Prior authorization is required per Section 6

Section 6 (Prior Authorization) identifies services that must be prior authorized and the limitations that may apply; providers must follow those requirements and obtain authorization before services that require it.

• When a service requires prior authorization, the provider should contact Moda Health before the service is provided.
• Emergency hospital admissions must be authorized within 48 hours after admission (or as soon as reasonably possible).

Use Member Dashboard to verify prior authorization

Check the Member Dashboard (www.modahealth.com/idaho) before providing services or supplies to determine whether prior authorization is required and to view the current list of services that need authorization.

• Member Dashboard includes tools to see if a service or supply must be prior authorized.
• Providers may also contact Customer Service for authorization information.

Certain services require prior authorization

Some services, including many outpatient services and all nonemergency inpatient and residential care, require prior authorization; providers must consult Section 6 or the Member Dashboard for the specific services that require authorization.

• Examples listing types of services that may require authorization include inpatient services, outpatient services, rehabilitation, and diagnostic imaging.
• A full, up‑to‑date list is available on the Moda Health website and is updated periodically.

Specialty pharmacy and provider/setting limits may apply

Certain medications are covered under the specialty pharmacy benefit and some medications may be limited to specific providers or settings; when limits apply, providers must follow the specialty pharmacy or provider-setting requirements.

• Some medications must be obtained from a Moda-designated specialty pharmacy or preferred medication supplier.
• When authorization is limited to certain suppliers, providers must use those suppliers or services may not be covered.

Authorize nutritional therapy for eating disorders (after first 5 visits)

Nutritional therapy for eating disorders requires prior authorization; document the authorization when submitting claims, especially for visits beyond the referenced first five.

• Authorization requirement applies after the first 5 visits as referenced in the Schedule of Benefits.
• Include authorization information on claims for visits beyond the initial visits to support coverage.

Prior authorization required for non‑Moda specialty pharmacies

Prior authorization is required to purchase specialty medications from non‑Moda‑designated specialty pharmacies; providers must obtain prior authorization if the member will use a non‑designated specialty pharmacy.

• Most specialty medications must be prior authorized and obtained from a Moda‑designated specialty pharmacy.
• If buying from a non‑Moda‑designated specialty pharmacy, prior authorization is required.

Obtain prior authorization for a broad list of services

Many services require prior authorization, including inpatient and residential programs, outpatient services, rehabilitation therapies, diagnostic imaging, infusion therapy, and medications; providers should obtain authorization for these services per Section 6.

• Inpatient services and residential programs require prior authorization.
• Diagnostic services, including most advanced imaging (MRI/MRA, CT, PET), require prior authorization.
• Infusion therapy requires prior authorization (see Section 7.4.18).

Authorizations can include time, scope, frequency, and provider limits

Authorizations may be limited in scope — by time period, specific services covered, number/amount/frequency, or by requirement to use a preferred treatment center or provider — and those limits will be described in the authorization letter.

• An authorization is valid for a set period; services outside that time may not be covered.
• The authorization letter will describe any limits (time, scope, frequency) and required providers or centers.

Prior authorization required for many outpatient, inpatient and anticancer meds

Many outpatient services and all nonemergency inpatient and residential care must be prior authorized; most anticancer medications also require prior authorization and often must be dispensed through designated specialty channels.

• All nonemergency inpatient and residential care must be prior authorized.
• Most anticancer medications require prior authorization and specialty pharmacy dispensing or enrollment in manufacturer programs.

Authorize genetic testing for breast cancer

Prior authorization is required for genetic testing related to breast cancer; obtain authorization before ordering genetic testing for BRCA or related services.

• Preventive screening, genetic counseling and genetic testing for breast cancer are covered but genetic testing requires prior authorization.
• Ask the provider to contact Moda Health for authorization before testing.

ABA services require prior authorization

Applied behavior analysis (ABA) for autism spectrum disorder is covered but must be prior authorized; do not provide ABA services without obtaining authorization.

• ABA services must be prior authorized.
• Services provided by family/household members, custodial or respite care, and certain alternative therapies are not covered.

Prior authorize behavioral programs, advanced imaging, and cochlear implants

Intensive outpatient mental health treatment, ACT, STAR, TMS, most advanced imaging, and cochlear implants require prior authorization; providers must obtain authorization before scheduling these services.

