Member Materials and Forms
Here you can find important documents about your Molina Medicare 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)
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.
2022 Annual Notice of Change – 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. 2022 Summary of Benefits – 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. 2022 Evidence of Coverage (EOC) – Molina Medicare Complete Care (HMO D-SNP)Formulary: a list of the drugs covered in this plan. To see what’s covered, visit ourPharmacy and Prescription Drugs page.
Low Income Subsidy (LIS): If you qualify for extra help, 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). To qualify in 2021, your yearly income is limited to $7,970 for an individual or $11,960 for a married couple living together.2022 LIS Chart – Molina Medicare Complete Care (HMO D-SNP)Mail Order Prescription Service Notice:we’d like to offer you a way to save time and money with Molina Medicare’s mail order prescription service.
2022 Mail Order Prescription Service Notice – Molina Medicare Complete Care (HMO D-SNP)Provider/Pharmacy Directory: outlines your plan's network of Primary Care Physicians, Specialists, Hospitals, Skilled Nursing Facilities, Outpatient Facilities, Pharmacies and Supplemental Provider contacts.
2022 Provider/Pharmacy Directory – Molina Medicare Complete Care (HMO D-SNP)Find a provider or pharmacy online here.
View 2022 Provider/Pharmacy Directory Information:
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. 2022 Medicare Quick Start Guide – Molina Medicare Complete Care (HMO D-SNP) -
Molina 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. 2022 Summary of Benefits – Molina Medicare Choice Care (HMO)
Evidence of Coverage (EOC): explains your rights, benefits, and responsibilities as a member of Molina Medicare. They also explain our responsibilities to you. 2022 Evidence of Coverage (EOC) – Molina 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.
Low Income Subsidy (LIS): If you qualify for extra help, 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). To qualify in 2021, your yearly income is limited to $7,970 for an individual or $11,960 for a married couple living together. 2022 LIS Chart – Molina Medicare Choice Care (HMO)
Mail Order Prescription Service Notice: we’d like to offer you a way to save time and money with Molina Medicare’s mail order prescription service. 2022 Mail Order Prescription Service Notice – Molina Medicare Choice Care (HMO)
Provider/Pharmacy Directory: outlines your plan's network of Primary Care Physicians, Specialists, Hospitals, Skilled Nursing Facilities, Outpatient Facilities, Pharmacies and Supplemental Provider contacts. 2022 Provider/Pharmacy Directory – Molina Medicare Choice Care (HMO)Find a provider or pharmacy online here.
View 2022 Provider/Pharmacy Directory Information:
Molina Medicare Choice Care (HMO)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. 2022 Medicare Quick Start Guide – Molina Medicare Choice Care (HMO) -
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 portal.
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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 Medicare
7050 Union Park Center, Suite 200
Midvale, UT 84047
Coverage 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.
Molina Medicare Complete Care (HMO D-SNP) Molina Medicare Choice Care (HMO)Complete this form and mail or fax to:
Address: 7050 Union Park Center, Suite 200
Midvale, Utah 84047
Fax: (866) 290-1309
How to Request a Redetermination - Please read this document to understand what you need to do to request an appeal Molina Medicare Complete Care (HMO D-SNP) Molina Medicare Choice Care (HMO)
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.
Molina Medicare Complete Care (HMO D-SNP) Molina Medicare Choice Care (HMO)Complete this form and mail or fax to:
Address: 7050 Union Park Center, Suite 200
Midvale, Utah 84047
Fax: (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.
Molina Medicare Complete Care (HMO D-SNP) Molina Medicare Choice Care (HMO)Grievance and Appeal forms & the Medicare.gov Complaint Form
Advance Directives Information Sheet: provides insight on Advance Directives. Advance Directives Information Sheet -
Member Newsletters
Created especially for Molina members. This important health news can help keep you and your family healthy.
2021 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.