Member Materials and Forms
Here you can find important documents about your Molina plan. Click the links below to view or download member materials, forms, and newsletters specific to your plan.
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Molina Medicare Complete Care (HMO D-SNP)
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.
2025 Molina Medicare Complete Care (HMO D-SNP)Evidence of Coverage (EOC): explains your rights, benefits, and responsibilities as a member of Molina Medicare. They also explain our responsibilities to you.
The information in this booklet is in effect from January 1, 2025 through December 31, 2025
2025 Molina Medicare Complete Care (HMO D-SNP)
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.
2025 Molina Medicare Complete Care (HMO D-SNP)Find a provider or pharmacy online here.
View Provider/Pharmacy Directory Information:
2025 Molina Medicare Complete Care (HMO D-SNP)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 Molina Medicare Complete Care (HMO D-SNP) -
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 Molina Medicare at:
Molina Healthcare
7050 Union Park Center, Suite 200
Midvale, UT 84047Coverage 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 online here
You may also complete the below form and mail or fax.
2025 Molina Medicare Complete Care (HMO D-SNP)
Complete this form and mail or fax to:Address:
7050 S Union Park Center Drive, Suite 200
Midvale, Utah 84047Fax:
How to Request a Redetermination - Please read this document to understand what you need to do to request an appeal
2025 Molina Medicare Complete Care (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.
2025 Molina Medicare Complete Care (HMO D-SNP)Complete this form and mail or fax to:
Address:
7050 S Union Park Center Drive, Suite 200
Midvale, Utah 84047Fax:
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.
2025 Molina Medicare Complete Care (HMO D-SNP)Advance Directives Information Sheet: provides insight on Advance Directives.
Advance Directives Information Sheet -
Low Income Subsidy (LIS)
2025 Molina Medicare Complete Care (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 2025, your yearly income is limited to TBD for an individual or TBD 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
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 Molina member portal.
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Member Newsletters
Created especially for Molina members. This important health news can help keep you and your family healthy.
Coming Soon
For more information, or if you have questions, please call Member Services.
*Printed copies of information posted on our website are available upon request.