Benefits You Can Get You Pay

Primary Care Provider (PCP)

Visits to your PCP when you are sick $0

Routine checkups $0

Immunizations (shots) $0

Physical exams $0

Allergy Shots (You may also get this from a specialist) $0

If you are pregnant, call us at 1-877-903-0082.

Screening Tests

Tests for cancer: breast, cervical, colorectal and prostate $0

Asthma, cholesterol, diabetes, glaucoma, heart disease, high blood $0

Prescriptions

Generic Medicines* $0

Preferred Name Brand Medicines* $2

Non-Preferred Name Brand Medicines $4

90-day supply of some generic maintenance medicines $0

*Includes some over-the-counter medicines, if ordered by your PCP.

Some prescriptions may need prior authorization. Some Medicare members may have a copay, if Part D covers the medicine.

My 2017 BenefitsFrom the Plan that Cares About Me!

Just take a look at some of the great benefits you have with Passport. As always, you pay $0 for most of your benefits.

Benefits You Can Get You Pay

Tests and Treatments

Lab and X-rays $0

Radiation therapy $0

Dialysis $0

Medical Supplies

Medical equipment and related supplies $0

Diabetes monitoring equipment and supplies $0

Prosthetics and orthotics $0

Dental Care

Cleanings (2 per year - 1 every 6 months) and other services for adults 21 and older $0

Cleanings (2 per year - 1 every 6 months) and other services for children and teens younger than age 21 $0

Plaque removal for pregnant women (1 per pregnancy) and 2 cleanings per year - 1 every 6 months $0

Vision Care

Eye exams for adults 21 and older (1 per year) $0

Eye exams for children and teens younger than age 21 (1 per year) $0

Eyeglasses for children and teens younger than age 21 (1 pair, if needed) $0

Other services for children and teens younger than age 21 $0

Benefits You Can Get You Pay

Behavioral or Mental Health Services

Medicines $0-$4

Office Visits $0

Inpatient stays and outpatient medical visits $0

Substance abuse treatment $0

Other Services Covered by KyHealth Choices Call 1-800-635-2570

Rides to medical visits $0

Member Services: 1-800-578-0603 • TDD/TTY: 1-800-691-5566 • www.passporthealthplan.com Member Services: 1-800-578-0603 • TDD/TTY: 1-800-691-5566 • www.passporthealthplan.com Member Services: 1-800-578-0603 • TDD/TTY: 1-800-691-5566 • www.passporthealthplan.com

Stay Healthy, Get Rewarded!

Member Services: 1-800-578-0603 • TDD/TTY: 1-800-691-5566 • www.passporthealthplan.com Member Services: 1-800-578-0603 • TDD/TTY: 1-800-691-5566 • www.passporthealthplan.com Member Services: 1-800-578-0603 • TDD/TTY: 1-800-691-5566 • www.passporthealthplan.com

Here’s How to Earn Rewards in 2017!

Take a close look at all of the gift cards you can earn as a Passport member!

Who’s Eligible What You Can EARN

What You Need to Do

Members with Diabetes

$50 gift card • Visit your primary care provider (PCP) or endocrinologist for your diabetes.

• Have either a urine test for protein, take an ACE/ARB medicine or see a nephrologist.

• Have your blood pressure checked.• Get a foot check.• Have your height, weight and BMI checked.• Get an HbA1c test.• See your eye doctor for a Dilated Retinal

Exam (DRE).

Females (ages 21 to 65)

$25 gift card Get a Pap test every three (3) years for women ages 21 to 65.

-or-If you have a total hysterectomy, you may earn this reward one time.

Females (ages 50 to 75)

$25 gift card Get a mammogram every two (2) years.-or-

If you have a bilateral mastectomy, you may earn this reward one time.

Young Members (ages 7 to 20)

$50 gift card Visit your doctor for a well-child visit.

Who’s Eligible What You Can EARN

What You Need to Do

Young Members (ages 9 to 13)

$50 gift card Receive the following immunizations (shots):• Meningococcal – must be done between

your 11th and 13th birthday.• Tdap – must be done between your 10th

and 13th birthday.• HPV – three (3) doses must be given

between your 9th and 13th birthday.

Pregnant Members Up to $110 in gift cards

• Earn a $50 gift card for attending six (6) prenatal visits.

• Earn a $50 gift card for attending a postpartum check-up within 3 to 8 weeks after delivery.

• If you had a C-section, earn a $10 gift card for having an incision check within 7 to 14 days after delivery

All Members $30 gift card Visit a dentist at least once a year.

Young Members (ages 2 to 20)

$15 gift card Visit a dentist two (2) times a year. Members ages 2 to 20 may earn both dental rewards for a total of $45.

All Members $20 gift card Get a flu shot once a year. Children under age 2 must get two (2) doses to receive this reward.

Members ages 21 and older

$25 gift card Visit your primary care provider (PCP) for a well-visit. You must be one of these:• A brand new Passport member who

completes a well-visit within the first 90 days of becoming a member.

• An existing member who completes a well-visit in 2017 that is at least 12 to 18 months from your last well-visit.

Who’s Eligible What You Can EARN

What You Need to Do

Adult Members with Depression who Have Taken Antidepressant Medicine for at least 12 weeks(18 years and older)

$30 gift card • Get your 1st three (3) antidepressant prescriptions filled on time.

For more details and to request your rewards, call us at 1-877-903-0082.

Updated January 2017 | MARK63204 APP_12/29/16

EXTRA BENEFITS FOR ALL MEMBERS!• Free or Low Cost Over-the-Counter Medicines for cough and cold, vitamins and

more!

• Free cell phone and text messaging service!

• Free resources to help pay for eyeglasses and dental work!

• Care for You 24-hour Nurse Advice Line – get free medical advice anytime!

• 24-hour Crisis/Behavioral Health Hotline (1-855-834-5651) – to lend an ear if you feel down or have thoughts of suicide.

Not sure how you can earn rewards or receive some of our extra benefits?Just call 1-877-903-0082 and ask us how.

As a member, you are responsible for going to the doctor on a regular basis. Passport uses rewards to encourage you to get care, but we have a limited supply and they are not guaranteed.