Currentmoda_health_plan_incPolicy 2026
Idaho Individual Medical Policy — Moda Select Idaho Silver 73% CSR 4000 Plan
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This document is the Idaho Individual Medical Policy for Moda Health Plan Inc describing benefits, exclusions, member resources, networks, prior authorization, and coverage sections for the Moda Select Idaho Silver 73% CSR 4000 individual plan; it governs plan terms for enrolled members and administrators.
Policy Summary
Payermoda_health_plan_inc
PolicyIdaho Individual Medical Policy — Moda Select Idaho Silver 73% CSR 4000 Plan
Policy CodePolicy Policy 2026
Change TypeNo material change
Effective DateJan 1, 2026
Last ReviewJan 26, 2026
Next Review Date
Key ActionObtain prior authorization via the Member Dashboard for services listed in Section 6 before providing non-emergency inpatient, outpatient, advanced imaging, infusion therapy, specialty medications, or other services that require prior authorization.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
1plan described
$4,000in-network deductible
$8,900in-network OOP max
>40TOC sections listed
50%/$2.5kprior auth penalty
Coverage Criteria & Benefits
Benefit Categories (TOC excerpt)
Table of contents lists covered benefit categories and subsections (partial list present in this part of the document).
The Table of Contents lists major benefit categories and their Section 7 subsections, including: Urgent & Emergency Care (7.2), Preventive Services (7.3), General Treatment Services and related topics (7.4), Maternity Care (7.5), and Pharmacy Prescription Benefit (7.6).
Selected subsection headings shown include Ambulance Transportation (7.2.1), Emergency Room Care (7.2.2), Urgent Care (7.2.3), Colorectal/Preventive screening and Immunizations (7.3.x), Anticancer Medication (7.4.1), ABA (7.4.2), Behavioral Health (7.4.3), Biofeedback (7.4.4), Clinical Trials (7.4.5), Dental Injury (7.4.6), Diabetes Services (7.4.7), Diagnostic Procedures (7.4.8), DME/Supplies & Appliances (7.4.9), Enterostomal Therapy (7.4.10), Gender Affirming Services (7.4.11), Hearing Services and Cochlear Implants (7.4.12–7.4.13), Home Healthcare and Hospice (7.4.13–7.4.14), Hospital Care (7.4.15), Infusion Therapy (7.4.18), Rehabilitation & Habilitation (7.4.27), Skilled Nursing Facility Care (7.4.28), Spinal Manipulation (7.4.29), Surgery (7.4.30), Therapeutic Injections (7.4.31), Therapeutic Radiology/Chemotherapy (7.4.32), Transplants (7.4.33), Virtual Care Visits (7.4.34), Pediatric and Adult Vision (7.4.35–7.4.36), and related maternity and pharmacy subsections (7.5, 7.6).
Essential Health Benefits
Essential health benefits coverage statement found in the document:
Except for pediatric dental, this policy covers the essential health benefits as defined by the Secretary of HHS. Annual and lifetime maximum dollar limits are not applied to any service that is an essential health benefit.
Schedule of Benefits - partial
Schedule of Benefits summary and key member cost-sharing rules (partial extract).
Schedule of Benefits provides a quick reference; members must read Section 7 for details and note that prior authorization may be required for some services (see Section 6).
Key cost sharing values: In-network annual medical deductible per member: $4,000; In-network annual out-of-pocket maximum per member: $8,900. Out-of-network deductibles and OOP maximums are higher and tracked separately.
Emergency and urgent care examples: Ambulance transportation in-network: 40% (deductible and OOP apply) or $350 for certain services; Emergency Room facility in-network: $350 (deductible and OOP apply); Urgent care office visit in-network: $50 per visit; out-of-network urgent care: 60% after deductible.
Schedule of Benefits examples and referenced rules
Selected examples of benefit cost sharing and limits from the Schedule of Benefits (Section 3):
Preventive services required by ACA are covered in-network at 0% (out-of-network generally 60% after deductible); colorectal screening beginning at age 45 with specified intervals; mammogram frequency and supplemental breast screening rules apply per Section 7.3/7.4.
Behavioral health and substance use disorder services: varied cost sharing (often 40% in-network after deductible); intensive outpatient, partial hospitalization and residential services have specified hour/session thresholds and many require prior authorization.
Rehabilitation & habilitation: up to 20 outpatient sessions per year (limits apply separately to rehab and habilitation; limits do not apply to medically necessary cardiac/pulmonary or behavioral health services).
Skilled Nursing Facility care: in-network 40% after deductible; limit: 30 days per year.
DME, supplies & appliances: covered after deductible with coinsurance (commonly 40% in-network); see Section 7.4.9 for examples and utilization limits (e.g., wheelchairs limited by age/frequency).
Transplants and therapeutic radiology/chemotherapy referenced with coinsurance and require prior authorization; travel and housing for transplant recipient and caregiver covered up to a maximum per transplant.
Virtual care visits using the preferred vendor are covered at no cost sharing when eligible; maternity breastfeeding support and certain supplies/pumps covered with MPA applying for retail purchases; take-home post-hospitalization prescriptions limited to 3-day supply.
Pharmacy coverage rules
Coverage and cost-sharing rules by pharmacy channel and tier
Retail pharmacy tier examples: Value Tier $2 per prescription (often $2 shown), Select Tier $20, Preferred Tier typically 40% coinsurance, Nonpreferred Tier typically 50% after deductible. Mail-order Value Tier example: $6 per prescription; mail-order Select Tier example: $60.
Supply limits and dispensing: Up to 90-day supply per prescription available where eligible; participating retail pharmacies may offer 90-day supply. One copay typically applies for a 30-day supply when dispensing partial quantities.
Mail order and specialty sourcing: Mail-order supply requires using a Moda-designated mail order pharmacy or pharmacies that agree to Moda's terms to access mail-order pricing. Specialty medications often must be obtained from Moda-designated specialty pharmacy; prior authorization is required for specialty medications and for non-Moda-designated specialty pharmacies.
If a member uses an out-of-network pharmacy they must pay any amounts charged above the Maximum Plan Allowance (MPA). Pharmacy deductible applies to certain tiers and coinsurance percentages are often described as 'after deductible.'
Pharmacy, cost sharing, network and related criteria
Pharmacy cost sharing and pharmacy network requirements as presented in the schedule of benefits excerpt.
Tier & network specifics: Value Tier copay examples (retail $2, mail-order $6); Select Tier copay examples (retail $20, mail-order $60); Preferred Tier commonly 40% coinsurance; Nonpreferred Tier commonly 50% after deductible; Specialty/Preferred Specialty often 40%.
Prior authorization requirements: Prior authorization required for specialty medications and for use of non-Moda-designated specialty pharmacies; some anticancer medications require use of designated specialty pharmacy or prior authorization to use a non-designated pharmacy.
