Authorizations for provider-administered medications

At Moda Health, we’re committed to supporting your practice and the care you provide your patients. Follow this guidance for submitting prior authorizations, which includes additional details about medical pharmacy programs.

Multiple paths to approvals

The medication and/or the member’s group will determine whether the request is reviewed through Moda Health directly, or through our trusted partner, Prime Therapeutics. Some medications must be reviewed under the member’s pharmacy benefit (see Pharmacy benefit optimization program below). To help determine which path to follow, review the infused/injectable medication list. If you have questions about the specific group coverage, reach out to our Customer Service team at 888-217-2363. We’re here to help.

How to submit your request

Prime Therapeutics

Online through the self-service Prime Therapeutics Portal
Via phone at 800-424-8114

Moda Health

Online through Benefit Tracker
Via fax Rx Preauthorization to 503-243-5105

Claim check program

Moda Health utilizes a claim check program, which monitors and promotes appropriate use, safety and cost effectiveness of medications prescribed to our members. We do this by reviewing claims post-service, but pre-payment for appropriate frequency, correct units, and eligible diagnosis codes. This program is limited to claims reviewed and to medications infused and/or injected in a professional office, home or outpatient setting.

Prior authorization criteria do not apply for these medications; however, there are covered diagnosis codes and dosing limits for each medication. If the services billed do not meet the criteria, the claims will be subject to review and potentially disallowed.

Claim check medications and requirements:

Injectable Medication Criteria

Moda Health Plan Delegates administrative functions to Prime Therapeutics Management.

Some injectable medications are reviewed by Moda Health. Please see the bottom of the Injectable Medication Prior Authorization List to find out which medications should be submitted to Moda Health.

Questions?

We're here to help. Call us toll-free at 888-217-2363 or email medical@modahealth.com.