FAQ

It’s only natural to have questions about your new Moda Health/Trust plan. If you can’t find the answer to your question here, please feel free to call our Customer Service Representatives.

Medical Customer Service: 855-294-1668
Pharmacy Customer Service: 855-264-1669

General questions
Pharmacy questions

General

  1. What is myModa
  2. How can I find doctor or clinic in my network?
  3. How do I know what network I am in?
  4. How do I send in my claims?
  5. Can I see my claims online?
  6. Is there a Member Handbook I can access?
  7. How can I view my benefits?
  8. Do I pay Moda Health when I get a bill from my medical or dental provider?
  9. Can you help me understand the Explanation of Benefits (EOBs) I will be receiving?
  1. What is myModa?
    As a Moda Health member, you have access to myModa, your personalized member website. With myModa, you can access health tools and resources to help you manage your health. To create your myModa account, please click on the “create an account” link in the myModa box on the right side of this screen. While in myModa, you can set your communication preferences for your EOBs. You can either receive EOBs electronically or through regular U.S. mail.

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  3. How can I find a doctor or clinic in my network?
    Click on the box on the right side of this screen that says “Moda Health Provider Network: Find a physician, pharmacy or clinic”. As a Moda Health/AIMS member, your medical network is the First Choice Health PPO Washington and Connexus network. If you live outside of Washington, Oregon, or Idaho, your medical network is the PHCS network. Your pharmacy network is the Washington Prescription Drug Plan (WPDP) network.

    If you are traveling, the Moda Health Travel Network allows you to receive emergency and nonemergency care outside of your primary service area. If you need care when you are traveling, you should choose a provider in the PHCS Healthy Directions network to receive in-network benefits.* If you have dependents living outside of the primary network area, your dependents can also use the Moda Health Travel Network to receive care at an in network benefit level.* The Moda Health Travel Network is not an alternative primary network. Members must seek in-network services whenever possible, and preauthorization is required for in-patient services.

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  5. How do I know what network I am in?
    As a Moda Health/Trusts member, your medical network is the First Choice Health PPO Washington and Connexus network. If you live outside of Washington, Oregon or Idaho, your medical network is the PHCS network.  Your pharmacy network is the Washington Prescription Drug Plan (WPDP) network.

    If you are traveling, the Moda Health Travel Network allows you to receive emergency and nonemergency care outside of your primary service area. If you need care when you are traveling, you should choose a provider in the PHCS Healthy Directions network to receive in-network benefits.* If you have dependents living outside of the primary network area, your dependents can also use the Moda Health Travel Network to receive care at an in network benefit level.* The Moda Health Travel Network is not an alternative primary network. Members must seek in-network services whenever possible, and preauthorization is required for in-patient services.

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  7. How do I send in my claims?
    Once you receive treatment, if your doctor, pharmacist or facility does not bill Moda Health for you, please send your claims to:

    Medical claims
    Moda Health
    P.O. Box 40384
    Portland, OR 97240-0384

    Please include the following information with your medical claim:

    • Patient’s name, identification number and group ID number
    • Date of treatment
    • Diagnosis (medical only)
    • An itemized description of services and charges

    If the treatment is for an accidental injury, include a statement with the date, time, place and circumstances of the accident when you send us the physician or professional provider’s bill.

    Pharmacy claims
    Moda Health
    P.O. Box 40168
    Portland, OR 97240

    To submit pharmacy claims, please fill out the pharmacy claims form.

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  9. Can I see my claims online?
    Yes. Once your coverage with Moda Health is active, you can see your claims online through your personalized member website, myModa. myModa also allows you to manage your benefits and access health tools and resources. To register for myModa, visit the myModa registration page on or after your effective date of coverage.

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  11. Is there a Member Handbook I can access?
    Yes. Once your coverage with Moda Health is active, you can access your Member Handbook, claims and benefit information, health tools, and other resources on myModa, your personalized member website. To register for myModa, visit the myModa registration page on or after your effective date of coverage.

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  13. How can I view my benefits?
    Once your coverage with Moda Health is active, you can view your benefits and claims information and access health tools and resources on myModa, your personalized member website. To register for myModa, visit the myModa registration page on or after your effective date of coverage.

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  15. Do I pay Moda Health when I get a bill from my medical provider?
    No. If you receive a bill from your medical provider, verify that your provider is billing you for the charges your health plan did not cover. Once you have confirmed the bill is for charges not covered by insurance, pay your provider directly.

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  17. Can you help me understand the Explanation of Benefits (EOBs) I will be receiving?
    Yes. You can view sample medical EOBs, which include a glossary and explanation.

