emergency admissions (no prior auth required).
colorectal screening intervals
Colorectal screening intervals (age 45+)FOBT/FIT every year; fecal DNA every 3 years; CT colonography or flexible sigmoidoscopy every 5 years; colonoscopy every 10 years; flexible sigmoidoscopy plus FIT annually; double contrast barium enema every 5 years.
Follow‑up colonoscopyOne follow‑up colonoscopy covered under preventive benefit after a positive USPSTF‑recommended screening.
High‑risk noteHigh‑risk individuals may be screened earlier/more often per provider recommendation and may be paid at medical benefit level if not meeting USPSTF A/B criteria.
prostate screening frequency
Prostate screening frequencyCovered once every year (including rectal exam and PSA test); cost sharing applies.
Provider discretionAlso covered when recommended by your provider.
Cost sharingProstate cancer screening subject to applicable cost sharing per Schedule of Benefits.
women's preventive exam frequency
Women's preventive exam frequencyOne preventive women's healthcare visit per year (includes pelvic and breast exams and a Pap test).
Mammogram frequencyOne mammogram between ages 35–39 and one per year age 40 and older; additional mammograms covered when symptomatic/high risk.
BRCA servicesPreventive BRCA counseling/testing covered with no cost sharing; genetic testing requires prior authorization.
Hearing aid and DME frequency limits
Hearing aid frequency (dependent children)One hearing aid per hearing‑impaired ear every 3 years for enrolled dependent children.
Wheelchair/scooter limits (DME)Wheelchair or scooter may be limited to one per year under age 19 and one every 3 years age 19 and over.
Hearing services covered itemsHearing evaluations, bone conduction processors, ear molds, and outpatient speech therapy up to 45 visits/year for hearing loss.
Outpatient therapy sessions per day
Outpatient therapy sessions per dayOnly one session of each type of outpatient physical, occupational or speech therapy is covered in one day (a session = one visit).
Annual limitsCovered outpatient rehabilitative and habilitative services have separate annual limits (except certain cardiac/pulmonary/behavioral health).
Therapy definitionsServices must be medically necessary and part of a written treatment plan; maintenance therapy not covered.
Skilled nursing facility payment limit
Skilled nursing facility payment limitCovered expenses are limited to the daily service rate for a semi‑private hospital room; coverage limited to a number of days.
Coverage contextSkilled nursing facility provides inpatient rehabilitative and 24‑hour nursing care; limited days covered.
ExclusionsCharges not covered include admissions before coverage, custodial care and long‑term residential care for cognitive decline/dementia.
medication supply limits
Medication supply limits (maternity take‑home)Take‑home hospital maternity prescriptions limited to a 3‑day supply at the same hospitalization benefit level.
Contraceptive supply optionsContraceptive medications/devices: up to 3‑month supply initially and up to 6‑month supply thereafter; Customer Service can advise on 12‑month supply process.
Diabetic supplies coverageInsulin and diabetic supplies covered under pharmacy benefit with prescription and preferred manufacturer requirements.
Prior Authorization, Documentation and Provider Requirements
Prior Authorization
Obtain required prior authorization before non‑emergency services
Providers must obtain prior authorization for services listed in the plan's authorization list (see Section 6.1.1). Emergency hospital admissions must be authorized by the provider within 48 hours after admission (or as soon as reasonably possible). If services using an out-of-network provider are not authorized in advance, a penalty of 50% (up to $2,500 per occurrence) will be applied and that penalty does not count toward the deductible or out-of-pocket maximum.
- Ask the provider to contact Moda Health for prior authorization before the service is provided.
- Prior authorization does not guarantee coverage; excluded services will be denied.
Prior Authorization
Check authorization requirements on Member Dashboard
Use the Member Dashboard (Find Care and Prescription Price Check) to confirm whether a service or supply requires prior authorization before scheduling or ordering.
- Member Dashboard shows if a service or supply must be prior authorized.
