Currentmoda_health_plan_incPolicy ModaAKIndvCSV0bk 1-1-2026
2026 Alaska Individual Medical Plan (Moda Select Alaska Silver 4500 AI/AI Zero)
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This document is the member policy booklet for Moda Health's 2026 Alaska individual medical plan describing benefits, coverage sections, member resources, networks, prior authorization, claims submission, and administrative provisions for subscribers and providers under the Moda Select Alaska Silver 4500 plan.
Policy Summary
Payermoda_health_plan_inc
Policy2026 Alaska Individual Medical Plan (Moda Select Alaska Silver 4500 AI/AI Zero)
Policy CodePolicy ModaAKIndvCSV0bk 1-1-2026
Change TypeNo material change
Effective DateJan 1, 2026
Next Review DateN/A
Key ActionCheck www.modahealth.com/medical/referral 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 (partial)
37-60pages referenced
10policy return/refund (days)
24/7Member Dashboard
50%/$2,500prior auth penalty
Coverage Criteria and Schedule of Benefits
Referenced benefit sections (TOC)
Table of Contents entries indicate covered areas and benefit topics; specific criteria appear in the corresponding sections (examples listed in TOC):
Preventive Services — Colorectal cancer screening, immunizations, well-baby and preventive health exams; see Sections 7.3 and Schedule of Benefits (TOC).
General Treatment Services — Acupuncture, anticancer medication, applied behavior analysis (ABA), behavioral health, biofeedback, clinical trials, cochlear implants, pediatric dental care, diagnostic procedures, DME, infusion therapy, rehabilitation, surgery, transplants; see Sections 7.4 and Schedule of Benefits (TOC).
Pharmacy Prescription Benefit — covered medication types, specialty pharmacy and step therapy processes; see Section 7.6 and Schedule of Benefits (TOC).
Vision and Hearing Benefits — pediatric and adult vision, hearing exams and hearing aids; vendor processes via VSP and hearing vendor; see Sections 7.7–7.8 and TOC.
Claims Administration & Payment — how to submit claims, payment rules and EOBs; see Claims sections referenced in the TOC.
Benefits available from other sources / Coordination
Sections related to coordination with other payers and third-party liability are listed in the TOC.
Coordination of Benefits (COB) — procedures to coordinate benefits with other coverage and Medicare; see Section listed in TOC (Benefits (COB)).
Third Party Liability — requirements to pursue third-party recovery when another party is responsible; see TOC references.
Benefits Available from Other Sources — describes when other sources (Medicare, third parties) apply and how they affect plan payments; see Section referenced in TOC.
Networks
Networks and tiers applicable to the plan:
Medical networks — Tier 1: Moda Select; Tier 2: First Choice (Alaska). Tier 1/2 service area and 50-mile reasonable access rules apply (see Network and Service Area).reasonable access: 50 miles
Dental network — Delta Dental Premier (pediatric dental benefits referenced in Schedule of Benefits).
Pharmacy network — Navitus (pharmacy benefit administration and specialty pharmacy requirements referenced).
Out-of-Area / Out-of-State network — Aetna PPO (Aetna Signature Administrators) for out-of-area coverage as noted in TOC and network sections.
Vision network — VSP (vendor handles Tier 1/2 benefit authorization for vision services).
Care Services
Care and support services available to members:
Care Coordination — Care Coordinators and Case Managers (nurses or behavioral health clinicians) coordinate services for complex or catastrophic needs; they assist with accessing and managing authorized services.
Disease Management & Health Coaching — Health Coaches support members with chronic conditions to follow care plans, self-manage disease, and prevent complications; contact Disease Management and Health Coaching for details.
Behavioral Health — Moda Behavioral Health provides specialty mental health and substance use disorder services and helps members find Tier 1/2 providers and understand benefits.
Extracted coverage criteria (partial)
High-level stance and common limits extracted from the schedule of benefits excerpt.
Benefit payment stance — the Plan has no deductible or out-of-pocket maximum and pays covered services at 100% of the maximum plan allowance; members may be responsible for amounts above the MPA for Tier 3 providers.
See Schedule of Benefits summary.
Common frequency/limit examples — certain services are limited (e.g., acupuncture, behavioral health, ABA, biofeedback) commonly to 24 visits per year or a 10-visit lifetime maximum where indicated in the Schedule of Benefits.acupuncture: 24 visits/year; some services: 10 visit lifetime max
Preventive schedule highlights — preventive services follow ACA/USPSTF/ACIP/HRSA guidance (examples: colorectal screening start age 45+, mammogram frequency guidance); refer to Preventive Services section for modalities and intervals.
Medical transportation — medically necessary air transportation limited to 2 round-trip tickets per member per year (prior authorization required).2 round-trip tickets/year
Prior authorization — prior authorization may be required for some services; consult Section 6.1 and the online prior authorization list for specifics.
Schedule limits (partial)
Benefit-level limits and restrictions (summary entries present in schedule):
Acupuncture — covered up to an annual visit limit (Schedule of Benefits lists 24 visits per year); services must be prior authorized when required.
Applied Behavior Analysis / Behavioral Health / Biofeedback / Anticancer medication — certain behavioral health and related services show limits (example: 10 visit lifetime maximum where specified); ABA and intensive behavioral services require prior authorization and individualized treatment plans where applicable.
Dental care age restriction — many dental benefit lines apply 'Under age 19' qualifier (diagnostic & preventive, minor restorative, other dental services); frequency limits apply to pediatric dental services as listed.
Schedule of Benefits qualifiers (partial)
Coverage fragments and qualifiers observed in this excerpt:
Dental care — pediatric dental benefits are qualified 'Under age 19' with frequency limits for many services; orthodontia is covered when medically necessary.
Biofeedback — covered only to treat tension or migraine headaches and subject to a lifetime visit limit (Schedule indicates a lifetime limit applies).
DME / Supplies / Appliances — limits apply to some DME, supplies and appliances; some items require prior authorization and rental may be covered up to purchase price.
Diagnostic and supplemental breast services — listed under diagnostic services; some entries note frequency limits or that supplies may be covered under pharmacy benefits.
Schedule of Benefits highlights
Benefit categories and their stated limits or notes as listed in the Schedule of Benefits.
Rehabilitation & Habilitation — outpatient rehab subject to annual limits (example: 45 sessions/year outpatient); inpatient habilitation and rehabilitation subject to day limits (examples noted in Schedule).
Skilled Nursing Facility Care — limited number of days covered; expenses limited to daily semi-private hospital room rate; see Section 3 details.
Massage Therapy — covered up to an annual visit limit (Schedule indicates 24 visits/year) and requires prior authorization.
Transplants — must use an authorized Center of Excellence when available; donor costs, travel and housing coverage described with a travel/lodging maximum per transplant; prior authorization required.
Virtual Care Visits — telehealth services covered when clinically appropriate; vendor contact modahealth.com/cirrusmd referenced.
Pharmacy particulars — retail/mail/specialty supply rules, designated specialty pharmacy requirements, day supply rules and early refill/travel allowances are noted in the Schedule and Pharmacy section.