Vision/pharmacy interplay and cost sharing rules: Pediatric vision under age 19 has no deductible for exam and lenses/frames/contacts (one per year); adult vision exam (age 19+) has a small copay (e.g., $10) with one exam per year; deductibles apply to many pharmacy charges and brand–generic substitution rules affect member cost responsibility.
Administrative rules: Formulary exceptions and step therapy processes exist (formulary exception decisions within 72 hours or 24 hours if urgent); early refill for travel allowed once every 6 months; some specialty meds may be limited to shorter day supplies.
Coverage criteria and operational rules
General coverage conditions and limits
Benefits payable only when coverage is in effect, member meets eligibility, is enrolled, and premiums paid for current month; benefits are payable only after service or supply provided.
Medical necessity and payment basis: Services and supplies are covered when medically necessary to diagnose or treat a condition or are preventive; payment of covered expenses is limited to the Maximum Plan Allowance (MPA).
Prior authorization and penalties: Many services must be prior authorized; if services are not authorized in advance or authorized provider not used, Moda may not pay benefits and a prior authorization penalty can apply (see Section 6). Emergency screening and stabilization do not require prior authorization but many non-emergency inpatient and outpatient services do.
Emergency services and ambulance: Emergency services covered at in-network benefit level worldwide; medically necessary ground/air ambulance to nearest capable facility is covered but ambulance providers are often out-of-network and may balance bill; stretcher/wheelchair car services are excluded as custodial.
Coverage criteria and limitations
Summary of coverage criteria and limitations:
Emergency care: Emergency services are covered and paid at in-network benefit level; prior authorization is not required for emergency medical screening exams or stabilization treatment.
Ambulance and transport exclusions: Medically necessary ambulance transport (ground/air) covered to nearest capable facility; stretcher car, wheelchair car, or similar non-medical transport services are excluded (custodial).
Preventive and screening rules: ACA-required preventive services covered at no cost in-network; colorectal screening covered starting at age 45 with specific intervals and modalities; women's preventive services and mammogram frequency described with some services requiring prior authorization for genetic testing.
Anticancer and specialty medication management: Anticancer medications are covered but most require prior authorization and specialty pharmacy sourcing; some require enrollment in manufacturer programs.
Behavioral health and ABA: ABA for autism spectrum disorder is covered when prior authorized with specific exclusions (family providers, custodial/respite, certain educational services); behavioral health coverage includes psychotherapy, intensive outpatient, ACT, STAR, TMS, ECT, partial hospitalization, inpatient and residential care with prior authorization for many intensive services; program licensing requirements apply for residential care.
Mental health services coverage
Covered mental health services by a mental health provider include:
Office or home visits, including psychotherapy.
Intensive outpatient program and partial hospitalization.
Case management, skills training, wrap-around services and crisis intervention.
Assertive Community Treatment (ACT) and Strength through Active Recovery (STAR) programs.
Transcranial magnetic stimulation (TMS) and electroconvulsive therapy (ECT).
Partial hospitalization, inpatient and residential mental health care (residential programs must be state-licensed).
Substance use disorder coverage
Covered substance use disorder services include:
State-licensed outpatient treatment programs that provide an organized course of outpatient treatment by appointment.
Room and treatment services for substance use detoxification provided by a state-licensed treatment program.
Biofeedback
Biofeedback coverage limitation:
Biofeedback therapy services are covered only to treat tension or migraine headaches and are subject to a lifetime visit limit.
Clinical trials
Clinical trial participation coverage:
Usual care costs in approved clinical trials are covered (medically necessary conventional care).
Items or services that are investigational, provided only for monitoring/data collection, or not covered outside the trial are excluded.
Participation in a clinical trial must be prior authorized and trials must meet funding/conduct criteria (NIH/CDC/AHRQ/CMS/DoD/VA funding, FDA IND/IDE/BLA, or federally exempt).
Dental injury
Dental injury coverage:
Dental services are not covered except to treat accidental injury to natural teeth when ALL of the following are met: a) injury caused by foreign object or acute trauma; b) diagnosis within 6 months of injury; c) treatment completed within 12 months of injury; d) treatment is medically necessary and provided while covered; e) treatment limited to restoring function. Implants and implant-related services are excluded.
Diabetes services
Diabetes services coverage examples:
Insulin and diabetic supplies (insulin, syringes, needles, lancets, test strips, glucometers, CGMs) are covered under the pharmacy benefit when purchased from a pharmacy with a prescription and using a preferred manufacturer.
Examples of covered medical services include HbA1c testing, kidney disease monitoring, annual dilated eye exam or retinal imaging, diabetes self-management programs, dietary/nutritional therapy, and routine foot care (see section 7.4.25).
Diagnostics
Diagnostic procedures coverage note:
Diagnostic services must support treatment of a medical or behavioral health condition; some procedures require prior authorization. A full list of diagnostic procedures that must be prior authorized is on the Moda Health website or via Customer Service.
DME coverage and exclusions
Durable Medical Equipment (DME), supplies & appliances coverage and exclusions:
DME for home use designed for repeated use is covered when medically necessary; examples include CPAP, hospital beds, insulin pumps, intraocular lenses post-cataract, orthotics/braces/orthopedic shoes meeting criteria, oxygen, prosthetics, and wheelchairs/scooters with utilization limits.
Diabetic supplies other than insulin pumps are covered under the pharmacy benefit when obtained from a pharmacy with a prescription and using a preferred manufacturer; rental covered up to purchase price for most DME; replacement/repair covered only if not abused and within specifications.
Exclusions: items primarily for comfort/convenience or cosmetic purposes, most therapeutic devices (except TENS), dental appliances/braces, incontinence supplies, certain supporting devices unless medically necessary, and testicular prostheses.
Enterostomal therapy
Enterostomal therapy:
Enterostomal therapy for patients with stomas, complex wounds and incontinence is covered when medically necessary.
Gender-affirming care
Gender-affirming services:
Gender-affirming services are covered when procedures are performed by a qualified provider, the treatment plan meets medical necessity criteria, and surgical procedures are prior authorized.
Covered services may include mental health, hormone therapy (including puberty suppression), and surgical procedures such as chest surgery, gonadectomy, genital reconstruction, and facial surgery (see surgical/reconstructive criteria).
Hearing and cochlear implants
Hearing services and cochlear implants:
Hearing services covered for enrolled dependent children with birth defect or acquired hearing loss that may affect speech or cognitive development include hearing evaluations, one hearing aid per impaired ear every 3 years, bone conduction processors, ear molds and replacement molds, and outpatient speech therapy up to 45 visits/year when billed for hearing loss; hearing aids must be prescribed, fitted and supplied by an authorized professional and referred by a physician.
Cochlear implants are covered for members of all ages when medically necessary and prior authorized.
