Coverage determination

Coverage determination is a decision about whether or not a prescription drug is covered. The determination also lets you know how much we cover and how much you need to pay.

If a pharmacy says your prescription is not covered, that is not coverage determination. We make that decision. Please call or write us with questions:

Please call our Moda Health Pharmacy Customer Service at 503-265-4709 or toll-free at 888-786-7509. TTY users, dial 711. Pharmacy Customer Service is available from 7 a.m. to 8 p.m., Pacific Time, seven days a week from October 1 through March 31. (After March 31, your call will be handled by our automated phone system Saturdays, Sundays and holidays.)

Making a coverage determination request

If you would like to request coverage determination, you or your provider may do one of the following:

• 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 prescription drug coverage determination form 

Making a coverage redetermination request

A redetermination request is an appeal of a denied coverage determination. If you would like to request coverage redetermination, you or your provider may do one of the following:

• Complete our online Prescription drug redetermination request form
• Contact Moda Health Pharmacy Customer Service at 888-786-7509. TTY users, dial 711.
• Mail your request by completing this prescription drug redetermination request form

Getting prior authorization

You may need to get prior authorization (pre-approval) from us to cover a prescription drug. If a drug in our formulary has a “PA,” you will need to get prior authorization. See our Prior authorization guidelines. To get prior authorization, you or your provider can,

• 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

Step therapy guidelines

We use step therapy to help you get the most effective drug for the best price. With step therapy, you try a lower-cost drug to see if it works before stepping up to a higher-cost one. See our step therapy guidelines.

Appointing a representative

You can assign someone you trust to help you manage your Medicare plan. This is what we mean when we say, “appoint a representative.” You can choose whomever you like. It could be a relative, friend, advocate, doctor, etc. To do this, please complete our Appointment of Representative form. You will need to have the person you appoint sign the form. Then, this person can request coverage determination, redetermination and/or file a grievance for you.