Network and payment rules
Network placement and payment rules determining benefit level and potential member liability
Tier benefit rules — Tier 1 providers deliver highest benefit level; Tier 2 benefits apply in areas outside Tier 1 service area; Tier 3 is out-of-network and member may be balance billed for amounts above the MPA.
Reasonable access / 50-mile rule — when no reasonable access to a Tier 1 provider within 50 miles, a Tier 2 or Tier 3 provider may be paid at Tier 1 level per Network rules; specifics provided in Network and Service Area section.50 miles
Balance billing — Tier 3 providers may bill the member for charges exceeding the maximum plan allowance unless other protections apply; services outside emergency care may not receive Tier 1 benefit level.
Authorization and coverage criteria
Coverage and authorization rules
Prior authorization required — many outpatient services and all nonemergency inpatient and residential care require prior authorization; a full list is maintained on the Moda Health website.
Prior authorization penalty — failure to obtain required prior authorization may result in a penalty of 50% up to $2,500 per occurrence applied to covered charges before benefits are computed; penalty does not apply to emergency admissions.
Authorization limitations — authorizations may be time-limited, limit services/amounts/frequency, or be provider-specific; limits appear in the authorization letter and may affect coverage.
Emergency coverage — emergency services paid at Tier 1 worldwide; prior authorization not required for emergency medical screening exams or stabilization; facility-billed emergency services covered at Tier 1.
Urgent care — urgent care visits covered when provided at an urgent care facility that bills as urgent care and member is examined by a professional provider; many walk-in clinics bill as office visits instead.
Ambulance and commercial transport rules — licensed ambulance covered when medically necessary to nearest capable facility; commercial one-way transport for life-endangering conditions covered at Tier 1 in Alaska; round-trip medical air limited to 2 round-trips/year and requires prior authorization.
Emergency services
Emergency room services
Emergency medical screening and stabilization — covered worldwide; facility emergency services paid at Tier 1; professional fees billed separately under inpatient/outpatient benefits; prior authorization not required for emergency stabilization.
Tier 3 provider caveat — using a Tier 1 or Tier 2 emergency room does not guarantee all treating providers are Tier 1/2; Tier 3 providers may balance bill unless restricted by law.
Urgent care coverage
Urgent care
Urgent care visits — covered for minor but urgent conditions when provided at an urgent care facility and the member is examined by a professional provider; facility must bill as urgent care for payment under urgent care benefit.
Preventive services
Preventive services required or recommended by federal bodies
ACA/USPSTF/ACIP/HRSA preventive coverage — evidence-based A/B USPSTF services, ACIP immunizations and HRSA recommended pediatric/women's preventive services covered with no cost sharing when delivered by Tier 1/2 providers; updates to recommendations may be implemented up to one year after issuance.
Colorectal cancer screening — covered for age 45+ with modality-specific intervals: FOBT/FIT yearly, fecal DNA every 3 years, CT colonography/flexible sigmoidoscopy/double contrast barium enema every 5 years, flexible sigmoidoscopy every 10 years plus annual FIT, colonoscopy every 10 years; follow-up colonoscopy after positive screen covered under preventive benefit.
Immunizations and pediatric screenings — routine ACIP immunizations and HRSA pediatric screenings (newborn hearing, vision screening age 3–5, developmental screenings) covered per recommended schedules.
Women's preventive care — preventive women's visits, Pap and breast exam frequency, mammogram frequency guidance (one between 35–39; annually age 40+).
Prostate screening — one rectal exam and one PSA test per year for age 40+ (and covered for ages 35–39 with African American race or family history).
General treatment services
Selected general treatment services
Acupuncture — covered up to an annual visit limit; services must be prior authorized as medically necessary; other services at the visit billed under standard benefits.
Anticancer medications — prescribed anticancer agents covered; most require prior authorization, specialty supply from designated specialty pharmacy, and may have benefit limitations and program enrollment requirements.
Applied Behavior Analysis (ABA) — ABA for autism spectrum disorder covered when medically necessary, provided/supervised by certified/licensed behavior analysts, authorized via individualized treatment plan and prior authorization; specified exclusions apply.
Biofeedback — covered only to treat tension or migraine headaches and subject to a lifetime visit limit as specified in the Schedule of Benefits.
Behavioral health and SUD
Behavioral health and substance use disorder services
Mental health services — office/home visits, psychotherapy, intensive outpatient, partial hospitalization, TMS, ECT, inpatient and residential care covered when medically necessary; some levels require prior authorization (e.g., intensive outpatient, residential).
Substance use disorder services — covered outpatient treatment and room/treatment services for detox by state-licensed programs; program levels defined (intensive outpatient, partial hospital, residential) and licensing requirements apply.
Program level definitions — intensive outpatient and partial hospital programs defined by hours of structured treatment; residential programs provide 24-hour care and must be state licensed for coverage.
Clinical trial coverage
Clinical trials
Usual care costs in approved clinical trials — covered when trial is approved under federal/state laws for cancer or life-threatening conditions, treating physician finds no clear superior non-investigational alternative, and available data provide reasonable expectation of benefit; costs subject to same cost sharing as non-trial care; participation requires prior authorization.
Biofeedback coverage
Biofeedback
Biofeedback for tension or migraine headaches — covered with a lifetime visit limit; prior authorization not universally required but coverage limited to listed clinical indication and lifetime cap.
Clinical trials coverage
Clinical trials (usual care costs)
Clinical trial usual care coverage — covers prevention, diagnosis, treatment and palliative care items that would otherwise be covered, plus items necessary to provide an investigational item or to manage complications; excludes drugs/devices not FDA approved, housing/nonclinical expenses, items only for data collection, items excluded in Section 8, and items paid for by grants; prior authorization required.
Cochlear implants coverage
Cochlear implants
Cochlear implants — covered when medically necessary and require prior authorization.
Pediatric dental coverage
Pediatric dental care (through age 19)
Diagnostic — exams twice per calendar year, full series x-rays once per 5 years, bitewings per intervals described; certain diagnostic services excluded as noted.
Preventive — prophylaxis up to twice per calendar year, topical fluoride twice/year, sealants once per 3 years, space maintainers and related services per limits.
Minor restorative — fillings, stainless steel crowns (under age 15 one per tooth per 5 years), and related restorative services subject to frequency limits.
Endodontic/Periodontic/Oral Surgery/Prosthodontic — specific services covered with procedural and frequency limits; orthodontia covered only when medically necessary with payment arrangements described.
Dental injury coverage
Dental injury
Accidental dental injury coverage — covers treatment to natural teeth caused by foreign object or acute trauma when diagnosis within 6 months and treatment begins within 12 months; treatment must be medically necessary and limited to restoration to functional state; implants and implant-related services excluded.
Diabetes coverage
Diabetes services and supplies
Insulin and diabetic supplies — insulin, syringes, needles, lancets, test strips, glucometers and CGMs 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 pharmacy.
Supportive diabetes services — HbA1c testing, kidney disease checks, annual dilated eye exam, outpatient self-management training and medical nutrition therapy covered as medically necessary.
Diagnostic services coverage
Diagnostic procedures
Diagnostic services — x-rays, lab tests, standard and advanced imaging, psychological and neuropsychological testing are covered when for treatment of a medical or behavioral health condition; most advanced imaging requires prior authorization and a full list is on the Moda Health website.