Home health and hospice coverage
Home healthcare and hospice:
Home healthcare services and supplies from a licensed home healthcare agency are covered when the member is homebound, services are medically necessary, ordered by a treating practitioner, and provided by qualified professionals (RN/LPN, PT/OT/SLP, licensed social worker); home health aides are not covered except as part of hospice.
Hospice care is covered for terminally ill members receiving palliative (not curative) care; hospice must be Medicare-approved and nationally accredited; services must be part of a written hospice treatment plan certified by treating provider.
Covered hospice home care services include RN/LPN, PT/OT/SLP, home health aide (as hospice employee providing intermittent custodial care under supervision), and licensed social worker services.
Facility and related services coverage
Covered services and conditions:
Hospice and inpatient hospice care: medically necessary palliative care covered when member is terminally ill; short-term hospice inpatient services covered.
Hospital care: inpatient care covered when medically necessary; covered items include room, ICU, isolation, facility charges for outpatient surgery, other medically necessary hospital services; take-home prescriptions limited to a 3-day supply at hospitalization benefit level.
Infusion therapy: medically necessary infusion services and supplies covered with prior authorization; may require use of preferred medication supplier or preferred infusion provider/setting; some infusion medications covered under pharmacy specialty benefit.
Kidney dialysis, maxillofacial prosthetic services, and nonprescription enteral formula are covered when medically necessary with specified criteria (e.g., enteral formula must be elemental and sole/essential source of nutrition).
Nutritional therapy: covered for certain conditions (not for obesity); nutritional therapy for eating disorders requires authorization after first 5 visits; preventive nutritional therapy per ACA covered under preventive benefits.
Office or home visits: a visit requires actual examination by a professional provider; consultations and second opinion surgery consultations are covered; naturopathic MD office visits are specialist visits unless credentialed as PCP.
Podiatry services: covered to diagnose and treat a specific current problem; routine podiatry not covered unless medically required (e.g., diabetes).
Rehabilitation & habilitation: PT/OT/SLP, cardiac and pulmonary rehab covered when medically necessary, part of a written treatment plan, and short-term with expectation of improvement; only one session of each therapy type covered per day; maintenance therapy not covered.
Skilled nursing facility care: covered in licensed SNF providing inpatient care with rehab services and 24-hour RN nursing; a limited number of days covered and expenses limited to daily semi-private room rate; exclusions apply for custodial, pre-coverage admissions, or care mainly for dementia.
Skilled Nursing Facility
Skilled Nursing Facility Care
Limited number of days covered; covered expenses limited to the daily service rate for a semi-private hospital room.
Exclusions: charges not covered if admitted before policy coverage began; care mainly for cognitive decline/dementia; routine nursing care; non-medical self-help or training; personal hygiene or custodial care.
Spinal manipulation visits
Spinal Manipulation
A limited number of spinal manipulation visits are covered each year (Schedule notes 18 visits/year). Other services at the visit (office visits, labs, x-rays, physical therapy) are not covered under this benefit but are paid under standard benefit for that service type; member pays highest copayment if multiple copays apply at same visit and any applicable coinsurance.
Surgery and reconstructive surgery
Surgery and reconstructive surgery
Surgery, including operating and recovery rooms, surgical supplies and services ordinarily provided by a hospital or surgical center, is covered when medically necessary.
Certain procedures are covered only when performed as outpatient; ask provider or Customer Service. Cosmetic surgery is not covered. Reconstructive surgery must be medically necessary and prior authorized or benefits will not be paid; partially cosmetic reconstructive procedures may be covered if medically necessary (including to treat covered mental health conditions, e.g., gender dysphoria).
Treatment for complications related to reconstructive surgery is covered when medically necessary; complications of cosmetic surgery are not covered except to stabilize an emergency medical condition. Post-mastectomy reconstruction benefits described (reconstruction, symmetry surgery, prostheses, lymphedema treatment).
Administrative services for therapeutic injections
Therapeutic injections
Administrative services for therapeutic injections (e.g., allergy shots) are covered when received in a professional provider's office.
If similar results can be achieved with self-administered medications at home, administrative services for provider-administered injections are not covered. Vitamin and mineral injections are not covered unless medically necessary to treat a specific medical condition.
Therapeutic radiology/chemotherapy coverage
Therapeutic radiology and chemotherapy
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.
Transplant coverage and limits
Transplants
Medically necessary transplants that follow standard medical practice and are not experimental/investigational are covered; providers should obtain prior authorization as soon as possible for transplant candidates.
Limits: if transplant performed at non-Center of Excellence, deductible and coinsurance may not accumulate toward out-of-pocket maximum; coinsurance still applies. Donor costs covered in certain circumstances; travel and housing for recipient and one caregiver covered up to a maximum per transplant; some chemotherapy with certain transplants not covered for non-approved indications.
Virtual Care Visits (Telemedicine)
Virtual care
Live, interactive audio/video virtual visits are covered when services can be safely and effectively provided virtually and technology meets privacy/security standards.
Virtual care visits using the preferred vendor are covered at no cost sharing (subject to eligibility and applicable details).
Vision coverage for members under 19
Pediatric vision services
For members under age 19: one complete well-vision exam and one pair of eyeglasses and frames or contact lenses once per year; contact lenses require minimum 3-month supply; specified optional lenses/treatments covered; certain exclusions apply (plano lenses <±50 diopter, two pairs instead of bifocals, contact lens service agreements, artistically painted lenses, extra office visits for contact lens pathology, contact lens modification/polishing/cleaning).
Vision coverage for members 19 and older
Adult vision services
For members age 19 and older: one complete eye exam annually including refraction; VSP provides benefit authorization directly to in-network providers and members must identify as VSP members to in-network doctors for authorization.
Maternity coverage and related services
Maternity care
Pregnancy care, childbirth and related conditions covered when provided by a professional provider; midwives must be licensed/certified to be covered.
Maternity services commonly billed as a global charge covering prenatal, labor/delivery and post-delivery care; some diagnostics may be reimbursed separately and may require prior authorization.
Breastfeeding support and supplies: support and counseling covered during pregnancy and breastfeeding; breast pump purchase or rental covered (MPA applies for retail purchases); hospital-grade pumps covered when medically necessary; extra ice packs/coolers not covered.
Circumcision within 3 months of birth covered without prior authorization; after 3 months must be medically necessary and prior authorized.
Hospital benefits: hospital room, facility charges including birthing center, nursery care (one in-nursery well-newborn physician preventive visit covered at no cost-sharing if in-network; no deductible for routine nursery care), other medically necessary hospital services; take-home prescription drugs limited to 3-day supply at hospitalization benefit level.
Special right upon childbirth: hospital length of stay not restricted to less than 48 hours after vaginal delivery or 96 hours after cesarean; no prior authorization needed to stay up to these limits.
Coverage criteria
Coverage criteria — maternity and pharmacy benefits details referenced across chunks.
