Getting prior authorization for services
When we say you need to get prior authorization for a service or prescription drug, it means that you need to get pre-approval from us to cover it. Prior authorization is also referred to as organization determination or coverage determination. Prior authorization is required for:
- Ambulatory surgical center (ASC) services
- Cardiac rehabilitation services
- Diabetic services and supplies
- Diagnostic radiology, MRI/CT/CAT/SPECT/PET, nuclear cardiology and radiation therapy
- Durable medical equipment (DME) and related supplies
- Home health
- All home health visits, including skilled nursing, physical therapy, occupational therapy and speech language pathology in the home
- Inpatient hospital care
- Inpatient mental health care
- Inpatient stay: covered services received in a hospital or skilled nursing facility (SNF) during a non-covered inpatient stay
- Medicare Part B prescription drugs, home-infusion drugs and biologicals. See Step Therapy requirements for Medicare outpatient (Part B) medications for more details.
- Outpatient rehabilitation services, including physical therapy, occupational therapy and speech language pathology
- Partial hospitalization services for mental health
- Prosthetic devices and related supplies
- Pulmonary rehabilitation services
- Specialty dental services (Medicare-covered)
Getting prior authorization for prescription drugs
- Complete our online Coverage determination and exception request (members and providers) form
- Contact Moda Health Pharmacy Customer Service at 888-786-7509. TTY users, dial 711.
- Mail your request by completing this coverage determination and exception request form
Request an exception
If you need a prescription drug that is not in our formulary, you or your provider can request that we cover it.
To request an exception, you or your provider may do one of the following:
- Call Moda Health Pharmacy Customer Service at 888-786-7509. TTY users, dial 711.
- Submit our online Coverage determination and exception request (members and providers) form
- Submit a written request by completing this coverage determination and exception request form. You may fax it to 800-207-8235, or mail it to:
Attn: Moda Health Coverage Determination
P.O. Box 40327
Portland, OR 97240
How to appeal a decision
You can request a review of a medical or pharmacy decision we have made. You can also file a complaint to Medicare.
Last updated Oct. 9, 2020