DME coverage and exclusions
Durable Medical Equipment (DME), supplies & appliances
DME coverage — examples include CPAPs, insulin pumps, hospital beds, orthotics, wheelchairs and prosthetics; DME is covered when medically necessary, some items require prior authorization, rental may be covered up to purchase price, and replacements/repairs covered when not abused.
DME exclusions/limits — comfort/cosmetic items, wigs, dental appliances/braces, incontinence supplies and certain devices are excluded; some DME limits apply and preferred DME providers are encouraged to reduce cost.
E-visit coverage
Electronic visits
E-visits — covered when you are an established patient of the provider and the e-visit is medically necessary for a covered condition.
Gender affirming services coverage
Gender affirming services
Gender-affirming services — covered when procedures are performed by qualified professional providers, the treatment plan meets medical necessity criteria, and prior authorization is obtained for surgical procedures; covered services may include mental health, hormone therapy (including puberty suppression), and surgical procedures (chest surgery, gonadectomy, genital reconstruction, facial surgery).
Health education coverage
Health education services
Health education — outpatient programs for tobacco cessation, diabetes, asthma, pain management, childbirth and parenting training are covered when relevant to a covered condition.
Gender-affirming services
Gender-affirming services are covered when conditions are met:
Procedures must be performed by a qualified professional provider.
Prior authorization is required for surgical procedures.
Treatment plan must meet medical necessity criteria.
Covered services may include
- Mental health services
- Hormone therapy including puberty suppression for adolescents
- Surgical procedures such as breast/chest surgery, gonadectomy, genital reconstruction, and facial surgery
Home healthcare
Home healthcare coverage conditions and limits:
Member must be homebound and services must be medically necessary and ordered by the treating physician.
Visits must be 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.
Annual limit applies to RN/LPN services; other home healthcare providers are limited to one visit per day.
Hospice and respite care
Hospice coverage requirements, covered services, and exclusions:
Hospice eligibility — hospice must be Medicare-approved or state licensed/certified and include a hospice treatment plan with physician certification of terminal illness.
Covered hospice services — intermittent medically necessary or palliative care services by RNs/LPNs, PT/OT/ST, certified respiratory therapists, home health aides, licensed social workers; short-term inpatient hospice and limited respite care when prior authorized.
Exclusions — services not included in the hospice treatment plan and hospice services provided to others than the terminally ill member (including bereavement counseling for family) are not covered.
Hospital care and visits
Hospital care coverage and conditions:
Inpatient hospital care — covered when medically necessary; includes hospital room, isolation care, ICU, facility charges for outpatient surgery and other medically necessary hospital services and supplies.
Take-home prescription drugs — limited to a 3-day supply at the same hospitalization benefit level.
General anesthesia for dental procedures — covered when medically necessary and prior authorized for patients under age 7, physically/developmentally disabled, or with medical risk factors.
Infusion therapy and provider-administered medications
Infusion and provider-administered medication coverage:
Infusion therapy components — covers solutions, medications, compounding/dispensing, DME, ancillary supplies, nursing services and related lab testing when medically necessary.
Prior authorization for infusion — professional provider must obtain prior authorization for infusion therapy; preferred medication suppliers may be available for cost savings.
Provider-administered medications — medications given in office, infusion center or home infusion are covered at same benefit level as supplies and appliances and may require prior authorization.
Kidney dialysis
Kidney dialysis:
Dialysis coverage — treatment planning, professional services for administration/supervision, treatments including therapist, facility and equipment charges are covered; ESRD members should enroll in Medicare Part B for best benefit.
Enteral formula and PKU formulas
Enteral formula and phenylketonuria formulas
Enteral formula — nonprescription elemental enteral formula for home use is covered when medically necessary, ordered by a physician, and is sole or essential source of nutrition.
PKU formulas — formulas necessary for treatment of phenylketonuria are covered.
Nutritional therapy
Nutritional therapy and preventive coverage:
Dietary/nutritional therapy — assessment and individualized counseling covered; preventive nutritional therapy required under the ACA is covered at no cost for specified BMI/age/sex criteria and risk factors; medical foods and nutritional supplements are not included.
Massage therapy
Massage therapy:
Massage therapy — covered up to an annual visit limit, requires prior authorization, and does not include other manual therapy services which follow standard plan benefits.
Podiatry services
Podiatry:
Podiatry services — covered to diagnose and treat a specific current problem; routine podiatry is not covered unless medically necessary (e.g., diabetes).
Pre-admission testing
Pre-admission testing:
Pre-admission testing — covered when ordered by a professional provider.
Podiatry Services
Podiatry
Podiatry services — coverage limited to diagnosing and treating a specific current problem; routine podiatry excluded unless required for a medical condition such as diabetes.
Pre-admission Testing
Pre-admission testing
Preadmission testing — covered when ordered by a professional provider.
Psychological/Neuropsychological Testing
Psychological or Neuropsychological Testing
Testing and evaluation — covered services include interpretation and report preparation necessary to prescribe an appropriate treatment plan.
Rehab/Habilitation & Chronic Pain Care
Rehabilitative, habilitative and chronic pain care
Rehabilitative services — must begin within 24 months of condition onset, be part of a physician's formal written program to improve/restore function, and are subject to annual limits (outpatient 45 sessions/year example).
Habilitative services — covered to develop bodily or cognitive functions when medically necessary; limits apply separately from rehabilitative services and exceptions exist for autism spectrum disorder and young children.
Chronic pain care — subject to annual limits; benefits not provided for both chronic pain care and neurodevelopmental therapy for the same condition.
Skilled Nursing Facility Care
Skilled Nursing Facility (SNF) care
SNF coverage — provides rehabilitative services and 24-hour nursing; a limited number of days are covered (see Section 3) and expenses limited to the daily semi-private hospital room rate; exclusions include custodial care and care mainly for cognitive decline/dementia.
Spinal & Other Manipulations
Spinal and other manipulations
Spinal manipulations — covered up to an annual visit limit for treatment of a medical condition; spinal manipulations must be prior authorized and other services at the visit are billed under standard benefits.
Surgery
Surgery
Surgery coverage — includes operating/recovery rooms, surgical supplies and typical surgical team services; eligible office surgeries require prior authorization; reconstructive surgery must be medically necessary and prior authorized; cosmetic surgery is excluded except when medically necessary for reconstructive or gender-affirming reasons.
Assistant surgeon MPA — assistant surgeon MPA is 20% of primary surgeon's MPA (10% for PA/CRNA) as stated in the Schedule of Benefits.
TMJ
Temporomandibular Joint (TMJ)
TMJ — related surgical procedures and splints require prior authorization and are covered only when medically necessary; orthodontia and related dental treatments are not covered under TMJ benefit.
Therapeutic Injections
Therapeutic injections
Therapeutic injections — administrative services for provider-administered injections (e.g., allergy shots) covered when given in a professional provider's office; self-administered alternatives may affect coverage; vitamin/mineral injections not covered unless medically necessary.
