Covers both adult and children
Does not cover cosmetic surgery
Age 21 and under
1 per year (unless ordered by provider)
26 visits per 12-month period
Limited to children who are eligible for the Kentucky Commission for Children with Special Health Care Needs
- Preventive services
- Diagnostic services
- 1 oral exam every 12-months
- 2 oral exams for members under 21 if included with a cleaning
- 1 cleaning each 12-months for members 21 and older
- 2 cleanings each 12-months for members under 21
- 1 set of X-rays every 12-months
- Extractions and fillings
- Oral surgery
- Orthodontic and prosthodontic services
Services and procedures that promote and help the functioning of the kidneys and related organsEarly & Periodic Screening, Diagnoses and Treatment (EPSDT) Services (health checks for children under age 21)
- 1 neonatal exam (right after the baby is born)
- 1 exam at 1, 2, 4, 6, 9, 12, 15, 18 and 24 months
- 1 exam each year for children ages 3 to 20
- Basic life support (BLS)
- Advanced life support (ALS) ambulance services
Provided at routine visits or family planning clinics
Services are available to children from birth to age 3.
Children must have a developmental delay or a physical or mental condition(s) related to a developmental delay.
1 complete hearing evaluation per calendar year
- Pregnant women
- Those who have an increased risk for the infection
- Anyone who asks for the test
- Adults and children
- Hepatitis B
Cosmetic surgery is not covered (except for post-mastectomy reconstructive surgery)
Used when other means of transportation could cause danger to your health (see Member Handbook section on Transportation)
Includes provider services
2 every 9-months unless your provider orders more (see Family Planning in Member Handbook)
Up to 20 visits per calendar year
Does not cover cosmetic surgery (except for post-mastectomy reconstructive surgery)
Up to 20 visits per calendar year.
Routine foot care not covered except for some conditions that need professional supervision
Unlimited prescriptions per month
Allows for 2,000 hours per year
- Provider assistants
- Nurse practitioners
- Nurse midwives
- Office visits
- Medical surgical care and consultations
- Diagnosis and treatment
For children 6 to 21
Intensive facility-based care alternatives to hospitals
Sexual abuse medical exams are covered for members under 18 when medically necessary
Up to 20 visits per calendar year
Behavioral health services that include at least 4 sessions in 1 month including a minimum of:
- 1 face-to-face contact
- 1 face-to-face contact with parent, family member, guardian or other person who has custody or supervision of the member
- 2 additional contacts face-to-face or by phone
Must use a provider in the Passport network
- 1 exam each calendar year
- *See Passport’s EXTRA Benefits & Rewards section for details on coverage for adult eyeglasses
- 1 eye exam each calendar year
- 1 pair of eyeglasses per year, or a second pair if first pair is broken or if the prescription changes
EXTRA Benefits and Rewards
The Details Who’s Eligible The Value Attend one postpartum visit 7-84 days after the birth of the baby New Moms
12 years & older
$25 Gift Card Go to a prenatal visit during the first trimester or within 42 days of enrollment Pregnant Moms
12 years & older
Car or Booster Seat Have a yearly diabetic retinal eye exam, Complete HbA1c lab work Members with Diabetes
18 - 75 years
$50 Gift Card each ($100 max annually) Have a yearly Mammogram (one per member per year) Females
50-74 years old
$25 Gift Card each Have up to 6 well-child visits on time within a 15-month period 1-3 years old $10 per visit (Max $60 Gift Card) Get a Pap test Females
21-64 years old
$25 Gift Card Get a chlamydia screening Females
16-24 years old
$25 Gift Card Go to a follow-up visit within 7 days of an inpatient hospital stay (medical stays go to PCP; behavioral health stays go to behavioral health provider or PCP) (no limits) All Members $50 Gift Card Have an annual adult preventive screening visit (one per year) 18 years and older $25 Gift Card Visit a dentist (one per year) All Members $50 Gift Card Have a diagnosis of diabetes or high blood pressure All Members with Diabetes or High Blood Pressure High Blood Pressure Cuff The Details Who’s Eligible The Value Get a free sports or school physical every year 6 - 18 years old Free annual physical The Details Who’s Eligible The Value Get $100 every 2 calendar years for one pair of eyeglasses or buying contact lenses 21 years old and older $100 The Details Who’s Eligible The Value Get up to 13 weeks of Weight Watchers free.
Providers, internal departments, care managers, or self-referral can refer members. Prior authorization is needed.
All Members $40 value The Details Who’s Eligible The Value Free cell phone includes 350 monthly minutes, 1 GB of data and unlimited texts.
If you have your own smartphone, you may receive 1 GB of free data and unlimited texts off your existing phone bill.
All Member Who Are Not in a Cell Phone Plan Free – No Cost to You! The Details Who’s Eligible The Value You get vouchers to take the GED test for free at testing centers. 18 years and older $120 value You get a gift card for passing the exam. 18 years or older $50 The Details Who’s Eligible The Value 20% discount on 1000’s of regularly priced CVS brand health-related items All Members Varies by usage The Details Who’s Eligible The Value Members who sign up and complete the 3-month Asthma Disease Management Breathe with Ease® Program receive an allergy-free pillowcase and mattress cover.
Passport will provide a second inhaler at no cost to children under 18 who are prescribed an inhaler.
Mattress / Pillow: All members in the Asthma Disease Management program.
2nd Inhaler: 6-18 years old
Mattress Cover: $60
Pillow Covers: $20
Second Inhaler: Free for members
The Details Who’s Eligible The Value Passport covers respite care to give a member's caregiver some relief and time for self-care and relax.
Prior authorization is needed.
Members with Special Health Care Needs who have a full-time caregiver 8 hours per year of respite care
Benefits and Rewards
Your easy-to-print list of what's covered under your Passport Health Plan by Molina Healthcare Medicaid Plan. View and Print.