Passport by Molina Healthcare (Passport) follows the most current edition of MCG, a nationally recognized set of guidelines. Passport may employ the Molina Clinical Policies if the MCG guidelines are insufficient. Molina clinical policies are located at www.MolinaClinicalPolicy.com. Please note, these policies do not constitute plan authorization, an explanation of benefits, or a guarantee of payment.
- Allogeneic Processed Thymus Tissue Effective Date December 4, 2025
- Aucatzyl (obecabtagene autoleucel) KY Effective Date December 4, 2025
- Breyanzi KY Effective Date December 15, 2025
- Gastric Electrical Stimulation KY Effective Date February 16, 2026
- Genetic Testing KY Effective Date May 24, 2026
- H2027 Psychoeducational Service Effective Date September 1, 2025
- Heart Transplantation with a Total Artificial Heart KY Effective Date February 16, 2026
- Intraoperative Neurophysiologic Monitoring (IONM) Effective Date August 22, 2026
- Kresladi (Marnetegragene autotemcel) Effective Date August 22, 2026
- Lenmeldy (atidarsagene autotemcel) Effective Date August 22, 2026
- Lung Transplantation KY Effective Date February 16, 2026
- Minimally Invasive Glaucoma Surgeries KY Effective Date February 16, 2026
- Mobile Cardiac Outpatient Telemetry KY Effective Date February 16, 2026
- Omisirge (omidubicel-onlv) Effective Date August 22, 2026
- Otarmeni (Lunsotogene Parvec-cwha) Effective Date August 22, 2026
- Papzimeos (zopapogene imadenovec) KY Effective Date February 16, 2026
- Phototherapy and Laser Therapy for Dermatological Conditions KY Effective Date December 4, 2025
- Pluvicto KY Effective Date December 4, 2025
- Pre-Transplant and Transplant Evaluations KY Effective Date August 22, 2026
- Radiation Therapy Services KY Effective Date December 4, 2025
- Radiofrequency Nerve Ablation for Neck and Back Pain Effective Date August 22, 2026
- Radiofrequency Treatment of Nasal Airway Obstruction (e.g. VivAer) KY Effective Date February 16, 2026
- Roctavian KY Effective Date December 14, 2025
- Small Bowel Multivisceral Transplantation KY Effective Date February 16, 2026
- Tethered Cord Policy Effective Date May 4,2025
- Vyjuvek (beremagene geperpavec) KY Effective Date December 4, 2025
- Zevaskyn (prademagene zamikeracel) KY Effective Date August 22, 2026
Molina Dental Services Policy Links
- Criteria for Cast Crowns Policy Effective Date January 1, 2026
- Criteria for General Anesthesia and IV Sedation Policy Effective Date January 1, 2026
- Criteria for Fixed Prosthodontics Policy Effective Date January 1, 2026
- Criteria for Occlusal Guards Policy Effective Date January 1, 2026
- Criteria for Maxillofacial Prosthetics Policy Effective Date January 1, 2026
- Criteria for Oral and Maxillofacial Surgery Effective Date June 8, 2026
Oncology & Radiology
Passport partners with New Century Health to administer cardiology and oncology services for members age 18+. For clinical policies related to cardiology and oncology, please visit New Century’s website www.NewCenturyHealth.com or click the following link: Compliance and Regulatory Information - New Century Health. Clinical policies are also housed within the provider portal at my.newcenturyhealth.com.
Pharmacy
MedImpact administers pharmacy benefits for Kentucky Medicaid Members. For information regarding Kentucky Medicaid Single PDL Prior Authorization Criteria please click here.
Please note that the effective date of any payment policy, and any subsequent revision to a payment policy, shall not be less than 30 days following the date of publication of that revision, pursuant to Section 27.12 of the Kentucky Managed Care Contract.
Published Date August 7, 2026 Effective Date September 7,2026
Breast Cancer Genetic Testing Tier 1 vs Tier 2
Published Date October 5, 2026 Effective Date November 5, 2023
Comprehensive Community Support Services (CCSS) (H2015)
Published Date March 19, 2026 Effective Date April 19, 2026
Published Date June 18, 2025 Effective Date July 18, 2025
Critical Care Codes when Discharged to Home
Published Date October 5, 2023 Effective Date November 5, 2023
Published Date July 25, 2023 Effective Date August 25, 2023
Duplicate Claim Reimbursement Policy
Published Date June 18, 2025 Effective Date July 18, 2025
Early Elective Delivery Payment Policy
Published Date May 20, 204 Effective Date June 20, 2024
Facility Emergency Department Evaluation and Management Leveling
Published Date December 5, 2024 Effective Date January 5, 2025
High Level E/M with Preventive Medicine Policy
Published Dated October 5, 2023 Effective Date November 5, 2023
Hospital Routine Supplies Services Reimbursement
Published Date November 13, 2023 Effective Date December 13, 2023
Hydrolyzed Enteral Formula Diagnosis
Published Date March 16, 2026 Effective Date April 16, 2026
Published Date February 8, 2026 Effective Date March 8, 2026
Inpatient Only Procedure Codes
Published Date March 1, 2024Effective Date April 1, 2024
Intensive Outpatient Program (H0015, S9480 and Revenue code 0905)
Published Date March 19, 2026 Effective Date April 19, 2026
Published Dated May 1, 2026 Effective Date June 1, 2026
Observation Reimbursement Policy
Published Dated May 17, 2024 Effective Date June 17, 2024
Published Date January 22, 2024 Effective Date February 22, 2024
Outpatient Definitive Presumptive Drug Testing Medicaid Medicare
Published Date July 12, 2023 Effective Date August 12, 2023
Reduced Services and Discontinued Procedures, Professional and Facility
Published Date December 17, 2025 Effective Date January 17, 2026
Published Date September 5, 2023 Effective Date November 5, 2023
Published Date June 18, 2025 Effective Date July 18,2025
Therapeutic Behavioral Health Services H2019_H2020
Published Date March 16, 2026 Effective Date April 16, 2026
Timely Filing Reimbursement Policy
Published Date January 23, 2026 Effective Date February 23, 2026
Published Date June 18, 2025 Effective Date July 18,2025