Member Materials and Forms
Here you can find important documents about your Passport Medicare plan. Click the links below to view or download member materials specific to your plan, member forms, and member newsletters.
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Passport Advantage (HMO D-SNP)
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.
2024 Passport Advantage (HMO D-SNP) 2025 Passport Advantage (HMO D-SNP) H1799-003-001 2025 Passport Advantage (HMO D-SNP) H1799-003-002Summary 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.
2024 Passport Advantage (HMO D-SNP) 2025 Passport Advantage (HMO D-SNP) H1799-003-001 2025 Passport Advantage (HMO D-SNP) H1799-003-002Evidence 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, 2024 through December 31, 2024
2024 Passport Advantage (HMO D-SNP) 2025 Passport Advantage (HMO D-SNP) H1799-003-001 2025 Passport Advantage (HMO D-SNP) H1799-003-002Formulary: a list of the drugs covered in this plan. To see what’s covered, visit our Pharmacy and Prescription Drugs page.
Provider/Pharmacy Directory: a list of your plan’s current network providers and pharmacies.
2024 Passport Advantage (HMO D-SNP) 2025 Passport Advantage (HMO D-SNP)Find a provider or pharmacy online here.
If you would like to request a printed copy of this directory, please call Member Services or email us at CentralizedOps.Medicare@MolinaHealthcare.com.
Medicare Quick Start Guide: A simple tool for new members to explain what you need to know, things you should do now and what to expect to get the most from your health plan.
2025 Passport Advantage (HMO D-SNP) H1799-003-0012025 Passport Advantage (HMO D-SNP) H1799-003-002Dental ABC: A list of dental services covered by your plan.
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Passport Medicare Choice Care (HMO)
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.
2024 Passport Medicare Choice Care (HMO)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.
2024 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, 2024 through December 31, 2024.
2024 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.
Provider/Pharmacy Directory: : a list of your plan’s current network providers and pharmacies.2024 Passport Medicare Choice Care (HMO)Find a provider or pharmacy online here.
If you would like to request a printed copy of this directory, please call Member Services or email us at CentralizedOps.Medicare@MolinaHealthcare.com.
Medicare Quick Start Guide: A simple tool for new members to explain what you need to know, things you should do now and what to expect to get the most from your health plan.
2024 Passport Medicare Choice Care (HMO)Dental ABC: A list of dental services covered by your plan.
2024 Passport Medicare Choice Care (HMO) -
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.
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
5100 Commerce Crossings
Louisville, KY 40229Coverage 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.
You may submit your Coverage determination request form here online.
You may also complete the below form and mail or fax.
2024 Passport Advantage (HMO D-SNP) 2024 Passport Advantage (HMO D-SNP) 2025 Passport Advantage (HMO D-SNP)Complete this form and mail or fax to:
Address:
7050 S Union Park Center Drive, Suite 600
Midvale, Utah 84047Fax:
(866) 290-1309
How to Request a Redetermination - Please read this document to understand what you need to do to request an appeal
2024 Passport Advantage (HMO D-SNP) 2024 Passport Medicare Choice Care (HMO) 2025 Passport Advantage (HMO D-SNP)Redetermination Form - Use this form to request a redetermination (appeal).
You may submit your Redetermination request form here online.
You may also complete the below form and mail or fax.
2024 Passport Advantage (HMO D-SNP) 2024 Passport Medicare Choice Care (HMO) 2025 Passport Advantage (HMO D-SNP)Complete this form and mail or fax to:
Address:
7050 S Union Park Center Drive, Suite 600
Midvale, Utah 84047Fax:
(866) 290-1309
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.
2024 Passport Advantage (HMO D-SNP) 2024 Passport Medicare Choice Care (HMO) 2025 Passport Advantage (HMO D-SNP)Advance Directives Information Sheet – provides insight on Advance Directives.
Advance Directives Information SheetGrievance and Appeal forms & the Medicare.gov Complaint Form
Voluntary Disenrollment – Disenrollment initiated by a member or his/her authorized representative.
Passport Advantage (HMO D-SNP) Passport Medicare Choice Care (HMO)You may mail in the Voluntary Disenrollment form to Passport Health Plan at:
Passport Health Plan Medicare Enrollment
5100 Commerce Crossings Dr
Louisville, KY 40229 -
Low Income Subsidy (LIS)
2024 LIS Chart – Passport Advantage (HMO D-SNP) & Passport Medicare Choice Care (HMO) 2025 LIS Chart – Passport Advantage (HMO D-SNP) 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).
Additionally, those who qualify won’t have a coverage gap or a late enrollment penalty.
To qualify in 2024, your yearly income is limited to $15,510 for an individual or $30,950 for a married couple living together.
If your income and resources are slightly higher, you should still apply. You may still qualify if you meet one of the following conditions:
- You or your spouse support other family members who live with you.
- You or your spouse have earnings from work.
- You or your spouse live in Alaska or Hawaii.
If you currently have an Employer/Union health plan or a State Pharmacy Assistance Program (SPAP) it will not affect the help you receive paying for the prescription drugs.
The above charts show you what your monthly plan premium will be if you get this subsidy. The premiums listed above include both your medical and prescription drug coverage.
If you aren't getting extra help, you can see if you qualify by calling Member Services.
Additionally, you may verify the details of qualification for extra help as well as review more information on extra help at the Centers for Medicare and Medicaid Services (CMS) website.
You may also call the following organizations to see if you qualify:
- Medicare: (800) Medicare or (800) 633-4227, TTY: (877) 486-2048, 24 hours a day, 7 days a week.
- Social Security Administration: (800) 772-1213, TTY: (800) 325-0778, 7 a.m. - 7 p.m., Monday to Friday.
- Over-the-Counter (OTC) Catalog
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Member ID Card
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.
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Member Education
Created especially for Passport members. This important health news can help keep you and your family healthy.
2023 Guide for Accessing Quality Health Care
2024 Guide for Accessing Quality Health Care
For more information or if you have questions, please call Member Services.
*Printed copies of information posted on our website are available upon request.
Low Income Subsidy (LIS) Low Income Subsidy (LIS)