Your Benefits

& Rewards
Take a look at some of the great benefits you
have with Passport. As always, you pay $0!

$0 Copays!

Your Benefits $0 Copays Extra Details

Allergy Services $0 Covers both adult and children

Ambulatory Surgical
$0 Does not cover cosmetic surgery.
Centers
Autism Spectrum
$0 Age 21 and under
Disorders

Cervical and Vaginal

Cancer Screening
$0 1 per year (unless ordered by provider)
(Pap tests, pelvic
exams)

Chemotherapy $0

Chiropractic Care
$0 26 visits per 12-month period
(limits may apply)

Commission for
Limited to children who are eligible for the Kentucky
Children with Special $0
Commission for Children with Special Health Care Needs
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
Dental Services $0
• 1 cleaning every 12-months for members 21 and older
• 2 cleanings every 12-months for members under 21
• 1 set of X-rays every 12-months
• Extractions and fillings
• Oral surgery
• Orthodontic and prosthodontic services
Your Benefits $0 Copays Extra Details

Dialysis End-Stage Services and procedures that promote and help the
$0
Renal Disease (ESRD) functioning of the kidneys and related organs

Durable medical
$0
equipment
Early & Periodic
Screening, Diagnoses
• 1 neonatal exam (right after the baby is born)
and Treatment
$0 • 1 exam at 1, 2, 4, 6, 9, 12, 15, 18, and 24 months
(EPSDT) Services
• 1 exam each year for children ages 3 to 20
(health checks for
children under age 21)

Emergency Room $0

Emergency Ambulance • Basic life support (BLS)

$0
and Air Transportation • Advanced life support (ALS) ambulance services

Family Planning $0 Provided at routine visits or family planning clinics

Services are available to children from birth to age 2.

First Steps Services $0 Children must have a developmental delay or a physical or
mental condition(s) related to a developmental delay.

Hearing Services for

$0 1 complete hearing evaluation per calendar year
Children Under 21
Screenings for:
• Pregnant women
HIV Screening $0
• Those who have an increased risk for the infection
• Anyone who asks for the test
Hospice $0
Inpatient Hospital
$0
Services
Inpatient Provider & Cosmetic surgery is not covered (except for post-
$0
Surgeon Services mastectomy reconstructive surgery)
Inpatient Mental
Health Substance Use $0
Services
Includes:
• Adults and children
Immunizations $0 • Flu
• Pneumonia
• Hepatitis B
Your Benefits $0 Copays Extra Details
Lab and Radiology
Services (by provider $0
or lab)
Maternity Services $0
Non-emergency Used when other types of transportation could cause
Ambulance Stretcher $0 danger to your health (see Member Handbook section on
Services Transportation)
Nursing Facility
$0 Includes provider services
Services

Nutritional Counseling $0

2 every 9-months unless your provider orders more (see

OB Ultrasounds $0
family planning in Member Handbook)
Occupational Therapy
$0 Up to 20 visits per calendar year
(OT)

Outpatient Hospital Does not cover cosmetic surgery

$0
Services (except for post-mastectomy reconstructive surgery)

Outpatient Mental
Health & Substance $0 Per visit
Use Services
Prenatal and Postnatal
$0
Care

Prescription Drugs $0 Unlimited prescriptions per month

Physical Therapy $0 Up to 20 visits per calendar year.

Includes:
• Specialists
Provider Services
• Provider assistants
(PCPs, specialists,
• Nurse practitioners
provider assistants, $0
• Nurse midwives
nurse practitioners,
• Office visits
nurse midwives)
• Medical surgical care and consultation
• Diagnosis and treatment
Routine foot care not covered except for some conditions
Podiatry Services $0
that need professional supervision
Preventative Care $0 Wellness visits
Private Duty Nursing $0 Allows for 2,000 hours per year
Your Benefits $0 Copays Extra Details
Prosthetic & Orthotic
$0
Devices
For children 6 to 21
Psychiatric Residential
$0 Intensive care and more highly structured setting than from
Treatment Facilities
family and other alternatives to hospitals
Radiation Therapy $0
Rural health clinic
(RHC), Federally
Qualified Health
$0
Center (FQHC), &
Primary Care Center
(PCC)
Specialized Children’s Sexual abuse medical exams are covered for members under
$0
Services Clinics 18 when medically necessary