Hospital maternity benefits: hospital room, facility charges including birthing center, nursery care (one no-cost in-nursery preventive physician visit if in-network), other medically necessary hospital services, and take-home prescriptions limited to a 3-day supply.
Newborn/perinatal stay length: Benefits not restricted to less than 48 hours after vaginal delivery or 96 hours after cesarean; prior authorization not required for stays up to these limits.
Pharmacy coverage for maternity-related medications: covered medication supply includes medically necessary prescription meds, compounded meds with covered main ingredient, certain ACA preventive meds, tobacco dependence meds (OTC nicotine with prescription covered with no cost-sharing at in-network retail), contraceptives with specific supply rules, and certain immunizations with no cost-sharing at in-network retail pharmacies.
Insulin and diabetic supplies (see diabetes services) covered under pharmacy when prescribed and using preferred manufacturer; specialty medications usually require prior authorization and Moda-designated specialty pharmacy sourcing; some specialty meds limited to <30-day supplies and some may be eligible for 90-day supply.
Formulary exception and step therapy: members/providers can request formulary exceptions based on medical necessity (decision within 72 hours standard or 24 hours if urgent); step therapy requires trial of Step 1 before Step 2 unless exception criteria met.
Limitations and exclusions: New FDA approvals reviewed with possible coverage requirements; brand medications may be prior authorized for limited time until generic availability; brand–generic cost differences may be member responsibility and do not count toward OOP max; many pharmacy exclusions specified in Section 7.6.9 (devices, excluded pharmacies, foreign claims, hair growth meds, travel immunization agents except ACA-required, institutional meds, administration charges except immunizations/contraceptives at retail, meds covered under other benefits, non-FDA approved meds, nutritional supplements, off-label use exceptions, OTC meds except contraceptives/tobacco dependence, repackaged meds, replacement meds/supplies, vitamins/minerals except as required by law, weight loss medications).
Partial exclusions list
Partial exclusions list — selected exclusions and limits from the policy (partial list):
Acupuncture is listed as excluded.
Services and supplies not specifically described in this policy as covered expenses are not covered unless required by federal or state law (Benefits Not Stated).
Cosmetic procedures are excluded (examples: rhinoplasty, breast enhancement, liposuction, hair removal); reconstructive or gender-affirming surgery may be covered if medically necessary and not specifically excluded.
Custodial care (routine assistance with activities of daily living) is excluded.
Experimental or investigational procedures and related expenses are excluded.
Infertility services and supplies for diagnosis and treatment, including reversal of elective sterilization, are excluded.
Excluded items (partial)
These items are described as excluded or limited; some entries include exceptions referenced to other sections.
Naturopathic supplies (herbal, naturopathic, homeopathic medicines and nonprescription supplements) are excluded.
Orthopedic shoes are excluded except as described in section 7.4.9 (coverage when medically necessary and criteria met).
Orthognathic surgery (and associated services/supplies) excluded except when medically necessary to repair accidental injury or to treat cancer.
Physical exercise programs, videos and exercise equipment are excluded.
Professional athletic activities (diagnosis, treatment, rehab for injuries from professional/semi-professional athletic participation) are excluded.
Recreation-related services and equipment used mainly for recreational activities are excluded.
Self-administered medications obtained directly from a physician's office/facility/clinic instead of through the pharmacy prescription medication or anticancer benefits are excluded.
Personal items such as basic home first aid, household supplies, and supportive environmental materials not required for treatment are excluded.
Enumerated exclusions
The policy excludes coverage for the following services, treatments, or circumstances (enumerated list, partial):
School services: educational or correctional services or sheltered living provided by a school or halfway house are excluded.
Self-administered medications obtained directly from a provider's office/facility/clinic instead of through the pharmacy benefit or anticancer benefits are excluded.
Self-improvement programs (psychological or lifestyle improvement programs, retreats, training) are excluded unless medically necessary for a covered condition.
Service-related conditions: treatment of conditions caused by military service excluded unless not covered by military/VA coverage.
Administrative or qualification services: exams/testing for employment, licensing, sports, insurance, legal determinations, corrections or social service placement are excluded.
Services otherwise available: services someone else is responsible to pay for are excluded (exceptions apply for certain state hospitals, community mental health programs, and VA when care is not service-related).
Services provided or ordered by a family member (except dental provider) are excluded.
Services provided by volunteer workers are excluded.
Sexual disorders and paraphilic disorders treatment and court-ordered sex offender treatment are excluded.
Support education (level 0.5 education-only programs, court-mandated education-only anger management, family education/support groups) excluded except as required by ACA.
Taxes, fees and interest are excluded unless required by law.
Telehealth is excluded except telemedicine specifically described in section 7.4.34 (virtual care visits).
Temporomandibular Joint Syndrome (TMJ) services and supplies excluded.
Therapies such as animal therapy and maintenance therapy/programs are excluded.
Third party liability claims: services to treat conditions for which a third party may be responsible are excluded to extent of recovery.
Transportation excluded except medically necessary ambulance transport.
Treatment in the absence of illness (counseling/treatment for non-illness issues, at-risk without diagnosis, normal stress responses) excluded.
Treatment after coverage ends excluded except limited hearing aid orders obtained within 90 days after coverage ends or specified benefit extensions.
Treatment before coverage begins excluded for admissions that began before policy effective date except for covered expenses incurred on/after effective date.
Treatment not medically necessary is excluded (detailed criteria provided, e.g., not standard, primarily convenience, not least-costly safe alternative).
Prior Authorization, Documentation & Provider Requirements
Prior Authorization
Prior Authorization (Section 6)
See Section 6 for the Plan’s prior authorization program, which includes requirements, the full list of services that require prior authorization, applicable limitations, and provisions for second opinions.
Prior Authorization
Prior authorization inquiry
Check the Member Dashboard (www.modahealth.com/idaho) to determine whether the specific service or supply you plan to provide requires prior authorization.
Prior Authorization
Prior authorization notice
Prior authorization may be required for some services; consult Section 6 for details on which services and any conditions that apply.
Prior Authorization
Prior authorization note
Prior authorization may be required for certain services—refer to Section 6 to confirm requirements before providing non-emergent care.
Prior Authorization
Behavioral health / nutritional therapy authorization
Nutritional therapy for eating disorders must be prior authorized; behavioral health treatment and behavioral health disorder services require authorization after the first five visits.
Prior Authorization
Prior authorization
Prior authorization is required for specialty pharmacy medications and for items obtained through non‑Moda‑designated mail order pharmacies unless prior authorization has been obtained.
Prior Authorization
Prior authorization for non-Moda-designated pharmacies
If a specialty medication is obtained from a non‑Moda‑designated specialty pharmacy, prior authorization is required; similarly, non‑Moda‑designated pharmacies require prior authorization for certain anticancer medications.