- A full list of services and supplies that must be prior authorized is maintained on the Moda Health website and updated periodically.
Prior Authorization
Be aware prior authorization may apply to some services
Prior authorization may be required for some services; verify specific service-level requirements in Section 6 before delivering care.
- Schedule of Benefits notes that prior authorization may be required for some services (see Section 6).
- Section 6 lists many outpatient and all nonemergency inpatient/residential services as potentially requiring authorization.
Prior Authorization
Follow authorization limits described in authorization letter
Prior authorization approvals may include limits on time, scope, quantity, frequency, or require use of preferred treatment centers or providers; those conditions will be detailed in the authorization letter.
- Authorized services are valid only for the specified time period and within limits described in the authorization letter.
- Care may be limited to preferred centers/providers to receive higher benefit level.
Billing Rule
Out‑of‑network pharmacy charges above MPA are member’s responsibility
If you or the member use an out‑of‑network pharmacy, the member is responsible for any amounts charged above the Maximum Plan Allowance (MPA); the pharmacy deductible also applies.
- Member must pay amounts charged above the MPA when using an out‑of‑network pharmacy.
- Pharmacy deductible applies to out‑of‑network fills as noted in the Schedule of Benefits.
Note
Advise members to avoid out‑of‑network pharmacy balance billing
When a member uses an out‑of‑network pharmacy, they must pay any amounts charged above the MPA; providers should counsel members to use in‑network pharmacies to avoid balance billing.
- MPA = Maximum Plan Allowance; charges above MPA may be balance billed by out‑of‑network pharmacies.
- Encourage members to use participating pharmacies to minimize out‑of‑pocket costs.
Billing Rule
Use Moda‑designated mail‑order pharmacy for 90‑day supplies
Mail‑order fills (up to a 90‑day supply) must be obtained through Moda‑designated mail order pharmacy or another pharmacy that agrees to follow Moda’s mail order terms.
- Mail Order Pharmacy: up to 90‑day supply per prescription.
- Must use Moda‑designated mail order pharmacy or pharmacies that agree to follow Moda’s mail order terms.
Prior Authorization
Verify Schedule entries that note prior authorization
Some Schedule of Benefits entries explicitly note that prior authorization is required for specific items or services; providers should check the Schedule Details and Section 6 before ordering.
- Schedule of Benefits links to Section 7 and Section 6 for details and prior authorization requirements.
- If required prior authorization is not obtained, charges may be denied or penalties may apply.
Prior Authorization
Prior authorize specialty medications and use Moda‑designated specialty pharmacy
Most specialty medications require prior authorization and may need to be obtained from Moda‑designated specialty pharmacy; if obtained from a non‑Moda specialty pharmacy, prior authorization is required.
- Specialty medications often require program enrollment and prior authorization.
- Purchases at non‑Moda‑designated specialty pharmacies require prior authorization.
- Some specialty prescriptions may be limited to less than 30 days; some may be eligible for 90‑day supply.
Prior Authorization
Do not rely on non‑Moda specialty pharmacies without prior authorization
If a member obtains specialty medications from a non‑Moda‑designated specialty pharmacy, prior authorization is required; providers should prescribe through Moda‑designated specialty pharmacy when possible.
- Schedule notes: “Specialty Pharmacy Prior authorization required for non‑Moda‑designated specialty pharmacies.”
- Contact Member Dashboard or Customer Service for specialty pharmacy and clinical program details.
Denial Risk
Failure to obtain required prior authorization may trigger financial penalties
Providers must obtain prior authorization for services listed on the Moda authorization list; failure to get required prior authorization for out‑of‑network services may trigger a 50% penalty (up to $2,500) per occurrence.
- Prior authorization penalty: 50% up to $2,500 per occurrence if out‑of‑network services are not authorized in advance.
- Penalty does not count toward deductible or out‑of‑pocket maximum.