Speech Therapy $0 Up to 20 visits per calendar year

Behavioral health services that include at least 4 sessions in

1 month including:
• 1 face to face contact
Targeted Care
$0 • 1 face to face contact with parent, family member,
Management Services
guardian or other person who has custody or supervision
of the member
• 2 additional contacts face to face or by phone

Telehealth $0 Must use a provider in the Passport network

Tobacco Cessation $0
Transplant Services $0

Urgent Care Visits $0

Vision • 1 exam per year

$0
Adults over 21 • 1 pair of eyeglasses per 24 months

• 1 eye exam each calendar year

Vision
$0 • 1 pair of eyeglasses per year, or a second pair if the first
Children under 21
pair is broken or if the prescription changes
Passport’s EXTRA

Benefits & Rewards

What You
The Details Who’s Eligible? The Value
Can Get
Attend one postpartum visit 21-56 days New Moms
$25 Gift Card
after the birth of the baby. 12 years & older

Go to a prenatal visit during the first Pregnant Moms Car or Booster

trimester or within 42 days of enrollment. 12 years & older Seat

$50 Gift Card

Have a yearly diabetic retinal eye exam Members with each
Get HbA1c lab work Diabetes 18 - 75 years ($100 max
annually)

Have a yearly Mammogram Females $25 Gift Card

(one per member per year) 50-74 years old each

$10 per visit

Have up to 6 well-child visits on time
1-3 years old (Max $60 Gift
Healthy within a 15-month period
Card)
Rewards
Females $10 per visit
Get a Pap test
21-64 years old $25 Gift Card

Females
Get a chlamydia screening $25 Gift Card
16-24 years old

Go to a follow-up PCP visit within 7 days

of an inpatient hospital or behavioral All Members $50 Gift Card
health stay (no limits)

Have an annual adult preventive

18 years and older $25 Gift Card
screening visit (one per year)

Visit a dentist (one per year) All Members $50 Gift Card

School
Get a free sports or school physical every Free annual
& Sports 6-18 years old
year physical
Physicals
What You
The Details Who’s Eligible? The Value
Can Get
Get $100 for eyeglasses or contacts
Vision 21 years old and older $100
every 24 months

Get up to 13 weeks of Weight Watchers

Obesity free.
& Weight Providers, internal departments, care All Members $40 value
Watchers managers, or self-referral can refer
members. Prior-authorization is needed.

Free cell phone includes 350 monthly

minutes, 1 GB of data and unlimited texts.
All Members Who Are
Free phone/ Free – No Cost
Not In a Cell Phone
data If you have your own smartphone, you to You!
Plan.
may receive 1 GB of free data and
unlimited texts off your existing phone bill.

You get vouchers to take the GED test for 18 years and older $120 value
free at testing centers
GED
You get at gift card for passing the exam 18 years and older $50

CVS Discount 20% discount on 1000’s of regularly

All Members Varies by usage
Card priced CVS brand health-related items

Members who sign up and complete the Mattress / Pillow: Mattress Cover:
3-month Asthma Disease Management All members in the $60
Breathe with Ease® Program receive an Asthma Disease Pillow Covers:
allergy-free pillowcase and mattress Management $20
Asthma cover. program. Second Inhaler:
Passport will provide a second inhaler at 2nd Inhaler: Free for
no extra cost to children under 18 who are 6-18 years old members
prescribed an inhaler.

Passport covers respite care to give a Members with Special

member’s caregiver some relief and time Health Care Needs 8 hours per year
Respite Care for self-care to recharge and relax. (ISHCN) who have a of respite care
Prior-authorization is needed. full-time caregiver

MARK04294 APP_10/28/2020