Billing Rule
Prior authorization rules and penalties
Providers must obtain prior authorization for many services (inpatient, outpatient, rehabilitation, diagnostic imaging, infusion therapy and other items listed on the website). Emergency admissions do not require prior authorization but must be authorized within 48 hours after admission. If out‑of‑network services are not authorized in advance, a penalty of 50% up to $2,500 per occurrence applies (this penalty does not count toward the deductible or out‑of‑pocket maximum). Authorizations may limit scope, frequency, amount, time period, or require use of preferred treatment centers.
Prior Authorization
Prior authorization requirements
Prior authorization is not required for emergency medical screening exams or stabilization treatment. However, many outpatient services and all non‑emergency inpatient and residential care must be prior authorized; anticancer and other specified therapies also commonly require prior authorization.
Prior Authorization
Prior authorization for intensive behavioral services
Intensive outpatient mental health treatment, Assertive Community Treatment (ACT), STAR, and transcranial magnetic stimulation (TMS) must be prior authorized.
Prior Authorization
Prior authorization for advanced imaging/diagnostics
Providers must obtain prior authorization for most advanced imaging services (including MRI/MRA, CT, PET and nuclear medicine) and other listed diagnostic procedures; a full list is on the Moda Health website.
Prior Authorization
Prior authorization for clinical trial participation
Participation in an approved clinical trial must be prior authorized; authorization is limited to trials meeting specified funding or regulatory criteria.
Prior Authorization
Prior authorization for gender-affirming surgery
Surgical gender‑affirming procedures require prior authorization and must meet medical necessity criteria to be covered.
Documentation Required
Prior authorization and documentation for DME
Some durable medical equipment (DME) requires prior authorization; replacement or repair is covered only if the item was not abused and used within specifications, and the provider may be asked to provide the equipment order and related records.
Prior Authorization
Prior authorization for cochlear implants
Cochlear implants are covered when medically necessary and require prior authorization.
Prior Authorization
Prior Authorization Requirements
Prior authorization is required for respite care when arranged by the attending professional provider; prior authorization is also required for infusion therapy and for certain other treatment programs and services noted in the referenced sections.
Billing Rule
Authorization and Supplier Restrictions
When an authorization is limited to a specific supplier, provider or setting, medications or infusion therapy obtained or administered outside that authorized supplier/setting may not be covered.
Prior Authorization
Prior authorization guidance (transplants, some maternity diagnostics)
Obtain prior authorization as soon as possible for transplant candidates; some maternity diagnostic procedures and a full list of services requiring prior authorization are available on the Moda Health website or via Customer Service.
Documentation Required
Vision prior authorization process (VSP)
Some vision services may require prior authorization; for eligible members, VSP provides benefit authorization directly to in‑network doctors who must be identified as VSP members when arranging services.
Step Therapy
Prior authorization, formulary exceptions, and step therapy
Most specialty medications require prior authorization and must be obtained from a Moda‑designated specialty pharmacy; formulary exceptions require provider documentation and will be decided within 72 hours (24 hours if urgent). Step therapy requires trying Step 1 medications before Step 2 will be covered unless exception criteria are met.
Denial Risk
Benefits Not Stated
Services and supplies not specifically described in this policy as covered expenses are not covered unless required by federal or state law; lack of a coverage statement creates a risk of denial.
Documentation Required
Inmates
Services and supplies provided while a member is in custody of law enforcement or in jail/prison are handled under a distinct coverage/exclusion policy and should be treated accordingly.
Billing Rule
Missed Appointments
Missed appointments are treated as an excluded/administrative item under the policy—verify billing and coverage rules before billing the plan.
Documentation Required
Medical necessity verification
Verify that requested services meet the Plan’s medical necessity criteria before seeking authorization; services that do not meet medical necessity are not covered even if prescribed by a provider.
Codes, Limits & Key Plan Values
plan identifiersmixed
| No CPT/HCPCS/ICD codes are present in this part of the document. |
Cost-sharing examplesmixed
| No codes listed |
DME / Suppliesmixed
| Durable Medical Equipment (DME) and supplies subject to Section 7.4.9; supplies covered under Pharmacy benefits where noted |
Not specified in this sectionmixed
vision/copay tiersmixed
| No codes listed |
Prior authorization service listmixed
| Full list of services and supplies requiring prior authorization is maintained on Moda Health website and updated periodically. |
Screening services (no CPT/HCPCS listed)mixed
| Colorectal and breast cancer screening services described (timing and coverage rules); no specific billing codes provided in this section. |
Advanced imagingmixed
| Advanced imaging (MRI, MRA, CT, PET, nuclear medicine) require prior authorization per policy |
Facility and therapy servicesmixed
| No codes listed |
Reconstructive vs cosmetic surgery coveragemixedCovered
| No codes listed |
Transplant benefit limitationsmixedCovered
| No codes listed |
Supply limits and tiering notesmixed
| No codes listed |
Procedure/topic referencedmixed
| No codes listed |
Routine foot care exclusionsmixedNot Covered
| Routine foot care services excluded unless required by medical condition (such as diabetes). |
Obesity and weight reductionmixedNot Covered
| Services and supplies to directly treat obesity/weight loss are excluded except as required under the Affordable Care Act; treatments for medical conditions caused or worsened by obesity are covered when medically necessary. |
Coverage timing and medical necessitymixed
| No codes listed |
Deductible
Plan identifierModa Select Idaho Silver 73% CSR 4000 Plan (named with $4,000 deductible)
Plan deductible (reference)$4,000 (referenced in plan name and schedule of benefits)
Policy effective detailsIdaho Individual Medical Policy 2026 (Policy 2026)
In-network annual deductible per member
In-network annual deductible (per member)$4,000
Family maximum (in-network)$8,000 maximum annual medical deductible per family
Out-of-network per member deductible (contrast)$8,000 (out-of-network per member) noted in Schedule of Benefits
Out-of-pocket maximum per member (in-network)
In-network annual out-of-pocket maximum (per member)$8,900
Family out-of-pocket maximum (in-network)$17,800 (maximum annual out-of-pocket per family)
Out-of-network out-of-pocket maximum (per member)$89,000 (out-of-network per member) noted in Schedule of Benefits
Calendar year accrual
Accrual period for annual limitsWhen a benefit has an 'annual' or 'per year' limit, it accrues on a calendar year basis unless otherwise specified
American Indian/Alaska Native exceptionSpecial payment rules (no cost for covered services through IHS/Tribal/Urban Indian Clinic or referral) noted alongside accrual guidance
Reference locationSee Section 3 (Schedule of Benefits) for additional limit details
Maximum supply per prescription
Maximum supply per prescription (retail/mail)Up to 90-day supply per prescription where eligible
One copay for 30-day supply noteOne copay for a 30-day supply when dispensing partial quantities (Schedule notes)
EligibilityNot all medications are eligible for 90-day supply; standard benefit rules (prior auth/step therapy) apply
Mail order supply limit
