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Medicare Advantage Member Support

The resources you need to manage your prior 2024 plan and benefits.

Jump to:

Provider Directories
File a claim
Formulary
Plan materials
Appeals and grievances
Star ratings

 


Provider Directories

Download a PDF/printable version of our 2024 Western Oregon directories.

Out-of-network coverage

If you have a PPO plan and you are seeing an out-of-network provider, you or your provider are encouraged to get prior approval from the plan before you get non-emergent or non-urgent services. To learn more, see your Evidence of Coverage. You can also contact Customer Service.

Questions?

Please call Moda Health Customer Service at 503-265-4762 or toll-free at 877-299-9062. TTY users, dial 711. Customer Service is available from 7 a.m.– 8 p.m. (Pacific Time), seven days a week October 1 – March 31 (closed on Thanksgiving and Christmas), and weekdays April 1 – September 30. Your call will be handled by our automated phone systems out-side business hours.

How to file a claim

We make decisions about reimbursement based on your Evidence of Coverage.

To submit a claim, please complete our medical paper claim form or our pharmacy paper claim form. Mail it and your medical or prescription receipt to the address on the form. You will need to submit this claim within 60 days of getting your out-of-network prescription filled.

Need help filing a claim?

Please contact us if you need help filing a claim. Please call our Moda Health Medical Customer Service at 877-299-9062 or our Pharmacy Customer Service 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.)

 

Formulary

Our formulary is our list of covered prescription drugs to see what generic and brand-name drugs are covered under our 2024 plans that have prescription drug coverage. You can also contact pharmacy customer service to request a printed copy of the formulary.

View our Formulary:

2024 Moda Medicare Advantage Formulary

Pharmacy Directory

 

Plan Materials

Evidence of Coverage (EOC)

Use your Evidence of Coverage to find out what is covered in your plan and how your plan works.

2024

  • Moda Health PPO (PPO)
    Benton, Clackamas, Columbia, Coos, Crook, Curry, Deschutes, Douglas, Hood River, Jackson, Jefferson, Josephine, Klamath, Lane, Linn, Marion, Multnomah, Polk, Wasco, Washington and Yamhill Counties 

Summary of Benefits (SB)

Your Summary of Benefits includes highlights of your plan such as your monthly premium, annual out-of-pocket maximum, and copays for medical services.

2024

Portland Metro Region

  • Moda Health PPO (PPO)
  • Moda Health Metro PPORX (PPO)
  • Moda Health + Fred Meyer PPORX (PPO)
  • Moda Health Elements PPORX (PPO)

Central Region

  • Moda Health PPO (PPO)
  • Moda Health Central PPORX (PPO)
  • Moda Health Value PPORX (PPO)

Mid-valley Region

  • Moda Health PPO (PPO)
  • Moda Health Mid-Valley PPORX (PPO)
  • Moda + PeaceHealth PPORX (PPO)

Southern Region

  • Moda Health PPO (PPO)
  • Moda Health Southern PPORX (PPO)
  • Moda Health Value PPORX (PPO)

 

Appeals and grievances

Filing a complaint

If you have concerns or problems with any part of your benefits, care, service or prescription drugs; you can file a complaint. Appeals and grievances are the two types of complaints you can file.

Filing an appeal

If you do not agree with a decision we have made, you can make an appeal (a request to change the decision) within 60 days. You can do this for decisions about services and payment. You can also request that we cover an item or service that is not in your plan.

If you need to ask for a review of a medical care coverage decision made by our plan, you or your provider may do one of the following:

  • Call 877 299-9062
  • Submit a written request and fax to 503 412-4003
  • Submit a written request and mail to:

Moda Health
Attn: Medicare Appeal and Grievance Unit
P.O. Box 40384
Portland, OR 97240-0384

For pharmacy appeals:

If your health requires a quick response, you must ask for a “fast appeal.” For an expedited appeal, you or your provider may do one of the following:

  • Call 866-796-3221 (voicemail only) and leave us a message with your name, plan ID and details of your request.
  • Submit a written request and fax to 503-412-4003, Attn: Medicare Expedited Appeal and Grievance Unit
  • Submit a written request and mail to:

    Moda Health
    Attn: Medicare Appeal and Grievance Unit
    P.O. Box 40384
    Portland, OR 97240-0384

Please make sure to write “expedited appeal” on your request.

Learn more about making an appeal in your Evidence of Coverage.

Filing a grievance

If you are not satisfied with us or one of our providers, you can file a grievance. A grievance is not for coverage or payment. Learn more about filing a grievance in your Evidence of Coverage.

Need help filing an appeal or grievance? Please call our Moda Health Customer Service at 503-265-4762 or toll-free at 877-299-9062. TTY users, dial 711. 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.) You can also find out how many appeals, grievances and exceptions we have received. Just ask us.

If you choose to mail your grievance, send it to:

Moda Health Plan, Inc.
Attn: Moda Health Medicare Appeals
P.O. Box 40384
Portland, OR 97240-0384

Appointing a representative

You can assign someone you trust to request authorization, or file a claim, grievance or appeal. To do this, please complete our Appointment of Representative form. You will need to have the person you appoint sign the form. You can submit this form with your appeal or grievance request.

Filing a complaint with Medicare

We work to resolve any issues you may have. You can also file a complaint directly with the Centers for Medicare & Medicaid Services (CMS) by using their online complaint form.

 

Star Ratings

The Centers for Medicare and Medicaid Services (CMS) Medicare Star Ratings system was made to help you compare options when choosing a health and drug plan. Each year, CMS evaluates Medicare Advantage and Part D plans and assigns Star Ratings based on a 5-star rating system.

The following ratings tell you the quality of the medical and prescription drug services, customer service, member experience and overall quality of the plan.

5-Star = Excellent
4-Star = Above average
3-Star = Average
2-Star = Below average
1-Star = Poor

2024

2024 Medicare Star Rating for Moda Health

 

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Last updated Oct. 1, 2024
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