Documentation Required
Second‑opinion requests: Moda‑requested vs member‑requested payment rules
Moda may request an independent second opinion for non‑emergency treatments; when Moda requests it, the second opinion visit is paid by Moda and the member pays nothing; if the member requests a second opinion, it is paid under regular benefits and standard cost‑sharing applies.
- Moda‑requested second opinion: no cost to member.
- Member‑requested second opinion: subject to deductible and applicable cost‑sharing.
Prior Authorization
Authorization approvals may include specific limitations
Authorizations may impose limits on time, scope, number, amount or frequency of services and may require use of preferred centers/providers; providers should review authorization letters for these limits.
- Examples of limits: expiration dates, quantity/frequency caps, requirement to use preferred treatment center.
- Care Coordinators/Case Managers can help interpret authorized treatment terms.
Prior Authorization
Prior authorize many outpatient and all non‑emergency inpatient/residential services
Many outpatient services and all nonemergency inpatient and residential care must be prior authorized. Failure to obtain required authorization may result in denial of coverage or member financial responsibility.
- Some services may require separate prior authorizations.
- If doctor does not get required prior authorization, charges may not be covered based on utilization review.
Prior Authorization
Prior authorize anticancer medications and use designated specialty pharmacy
Most anticancer medications require prior authorization and must be obtained from Moda’s designated specialty pharmacy; prior authorization is also required to use a non‑designated specialty pharmacy. Some anticancer drugs require enrollment in manufacturer or safety programs.
- Prescribed anticancer medications (oral, IV or injected) are covered but most need prior authorization.
- Specialty anticancer medications must come from the designated specialty pharmacy or have prior authorization to use a non‑designated specialty pharmacy.
Prior Authorization
Obtain prior authorization for ABA and intensive behavioral health services
Applied Behavior Analysis (ABA) and certain intensive behavioral health services (intensive outpatient, ACT, STAR, TMS) require prior authorization; providers must submit authorization requests before delivering these services.
- ABA for autism spectrum disorder is covered but services must be prior authorized.
- Intensive outpatient mental health treatment, ACT, STAR and TMS must be prior authorized.
Prior Authorization
Prior authorization required for clinical trial participation; verify trial eligibility
Participation in clinical trials must be prior authorized; approved trials are limited to those funded/supported by specified federal agencies, conducted as FDA IND/IDE/BLA submissions, or federally exempt.
- We must prior authorize participation in clinical trials.
- Approved clinical trials are restricted to specified federal funders or regulatory categories as listed.
Prior Authorization
Prior authorize most advanced imaging studies
Providers must obtain prior authorization for most advanced imaging (MRI, MRA, CT, PET, nuclear medicine and cardiac imaging); a full list of diagnostic procedures requiring prior authorization is available on the Moda website or via Customer Service.
- Provider must get prior authorization for most advanced imaging services.
- A full list of diagnostic procedures requiring prior authorization is on the Moda Health website.
Prior Authorization
Obtain prior authorization for some DME; rental and repair rules apply
Some DME requires prior authorization; rental charges are covered up to the purchase price and replacement/repair is covered only if the item was not abused and used within its specifications. Providers may be asked to supply DME order details to support claim payment.
- Provider may need to prior authorize certain DME.
- Rental covered up to purchase price; replacement/repair covered if not abused and within specifications.
- Provider must authorize DME supplier to provide order and equipment information if requested.
Prior Authorization
Prior authorize gender‑affirming surgical procedures
Surgical gender‑affirming procedures require prior authorization and must meet medical necessity criteria; treatment plans must be provided by qualified professionals.
- Procedures must be performed by qualified professional providers.
- Prior authorization is required for surgical procedures; treatment plan must meet medical necessity criteria.
Prior Authorization
Prior authorization required for cochlear implants
Cochlear implants are covered when medically necessary and require prior authorization; providers should submit authorization requests before scheduling implantation.