Mail order supply limitUp to 90-day supply per prescription via mail order (must use Moda-designated or agreeable mail order pharmacies)
Mail-order pharmacy requirementMust use Moda-designated mail order pharmacy or pharmacies that agree to Moda's terms
Mail-order copay examplesMail Order Value Tier shown as $6 in Schedule of Benefits
Prior authorization penalty
Prior authorization penaltyIf services are not authorized in advance, a penalty of 50% (up to a maximum deduction of $2,500) applies per occurrence before regular plan benefits begin
Penalty exclusionsPenalty does not apply for emergency admissions
Counts toward thresholdsPrior authorization penalty does not count toward deductible or out-of-pocket maximum
Colorectal screening age threshold
Colorectal screening starting ageRecommended starting at age 45 for preventive colorectal cancer screening
Frequency examplesColonoscopy every 10 years (other modalities have different intervals); follow-up colonoscopy after positive screening covered under preventive benefit
High-risk exceptionsScreening may occur earlier/more often if medically necessary or high risk per provider
Supplemental breast screening frequency for increased risk
Supplemental breast screening frequency (increased risk)One supplemental breast screening per year for members with increased risk
Eligible modalitiesStandard or abbreviated MRI, contrast mammogram, or ultrasound if recommended and MRI not possible
Cost sharingNo cost sharing for supplemental screening when performed in-network
SUD intensive outpatient hours (adults)
SUD intensive outpatient hours — adults9-19 hours per week (adults)
SUD intensive outpatient hours — adolescents6-19 hours per week (adolescents)
Prior authorizationIntensive outpatient services must be prior authorized (see behavioral health section)
SUD intensive outpatient hours (adolescents)
SUD intensive outpatient hours — adolescents6-19 hours per week (adolescents)
Adult comparisonAdults: 9-19 hours per week
Program definitionIntensive outpatient is more intensive than routine outpatient and less than partial hospital program
Mental health intensive outpatient minimum
Mental health intensive outpatient minimumDefined as 3 or more hours per week of direct treatment (≥3 hours/week)
Program scopeMore intensive than routine outpatient care; prior authorization required for certain intensive services
Relation to partial hospitalLess intensive than partial hospital program which provides ≥20 hours/week
Partial hospital program hours
Partial hospital program hoursAt least 20 hours per week and no less than 4 hours per day (≥20 hours/week; ≥4 hours/day)
Program characteristicProvides structured direct treatment and does not include overnight 24-hour care
Licensure requirementProgram must be appropriately licensed to be covered
Take-home prescription limit
Take-home prescription limit after hospitalizationLimited to a 3-day supply at the same benefit level as hospitalization
Hospital medication coverage noteInpatient medications paid under medical plan; take-home outpatient meds limited to 3-day supply
Prior authorization for related servicesSome related services (e.g., anesthesia for dental procedures) may require prior authorization
Outpatient therapy sessions per day
Outpatient therapy sessions per dayOnly one session of each type of outpatient physical, occupational or speech therapy is covered per day
Session definitionA session is one visit; multiple therapy types may not be combined into multiple sessions of same type in one day
Annual limitsCovered outpatient rehabilitative and habilitative services have separate annual limits (except cardiac/pulmonary/behavioral health)
travel and housing coverage limit per transplant
Travel & housing coverage per transplantTravel and housing expenses for recipient and one caregiver are covered up to a maximum per transplant (maximum is specified elsewhere in the policy)
ScopeApplies to recipient and one caregiver; outpatient transplant drugs covered under pharmacy benefit; immunosuppressive inpatient drugs paid as medical supply
Center of Excellence impactIf transplant performed outside a Center of Excellence, deductible/coinsurance may not accumulate toward OOP maximum
Maximum day supply / refill limits
Maximum day supply / refill limits90-day retail supply available at participating pharmacies where eligible; some specialty medications may be limited to a 2-week supply or less than 30 days; early refill for travel permitted once every 6 months but cannot extend beyond policy year
Eligibility and exceptionsNot all medications eligible for 90-day supply; prior authorization, step therapy and other pharmacy rules still apply
Mail-order/modesMail order through Moda-designated or equivalent registered mail order pharmacies; participating retail pharmacies indicate '3 months' in Day Supply column
Obesity exception
Obesity exception summaryServices and supplies necessary to treat medical conditions caused or made worse by obesity are covered; direct obesity treatments (weight loss surgery, weight management programs, medications/formulas) are excluded except as required under the ACA
Examples of excluded obesity servicesGastric restrictive procedures, weight management programs, counseling, and medications for weight loss are excluded unless ACA requires coverage
Coverage for comorbiditiesTreatments for established medical conditions resulting from obesity may be covered when medically necessary
post-coverage hearing aid order window
Hearing aid order window after coverage endsCovered hearing aids ordered before coverage ends must be obtained no more than 90 days after the policy ends to remain eligible
Related extensionsExceptions also noted under specified extension of benefits sections (10.14.1 or 10.14.2)
ReferenceSee 'Treatment After Coverage Ends' for full conditions
Key Definitions & Member Notices
Pharmacy/Prescription Benefit
Pharmacy/Prescription Benefit referenceSee Section 7.6 for Pharmacy Prescription Benefit definitions, formulary, tiers, specialty medication rules, and supply limits
Formulary & tiersFormulary and tier definitions (Value, Select, Preferred, Nonpreferred, Specialty) and Prescription Medication List available on Member Dashboard
Specialty medications noteSpecialty medications often require prior authorization and must be obtained from Moda-designated specialty pharmacies; many specialty meds have supply or enrollment requirements
Right to Return Policy
Right to return periodSubscriber may return the policy within 10 days before or after coverage effective date for refund and cancellation as if no policy had been issued
Effect of returnIf returned within the period the policy is canceled from the beginning; premium refunded
Reference locationPolicy front matter (Policy 2026) shows return instructions
Child-only coverage note
Child-only coverage adjustmentIf this is a child-only policy, references to dependents (spouse, domestic partner or children) are deleted; siblings of subscriber are eligible
Policy wording changeChild-only specific wording adjustments apply throughout the policy where dependent language appears
ReferenceSee 'For Child Only Coverage' section for details
Medicare supplement exclusion
Medicare supplement exclusionThis policy is not a Medicare Supplement policy; Medicare-eligible individuals should consult CMS resources (medicare.gov)
Guidance for Medicare-eligibleReview the Guide to Health Insurance for People with Medicare from CMS
ImplicationPolicy provisions do not substitute for Medicare coverage; coordination considerations may apply
Member ID Card
Member ID card requirementAfter enrollment we send ID cards that show member ID number and provider network; present card each time you receive services
ReplacementIf you lose your ID card get a new one via Member Dashboard or Customer Service
PurposeHelps provider identify you as a Moda Health member and apply in-network benefits
Care Coordination
Care Coordination descriptionCare Coordinators and Case Managers are nurses or behavioral health clinicians who coordinate care for complex and/or catastrophic medical situations
