Coverage for provider-administered medications
Moda Health covers most medications ordered and administered by providers in a healthcare setting under the member's medical benefits. Select provider-administered medications may be covered under the pharmacy benefit for some groups. Prior authorization is required for all medications listed here. Most infused/injectable medications are reviewed by our trusted partner, Prime Therapeutics LLC, while some medications are reviewed directly by Moda Health.
Below you'll find everything you need to submit an authorization request.
Pharmacy benefit optimization program
Certain specialty infused/injectable medications are covered separately under our Pharmacy benefit optimization program. Prior authorization is requested under the pharmacy benefit and these medications are filled by the plan's preferred specialty pharmacies, Ardon and Emerging Health. These medications include:
- Cinqair® (reslizumab)
- Fasenra® (benralizumab)
- Nucala® (mepolizumab)
- Tezspire® (tezepelumab-ekko)
- Xolair® (omalizumab)
- Ocrevus® (ocrelizumab)
- Ocrevus Zunovo™ (ocrelizumab and hyaluronidase)
Prior authorizations for injectable/infused medications
Moda Health has three categories of injectable/infused medications for authorization:
- Medications that are included in the members plan and do not require prior authorization review
- Medications that are reviewed by our in-house pharmacy team
- Medications that go out to Prime Therapeutics Management LLC for authorization
A list of injectable medications for prior authorization: View now
Are you in Texas? A list of injectable medications for prior authorization can be found here.
How to submit a request for prior authorization
Prime Therapeutics: Visit the self-service provider portal at Medical Rx Prior Authorization | Prime Therapeutics Management LLC or call 800-424-8114.
Moda Health: To submit a request to our pharmacy team, submit electronically at: modahealth.com/EBTWeb or complete the form and follow the instructions on the form to submit.
Additional Resources
- Infused Medications Covered Under the Pharmacy Benefit for Select Groups
- Group Exclusion List
- FAQ: Coverage Changes for Infused Specialty Medications
Questions
We're here to help. Call us toll-free at 877-605-3229 or email medical@modahealth.com. TTY users, please call 711.
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