- Cochlear implants are covered for members of all ages when medically necessary and prior authorized.
Prior Authorization
Prior authorize hospice and arrange respite through attending provider
Arrange hospice respite through the attending provider and obtain prior authorization; hospice services require a hospice treatment plan and certification of terminal illness.
- Respite care must be arranged by the attending professional provider and prior authorized.
- Hospice requires a hospice treatment plan certifying terminal illness and services by approved hospice provider.
Prior Authorization
Prior authorize hospital dental anesthesia when medically indicated
General anesthesia for dental procedures performed in hospital or outpatient clinic settings requires prior authorization when the dental procedure is high‑risk or the patient cannot be safely treated in a dental office.
- Covered when dental procedure is risky or patient disabled and cannot be safely treated in dental office.
- Related facility charges also require prior authorization.
Prior Authorization
Obtain authorization for hospital dental anesthesia and facility charges
General anesthesia and related facility charges for dental procedures performed in hospital/outpatient clinic settings require prior authorization when the dental procedure is risky or the patient cannot be safely treated in a dental office.
- Services must be prior authorized.
- Provider should document medical necessity for hospital dental anesthesia.
Prior Authorization
Prior authorize infusion therapy and use preferred suppliers when required
Infusion therapy requires prior authorization. Some medications may require use of preferred medication suppliers, home infusion providers or preferred treatment centers; when authorization is limited to certain suppliers or settings, services from other suppliers or settings may not be covered.
- Prior authorization required for infusion therapy services and supplies.
- You may be required to use a preferred medication supplier or home infusion provider for coverage.
- Some infusion medications are covered under the pharmacy specialty medication benefit.
Prior Authorization
Prior authorize provider‑administered medications and follow supplier requirements
Certain medications administered in provider offices, treatment/infusion centers or home infusion programs require prior authorization and/or use of preferred treatment centers or preferred medication suppliers.
- Some medications may only be covered if obtained from a preferred medication supplier or administered at a preferred treatment center.
- Treatment and medication programs must be prior authorized.
Prior Authorization
Request transplant prior authorization promptly once candidate identified
Obtain prior authorization as soon as possible when a member is identified as a potential transplant candidate; some transplant-related services and certain maternity diagnostic procedures may require prior authorization as listed on the Moda website.
- Provider should obtain prior authorization as soon as possible after a potential transplant candidate is identified.
- Donor, travel and housing cost rules and limits apply; many transplant services may require prior authorization.
Step Therapy
Follow prior authorization and step therapy rules for prescription medications
Certain prescription medications and quantities may require prior authorization; most specialty medications must be prior authorized and must be obtained from a Moda‑designated specialty pharmacy. Step therapy requires trying Step 1 medication before Step 2, unless an exception is granted.
- Most specialty medications must be obtained from a Moda‑designated specialty pharmacy.
- Step therapy: Step 1 must be tried before Step 2; exceptions allowed if Step 1 is ineffective, harmful or not tolerated.
Documentation Required
Submit formulary exceptions with medical‑necessity documentation; expect 72/24‑hour decision
Formulary exception requests must include supporting medical‑necessity documentation from the prescribing professional provider (evidence of trials, intolerance, harm, or non‑equivalence). Moda will decide standard requests within 72 hours and urgent requests within 24 hours.
- Provider must supply documentation showing trials of formulary medications and clinical rationale for exception.
- Decision timeframe: 72 hours standard, 24 hours if urgent.
Key Definitions and Plan Terms
Right to return policy
Right to return windowSubscriber may return this policy within 10 days before or after the coverage effective date and receive a refund of premium; policy canceled retroactively to the start date.
Effect of returnIf returned within the 10‑day window, it is as if no policy had been issued (policy canceled from the beginning).
Where statedPolicy front page — 'Moda Select Bronze 7500 AI/AN Limited Plan' introductory section.
