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Medical necessity criteria

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Moda Health Commercial Plans Criteria

Moda Health Medicare Advantage Plans

Moda Health may develop or adopt medical necessity criteria for certain complex, high cost or highly utilized services on the prior authorization list that do not have an existing National Coverage Determination, Local Coverage Determination, Local Coverage Article, or applicable clinical care guidelines associated with them. These services include, but are not limited to, new technologies (Medical, Behavioral Health, Pharmaceuticals, Devices), new medications and frequently requested services by healthcare providers that require a review for medical necessity.

Medical Necessity Criteria is developed using published scientific evidence and information from relevant governmental regulatory bodies. The criteria is reviewed by the Medical Director, Licensed Psychiatrist, and/or an external specialist review for content and appropriateness.

We have created a complete list of medical necessity criteria for Medicare Advantage below:

Injectable Medication Criteria

MagellanRx - Moda Health Plan Delegates administrative functions to MagellanRx. Medicare coverage for outpatient (Part B) drugs is outlined in the Medicare Benefit Policy Manual (Pub. 100-2), Chapter 15, ??50 Drugs and Biologicals. In addition, National Coverage Determination (NCD), Local Coverage Articles (LCAs) and Local Coverage Determinations (LCDs) may exist and compliance with these policies is required where applicable. They can be found at: http://www.cms.gov/medicare-coverage-database/search/advanced-search.aspx. Additional indications may be covered at the discretion of the health plan.

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.

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