Moda Health Prior Authorization Lookup
Latest Moda Health prior authorization updates25
- Prior AuthClinical/Medical PolicyEff. 2026-07-01Breast Implant RemovalCriteria and coverage rules for removal and reinsertion of breast implants, including indications, limitations, coding, and prior authorization documentation requirements for Moda Health members.All Moda Health updates
- Prior AuthClinical/Medical PolicyEff. 2026-07-01Corneal Collagen Cross-linking for Treatment of KeratoconusPolicy governing coverage and prior authorization requirements for corneal collagen cross-linking (CXL) to treat progressive keratoconus or corneal ectasia after refractive surgery for Moda Health members and providers.All Moda Health updates
- Prior AuthClinical/Medical PolicyEff. 2026-06-01Continuous Glucose Monitoring (CGM)Defines Moda Health coverage, prior authorization information, and clinical criteria for short-term diagnostic and long-term therapeutic use of FDA‑approved continuous glucose monitoring systems for members with diabetes.All Moda Health updates
- Prior AuthClinical/Medical PolicyEff. 2026-05-05Cosentyx (secukinumab) (Subcutaneous/Intravenous) — Prior Authorization and Medical NecessityDefines prior authorization, dosing limits, initial and renewal authorization periods, and medical necessity criteria for Cosentyx (secukinumab) for Moda Health members across labeled indications. Applies to providers requesting coverage for subcutaneous and intravenous formulations.All Moda Health updates
- Prior AuthClinical/Medical PolicyEff. 2026-05-05Denosumab (Prolia, Xgeva, biosimilars) — medical necessity and prior authorization criteriaMedical necessity, dosing limits, authorization periods, and coverage criteria for denosumab products for members in scope of Moda Health. Applies to providers requesting prior authorization for denosumab formulations listed in the policy.All Moda Health updates
- Prior AuthClinical/Medical PolicyEff. 2026-04-01Bone Growth Stimulators - ElectricPolicy governing coverage and prior authorization requirements for electrical bone growth stimulators (non-invasive, semi-invasive, and invasive) for Moda Health members, including spinal and non-spinal indications and related documentation requirements.All Moda Health updates
- Prior AuthClinical/Medical PolicyEff. 2026-04-01Lumizyme (alglucosidase alfa) (Intravenous)Defines Moda Health prior authorization, dosing limits, medical necessity criteria, renewal conditions, and billing codes for intravenous Lumizyme (alglucosidase alfa) for treatment of Pompe disease.All Moda Health updates
- Prior AuthClinical/Medical PolicyEff. 2026-03-03Cimzia (certolizumab pegol) (Subcutaneous) — Prior Authorization and Coverage CriteriaDefines Moda Health prior authorization, dosing limits, length of authorization, and medical necessity criteria for Cimzia (certolizumab pegol) for multiple indications (e.g., RA, Crohn's disease, PsA, AS, pJIA). Applies to providers requesting coverage for members under Moda Health plans.All Moda Health updates
- Prior AuthClinical/Medical PolicyEff. 2026-03-03Cinqair (reslizumab) (Intravenous)Policy M-P0273 defines prior authorization, dosing limits, initial and renewal medical necessity criteria, contraindicated concomitant therapies, and administration dosing for Cinqair (reslizumab) for Moda Health members.All Moda Health updates
- Prior AuthClinical/Medical PolicyEff. 2026-03-01BRCA Testing (BRACAnalysis CDx; myChoice CDx) (Myriad)Coverage and prior-authorization criteria for Myriad's BRACAnalysis CDx (germline) and myChoice CDx (tumor/somatic) tests for members being considered for specific targeted therapies, including required documentation for prior authorization.All Moda Health updates
- Prior AuthClinical/Medical PolicyEff. 2026-02-03Cerezyme (imiglucerase) (Intravenous) — Coverage CriteriaPolicy governing prior authorization, dosing limits, indications, and renewal criteria for intravenous Cerezyme (imiglucerase) for members covered by Moda Health.All Moda Health updates
- Prior AuthClinical/Medical PolicyEff. 2026-02-03Nplate (romiplostim) coverage and authorizationPolicy IC-0089 defines prior authorization, dosing limits, indications, renewal criteria, and billing/coding rules for romiplostim (Nplate) for Moda Health members.All Moda Health updates
- Prior AuthClinical/Medical PolicyEff. 2026-02-01Balloon Dilation of the Eustachian TubeDefines Moda Health coverage, medical necessity criteria, exclusions, required documentation, and coding for balloon dilation of the eustachian tube (BDET) in adults; applies to providers requesting prior authorization for members.All Moda Health updates
- Prior AuthClinical/Medical PolicyEff. 2026-02-01Chiropractic ServicesDefines Moda Health coverage, medical necessity criteria, exclusions, and prior authorization information for chiropractic services for members with applicable benefits.All Moda Health updates
- Prior AuthClinical/Medical PolicyEff. 2026-01-01Wearable Cardiac Defibrillators (WCD) Coverage CriteriaCriteria and coverage policy for wearable (vest-like) external cardiac defibrillators and related AED devices for adult members, including prior authorization information and applicable billing codes for Moda Health.All Moda Health updates
- Prior AuthClinical/Medical PolicyEff. 2025-12-02Myobloc® (rimabotulinumtoxinB) — Intramuscular/Intradermal/IntraglandularDefines prior authorization, dosing limits, initial and renewal medical necessity criteria for rimabotulinumtoxinB (Myobloc) for intramuscular/intradermal/intraglandular use affecting providers seeking coverage for adult indications.All Moda Health updates