Child-only policy handling
Child‑only policy handlingIf this is a child‑only policy, references to dependents including spouse or domestic partner are deleted; siblings of the subscriber are eligible.
ApplicabilitySpecific child‑only text appears in the policy's 'For Child Only Coverage' section.
Effect on benefit languageLanguage throughout the policy adjusts to remove spouse/domestic partner references for child‑only coverage.
Medicare status
Medicare statusThis policy is not a Medicare Supplement policy.
Guidance for Medicare‐eligibleIf you are eligible for Medicare, review the Guide to Health Insurance for People with Medicare from CMS (medicare.gov).
Where statedExplicit statement in policy 'This is not a Medicare Supplement Policy'.
Member ID Card
Member ID CardAfter enrollment, Moda will send identification cards showing member ID number and provider network; replacement available via Member Dashboard or Customer Service.
Use of cardShow ID card each time you receive services so provider knows you are a Moda Health member.
How to replaceGet a new card through Member Dashboard or by calling Customer Service if lost.
Medical Network
Medical Network name and service areaModa Select network — list of Idaho counties served (Ada, Adams, Bannock, Bear Lake, Benewah, Bingham, Boise, Bonner, Bonneville, Boundary, Canyon, Caribou, Cassia, Clearwater, Elmore, Franklin, Fremont, Gem, Jefferson, Idaho, Kootenai, Latah, Lewis, Minidoka, Madison, Nez Perce, Oneida, Owyhee, Payette, Power, Shoshone, Teton, Washington).
Find Care toolUse 'Find Care' on Member Dashboard to choose in‑network providers and confirm network participation.
ID card lists networkMember ID card will list your network.
Disease Management & Health Coaching
Disease Management & Health CoachingProgram provides education, support and health coaching to help members self‑manage chronic disease and follow provider care plans.
PurposeHelps improve health status, quality of life and productivity through coaching and support.
ContactContact Disease Management and Health Coaching for more information (Member Dashboard/Customer Service).
Behavioral Health
Behavioral HealthModa Behavioral Health provides specialty services for mental health and substance use disorder benefits and helps members locate in‑network providers.
Access helpBehavioral Health Customer Service can assist with authorizations and locating providers.
Prior authorization noteCertain intensive behavioral health services (e.g., ABA, ACT, STAR, TMS) require prior authorization.
In-network
In‑network benefits (general)Using in‑network providers yields higher benefits and lower out‑of‑pocket cost; in‑network provider agreements limit member balance billing beyond cost sharing.
Find Care toolUse Member Dashboard 'Find Care' to identify in‑network providers and preferred DME suppliers.
Balance billing cautionWhen services involve out‑of‑network providers at in‑network facilities, balance billing rules and MPA considerations apply (see Section 5).
Out-of-network
Out‑of‑network benefits (general)Out‑of‑network benefits are lower; members may be responsible for amounts above the Maximum Plan Allowance (MPA) and may need to file claims.
Balance billingOut‑of‑network providers may balance bill for amounts over the MPA when permitted by law.
Prior authorization riskIf required prior authorization is not obtained for out‑of‑network services, a penalty (50% up to $2,500) may apply and does not count toward deductible/OOP max.
MPA / Out-of-network pharmacy responsibility
MPA / Out‑of‑network pharmacy responsibilityMPA = Maximum Plan Allowance; if you use an out‑of‑network pharmacy you must pay any amounts charged above the MPA; pharmacy deductible applies.
MPA payment basisModa pays covered expenses based on the MPA (defined in Section 11); member may owe difference if provider/pharmacy charges above MPA.
Effect on cost sharingAmounts above the MPA are member responsibility and may not count toward deductible/OOP maximum depending on the charge type.
Maximum Plan Allowance (MPA)
Maximum Plan Allowance (MPA)MPA is the basis Moda Health uses to pay covered expenses (definition provided in Section 11); in‑network providers agree to look solely to Moda when Moda is paying insurer.
