Molinalogo

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.

• Tethered Cord Policy Effective Date May 4,2025
• H2027 Psychoeducational Service Effective Date September 1, 2025
• 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
• 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 December 4,2025
• Radiation Therapy Services KY Effective Date December 4, 2025
• Roctavian KY Effective Date December 14, 2025
• Vyjuvek (beremagene geperpavec) KY Effective Date December 4, 2025
• Zevaskyn (prademagene zamikeracel) KY Effective Date December 4, 2025
• Gastric Electrical Stimulation KY Effective Date February 16, 2026
• Heart Transplantation with a Total Artificial Heart KY Effective Date February 16, 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
• Papzimeos (zopapogene imadenovec) KY Effective Date February 16, 2026
• Radiofrequency Treatment of Nasal Airway Obstruction (e.g. VivAer) KY Effective Date February 16, 2026
• Small Bowel Multivisceral Transplantation KY Effective Date February 16, 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

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.