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Pharmacy

  1. How will my medications be covered under Moda Health prescription benefits?
    We recommend you view the WPDP Preferred Drug List, available on our website or through myModa, your personalized member website. The WPDP Preferred Drug List is a listing of commonly prescribed medications and the tiering of those medications under the Moda Health formulary. This PDL is a sample PDL, for the PDL for your specific plan, please log on to your myModa account and access your plan’s PDL.

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  3. How will I know if my medication requires a prior authorization or if it has any limitations?
    You can view a listing of Prescriptions requiring authorization on our website and through myModa, your personalized member website. You may also call Moda Health Pharmacy Customer Service at 855-294-1669 to inquire.

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  5. What should I do if my medication requires authorization?
    If a medication that is being prescribed requires authorization, you should call Moda Health Pharmacy Customer Service at 855-294-1669. Moda Health will then work with your provider to obtain the necessary information to complete the review of the requested medication.

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  7. If my medication requires prior authorization, but I already had authorization in place with the previous carrier, will I need to start the process again?
    Yes, a review by Moda Health is required. You should call Moda Health Pharmacy Customer Service at 855-294-1669 to initiate the review process.
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  9. If I receive a brand-name medication that has a generic formulation, what will I be responsible for paying?
    If you request, or if your provider prescribes a brand-name drug when an equivalent generic formulation is available, you will be required to pay the generic co-insurance, plus the difference in cost between the generic and brand-name medications.

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  11. If I have dual pharmacy coverage and Moda Health is the secondary plan, how will claims be paid?
    When the primary plan has approved a pharmacy claim and paid towards that claim, the secondary plan will pay up to what would have been covered had the claim been submitted to Moda Health for primary processing. Moda Health will not pay more on the secondary claim than a member’s total out-of-pocket expense on the primary claim.

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  13. What is the Washington Prescription Drug Program (WPDP)?
    The Washington Prescription Drug Program (WPDP) was created to pool eligible groups and individual purchasers of prescription drugs in an effort to negotiate lower prices which would, in turn, increase access to prescription drugs for both insured and uninsured Washingtonians. The WPDP joined the Oregon Prescription Drug Program in 2006 to form the Northwest Prescription Drug Consortium which created a larger pool to leverage even greater negotiating power for securing competitive administrative costs and transparent pharmacy benefit management services which lowers prescription drug costs for purchasers in both states.

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  15. How do I know what pharmacies are in the Washington Prescription Drug Program (WPDP) network?
    A list of participating WPDP pharmacies can be found online through your myModa account. To view a list of participating pharmacies prior to your effective date, please visit the Moda Health participating pharmacy providers search tool.

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  17. Is there a mail-order pharmacy I can use?
    Members may use Postal Prescription Services (PPS). You may enroll by calling PPS at 800-552-6694.

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  19. How do I establish my mail-order prescriptions?
    You should be prepared to submit a new prescription for the medication you would like to have filled through the mail-order program.

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  21. Am I required to access specialty medications (e.g., self-injectables, biologics, etc.) through an exclusive specialty pharmacy?
    Yes. Specialty medications must be accessed through the exclusive specialty pharmacy, Ardon Health Specialty Pharmacy. Each specialty prescription is limited to a 30 day supply and will require prior authorization by Moda Health. A listing of specialty medications is available in your myModa account. This specialty medication listing is a sample list, for the list for your specific plan, please log on to your myModa account and access your plan’s specialty medication list.

    Ardon Health is the exclusive specialty pharmacy servicing Moda Health and Washington Prescription Drug Program (WPDP) members. To begin accessing specialty medications, please call Ardon toll-free at 855-425-4085. Learn more at ardonhealth.com.

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  23. Why are changes sometimes made to how medications are covered?
    At Moda Health, we take pride in actively managing our members’ pharmacy benefits to ensure that the programs provide quality, comprehensive coverage and remain current with industry standards and the changes occurring in the marketplace. Moda Health considers the following when making changes to the pharmacy benefits:

    • How safe is the medication?
    • How effective is the medication?
    • How cost effective is the medication?

    Moda Health has a clinical team that reviews the formulary and makes recommendations for program changes throughout the benefit year. This approach allows Moda Health to make changes when the FDA has approved new medications, when generic alternatives become available or when changes occur to existing drug profiles (e.g., dosage recommendations, patient safety information or approved uses). Changes are enforced as a way to maintain a comprehensive benefit and to provide members with an open formulary and choice, as well as to ensure the ongoing stability of the pharmacy program.

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  25. If a drug costs less than the copayment, do members pay the total cost of the prescription or the copayment?
    Members would pay the actual cost of the prescription.

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