• Most advanced imaging (MRI, MRA, CT, PET, nuclear medicine) requires prior authorization.
• Cochlear implants require medical necessity and prior authorization.
• Intensive outpatient mental health programs (IOP) and procedures like TMS must be prior authorized.

Prior authorization required for clinical trial participation

Participation in an approved clinical trial must be prior authorized; providers should request authorization before enrolling the member in a qualifying trial.

• Approved clinical trials must meet specific funding or regulatory criteria to be covered.
• Ask your provider to obtain prior authorization for trial participation.

Prior authorization required for infusion therapy and supplier/setting limits apply

Infusion therapy requires prior authorization; when authorization is limited to specific suppliers, providers, or settings, ensure services and supplies come from the authorized suppliers or they may not be covered.

• Providers must get prior authorization for infusion therapy services and supplies.
• Some infusion medications may require use of a preferred medication supplier or be covered under the pharmacy specialty benefit.

Authorize reconstructive surgery, transplant services, and some vision care

Reconstructive procedures (when not emergent), many transplant services, and some vision services require prior authorization; obtain authorization and document medical necessity before proceeding.

• All reconstructive procedures must be medically necessary and prior authorized or benefits will not be paid.
• Transplant candidates should obtain prior authorization as soon as possible; outpatient transplant drugs are covered under the pharmacy benefit.
• Some vision services may require prior authorization; VSP handles in‑network authorizations.

Prior authorization and medical necessity required for circumcision after 3 months

Circumcision performed after 3 months of age requires prior authorization and documentation of medical necessity; circumcision within 3 months of birth is covered without prior authorization.

• Circumcision within 3 months of birth is covered without prior authorization.
• Circumcision after 3 months must be prior authorized and medically necessary.

Prior authorization required for certain and specialty medications

Certain prescription medications and most specialty medications require prior authorization; prior authorization is also required if purchasing specialty medications from a non‑Moda‑designated specialty pharmacy.

• Most specialty medications must be prior authorized and obtained from a Moda‑designated specialty pharmacy.
• Prior authorization is required for certain prescription medications and quantities per Section 6.

Authorize exception services and document medical necessity

Services that are exceptions to exclusions (for example medically necessary reconstructive or gender‑affirming surgery, or limited infertility treatments) may require prior authorization and documentation of medical necessity; prior authorization alone does not guarantee coverage if the service is excluded elsewhere in the policy.

• Document medical necessity when requesting authorization for services that might otherwise be excluded.
• Prior authorization for an excluded service does not override an explicit exclusion in the policy.

Ensure prior authorization and admissions reflect member effective date

Services that began before a member's coverage effective date are not covered except for covered expenses incurred on or after the effective date; ensure prior authorization and admissions reflect the member's effective date.

• Prior authorization should reflect member effective date for facility admissions.
• Claims for services that began before coverage are excluded unless expenses incurred on/after effective date.

Follow plan step therapy rules under the pharmacy benefit

Step therapy is managed under the Pharmacy Prescription Benefit (Section 7.6); when a medication is part of step therapy the member must try Step 1 medications before Step 2 will be covered unless an exception applies.

• If a prescription is submitted out of step order (Step 2 without prior trial of Step 1), it will not be covered and the provider must prescribe the Step 1 medication.
• Exceptions to step therapy allowed if Step 1 is ineffective, harmful, or not equivalent.

Use Member Dashboard/formulary to check tiers and step therapy

Member Dashboard and formulary tools indicate medication tiers and may reflect step therapy; use those tools to verify tier, step therapy requirements, and formulary status before prescribing.

• Use the Prescription Price Check and formulary on the Member Dashboard to identify benefit tiers and step therapy requirements.
• Formulary exceptions require provider documentation and are decided within 72 hours (24 hours if urgent).

Follow pharmacy network and mail‑order pharmacy requirements

Pharmacy network tiers and mail‑order rules require use of Moda‑designated pharmacies for certain tiers and mail order; providers should direct members to designated pharmacies and follow supply limits.

• Some tiers require use of a Moda‑designated mail order pharmacy or participating retail pharmacies for a 90‑day supply.
• Some specialty prescriptions may be limited to less than 30 days; certain medications eligible for 90‑day supply at participating retail pharmacies.