- Prior AuthClinical/Medical PolicyEff. 2025-12-01Electrical Stimulation DevicesDefines medical necessity, coverage, and exclusions for electrical stimulation devices (TENS, NMES, FES, PENS, implanted peripheral stimulators, and other modalities) for Moda Health members. Applies to ordering providers, DME suppliers, and clinical reviewers requesting prior authorization or claims adjudication for these devices.All Moda Health updates
- Prior AuthClinical/Medical PolicyEff. 2025-11-01Coordinated Specialty Programs (EASA, IOSS, IIBHT, ACT)Defines medical necessity criteria, prior authorization information, and covered CPT/HCPCS codes for coordinated specialty behavioral health programs (EASA, ACT, IOSS, IIBHT) offered under Moda Health; applies to providers and programs delivering these services in accordance with referenced Oregon administrative rules.All Moda Health updates
- Prior AuthClinical/Medical PolicyEff. 2025-11-01Disease Management Program for Pain (Pain Schools)Defines medical necessity, prior authorization documentation, covered CPT/HCPCS codes, and criteria for initial and subsequent enrollment in multidisciplinary disease management programs for chronic pain. Applies to providers requesting authorization for pain school services under Moda Health.All Moda Health updates
- Prior AuthClinical/Medical PolicyEff. 2025-10-02Azedra (iobenguane I-131) (Intravenous) coverage criteriaDefines Moda Health coverage, billing limits, and medical necessity criteria for Azedra (iobenguane I-131) for patients with pheochromocytoma/paraganglioma and related neuroendocrine adrenal tumors; affects providers submitting claims and seeking prior authorization for doses. Pre-payment claim edits apply; prior authorization criteria noted but PA does not apply for this policy for payment edits.All Moda Health updates
- Prior AuthClinical/Medical PolicyEff. 2025-10-02Hicon® (Sodium Iodide I-131) (Oral) coverage criteriaDefines Moda Health's medical necessity, dosing limits, billing codes, and authorization rules for oral Hicon (sodium iodide I-131) for hyperthyroidism and thyroid carcinoma; applies to Moda members and providers submitting claims. Prior authorization criteria do not apply, but pre-payment claims edits and PA validity rules are included.All Moda Health updates
- Prior AuthClinical/Medical PolicyEff. 2025-09-01Cooling Devices (Passive and Active) Coverage CriteriaDefines Moda Health coverage for passive and active cooling devices used for postoperative and musculoskeletal/soft-tissue injury care, and the documentation required for prior authorization requests.All Moda Health updates
- Prior AuthClinical/Medical PolicyEff. 2025-09-01Zaltrap (ziv-aflibercept) — Intravenous prior authorization and coverage criteriaPrior authorization, dosing, and medical necessity criteria for intravenous ziv-aflibercept (Zaltrap) for oncology indications (primarily metastatic colorectal and appendiceal adenocarcinoma) for Moda Health providers and reviewers.All Moda Health updates
- Prior AuthClinical/Medical PolicyEff. 2025-08-05Berinert (C1 esterase inhibitor, human) — IntravenousClinical coverage and prior authorization criteria for intravenous Berinert for acute treatment of hereditary angioedema (HAE), including dosing limits, authorization length, and required diagnostic confirmation; applies to Moda Health benefit administration.All Moda Health updates
- Prior AuthClinical/Medical PolicyEff. 2025-08-05Cinryze (C1 Esterase Inhibitor, Human) (Intravenous)Defines prior authorization, dosing limits, indications, renewal criteria, and billing/coding for intravenous Cinryze for hereditary angioedema prophylaxis for Moda Health members and providers.All Moda Health updates
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Tool Description
Search Moda Healthprior authorization policies by drug name, procedure, or policy title. Results include any policy that mentions prior authorization requirements (drug coverage criteria, imaging guidelines, site-of-service rules) not just documents titled “prior authorization.” Every result links to a full policy page with clinical criteria, covered billing codes, documentation requirements, and effective dates.
Filter by payer, specialty, policy type, or effective year; or search directly for a drug (“Wegovy,” “Ozempic”), a procedure (“MRI,” “knee arthroplasty”), or a policy number.
Coverage spans 110+ payers. Jump straight to the busiest prior-auth publishers: UnitedHealthcare, Cigna, Aetna, Anthem, and Centene. You can also browse the full policy updates feed.
Pair a prior-auth search with the billing code lookup to confirm the CPT or J-code on the claim, the payer lookup for plan footprint, and payer profiles for contacts and coverage context.
FAQ
Type a drug name (“Wegovy,” “Ozempic”), a procedure (“MRI,” “knee”), or a policy title into the search bar. Filter results by payer, specialty, policy type, or effective year. Open any result for the full policy page with clinical criteria, covered billing codes, documentation requirements, and effective dates.
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Prior auth requirements change all the time. Keep up with every payer policy update in the live policy feed, or browse payers with prior authorization policies.
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