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Medicare Advantage Member Support

The resources you need to manage your plan and benefits.

Jump to:

Find a Provider
File a claim
Formulary
Medication Therapy Management
Prior authorization
Prescription drug coverage determination
Plan materials
Appeals and grievances
Star ratings

 


Find healthcare providers

Moda Health Medicare Advantage network

You can find an in-network provider by searching the Medicare Advantage network on our online directory Find Care.

To find providers for routine vision exams, use the VSP Vision Provider Search tool or call VSP at 1-844-693-8863

To find providers for routing hearing exams, call the number for TruHearing on the back of your member ID card.

For a printed directory, email medicalmedicare@modahealth.com. Or, to download your own copy of the provider directory, please see links below.

Provider Directories

Download a PDF/printable version of our 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

If you get medical services or a prescription filled at an out-of-network service area for one of the reasons below, you can request that we reimburse you. We make decisions about reimbursement based on your Evidence of Coverage.

Circumstances for out-of-network prescription coverage:

  • Medical emergencies
  • If a pharmacy that is open 24 hours is not within a reasonable driving distance
  • You cannot get the prescription you need because an in-network pharmacy does not have it in stock
  • You are traveling outside your plan service area and run out of or lose your covered Part D drugs
  • You become ill and need a covered Part D drug, and cannot access a network pharmacy

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 plans that have prescription drug coverage. Please note this formulary may change. Please see our formulary updates section below to view changes. If you do not see the drug you are looking for in the formulary, please call our pharmacy customer service (number listed below). We may cover that drug. 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

 

Medication Therapy Management

Our Medication Therapy Management (MTM) program can help members who qualify get the most benefits from the drugs they are taking. MTM is free. To qualify for MTM, you need to have three or more of these chronic conditions:

  • Chronic heart failure (CHF)
  • Chronic obstructive pulmonary disease (COPD)
  • Depression
  • Diabetes
  • High blood pressure
  • High cholesterol
  • Human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS)
  • Osteoporosis
  • Rheumatoid arthritis

You also need to:

  • Be taking eight or more medications
  • Have drug cost of $5,330 or more per year

We will review your medication usage each quarter. If we see that you qualify, we will enroll you in the program. Then, we will send you an invitation to talk about your medications with one of our pharmacists or other health professionals.

If you accept the invite, we will set up a comprehensive medication review (CMR). This usually takes 30 – 60 minutes. After the CMR, you will receive a Medication Action Plan (MAP). The action plan has steps you should take to help you get the best results from your medications. You will also receive a Personal Medication List (PML), which will help you keep track of your medications and how to use them the right way. You can use this action plan and medication list to show your healthcare providers all of the medications you are taking.

Obtain a blank copy of the Personal Medication List (PML)

MTM also includes a targeted medication review (TMR). A TMR identifies any ways your medication use can be improved for your safety. If we notice any, we will contact the provider who prescribed the drugs and ask them to make any needed changes.

 

Getting prior authorization for services

To request prior authorization, you or your provider can call Moda Health Healthcare Services at 800-592-8283. They can also fax our prior authorization request form to 855-637-2666.

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.
  • 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

Prescription drugs that require prior authorization are listed in our formulary. They will have a “PA” next to them. See our Prior authorization guidelines. You or your provider can,

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:

Moda Health
Attn: Moda Health Coverage Determination
P.O. Box 40327
Portland, OR 97240

 

Making a prescription drug coverage determination request

Coverage determination is a decision about whether or not a prescription drug is covered.

To request coverage determination, you or your provider may do one of the following:

Making a prescription drug coverage redetermination request

A redetermination request is an appeal of a denied coverage determination.

To request coverage redetermination, you or your provider can do one of the following:

 

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)

Annual Notice of Changes (ANOC)

Each fall, we will send you an Annual Notice of Changes. Review the Annual Notice of Changes to see any changes in costs, coverage and service area. These changes will take place in January.

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

 

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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