PEBB Non-Emergency Medical Travel (NEMT) request form
Form and criteria for requesting travel and lodging reimbursement for Moda Health PEBB members who must travel for medically necessary care when in-network services are not reasonably available.
No material clinical or coverage changes in this revision.
Eligibility for Travel & Lodging Reimbursement
Eligibility criteria for travel reimbursement
Travel and lodging reimbursement may be available if member cannot find a nearby in-network provider to provide medically necessary covered services due to one of the following:
ANY of the following
ALL of the following
- An in-network provider is not available within 50 miles of the member's home50 miles
ALL of the following
- Covered services are not available in the member's state due to a law or regulation, and the services can be received legally in another state
ALL of the following
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