Therapeutic Radiology
Therapeutic radiology
Therapeutic radiology — covered expenses include treatment planning/simulation, professional services for administration and supervision, and treatments including therapist, facility and equipment charges.
Transplants
Transplants
Transplants — medically necessary non-experimental transplants covered when done at a Center of Excellence (unless unavailable); prior authorization in writing required; donor costs, limited travel and lodging reimbursement (maximum per transplant) and immunosuppressive drug payment rules described.
Travel & lodging threshold — travel and housing for recipient and caregiver covered when recipient lives more than 50 miles from Center of Excellence; specific maximum applies per transplant.
Virtual Care Visits
Virtual Care (Telehealth)
Virtual care visits — covered when generally accepted practices allow safe and effective telehealth provision and the provider is licensed in Alaska or referred by such a provider; privacy/security standards apply.
Maternity Care
Maternity care
Maternity services — pregnancy care, childbirth and related conditions covered when provided by a professional provider; maternity often billed as a global charge with some diagnostics reimbursed separately; hospital stay up to 48 hours (vaginal) or 96 hours (cesarean) permitted without prior authorization.
Hospital take-home drugs after maternity — limited to 3-day supply at hospitalization benefit level.
Abortion
Abortion
Abortion — elective abortions are covered.
Breastfeeding Support
Breastfeeding Support
Breastfeeding support — comprehensive lactation support and counseling covered during pregnancy and/or breastfeeding; breast pump purchase or rental covered (rental not to exceed purchase price) and MPA applies to retail purchases; hospital-grade pumps covered when medically necessary; extra ice packs/coolers not covered.
Circumcision
Circumcision
Coverage conditions
- Circumcision within 3 months of birth — covered without prior authorization.
- Circumcision after 3 months — requires medical necessity and prior authorization.
Breastfeeding Support
Breastfeeding and lactation support coverage
Lactation support and counseling — covered during pregnancy and/or breastfeeding; supplies and counseling covered per Section 7.5.2.
Breast pump — purchase or rental covered up to purchase price; MPA applies for retail purchase; hospital-grade pumps covered when medically necessary.
Circumcision
Circumcision coverage
Circumcision — within 3 months of birth covered without prior authorization; after 3 months requires medical necessity and prior authorization.
Hospital and Diagnostic Procedures
Maternity and hospital benefits
Hospital maternity care — hospital room, facility charges including birthing center, nursery care (covered under newborn's coverage while mother confined) and other medically necessary hospital services and supplies covered; take-home prescriptions limited to 3-day supply.
Diagnostic procedures related to maternity — lab tests and ultrasounds covered; some may require prior authorization; refer to Moda website or Customer Service for full list.
Postpartum hospital stay — Special Rights: up to 48 hours for vaginal delivery and 96 hours for cesarean without prior authorization.
Pharmacy Prescription Benefit
Pharmacy prescription benefit coverage, requirements, limitations, and exclusions
Covered medication supply — prescription meds, certain compounded meds, insulin and diabetic supplies, tobacco dependence meds with prescription and in-network retail pharmacy, preventive meds, contraceptives, certain immunizations, inhalation spacers and peak flow meters; specialty meds require use of Moda-designated specialty pharmacy and most require prior authorization.
Formulary and exceptions — formulary exceptions permitted for medical necessity with required provider documentation; decisions made within 72 hours (24 hours urgent).
Specialty medication rules — most specialty meds must be prior authorized and obtained from Moda-designated specialty pharmacy or will not be covered; some specialty supplies limited to shorter day supply (e.g., 15-day) and emergency local fills may be prior authorized when delay threatens treatment.
Step therapy — Step 1 medications must be tried before Step 2 will be covered; out-of-order submissions are not covered and provider must prescribe Step 1 or request exception.
Limitations and exclusions — new FDA meds reviewed, some brand meds time-limited, medications purchased outside US covered only in emergency/urgent care, excluded items include devices, foreign medication claims, hair growth meds, travel immunization agents (except ACA-required), institutional meds, medication administration charges (except retail immunizations), nutritional supplements/medical foods, off-label use exceptions, OTC meds excluded except tobacco dependence, repackaged/replacement meds, vitamins except as required by law, weight loss meds.
Day supply and refill rules — take-home hospital prescriptions limited to 3-day supply; early refill for travel allowed once every 6 months; some specialty meds limited to less than 30 days; formulary exception timelines apply.
Pediatric Vision Services
Pediatric vision coverage
Pediatric vision — one complete well-vision exam per year and one pair of eyeglasses and frames or contact lenses until the end of the month the member reaches age 19; contact lenses require minimum supplies; optional lens upgrades limited as listed; some vision services may require prior authorization and VSP handles Tier 1/2 authorizations.
Pediatric vision services
Pediatric vision coverage (through month you reach age 19):
Well-vision exam — one per year for members under age 19.
Eyeglasses or contact lenses — one pair per year in lieu of frames; contact lenses require minimum supply rules per vendor tiers; optional lens upgrades limited as listed.
Adult vision services
Adult vision coverage (age 19 and older):
Adult vision benefits — one complete eye exam annually, one pair of frames every 2 years, one pair of corrective lenses annually (or elective contact lenses in lieu of eyeglasses), low vision testing/aids frequency as specified; benefits limited to one pair of contact lenses or lenses per year and one set of frames every 2 years.
Hearing services
Hearing services coverage:
Hearing services — one audiological exam and evaluation annually; one hearing aid per ear once in a 3-year period (from date of otological exam) with related items (ear molds, initial batteries, warranty, repairs) covered as described; requirement to be examined by licensed physician before obtaining hearing aid; implantable hearing aids and implantation surgery excluded.
General exclusions
General exclusions (non-covered services):
Examples of general exclusions include
- Cosmetic procedures and services primarily for appearance (examples listed).
- Custodial care and routine non-medical personal care services.
- Experimental or investigational procedures and medications and related expenses.
- Hearing implants and surgical implantation procedures for hearing aids (implantable hearing aids excluded).