Balance billing relationCharges above the MPA may result in balance billing by out‑of‑network providers when permitted by law.
Payment implicationsMPA determines Moda's payment; member may be responsible for amounts over MPA when using out‑of‑network providers or pharmacies.
Formulary tiers referenced for pharmacy cost-sharing
Formulary tiers referencedValue, Select, Preferred and Nonpreferred tiers are used to categorize medications and cost sharing (Value Tier examples show $0 for a 30‑day supply).
Tier changes and toolsTier placement may change; use the Member Dashboard prescription price check tool for current coverage and cost estimates.
Specialty tierSpecialty medications are separately tiered and often require prior authorization; specialty fills often sourced from Moda‑designated specialty pharmacy.
MPA (member payment above MPA)
Member payment above MPA (definition)Member may have to pay amounts charged above the Maximum Plan Allowance (MPA) when using out‑of‑network pharmacies or providers.
MPA defined elsewhereMPA definition referenced in Section 11; Moda pays based on MPA.
Implication for claimsAmounts above MPA may be disallowed charges and not count toward deductible/OOP maximums per policy rules.
Moda-designated mail order pharmacy
Moda‑designated mail order pharmacyMail‑order pharmacy fills (up to 90‑day supply) must use a Moda‑designated mail order pharmacy or other pharmacies that agree to follow Moda's mail order terms.
Mail‑order supply limitMail order up to 90‑day supply per prescription when medication eligible.
Participating pharmaciesMember Dashboard lists participating pharmacies and mail order options; participating retail pharmacies indicate '3 months' in the Day Supply column.
Value Tier ($0 copay for 30-day supply)
Value Tier — example cost sharingValue Tier copay example: $0 for a 30‑day supply (per Schedule of Benefits entries).
Applies to retail and mail orderValue Tier $0 examples appear for both retail and mail‑order supply options where eligible.
Check Member DashboardMembers should confirm current Value Tier listings and copays via Member Dashboard prescription price check tool.
Moda-designated mail order pharmacy (terms)
Moda‑designated mail order pharmacy (terms)Mail‑order fills must use Moda‑designated mail order pharmacy or pharmacies that agree to follow Moda's mail order terms; applies to up to 90‑day mail‑order fills.
Member actionUse Member Dashboard to identify Moda‑designated mail order or participating retail pharmacies for 90‑day fills.
Tiered cost sharing appliesMail‑order fills follow the same formulary tier cost sharing shown in Schedule of Benefits.
non‑Moda‑designated specialty pharmacy
Non‑Moda‑designated specialty pharmacyPrior authorization required for non‑Moda‑designated specialty pharmacies; most specialty medications must be obtained from Moda‑designated specialty pharmacy or prior authorization required to use non‑designated suppliers.
Specialty meds prior authMost specialty medications require prior authorization and program enrollment or designated supplier sourcing for coverage.
Supply limits for specialty medsSome specialty medications may be limited to <30 days or a 2‑week supply per Section 7.6 notes.
MPA definition reference
MPA (definition reference)Maximum Plan Allowance (MPA) — the basis Moda Health uses to pay covered expenses; defined in Section 11.
Payment practiceModa pays covered expenses based on MPA; in‑network providers agree to look solely to Moda for compensation when Moda is paying the insurer.
ConsequencesCharges above MPA may be disallowed and can lead to member financial responsibility when using out‑of‑network providers/pharmacies.
Extra-contractual services
Extra‑contractual servicesModa may cover services outside the policy contract (extra‑contractual) when Moda, the member and provider agree after case evaluation; such payments are not precedent and will be included in benefit calculations.
TerminationAny party can end extra‑contractual services by giving written notice.
No precedencePayment for extra‑contractual services for one member does not obligate Moda to pay for others or continued services.
Balance billing
Balance billingBalance billing refers to amounts charged above the MPA by out‑of‑network providers that the member may have to pay when permitted by law.
