Molinalogo

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

Covers:

• 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 organs

• 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

Screenings for:

• Pregnant women
• Those who have an increased risk for the infection
• Anyone who asks for the test

Includes:

• Adults and children
• Flu
• Pneumonia
• 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)

Per visit

Up to 20 visits per calendar year.

Routine foot care not covered except for some conditions that need professional supervision

Unlimited prescriptions per month

Wellness visits

Allows for 2,000 hours per year

Includes:

• Specialists
• 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