Coding, Billing and Reference Codes
Unlabeled referencemixed
Pharmacy supplies referencemixed
| Supplies covered under Pharmacy benefits (see Section 7.4.10) |
Prior authorization list referencemixed
| Full list of services and supplies that must be prior authorized is maintained on the Moda Health website and updated periodically |
Emergency billing notesmixed
| Facility-billed emergency services paid at Tier 1; professional fees billed separately under inpatient/outpatient benefits; prior authorization not required to stabilize emergency medical conditions |
Pediatric dental service categoriesmixedCovered
| Diagnostic: exams twice/year; limited exams twice/year; full series x-rays once per 5 years; periapical, bitewing, occlusal and cephalometric provisions as listed | |
| Preventive: prophylaxis twice/year; topical fluoride twice/year; interim caries arresting medicament twice per tooth/year; sealants once per 3 years; space maintainers | |
| Minor restorative: fillings and related services (see Section 7.4.36) | |
| Endodontic, periodontic, oral surgery, major restorative/prosthodontic/orthodontia subject to listed criteria and frequency limits; orthodontia only when medically necessary |
DME examples and coveragemixedCovered
| Examples: CPAP for sleep apnea, insulin pumps, hospital beds and accessories, oxygen and supplies, prosthetics, wheelchairs/scooters (including maintenance), orthotics/braces/orthopedic shoes, intraocular lens within 90 days of cataract surgery, light boxes/wands when needed | |
| Diabetic supplies (other than insulin pumps) covered under pharmacy when obtained from a pharmacy with prescription and preferred manufacturer |
Gender-affirming services (listed types)mixed
| No codes listed |
Surgical payment allocationmixed
| Maximum Plan Allowance (MPA) for assistant surgeon is 20% of the physician's MPA (or 10% of the PA's or CRNA's MPA) as primary surgeon |
Formulary / Specialty medication referencesmixed
| No codes listed |
inv-73: Colonoscopy frequency — key facts/values (one per 10 years, age 45+)
Colonoscopy frequencyOne colonoscopy every 10 years for average-risk members beginning at age 45+
Supporting noteFollow-up colonoscopy after a positive screening is covered under the preventive benefit as part of the screening procedure
ExceptionsMembers at high risk may be screened earlier or more often as medically necessary
inv-74: Mammogram frequency — screening frequency key-value
Mammogram frequency (screening)One mammogram between ages 35–40 (per schedule) and then per preventive schedule as described in Section 7.3
ReferencePreventive women's healthcare frequencies are listed in Section 7.3 (see Schedule of Benefits)
Age-based guidancePreventive health exams include age-specific schedules (see Section 7.3.5)
inv-75: Medical transportation — key-value for 2 round-trip tickets per year
Medical transportation annual allotmentMaximum of 2 round-trip medically necessary tickets per member per year
Covered transport typeMedically necessary round-trip air transportation by a licensed commercial carrier (ground/water ambulance described elsewhere)
Prior authorizationPrior authorization and written certification from attending physician required; reimbursement limited to lowest available commercial airfare
inv-76: Visit limits example — acupuncture 24/yr; 10 visit lifetime max for specified services
Acupuncture annual limitCovered up to 24 visits per year (annual visit limit)
Lifetime visit max exampleSome services listed with a 10‑visit lifetime maximum (e.g., certain behavioral health/applied behavior analysis/biofeedback entries)
Frequency limits noteFrequency limits apply to some services; see specific sections (e.g., 7.4.x) for details and prior authorization requirements
inv-77: Biofeedback lifetime visits — numeric key-value (10)
Biofeedback lifetime maximum10 visits lifetime maximum for biofeedback treatment (for tension or migraine headaches)
ConditionCovered only to treat tension or migraine headaches; lifetime limit applies
Prior authorizationSee applicable section for any prior authorization or medical necessity qualifiers
inv-78: Age-limited dental coverage — pediatric dental qualifier (Under age 19)
Pediatric dental age qualifierPediatric dental benefits apply through the end of the month in which the member reaches age 19 (Under age 19)
ImplicationMany diagnostic, preventive and restorative dental services have frequency limits that apply only while member is under age 19
Reference sectionsSee Pediatric Dental Care section for specific frequency rules (e.g., prophylaxis twice/year, x-rays intervals)
inv-79: medical_transport_limit — maximum 2 round-trip medically necessary air transportation tickets per member per year
Maximum air transportation ticketsMaximum of 2 round‑trip medically necessary air transportation tickets per member per year
Coverage scopeCovers member travel to the nearest facility equipped to provide treatment not available locally; parent/guardian may accompany members under 18 when medically necessary
Authorization & limitsPrior authorization with written certification required; reimbursement limited to lowest available fare; additional expenses not covered
inv-80: Colorectal screening intervals — FOBT/FIT yearly; fecal DNA q3yrs; CT colonography/flexible sig every 5 yrs etc.
FOBT/FIT intervalFecal occult blood test (FOBT) or fecal immunochemical test (FIT): every year
Fecal DNA intervalFecal DNA test (e.g., MT‑sDNA/FIT‑DNA): every 3 years
Imaging/endoscopy intervalsCT colonography, flexible sigmoidoscopy, or double contrast barium enema: every 5 years; flexible sigmoidoscopy every 10 years plus annual FIT; colonoscopy every 10 years
inv-81: Prostate screening frequency — one rectal exam and PSA per year for age 40+ (with earlier exceptions)
Prostate screening frequencyOne rectal exam and one PSA test covered every year for members age 40 and over
Younger-age exceptionAlso covered annually for ages 35–39 if African American or with family history of prostate cancer
ReferenceSee Prostate Rectal Exam & PSA Test section for details
inv-82: Frequency limits — pediatric dental frequency examples (prophylaxis twice/yr; x-rays etc.)
Pediatric dental prophylaxis frequencyProphylaxis (cleaning) covered twice per calendar year; additional cleanings may be eligible if pregnant or diabetic
X-ray frequency examplesFull series or panoramic x‑rays once in any 5‑year period; bitewing x‑rays once in any 6‑month period; occlusal intraoral x‑ray once in any 2‑year period
Crowns/major restorationsCrowns/onlays once per tooth in any 5‑year period; prefabricated stainless steel crowns for under age 15: one per tooth per 5‑year period
inv-83: Take-home prescription drug supply limit — 3-day supply
Take‑home prescription limitTake‑home prescription drugs provided at hospital discharge are limited to a 3‑day supply at the same hospitalization benefit level
ApplicabilityApplies to prescriptions supplied at hospital discharge; outpatient pharmacy rules differ under pharmacy benefit
ReferenceSee Hospital Care section for inpatient take‑home drug rules
inv-84: Home health visit frequency — other home healthcare providers limited to one visit per day
Home health daily visit limitOther home healthcare providers (non‑nursing) are limited to one visit per day
Nursing visits limitVisits by a registered or licensed practical nurse are subject to an annual limit (see applicable section)
Provider typesCovered home health providers include RNs/LPNs, physical/occupational/speech/respiratory therapists and licensed social workers; home health aides do not qualify as home health service providers
inv-85: transplant travel/housing distance threshold — 50-mile threshold for travel/housing support
Transplant travel/housing distance thresholdTravel and housing expenses for recipient and caregiver(s) covered up to a maximum per transplant when recipient lives more than 50 miles from the Center of Excellence
Center of Excellence requirementTransplants must be done at a Center of Excellence unless unavailable; travel/housing coverage applies when recipient lives >50 miles from the Center of Excellence
Prior authorizationPrior authorization in writing from Moda Health is required for transplant services
inv-86: specialty medication short supply limit — some specialty meds limited to 15-day supply
Specialty medication short supply limitCertain specialty medications with high discontinuation rates or short duration of use may be limited to a 15‑day supply
Formulary and prior auth noteMost specialty medications must be prior authorized and obtained from Moda‑designated specialty pharmacy; exceptions for urgent local fills may be prior authorized
Review & limitsNew FDA‑approved medications may be reviewed and subject to coverage requirements or time‑limited authorizations
inv-87: early refill travel allowance frequency — early refill for travel allowed once every 6 months
Early refill for travel frequencyEarly refill for travel is allowed no more than once every 6 months
LimitationsEarly refill cannot be used to extend supply beyond the end of the policy year
ProcessMember may request early refill for travel; plan restricts frequency to once per 6‑month period
Provider Requirements, Prior Authorization and Billing Guidance
Prior Authorization
Where prior authorization appears in TOC
Prior Authorization and Services Requiring Prior Authorization are listed in the Table of Contents (see Prior Authorization; Prior Authorization Requirements; Services Requiring Prior Authorization; Prior Authorization Limitations).
