Member Materials and Forms

Here you can find important documents about your Passport Medicare plan. Click the links below to download each document.

Annual Notice of Change (ANOC): The Annual Notice of Changes (ANOC) is a brief summary of benefits and benefit changes to your plan. For a more comprehensive description of your benefits, please refer to the Evidence of Coverage (EOC) below.

icon PDF 2022 Annual Notice of Change Passport Advantage (HMO D-SNP) 


Summary of Benefits: 
a summary of what we cover and what you pay. For a complete list of covered services and exclusions, refer to your Evidence of Coverage below.

icon PDF 2022 Summary of Benefits – Passport Advantage (HMO D-SNP)

icon PDF 2022 Summary of Benefits – Passport Medicare Choice Care (HMO)


Evidence of Coverage (EOC):
 your Medicare health benefits and services and prescription drug coverage as a member of Passport Medicare.

The information in this booklet is in effect from January 1, 2022 through December 31, 2022.

icon PDF 2022 Evidence of Coverage (EOC) – Passport Advantage (HMO D-SNP)

icon PDF 2022 Evidence of Coverage (EOC) – Passport Medicare Choice Care (HMO)


Formulary:
 a list of the drugs covered in this plan. To see what’s covered, visit our Pharmacy and Prescription Drugs page.

Low Income Subsidy (LIS) Premium Summary Chart: If you qualify for extra help, Low Income Subsidy (LIS), to pay for your prescription drug costs, Medicare could also pay 75% or more of your Plan Premium, annual deductibles and co-insurance (if applicable). To qualify in 2021, your yearly income is limited to $7,970 for an individual or $11,960 for a married couple living together.

icon PDF 2022 LIS Chart

Mail Order Prescription Service Notice: we’d like to offer you a way to save time and money with Passport Medicare’s mail order prescription service.

icon PDF 2022 Mail Order Prescription Service Notice Passport Advantage (HMO D-SNP)

icon PDF 2022 Mail Order Prescription Service Notice – Passport Medicare Choice Care (HMO)


Provider/Pharmacy Directory: : 
a list of your plan’s current network providers and pharmacies.

icon PDF 2022 Provider/Pharmacy Directory – Passport Advantage (HMO D-SNP)

icon PDF 2022 Provider/Pharmacy Directory – Passport Medicare Choice Care (HMO)

Find a provider or pharmacy online here.

View 2022 Provider/Pharmacy Directory Information:

icon PDF Passport Advantage (HMO D-SNP)

icon PDF Passport Medicare Choice Care (HMO)

If you would like to request a printed copy of this directory, please call Member Services or email us at CentralizedOps.Medicare@MolinaHealthcare.com.


New Member Guide:
 a simple guide to your new benefits.

icon PDF 2022 New Member Guide – Passport Advantage (HMO D-SNP)

icon PDF 2022 New Member Guide – Passport Medicare Choice Care (HMO)


Member ID Card

You will receive your Member ID Card after your enrollment is confirmed

While you are a member, you must use your membership card whenever you get any services covered by this plan. It is also to be used for prescription drugs you get at network pharmacies.

If your plan membership card is damaged, lost, or stolen, you can request for a new card on your My Passport Health Plan portal.

 

Member Forms

Click on the links below to access important member forms.

Appointment of Representative Form (CMS-1696) – An appointed representative is a relative, friend, advocate, doctor or other person authorized to act on your behalf in obtaining a grievance, coverage determination or appeal.

icon PDF Appointment of Representative Form (CMS-1696)

If you would like to appoint a representative, you and your appointed representative must complete this form and mail it to Passport Health Plan at:

Passport Health Plan
7050 Union Park Center, Suite 200
Midvale, UT 84047


Coverage Determination Request Form
 – Use this form to request coverage for a drug that is not on the formulary (a formulary exception), an exception to a quantity limit, a lower copayment for a drug on the formulary (a tiering exception) or reimbursement for a covered drug that you purchased at an out-of-network pharmacy.

icon PDF Passport Advantage (HMO D-SNP)

icon PDF Passport Medicare Choice Care (HMO)

Complete this form and mail or fax to:

Fax:     (866) 290-1309

Mail:     Passport Health Plan

             7050 Union Park Center, Suite 200

             Midvale, Utah 84047

You may also submit your Coverage determination request form online here.


How to Request a Redetermination 
- Please read this document to understand what you need to do to request an appeal

icon PDF Passport Advantage (HMO D-SNP)

icon PDF Passport Medicare Choice Care (HMO)


Redetermination Form
 - Use this form to request a redetermination (appeal).

icon PDF Passport Advantage (HMO D-SNP)

icon PDF Passport Medicare Choice Care (HMO)

Complete this form and mail or fax to:

Fax:     (866) 290-1309

Mail:     Passport Health Plan

             7050 Union Park Center, Suite 200

             Midvale, Utah 84047

You may also submit your Redetermination request form online here.


Direct Member Reimbursement Form 
- Use this form to request a reimbursement for something you have paid out of pocket but believe should have been covered by your plan.


Redetermination Form
 - Use this form to request a redetermination (appeal).

icon PDF Passport Advantage (HMO D-SNP)

icon PDF Passport Medicare Choice Care (HMO)

 

Grievance and Appeal forms & the Medicare.gov Complaint Form


Advance Directives Information Sheet: 
provides insight on Advance Directives.

icon PDF Advance Directives Information Sheet

 

Member Newsletters

Created especially for Molina members. This important health news can help keep you and your family healthy.

Coming Soon

 

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

 

For more information or if you have questions, please call Member Services.

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