Use preferred providers/treatment centers when required

Some treatments require use of a preferred treatment center or provider for coverage or a higher benefit level; verify preferred center requirements and any travel/housing limits before referring or scheduling.

• Authorizations may require treatment at a preferred center; travel and housing expenses may be covered up to limits described in the authorization.
• Failure to use an authorized provider may result in nonpayment or reduced benefits.

Prescribe most cost‑effective contraceptive or document medical reason for alternative

The plan covers the most cost‑effective contraceptive option; if that option is medically inadvisable for the member, document the medical rationale and the plan will cover an alternative prescribed by the provider.

• Providers should document why the cost‑effective contraceptive is medically inadvisable if recommending an alternative.
• Over‑the‑counter contraceptives are covered under the Pharmacy benefit.

Provide infusion medications through preferred supplier or specialty benefit when required

Some infusion medications may be covered only from a preferred medication supplier or under the pharmacy specialty medication benefit; when limited, ensure prescriptions and ordering follow those supplier requirements.

• When authorization is limited to a certain supplier, medications from other suppliers may not be covered.
• Some infusion medications are covered under the pharmacy specialty benefit and may require enrollment in manufacturer programs.

Transplant outpatient meds billed under pharmacy benefit

Outpatient oral and self‑injectable immunosuppressive medications for transplant patients are paid under the Pharmacy Prescription Benefit; prescribe and route these drugs through the pharmacy benefit as appropriate.

• Immunosuppressive drugs given during hospital stay are paid as a medical supply; outpatient oral/self‑injectable transplant meds are paid under pharmacy benefit.
• Coordinate with Pharmacy Customer Service for specialty/transplant medication logistics.

Adhere to step therapy sequence or document exception criteria

When a medication is subject to step therapy, the member must try Step 1 medications before Step 2 will be covered; if Step 1 is ineffective, harmful, or not equivalent, document that to request an exception.

• If a prescription is submitted out of order, it will not be covered and the provider must prescribe the Step 1 medication.
• Formulary exception requests must document trials, intolerance, harm, or expected lack of equivalent effect.

Step therapy not applicable to excluded obesity treatments

Step therapy does not apply to services that are explicitly excluded (for example obesity/weight reduction treatments); excluded services remain non‑covered regardless of step therapy.

• Obesity/weight reduction procedures and related medications are excluded except as required by ACA; step therapy does not reinstate coverage for excluded services.

Self‑improvement programs excluded unless medically necessary

Self‑improvement or educational programs are excluded unless they are medically necessary treatments for a covered condition; do not charge or bill these programs as covered services without documented medical necessity.

• Examples include retreats, assertiveness training, and other lifestyle improvement programs that are not medically necessary.
• If program is medically necessary for a covered condition, document the medical need to support coverage.

Use Member Dashboard or Customer Service for policy and authorization help

Providers and members may find policy details and contact customer service via the Member Dashboard (www.modahealth.com/idaho) or the phone numbers listed in Section 2.1 for authorizations and policy questions.

• Member Dashboard available 24/7 for policy info, authorization checks, and formulary tools.
• Contact Customer Service or Behavioral Health Customer Service for authorization help.

Verify member coverage using the Moda ID card at time of service

Ask members to present their Moda ID card at the time of service so providers can verify coverage, network participation, and benefit tiers prior to providing services.

• If a member loses their ID card, they can request a replacement via the Member Dashboard or Customer Service.
• ID card lists the member's network and helps determine in‑network vs out‑of‑network status.

Document medication administration setting and specialty pharmacy use

Document whether medications are administered in limited providers or settings and indicate when specialty pharmacy coverage applies; this documentation supports correct benefit routing and claims processing.

• When medications are limited to specific providers or settings, include setting/supplier information on claims.
• Indicate when specialty pharmacy coverage applies so claims are processed under the pharmacy specialty benefit when appropriate.

Include authorization on claims for nutritional therapy beyond first five visits

Authorization is required for nutritional therapy for eating disorders after the first five visits; include authorization details on claims for visits beyond that point.

• First five visits are referenced before the authorization requirement applies in the Schedule of Benefits.
• Ensure claims for visits beyond five include authorization numbers.