Prior Authorization
Prior authorization processing timeframes (TOC)
Time Frames for Processing Prior Authorizations and Utilization Review are listed in the Table of Contents (see entry for Time Frames for Processing Prior Authorizations and Utilization Review, page 53).
Prior Authorization
Web lookup for prior authorization requirements
Check whether a service or supply requires prior authorization online at www.modahealth.com/medical/referral via the Member Dashboard.
Documentation Required
Member ID card use and replacement
Members must show their ID card at each visit so providers know they are Moda Health members; lost cards can be replaced through the Member Dashboard or by calling Customer Service.
Prior Authorization
General prior authorization note (see section 6.1)
Some services may require prior authorization; see Section 6.1 for details on which services need authorization.
Documentation Required
Medical necessity cross-reference
Certain services are covered 'when medically necessary' and reference medical necessity criteria (see Section 7.4.9 for specific entries).
Documentation Required
DME/supplies/appliances limits and frequency notes
Durable medical equipment, supplies and appliances have limits that apply to some items and may require prior authorization or have frequency/medical necessity qualifiers.
Prior Authorization
Extra‑contractual services may be authorized
Moda Health may authorize extra‑contractual (outside-policy) services after case evaluation and agreement with the member and provider; any party may end these services with written notice.
Prior Authorization
Request prior authorization and timing for emergency admissions
Providers must request prior authorization for services listed in the plan; emergency hospital admissions must be authorized within 48 hours (or as soon as reasonably possible). Failure to obtain required prior authorization may result in penalties described in the policy.
- Emergency hospital admissions: authorize within 48 hours or as soon as reasonably possible.
- Failure to obtain required prior authorization can trigger a penalty (see Prior Authorization Requirements).
Documentation Required
Second opinion: Plan‑paid for nonemergency treatments
The Plan may recommend and pay for a second opinion to confirm that nonemergency treatment is medically necessary; the Plan pays the full cost of the second opinion.
Prior Authorization
Emergency care does not require prior authorization
No prior authorization is needed for emergency medical screening exams or treatment to stabilize an emergency medical condition; all emergency service claims are paid at the Tier 1 benefit level.
- Prior authorization not required to stabilize an emergency medical condition.
- Emergency services claims paid at Tier 1 benefit level.
Prior Authorization
Nonemergency inpatient/residential and many outpatient services require prior authorization
Many outpatient services require prior authorization, and all nonemergency inpatient and residential care must be prior authorized; failure to obtain required prior authorization may lead to denial of benefits or penalties.
Prior Authorization
Prior authorization for anticancer meds and clinical trials
Some anticancer medications and participation in clinical trials require prior authorization; participation in a clinical trial must be prior authorized by Moda Health.
- Most anticancer medications need prior authorization and may require use of a designated specialty pharmacy.
- Clinical trial participation requires prior authorization.
Prior Authorization
Service‑specific prior authorization (e.g., acupuncture, ABA, IOP, TMS)
Specific services such as acupuncture, applied behavior analysis (ABA), intensive outpatient treatment and transcranial magnetic stimulation (TMS) require prior authorization.
Prior Authorization
Clinical trial participation requires prior authorization
Participation in an approved clinical trial must be prior authorized by Moda Health to have usual care costs covered under the Plan.
Prior Authorization
Cochlear implants require prior authorization
Cochlear implants are covered when medically necessary and require prior authorization before services are provided.
Prior Authorization
Advanced imaging and some DME require prior authorization
Most advanced imaging services (MRI, MRA, CT, PET, nuclear medicine, cardiac imaging) and some DME require prior authorization; a full list is available on the Moda Health website or via Customer Service (see section 6.1.1).
Prior Authorization
Prior authorization required for gender‑affirming surgery
Surgical gender‑affirming procedures require prior authorization as part of the gender‑affirming services criteria.
Documentation Required
Home health must be ordered and authorized; visit limits apply
Home healthcare must be medically necessary and ordered by the treating physician; visits are subject to limits, including an annual limit for RN/LPN services and one visit per day limits for other home health providers.
- Homebound status required for home healthcare.
- Registered/licensed practical nurse services subject to an annual limit; other providers limited to one visit per day.
Prior Authorization
Prior authorization required for infusion therapy
The professional provider must obtain prior authorization for infusion therapy before services are provided; preferred medication suppliers may be available for cost savings.
Prior Authorization
Massage therapy requires prior authorization
Massage therapy is covered up to an annual visit limit and must be prior authorized.
Prior Authorization
Respite care must be prior authorized and arranged by attending provider
Respite care must be arranged by the attending professional provider and is covered only if prior authorized; limited hours are covered in the most appropriate setting.
Prior Authorization
Prior authorization required for spinal manipulation
Spinal manipulations are covered up to an annual visit limit and must be prior authorized.
Prior Authorization
Transplant candidates: obtain written prior authorization promptly
Obtain prior authorization as soon as possible for transplant candidates; to be valid, prior authorization approval must be in writing from Moda Health.
Prior Authorization
Office surgeries and reconstructive surgery require prior authorization
Eligible surgeries performed in a physician's office are covered subject to appropriate prior authorization; reconstructive surgery must be medically necessary and prior authorized or benefits will not be paid.
Prior Authorization
Circumcision: prior authorization rules by age
Circumcision within 3 months of birth is covered without prior authorization; circumcision after age 3 months must be medically necessary and prior authorized.
- Within 3 months of birth: no prior authorization required.
- After 3 months: medical necessity and prior authorization required.
Prior Authorization
Circumcision coverage and prior authorization timing
Circumcision within 3 months of birth is covered without prior authorization; circumcision after 3 months requires medical necessity and prior authorization.
Prior Authorization
Maternity diagnostics: some require prior authorization
Diagnostic services related to maternity care are covered; some of these procedures may require prior authorization—see the full list on the Moda Health website or ask Customer Service.
Prior Authorization
Specialty medications: prior authorization and designated pharmacy required
Most specialty medications must be prior authorized and obtained from a Moda‑designated specialty pharmacy or the expense will not be covered; exceptions for urgent local fills may be prior authorized.
- Failure to obtain specialty meds from designated specialty pharmacy may result in no coverage.
- Urgent local fill may be prior authorized if delay threatens treatment or life.
Step Therapy
Step therapy enforcement: try Step 1 before Step 2
Step therapy requires trying Step 1 medications before Step 2 will be covered; prescriptions submitted out of order (without first trying Step 1) will not be covered and the provider must prescribe Step 1 or seek an exception.
Prior Authorization
Prior authorization and vendor processes for vision and hearing
Some vision and hearing services may require prior authorization; VSP provides benefit authorization directly to Tier 1 or Tier 2 vision providers and members must identify themselves as VSP members when contacting providers. Tier 1 audiologist selection and vendor processes are available by contacting the vendor for hearing services.
- VSP provides benefit authorization directly to Tier 1/2 vision providers.
