Prior authorization

Coverage Determination (for prior authorizations and exceptions)

We may be able to cover a drug for you if you ask us to make an exception. You can request an exception if:

• Your Part D-eligible drug is not on our formulary
• We ask you to try another drug before you receive a drug you’ve requested
• We limit the quantity or dose of a drug you have requested

To request an exception, you or your provider may do one of the following:

• Complete our online coverage determination and exception request (members and providers)
• Contact the Moda Health Pharmacy Customer Service team at 888-786-7509 (TTY: users, dial 711)
• Mail your request by completing this coverage determination and exception request form
• Coverage Determination guidelines can be found below:
• Prior Authorization Guidelines
• Step Therapy Guidelines

Filing an appeal

• Complete our online prescription drug redetermination request form
• If you prefer to mail or fax your request, you may complete this prescription drug redetermination request form

Learn more about making an appeal in your Evidence of Coverage