In‑network facility cautionWhen care is at an in‑network facility, request related services be performed by in‑network providers to avoid balance billing; legal protections may apply in some cases.
MPA relationAmounts above MPA may be member responsibility and may not count toward deductible/OOP max per policy rules.
Urgent care definition
Urgent care — definitionShort‑term medical care for minor but urgent conditions not posing significant threat to life or health; must be provided at facilities that bill as urgent care and include an examination by a professional provider.
Billing noteVisits to facilities that do not bill as urgent care (e.g., many walk‑in clinics) will be covered under office visit benefits instead.
Coverage conditionMember must be actually examined by a professional provider for urgent care benefit to apply.
Emergency services definition
Emergency services — definition and coverageTreatment for emergency medical conditions; emergency services are covered at the in‑network benefit level worldwide; prior authorization not required for emergency screening or stabilizing treatment.
Admission authorization timingEmergency admissions must be authorized within 48 hours after admission (or as soon as reasonably possible).
Out‑of‑network protectionsOut‑of‑network providers in emergency settings may not balance bill beyond applicable cost sharing when prohibited by law.
urgent care facility
Urgent care facility — definitionAn office or clinic distinct from a hospital emergency room intended to diagnose and treat illness or injury for patients without an appointment seeking immediate care.
Billing distinctionFacilities must bill as urgent care to be paid under urgent care benefits; otherwise the visit is paid as office visit.
ExclusionsMost walk‑in or same‑day clinics do not bill as urgent care and will not receive urgent care benefit payment.
high risk (colorectal cancer)
High risk for colorectal cancer — definitionHigh risk includes family history of genetic disorders (e.g., Lynch syndrome), prior colorectal cancer or adenomatous polyp, or inflammatory bowel disease; high‑risk screening paid at medical benefit level and may follow provider recommendations.
Screening differenceHigh‑risk individuals may be screened earlier or more often as medically necessary.
Coverage implicationScreening exams and lab tests for high‑risk individuals may be paid under medical benefits if not meeting USPSTF A/B preventive criteria.
approved clinical trial
Approved clinical trial — eligibilityApproved clinical trials must be funded/supported by specified federal agencies, be FDA IND/IDE/BLA submissions, or be federally exempt trials; participation must be prior authorized.
Usual care costsUsual care costs in approved clinical trials are covered with the same cost sharing as non‑trial care.
Excluded trial costsItems solely for the trial, for monitoring the investigational item, or for data collection only are not covered.
Usual care costs
Usual care costs — definitionUsual care costs are medically necessary conventional care, items or services that are covered if received outside of a clinical trial; cost sharing is the same as non‑trial care.
Trial exclusionsCosts provided only for the investigational intervention, monitoring, or data collection are excluded from coverage.
Prior authorizationParticipation in clinical trials must be prior authorized and meet trial funding/approval criteria.
Homebound
Homebound — definitionHomebound means you generally cannot leave home because of your condition; exceptions for infrequent/short trips mainly to get medical treatment.
Home healthcare eligibilityHome healthcare covered if homebound, services medically necessary, ordered by treating practitioner, intermittent visits by qualified professionals.
Provider typesCovered home health providers include RNs/LPNs, PT/OT/SLP/respiratory therapists, licensed social workers; home health aides not covered except under hospice.
hospital
Hospital — definition/contextHospital is a licensed facility providing surgical, medical and psychiatric care with 24‑hour nursing and supervised by licensed physicians; inpatient care covered when medically necessary.
Take‑home meds limitTake‑home prescription drugs after hospitalization limited to a 3‑day supply at same hospitalization benefit level.
Dental anesthesiaGeneral anesthesia for risky dental procedures in hospital/outpatient clinic covered with prior authorization.
inborn errors of metabolism
Inborn errors of metabolism — definitionGenetic metabolic disorders present at birth affecting metabolism of proteins, carbohydrates and fats; treatment covered when there are medically standard diagnostic, treatment and monitoring methods.