- Members must identify as VSP members when contacting Tier 1/2 vision doctors.
- Tier 1 audiologist selection available via hearing vendor phone for hearing aid benefit.
Definitions and Administrative Terms
inv-119: Policy return/refund period — 10-day return/refund period for subscriber
Policy return/refund periodSubscriber may return the policy to Moda Health within 10 days of delivery for a full premium refund; policy is canceled from the beginning if returned
Effect of returnIf returned, it will be as if no policy had been issued
Authorized signaturePolicy is authorized by Moda Health's representative (signature block included)
inv-120: Authorization — policy signature / authorized representative
Authorization signatureThis policy is authorized by the signature of Moda Health's representative (Scott Loftin, Senior Vice President)
AuthoritySignature indicates Moda Health's representative authorization of the policy document
Document noteSignature appears on the policy cover/authorization block
inv-121: Definitions (TOC) — Definitions section location in TOC
Definitions section locationDefinitions are listed in the Table of Contents (see page 55)
PurposeDefinitions section provides terms used throughout the policy
ReferenceSee Table of Contents for exact page location
inv-122: Coordination of Benefits (COB) — COB TOC reference
COB TOC referenceCoordination of Benefits (COB) appears in the Table of Contents (page 57)
FunctionCOB section explains benefits available from other sources and coordination rules
ReferenceSee COB section for detailed coordination rules
inv-123: Member Dashboard — Member Dashboard availability and reference
Member Dashboard availabilityMember Dashboard available 24 hours a day, 7 days a week for policy information and tools
UsageUse the Member Dashboard for policy documents, Find Care, prescription price check and other resources
Access noteCustomer Service can assist and coordinate interpreter services if needed
inv-124: Child-only coverage — child-only policy note (dependents language removed)
Child-only policy noteIf this is a child-only policy, references to dependents (spouse, domestic partner, children) are deleted; siblings of the subscriber are eligible
Effect on languagePolicy language is adjusted for child-only coverage to remove references to non-applicable dependents
ReferenceSee Important Note: Child Only Coverage section
inv-125: Care Coordinators and Case Managers — role definition and responsibilities
Care Coordinator / Case Manager roleCare Coordinators and Case Managers are nurses or behavioral health clinicians who coordinate care for complex or catastrophic medical situations
ResponsibilitiesCoordinate access to a wide range of services across levels of care to help members get appropriate services at the right time
ContactMembers may contact Care Coordination for assistance when experiencing complex medical needs
inv-126: Health Coach — health coach role definition
Health Coach roleHealth Coaches provide education and support to help members follow medical care plans, self-manage disease, and prevent complications
ScopeAssist members with chronic conditions to identify healthcare goals and adhere to provider care plans
ContactContact Disease Management and Health Coaching for more information
inv-127: Health Coach / Disease Management — disease management and health coach scope
Health Coach / Disease Management scopeHealth Coaches support members in following care plans, self-managing disease, preventing complications and identifying healthcare goals
Program linkPart of Disease Management & Health Coaching services; contact for program details
Intended outcomesImprove health status, quality of life and productivity for members with chronic conditions
inv-128: Behavioral Health (Moda Behavioral Health) — behavioral health vendor reference
Behavioral health vendorModa Behavioral Health provides specialty services for mental health and substance use disorder benefits
SupportBehavioral Health Customer Service helps members find Tier 1 and Tier 2 providers and understand benefits
Program coverageIncludes intensive outpatient, partial hospital, residential and inpatient levels as described in behavioral health sections
inv-129: Frequency limits — definition that frequency limits apply to some services
Frequency limits applyFrequency limits apply to some services (examples include acupuncture, pediatric dental services, and biofeedback)
Common limits examplesExamples include 24 visits/year for acupuncture and specified per‑period limits for pediatric dental services
Refer to sectionsSee specific coverage sections (e.g., 7.4.x) for exact frequency rules and any prior authorization requirements
inv-130: Medical necessity — definition and cross-reference
Medical necessity definition referenceMedical necessity is referenced throughout the plan and used to determine coverage of services and supplies (see Section 7.4.x for service‑specific medical necessity language)
ApplicationMedical necessity qualifiers appear in multiple coverage sections (e.g., DME, orthodontia, home health)
Cross‑referenceSee applicable service sections for the specific medical necessity criteria
inv-131: Biofeedback — biofeedback lifetime maximum definition
Biofeedback lifetime maximum (definition)Biofeedback is limited to a 10‑visit lifetime maximum when used to treat tension or migraine headaches
Coverage conditionCovered only for specified indications (tension or migraine headaches)
See sectionRefer to the Biofeedback coverage section for details on limits and prior authorization (if any)
inv-132: Dental Care (Under age 19) — pediatric dental qualifier definition
Pediatric dental qualifierDental benefits listed with the qualifier 'Under age 19' indicate pediatric dental coverage through the end of the month you reach age 19
Effect on limitsFrequency limits and specific service rules apply while member is under age 19 (see Pediatric Dental Care section)
ExamplesIncludes diagnostic exams twice/year, prophylaxis twice/year, x‑ray intervals and restorative limits
inv-133: Orthodontia — orthodontia coverage conditional when medically necessary
Orthodontia coverage conditionOrthodontia is covered only when medically necessary
ApplicabilityOrthodontia benefit falls under pediatric dental coverage rules when applicable and requires medical necessity documentation
ReferenceSee Pediatric Dental Care and Orthodontia entries for specific criteria and prior authorization requirements
inv-134: Durable Medical Equipment (DME) — DME definitions and limit notes
DME limits noteDurable Medical Equipment, Supplies & Appliances have limits that apply to some items and some DME may require prior authorization
ExamplesExamples include CPAP, insulin pumps, hospital beds, orthotics, wheelchairs and prosthetics (see DME section)
Rental vs purchaseRental may be provided up to purchase price; replacement and repair covered if not due to abuse
inv-135: Network tiers — Tier 1/2/3 definition
Network tiersTier 1, Tier 2 and Tier 3 network designations determine benefit levels and potential member liability
Tier definitionsTier 1: Moda Select (highest benefits); Tier 2: First Choice in Alaska; Tier 3: out‑of‑network providers with MPA established by a national database
50‑mile access ruleIf no reasonable access to a Tier 1 provider within 50 miles, Tier 2 providers may be used at Tier 1 benefit level
inv-136: MPA — Maximum Plan Allowance definition and notes
MPA definitionMaximum Plan Allowance (MPA) is the contracted fee used to determine payment to providers; Tier 3 MPAs are set by a national database and may result in balance billing
EffectMembers may be responsible for charges above the MPA when using Tier 3 providers
ReferenceSee Payment and Network Information sections for more details
inv-137: Urgent care facility — definition text for urgent care facility
Urgent care facility definitionAn urgent care facility is an office or clinic distinct from a hospital emergency room that diagnoses and treats illness or injury for patients without an appointment seeking immediate medical attention
Billing requirementVisits must be billed as urgent care to be paid under the urgent care benefit; many walk‑in clinics bill as office visits instead
Coverage noteMember must be examined by a professional provider to receive urgent care coverage
inv-138: Emergency medical services — definition and worldwide coverage note