RoleThey work directly with members and professional providers to coordinate access to services across levels of care
AccessMembers can use Care Coordinators for complex case management needs
1 = In-Network Benefits; 2 = Out-of-Network Benefits
Indicator explanation1 = In-Network Benefits; 2 = Out-of-Network Benefits as used in Schedule of Benefits
ImplicationDifferent cost sharing and deductible/OOP maximums apply depending on network indicator
ReferenceSee Section 3 Schedule of Benefits for details
Cost sharing explanation
Cost sharing explanationCost sharing is the amount the member pays (deductible, copay, coinsurance); deductible and out-of-pocket maximums explained in Section 4; in-network use avoids charges above the Maximum Plan Allowance (MPA)
Non-counting itemsDisallowed charges, copayments, prior authorization penalties and manufacturer discounts/copay assistance do not count toward deductible or out-of-pocket maximum
Payment basisModa pays based on the Maximum Plan Allowance (MPA); balance billing may occur for out-of-network charges above MPA where permitted by law
Moda-designated mail order pharmacy
Moda-designated mail order pharmacyMail order and many specialty medications must be obtained through Moda-designated mail order or specialty pharmacies to access specified pricing and coverage
Implication for specialty medsMost specialty medications require prior authorization and sourcing from Moda-designated specialty pharmacy; some specialty meds limited to shorter day supplies
Member consequenceUsing non-Moda-designated pharmacies may require prior authorization and could lead to higher member payment for amounts above MPA
Up to 90-day supply
Up to 90-day supply guidanceRetail or mail-order dispensing may provide up to a 90-day supply for eligible medications at participating pharmacies; not all drugs eligible
Participating retail noteParticipating retail pharmacies will indicate '3 months' under Day Supply in Member Dashboard
Pharmacy rules still applyPrior authorization, step therapy and supply limits (including some specialty exceptions) continue to apply to 90-day supplies
Deductible definition
Deductible definitionAmount a member must pay for covered expenses before the plan begins sharing costs; separate in-network and out-of-network deductibles apply
ApplicationYou must pay all covered expenses until deductible met unless policy states otherwise; family and per-member rules apply
Non-counting itemsDisallowed charges, copayments, prior authorization penalty and manufacturer discounts/copay assistance do not count toward annual deductible
Out-of-pocket maximum definition
Out-of-pocket maximum definitionUpper limit on covered charges a member must pay each year; once met we pay 100% of covered services for rest of year; in-network and out-of-network tracked separately
Non-counting itemsPrior authorization penalty and manufacturer/copay assistance do not count toward out-of-pocket maximum
ExceptionsYou still pay disallowed charges and certain transplant expenses not performed at a center of excellence even after OOP maximum met
Maximum Plan Allowance (MPA)
Maximum Plan Allowance (MPA)The payment basis Moda Health uses to pay covered expenses; defined in Section 11 and used to determine allowed amounts
Member liabilityIf provider charges above the MPA and is out-of-network, member may be responsible for amounts above MPA where permitted by law (balance billing)
ReferenceSee Section 11 for full MPA definition and application
Balance billing
Balance billing explanationWhen out-of-network providers charge amounts above the MPA, the member may be responsible for the difference (balance billing) where permitted by law
In-network protectionIn-network providers agree to look solely to Moda Health for compensation for covered services when Moda is payer
RecommendationAsk providers to send lab work/x-rays to in-network facility to avoid balance billing
Primary Care Provider (PCP)
Primary Care Provider (PCP) definitionAn in-network clinician (family/general practitioner, general internist, pediatrician, obstetrician/gynecologist, PA, ARNP, or certified nurse midwife designated by the plan) who coordinates member care; members encouraged to choose and may change at any time
Women's healthcare PCPWomen's healthcare provider defined as in-network OB/GYN, PA or ARNP in women's health, or certified nurse midwife practicing within scope
Find Care toolUse Find Care on Member Dashboard to select or change PCPs
Prior authorization (definition)
Prior authorization definitionA plan process to evaluate and authorize services in advance to confirm medical necessity; required for many non-emergent services and may include limits or required providers
Emergency admissionsEmergency hospital admissions do not require prior authorization but must be authorized within 48 hours after admission
Penalty for non-authorized out-of-networkIf out-of-network services not authorized in advance, 50% penalty up to $2,500 per occurrence applies
Emergency services
Emergency services definitionCare for emergency medical conditions covered worldwide at in-network benefit level; seek nearest appropriate provider and call 911 if needed
Out-of-country emergency careYou may pay at time of service and submit claim later for reimbursement
Ambulance coverageMedically necessary ground/air ambulance to nearest capable facility is covered; ambulance providers often out-of-network and may balance bill
Urgent care facility
Urgent care facility definitionAn office or clinic distinct from a hospital ER that diagnoses and treats illness or injury for patients without appointment seeking immediate care
Billing noteMany walk-in/same-day clinics bill as office visits and will be paid under office visit benefit, not urgent care benefit
Coverage conditionVisit must include actual examination by a professional provider to be covered
Custodial care (transport)
Custodial transport definitionServices by stretcher car, wheelchair car or similar methods are considered custodial and are not covered
Ambulance vs custodialMedically necessary ground/air ambulance covered; stretcher/wheelchair car services excluded as custodial
ReferenceSee Ambulance Transportation section for coverage distinctions
Behavioral health program levels
Behavioral health program levelsDefinitions include intensive outpatient, partial hospital, and residential programs with minimum hours and licensure requirements
Intensive outpatientMental health intensive outpatient: ≥3 hours/week; SUD adult intensive outpatient: 9-19 hours/week; adolescents: 6-19 hours/week
Partial hospital and residentialPartial hospital: ≥4 hours/day and ≥20 hours/week; residential: organized full-day including overnight care and must be state-licensed
Intensive outpatient
Intensive outpatient definitionIntensive outpatient services are more intensive than routine outpatient and less intensive than a partial hospital program
Mental health minimum hoursMental health intensive outpatient is 3 or more hours per week
Prior authorizationCertain intensive outpatient services must be prior authorized
Partial hospital program
Partial hospital program definitionAn appropriately licensed behavioral health facility providing no less than 4 hours/day and 20+ hours/week of direct, structured treatment (no overnight care)
Coverage requirementProgram must be licensed for coverage to apply
ComparisonMore intensive than intensive outpatient but less than inpatient/residential overnight care
Residential program
Residential program definitionProvides organized full-day or part-day treatment including overnight 24-hour care; must be state-licensed for coverage
Coverage noteResidential programs that provide less than 4 hours/day of direct treatment are not considered residential for coverage
Prior authorizationMost residential services require prior authorization
Substance use disorder
Substance use disorder (SUD) definitionAn addictive physical and/or psychological relationship with any drug or alcohol that interferes with major life areas; excludes addiction to foods or tobacco
