2022 Member Materials and 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.

2022 Annual Materials 

Annual Notice of Change (ANOC): describes changes to your Molina 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 Directory

A current list of our plan’s network providers and pharmacies for 2022.
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

Molina Drug Transition Policy

Drugs Requiring Prior Authorization
English-Spanish

Search the pharmacy 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.