Emergency medical services definitionTreatment of emergency medical conditions as defined in Section 11; emergency services covered worldwide and paid at the Tier 1 benefit level; prior authorization not needed to stabilize an emergency medical condition
PaymentFacility‑billed emergency services are paid at Tier 1; professional fees billed separately under other benefits
Balance‑billing protectionTier 3 providers cannot balance bill except when permitted by law
inv-139: Urgent care facility — duplicate urgent care definition entry
Urgent care facility (duplicate)An urgent care facility is an office or clinic distinct from a hospital emergency room that diagnoses and treats illness or injury for patients without an appointment seeking immediate medical attention
Billing reminderVisit coverage requires the facility to bill as urgent care; otherwise office visit benefit applies
See alsoRefer to Urgent Care coverage section for more details
inv-140: Applied Behavior Analysis (ABA) — ABA definition
ABA definitionApplied Behavior Analysis (ABA) is a structured treatment program using behavioral principles to help children with autism spectrum disorder; provided or supervised by certified/licensed behavior analysts and requires an individualized treatment plan
Coverage conditionsServices must be medically necessary, prior authorized, and provided in approved settings; certain services are excluded
Exclusions examplesServices by family members, respite, certain therapies, IEP services and DHSS‑provided services are excluded
inv-141: Behavioral health program levels — definitions for IOP, PHP, residential levels
Behavioral health program levelsDefinitions for intensive outpatient (hours/week), partial hospital (>=4 hours/day, >=20 hrs/week), and residential (24‑hour care; state‑licensed) programs
IOP specificsMental health IOP: 3+ hours/week; SUD IOP: 9–19 hrs/week (adults) or 6–19 hrs/week (adolescents)
LicensingResidential programs must be state‑licensed for coverage
inv-142: e-visit — electronic visit definition
E-visit definitionAn electronic visit (e‑visit) is a structured, secure online consultation between you and your professional provider; covered when you are an established patient and the e‑visit is medically necessary for a covered condition
EligibilityMember must be previously treated and established with the provider
Coverage conditionE‑visits are covered when medically necessary for a covered condition
inv-143: Natural teeth / Dental injury — dental injury definition
Natural teeth / dental injury definitionNatural teeth are teeth that grew in your mouth; dental injury coverage applies only to accidental injury caused by a foreign object or acute trauma with diagnosis within 6 months and treatment begun within 12 months
Coverage limitsTreatment must be medically necessary, provided by a physician or dentist while covered, and limited to restoring function; implants and implant‑related services not covered
DocumentationDiagnosis within 6 months and treatment start within 12 months are required
inv-144: Homebound — homebound definition
Homebound definitionHomebound means you generally cannot leave home because of your condition; if you leave, it must be infrequent, for short times, and mainly to get medical treatment
ApplicationDefinition used to determine eligibility for home healthcare benefits
Related rulesHome healthcare must be ordered by treating physician and provided by qualified professionals
inv-145: Hospice treatment plan — hospice plan definition
Hospice treatment plan definitionA written plan of care established and periodically reviewed by the attending physician certifying terminal illness and describing services and supplies for medically necessary or palliative care
RequirementPhysician must certify terminal illness and plan must describe services to be provided by hospice
Coverage linkageHospice services covered only when included in the hospice treatment plan
inv-146: Hospital — hospital definition and inclusion notes
Hospital definitionA facility licensed to provide surgical, medical and psychiatric care with 24‑hour nursing supervised by licensed physicians; includes certain federal facilities when payment required by law
Service scopeCovers hospital room, ICU, facility charges for outpatient surgery and other medically necessary hospital services and supplies
Take‑home drug noteTake‑home prescription drugs limited to a 3‑day supply at hospitalization benefit level
inv-147: Transplant — transplant definition
Transplant definitionTransplant: transfer of tissue between persons or removal and later reimplantation of a patient's own tissue; covered when medically necessary and not experimental
Prior authorizationPrior authorization should be obtained as soon as possible for transplant candidates and must be in writing to be valid
Center of ExcellenceTransplants must be done at a Center of Excellence unless unavailable; donor costs and travel/housing rules apply
inv-148: Rehabilitative services — rehabilitative services definition
Rehabilitative services definitionRehabilitative services are those necessary for restoration of bodily or cognitive functions lost due to a medical condition; maintenance therapy without significant improvement is not rehabilitative
LimitsRehabilitative services are subject to annual visit limits except for autism spectrum disorder care; therapy must begin within 24 months of condition onset to be covered
Provider typesProvided by licensed physical, occupational or speech therapists, physicians, chiropractors, massage therapists or other licensed professional providers
inv-149: Habilitative services — habilitative services definition
Habilitative services definitionHabilitative services are necessary for development of bodily or cognitive functions to perform activities of daily living that never developed or did not develop appropriately based on chronological age
ScopeIncludes medically necessary therapy to retain skills and prevent regression; excludes respite, day habilitation for adults, chore, educational, vocational, recreational or custodial services
LimitsSubject to annual visit limits separate from rehabilitative services except for autism spectrum disorder care
inv-150: Formulary — formulary definition
Formulary definitionFormulary is a list of prescription medications and how they are covered under the pharmacy benefit; available on the Member Dashboard
UseUse prescription price check tool on Member Dashboard for coverage information and price estimates
UpdatesFormulary may be updated periodically as new medications are reviewed
inv-151: Specialty Medications — specialty medication definition and prior authorization expectation
Specialty Medications definitionSpecialty medications treat complex chronic conditions, require special handling/ordering, and most must be prior authorized
Prior authorization expectationMost specialty medications require prior authorization and must be obtained from a Moda‑designated specialty pharmacy or they will not be covered
Supply limitsSome specialty meds may have specific day‑supply limits (e.g., 15‑day supply for certain meds)
inv-152: Medication Tiers — medication tiering definition (Preferred/Select/Value/Nonpreferred)
Medication tiersMedication tiers include Preferred, Select, Value and Nonpreferred to categorize medications for cost and coverage
Tier examplesSelect Tier: most cost‑effective options; Preferred and Value tiers include reviewed brand/generic options
ReferenceSee Definitions and Formulary on Member Dashboard for lists and tier placement
inv-153: Vision care benefit; Hearing services benefit; General exclusions — vision/hearing benefits and exclusions summary
Vision & hearing benefits summaryPediatric vision and hearing services are covered with age‑based frequencies; adult vision and hearing benefits have separate limits and some services may require prior authorization
Pediatric visionOne complete well‑vision exam and one pair of eyeglasses/contact lenses per year through end of month member turns 19
Hearing servicesOne audiological exam annually; one hearing aid per ear every 3 years with associated equipment and follow‑up
Policy Summary
Payermoda_health_plan_inc
Policy2026 Alaska Individual Medical Plan (Moda Select Alaska Silver 4500 AI/AI Zero)
Policy CodePolicy ModaAKIndvCSV0bk 1-1-2026
Change TypeNo material change
Effective DateJan 1, 2026
Next Review DateN/A
Key ActionCheck www.modahealth.com/medical/referral to see if a service or supply requires prior authorization.
SourceLink
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