Pharmacy and Prescription Drugs

Passport Health Plan covers a comprehensive list of drugs chosen for their effectiveness. We choose these drugs with help from a team of doctors and pharmacists. Your drugs are covered when you show your member ID card at a network pharmacy whenever you get your prescriptions filled.

Passport Health Plan will generally cover any prescription drug listed in our formulary if:

  • the drug is medically necessary,
  • the prescription is filled at a Passport Health Plan network pharmacy,
  • and other plan rules are followed.

What drugs does Passport Health Plan cover?

For the Prescription Drugs you may need:

Search the 2022 Formulary - Passport Advantage (HMO D-SNP)

Search the 2022 Formulary - Passport Medicare Choice Care (HMO)

Important Pharmacy & Prescription Benefits Documents

Comprehensive Formulary

icon PDF 2022 Passport Advantage (HMO D-SNP)

icon PDF 2022 Passport Medicare Choice Care (HMO)

Changes to the Formulary

icon PDF Passport Advantage (HMO D-SNP)

icon PDF Passport Medicare Choice Care (HMO)

Over-the-Counter (OTC) Catalog

icon PDF 2022 OTC Catalog


Medication Safety

icon PDF 2022 Passport Advantage (HMO D-SNP)

icon PDF 2022 Passport Medicare Choice Care (HMO)

Transition Policy

icon PDF 2022 Passport Advantage (HMO D-SNP)

icon PDF 2022 Passport Medicare Choice Care (HMO)

Rx Mail Order Form

icon PDF 2022 Passport Advantage (HMO D-SNP)

icon PDF 2022 Passport Medicare Choice Care (HMO)

Prior Authorization Grid

icon PDF 2022 Passport Advantage (HMO D-SNP)

icon PDF 2022 Passport Medicare Choice Care (HMO)

Step Therapy Grid

icon PDF 2022 Passport Advantage (HMO D-SNP)

icon PDF 2022 Passport Medicare Choice Care (HMO)

Out-of-Network Pharmacies

icon PDF 2022 Passport Advantage (HMO D-SNP)

icon PDF 2022 Passport Medicare Choice Care (HMO)

Can the Formulary Change?

We may add or remove drugs from the formulary during the year. Changes in the formulary may affect which drugs are covered and how much you will pay when filling your prescription. If we remove drugs from the formulary, or add prior authorizations, quantity limits and/or step therapy restrictions on a drug, and you are 
taking the drug affected by the change, we will notify you of the change at least 30 days before the date that the change becomes effective. However, if a drug is removed from our formulary because the drug has been recalled from the market, we will not give 30-day notice before removing the drug from the formulary. Instead, we will remove the drug from our formulary immediately and notify members about the change as soon as possible.

For more information on covered drugs and how to fill your prescriptions, including obtaining prescriptions at Out-of-Network Pharmacies (see above) and how to get a temporary supply of drugs as a new member, see Transition Policy (above). You can ask Passport Health Plan to make an exception to our coverage rules by completing the Coverage Determination Request form or the Drug Determination Request form (see Member Materials & Forms Page).

What is prior authorization? 
For certain drugs, you or your provider need to get preapproval (or prior authorization) from Passport Health Plan before you fill your prescriptions. If you don’t get approval, we may not cover the drug.

See the Prior Authorization Grid (above) for drugs that require prior authorization. 

What is step therapy?
In some cases, we require that you first try certain drugs to treat your medical condition before we will cover another drug for that same condition. For example, if Drug A and Drug B both treat the condition but Drug A costs less, you may need to try Drug A first. If Drug A doesn’t work for you, we’ll then cover Drug B.

Can I get help managing my prescriptions (Medication Therapy Management MTM)?
Passport Health Plan’s Medication Therapy Management (MTM) program is a service provided at no cost. MTM is not considered a benefit and is offered to members that meet certain criteria. A pharmacist or other trained health care provider will review your prescription, over-the-counter (OTC) and supplement/herbal medications with you over the phone. The goal of MTM is to help you understand your medicines, resolve side effects and answer questions you may have about your medication.

How do I Qualify for MTM?

Passport Health Plan determines MTM eligibility on a quarterly basis using medical and pharmacy claims information. You qualify for MTM if you meet each of the three criteria below:


  1. Have three or more of the following conditions:

    • Chronic Heart Failure (CHF)
    • Diabetes
    • Dyslipidemia
    • Hypertension
    • Depression
    • Chronic Obstructive Pulmonary Disease (COPD)


  2. Take at least eight drugs that are covered under your Medicare Part D plan


Are likely to incur annual costs for covered Part D drugs equal to or greater than $4,376 in 2021

Once you meet the criteria, you will be automatically enrolled in the MTM program and mailed a letter with information about the program and how to contact us. We may also call you to schedule an appointment to speak with a pharmacist.

What is discussed during my MTM consultation?

In the comfort of your own home, a pharmacist or other trained health care provider will help you:


  • Review all your prescription, over-the-counter (OTC) and supplement/herbal medicines
  • Discuss side affects you may have when taking certain medicines
  • Answer questions you have about your medicine
  • Suggest potential improvements to your medication regimen
  • Make a list of your medicines with when and how you should take them
  • Create goals for taking your medicine

MTM is performed over the phone and the appointment will last approximately 30 minutes. After the appointment, you will be mailed a Personal Medication List that you can share with your health care providers. You will also be mailed a Medication Action Plan that summarizes what was discussed during your MTM encounter. If the MTM provider has any concerns about your medications, such as drug interactions, your prescribing doctors will be made aware. We encourage you to participate in this Comprehensive Medication Review at least once a year and if possible, before your annual wellness visit with your doctor.

How do I contact Passport Health Plan to participate in MTM?

To participate in the Medication Therapy Management Program, please call (855) 658-0918, TTY 711, Monday to Friday.


Check the Member Materials and Forms to see all the standard benefits offered by Passport Health Plan.


2021 Passport Advantage Member Materials and Forms can be found here.

*Printed copies of information posted on our website are available upon request.