2022 Member Materials & Forms

On this page, you’ll find important documents related to your Molina Medicare Complete Care health plan. Click the links below to download each document.

Annual Materials 2022

Annual Notice of Change (ANOC): describes changes to your plan coverage, costs or service area.
English          Spanish

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.
English          Spanish

Evidence of Coverage (EOC): your Medicare health benefits and services and prescription drug coverage as a member of Molina Medicare Complete Care.
English          Spanish

 

Provider & Pharmacy Directories

Directory of Medical Health Providers and Pharmacies 
English-Spanish

Directory of Behavioral Health Providers (updated November 2021)
English          Spanish

 

Pharmacy & Prescription Drugs Materials

LIS Premium Summary: explains your monthly plan premium if you get Extra Help paying for your prescription drugs.
English          Spanish

Formulary: a list of the drugs covered in this plan. 
English          Spanish 

Medicare Part D Coverage Determination Request Form (download and mail or fax form)
English          Spanish

Drugs Requiring Prior Authorization 
English-Spanish

Molina Drug Transition Policy

Molina Step Therapy Criteria
English          Spanish

Search the formulary drug list here

Search for a pharmacy here

 

2022 Member Information

Notice of Privacy Practices: This document explains the steps Molina takes to protect your Personal Health Information (PHI).
English          Spanish

Notice of Nondiscrimination: This document explains our policies on nondiscrimination.
English          Spanish

Multi-Language Interpreter Services: This document explains how to get help if you speak languages other than English.