Our pharmacy services team provides you with pharmacy benefits that show how much we care about the health and safety of you and your family. We thank you for the opportunity to support your prescription needs.

Pharmacy network

Our network lets you choose when and how to get your prescription drugs. We have contracts with over 63,000 pharmacies throughout the U.S., including retail pharmacies, home infusion, long-term care, Indian health service pharmacies, and specialty and mail-order pharmacies.

Use our online directory to find a pharmacy in our network. You may request a printed directory by emailing phipquestions@modahealth.com. You can also download a pharmacy directory below.

• 2024 Moda Health Rx (PDP) Pharmacy Directory
• 2023 Moda Health Rx (PDP) Pharmacy Directory

Formulary

Our formulary is our list of covered prescription drugs. You can use it to see what generic and brand-name drugs are covered under our plan. Please note this formulary may change (see our formulary updates section below to view changes). If you do not see the drug you are looking for, please call our pharmacy customer service at the number listed below. That drug may be covered. You can also contact pharmacy customer service to request a printed copy of the formulary.

• 2024 Moda Health Rx (PDP) Formulary
• 2023 Moda Health Rx (PDP) Formulary

Formulary updates

Changes to the formulary may include:

• Adding or removing drugs. This happens if a drug is recalled, not working, or a new drug becomes available
• Moving a drug to a higher or lower cost-sharing tier
• Adding or removing a restriction on coverage
• Replacing a brand-name drug with a generic drug

We will send you a notice if we make changes to a drug you're using.

Search for prescription drugs* on the online benefit tool

With this tool you can:

• Search for a drug to see if it's covered
• Get a prescription drug cost estimate
• See if there is an alternative drug available
• Find the price and location of pharmacies near you
• Check the price or mail order option

Follow these steps to use the online tool:

1. Choose the plan name below. A new window will open up
   1. Moda Health Rx (PDP)
2. Enter a drug name
3. Select the medication form and strength
4. Provide the total quantity and the number of days
5. Enter your ZIP code

*Prescription drug information displayed on the online benefit tool is subject to change without notice and is not a guarantee of benefits. Your coverage is based on your plan benefit and eligibility at the time of service. If you have copay assistance, it may affect your maximum out-of-pocket amount. Coverage and cost sharing may vary for preventive services.

Making an exception

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

How to file a claim

If you get a prescription filled at an out-of-network pharmacy for one of the reasons below, you can request to be reimbursed. Our decisions on reimbursement are based on your Evidence of Coverage (EOC).

Circumstances for out-of-network prescription coverage:

• Medical emergencies
• If a 24-hour pharmacy is not within a reasonable driving distance
• An in-network pharmacy does not have your prescription in stock
• You're traveling outside your plan service area and run out of or lose your covered Part D drugs
• You can't access a network pharmacy when you're ill and need a covered Part D drug

Follow these steps to submit a claim:

1. Complete our pharmacy paper claim form
2. Mail it and your prescription receipt to the address on the form. Please note that you'll need to submit the claim within 60 days of getting your out-of-network prescription filled.

Need help filing a claim?

We're here to help. Please call our Moda Health Pharmacy Customer Service team at 888-786-7509 (TTY users, dial 711). Our regular business hours are 7 a.m. to 8 p.m., Pacific time, seven days a week from Oct. 1 to March 31. After March 31, your call will be handled by our automated phone system on Saturdays, Sundays and holidays).