Covered SUD servicesIncludes outpatient treatment programs and room/treatment services for detox by state-licensed programs
Program licensureOutpatient programs must be state-licensed to be covered
Diabetes supplies coverage
Diabetes supplies coverageInsulin and diabetic supplies (syringes, needles, lancets, test strips, glucometers, CGMs) are covered under the pharmacy benefit when purchased from a pharmacy with a prescription and using a preferred manufacturer
Insulin pump noteInsulin pumps may be covered under DME if not obtained from pharmacy
Formulary referencePreferred manufacturer and prescription requirements available on Member Dashboard
Hospice
Hospice definitionA hospice is a private or public hospice agency approved by Medicare and accredited by a nationally recognized entity; hospice care is covered for terminally ill members receiving palliative care
Plan of careServices must be part of a written hospice treatment plan certified by treating provider
Accreditation requirementHospice must be Medicare-approved and nationally accredited for coverage
Skilled nursing facility
Skilled nursing facility (SNF) definitionA licensed facility providing inpatient care under supervision of medical staff with rehabilitative services and 24-hour RN nursing
Coverage limitA limited number of days are covered; expenses limited to daily service rate for a semi-private room
ExclusionsNot covered if admitted before coverage begins or care is mainly custodial/non-medical
Rehabilitation vs Habilitation
Rehabilitation vs HabilitationRehabilitative services restore or improve lost function; habilitative services develop skills not previously formed due to medical condition; maintenance therapy without documented improvement is not covered
Covered therapy typesPT, OT, SLP, cardiac and pulmonary rehab are covered when medically necessary and part of a written treatment plan
Session limitsOutpatient rehabilitative/habilitative services have separate annual limits (except cardiac/pulmonary/behavioral health)
Donor costs
Donor costs definition (transplant)Donor costs are covered expenses for removing tissue from a donor, preserving or transporting it to transplant site and other charges directly related to finding/getting the organ
Coverage conditionsDonor costs covered when recipient or self-donor; not covered if donor/recipient not enrolled as specified
ReferenceSee Transplants section for donor cost details and limitations
Virtual care visit
Virtual care visit definitionA live, interactive audio and video visit with a provider including diagnosis and treatment when services can be safely and effectively provided virtually and technology meets privacy/security standards
Cost sharingVirtual care visits using the preferred vendor are covered at no cost sharing
Coverage conditionServices must be appropriate for virtual delivery and technology must meet state/federal privacy/security standards
Brand Medications
Brand medications definitionBrand Medications are medications sold under a trademark and protected name
Formulary interactionBrand substitution policy may require member to pay nonpreferred cost sharing plus difference if opting out of generic
Coverage timingModa may prior authorize brand meds for limited time until generic becomes available
Generic Medications
Generic medications definitionGeneric Medications are FDA-designated therapeutically equivalent medications with same active ingredients, strength, dosage form and route
Cost advantageGenerics generally save member money; brand substitution rules may apply if generic available
Formulary placementGeneric placement in tiers may change; check Member Dashboard for current tier
Formulary
Formulary definitionFormulary is a list of prescription medications and how they are covered under the pharmacy benefit; available on the Member Dashboard and subject to change
UsageUse the prescription price check tool on Member Dashboard for coverage info and price estimates
UpdatesFormulary may be updated; new meds reviewed and coverage limitations set as needed
Specialty Medications
Specialty medications definitionSpecialty medications often treat complex chronic conditions, require special handling, unique ordering processes, usually require prior authorization and often must be obtained from a Moda-designated specialty pharmacy
Supply limitsSome specialty meds limited to 2-week supply or other short supplies as noted in limitations
Prior authorization & sourcingMost specialty medications must be prior authorized and sourced through designated specialty pharmacies; non-Moda specialty pharmacies may require prior authorization
Custodial care
Custodial care general definitionRoutine care and assistance with activities of daily living provided by non-medical personnel (bathing, dressing, meal prep) is custodial care and excluded
Exclusion implicationCustodial services are not covered except as part of hospice when provided by hospice employee under supervision
Related exclusionsTransportation by stretcher/wheelchair car also considered custodial and excluded
Experimental or Investigational Procedures
Experimental or investigational proceduresExpenses due to experimental or investigational procedures and related expenses are excluded even if they would otherwise be covered
Definition locationSee Section 11 for full definition and scope of experimental/investigational exclusions
Claim impactClaims for such procedures will be denied unless policy or law requires otherwise
Cosmetic Procedures
Cosmetic procedures definitionProcedures or medications whose main purpose is changing or maintaining appearance without significant improvement in body function; cosmetic services excluded
Reconstructive exceptionReconstructive or gender-affirming surgery may be covered if medically necessary and not specifically excluded
ExamplesRhinoplasty, breast enhancement, liposuction, hair removal listed as cosmetic examples
Never Events
Never events definitionNever events are events that should never happen in a hospital (wrong surgery, wrong body part/patient, hospital-acquired conditions) and related services/supplies are treated accordingly
Policy effectServices/supplies related to never events are excluded or addressed under specific rules
ReferenceSee CMS guidelines for list and definitions of never events
Nuclear Radiation
Nuclear radiation exclusionMedical conditions arising from ionizing radiation, pollution or contamination by radioactivity are excluded unless otherwise required by law
ScopeIncludes conditions from nuclear waste, combustion of nuclear fuel, or explosive nuclear assembly components
ReferenceSee exclusions section for full wording and any statutory exceptions
Not Medically Necessary
Not medically necessary definitionServices or supplies that do not meet medical necessity criteria (not the least costly safe alternative, inconsistent with diagnosis, for convenience, etc.) are not covered
Provider prescriptionsEven if prescribed or ordered by a professional provider, lack of medical necessity makes service non-covered
ReferenceSee Section 11 for medical necessity criteria and examples
Services Otherwise Available
Services Otherwise AvailableServices or supplies for which another party is responsible for payment are excluded (e.g., government programs) except specified state or VA exceptions
ExamplesSituations where another third party has paid or is obligated to pay; items not normally charged if you don't have insurance
ExceptionsDoes not apply to hospital care from state-owned hospitals or certain state-approved community programs where coverage rules differ
Policy Summary
Payermoda_health_plan_inc
PolicyIdaho Individual Medical Policy — Moda Select Idaho Silver 73% CSR 4000 Plan
Policy CodePolicy Policy 2026
Change TypeNo material change
Effective DateJan 1, 2026
Last ReviewJan 26, 2026
Next Review Date
Key ActionObtain prior authorization via the Member Dashboard for services listed in Section 6 before providing non-emergency inpatient, outpatient, advanced imaging, infusion therapy, specialty medications, or other services that require prior authorization.
SourceLink
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