Molinalogo

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

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

Search the 2023 Formulary – Passport Advantage (HMO D-SNP)

Search the 2023 Formulary – Passport Medicare Choice Care (HMO)

• Comprehensive Formulary

  Please familiarize yourself with the Preferred Drug List as you prescribe medications for Passport Health Plan beneficiaries. Thank you for your cooperation.

   2022 Passport Advantage (HMO D-SNP)

   2022 Passport Medicare Choice Care (HMO)

   2023 Passport Advantage (HMO D-SNP)

   2023 Passport Medicare Choice Care (HMO)

  
  
  Changes to the Formulary

   Passport Advantage

   Passport Medicare Choice Care (HMO)

• Prior Authorizations

   

  Passport’s decisions are based upon the information included with the PA request. Clinical notes are recommended.

   2022 Prior Authorization Criteria – Passport Advantage (HMO D-SNP)

   2022 Prior Authorization Criteria – Passport Medicare Choice Care (HMO)

   2023 Prior Authorization Criteria – Passport Advantage (HMO D-SNP)

   2023 Prior Authorization Criteria – Passport Medicare Choice Care (HMO)

• Step Therapy

   

  In some cases, Passport Health Plan requires members to first try certain drugs to treat their medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat the member’s medical condition, Passport Health Plan may not cover Drug B unless you try Drug A first. If Drug A does not work for the member, Passport Health Plan will then cover Drug B.

   2022 Step Therapy Criteria Grid – Passport Advantage (HMO D-SNP)

   2022 Step Therapy Criteria Grid – Passport Medicare Choice Care (HMO)

   2023 Step Therapy Criteria Grid – Passport Advantage (HMO D-SNP)

   2023 Step Therapy Criteria Grid – Passport Medicare Choice Care (HMO)