Covered itemsIncludes nutritional and medical care, biochemical analysis and medical foods where medically necessary.
Policy sectionSee Section 7.4.17 for details on coverage conditions.
Virtual care visit
Virtual care visit — definitionA virtual care visit is a live, interactive audio and video visit with a provider that includes diagnosis and treatment delivered in real time and meets privacy/security standards.
Coverage conditionsCovered if services can be safely and effectively provided virtually and technology meets state/federal privacy/security standards.
Preferred vendorVirtual visits using the preferred vendor are covered at no cost sharing (see Section 3).
Pharmacy benefit tiers and medication types
Pharmacy benefit tiers and medication typesTiers include Value, Select, Preferred, Nonpreferred and Specialty; Self‑Administered and Specialty Medications defined; Value Tier examples show $0 copay for 30‑day supply.
Tier changes and toolsTier placement may change; use Member Dashboard prescription price check tool for current coverage and pricing.
Specialty meds handlingSpecialty medications often require prior authorization, special handling, and are typically sourced from Moda‑designated specialty pharmacy.
Donor costs (transplant)
Donor costs (transplant)Donor costs are covered for recipient or self‑donor and include expenses to remove tissue, preserve/transport it to transplant site and related necessary charges; coverage differs if donor/recipient enrolled on policy.
When not coveredIf donor not enrolled or recipient not enrolled for a donor‑donor relationship, some donor costs and complications may not be covered as specified.
Transplant sectionSee Section 7.4.33 for detailed transplant and donor cost rules.
Select Tier Medications
Select Tier medications — referenceSelect Tier: cost‑effective options in therapeutic categories; cost sharing noted as 0% after deductible in Schedule entries.
Value vs SelectValue Tier examples show $0 copay for 30‑day supply; Select/Preferred often shown as 0% after deductible per Schedule of Benefits entries.
Formulary toolUse Member Dashboard to confirm specific medications in Select Tier and current cost sharing.
Self-Administered Medications
Self‑Administered Medications — definitionMedications labeled by the FDA for self‑administration outside a medical setting; subject to pharmacy benefit rules and prior authorization when specialty.
Coverage rulesSelf‑administered injectables are covered under pharmacy benefit when prescribed and filled per policy; administration of self‑administered meds in provider office may not be covered under pharmacy benefit.
Specialty overlapSelf‑administered specialty medications often require prior authorization and specialty pharmacy sourcing.
Specialty Medications
Specialty Medications — key pointsSpecialty medications often require prior authorization, must come from Moda‑designated specialty pharmacy for coverage or have prior authorization to use non‑designated suppliers; some specialty meds limited to short supplies (e.g., 2 weeks).
Program requirementsSome specialty drugs require enrollment in manufacturer/provider programs for safe use and coverage.
Coverage limitsCertain specialty meds may not be eligible for 90‑day fills and may have distinct day‑supply limits.
Value Tier Medications
Value Tier Medications — summaryValue Tier medications include commonly prescribed, cost‑effective meds; Schedule examples show $0 copay for a 30‑day supply and up to 90‑day supply where eligible.
Check Member DashboardMembers should verify specific Value Tier medications and current copays via the Member Dashboard formulary/pricing tool.
Applies to mail order and retailValue Tier cost sharing references appear across retail and mail‑order supply options in Schedule of Benefits.
Policy Summary
Payermoda_health_plan_inc
PolicyIdaho Individual Medical Policy (Moda Select Bronze 7500 AI/AN Limited Plan)
Policy CodePolicy Policy 2026
Change TypeNo material change
Effective DateJan 1, 2026
Last ReviewJan 26, 2026
Next Review DateN/A
Key ActionProviders must obtain prior authorization for services listed in the plan's authorization list and follow timing/penalty rules for emergency and nonemergency admissions.
SourceLink
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