Molina Medicare Complete Care (HMO D-SNP)

3 out of 5 stars
$0.00
Monthly Premium

Molina Medicare Complete Care (HMO D-SNP) is a HMO D-SNP plan offered by Molina Healthcare, Inc.,

Plan ID: H5628-001

HelpAdvisor Editorial Team analysis of data from the 2025 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.

Medicare beneficiaries may find it helpful to review available Medicare Advantage plans in their area. Medicare Advantage plans are designed to combine the coverage offered from Original Medicare (Medicare Part A and Part B) while also offering additional benefits.

Many Medicare Advantage plans may cover prescription drug coverage as well as additional benefits such as Dental, Vision and Hearing.

Learn more about Medicare Advantage plans such as Molina Medicare Complete Care (HMO D-SNP) - H5628-001 by Molina Healthcare, Inc., as well as other Medicare Advantage plans available in your area.

$0.00
Monthly Premium

Utah Counties Served

BeaverBox ElderCacheDavisDuchesneEmeryGarfieldIronJuabKaneMillardMorganPiuteRichSalt LakeSanpeteSevierTooeleUtahWasatchWashingtonWayneWeber

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $0
Out of Pocket Max In-Network: $9250
Out-of-Network: N/A
Initial Coverage Limit $0
Catastrophic Coverage Limit $2100
Primary Care Doctor Visit

Doctor Office Visit:
Copayment for Primary Care Office Visit $0
Specialty Doctor Visit

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $0
Inpatient Hospital Care

Acute Hospital Services:
Copayment for Acute Hospital Services per Stay $0
Prior Authorization Required for Acute Hospital Services
Urgent Care

Urgent Care:
Copayment for Urgent Care $0

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $0
Maximum Plan Benefit of $10,000

Emergency Room Visit

Emergency Care:
Copayment for Emergency Care $0
Coinsurance for Medicare Covered Emergency Care waived if you are admitted to the hospital with in 24 hours

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $0
Copayment for Worldwide Emergency Transportation $0
Maximum Plan Benefit of $10,000

Ambulance Transportation

Ground Ambulance:
Copayment for Ground Ambulance Services $0

Prior authorization required for non-emergent ambulance only.

Air Ambulance:
Copayment for Air Ambulance Services $0
Prior Authorization Required for Air Ambulance

Health Care Services and Medical Supplies

Molina Medicare Complete Care (HMO D-SNP) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).

Coverage Cost
Chiropractic Services

Chiropractic Services:
Copayment for Medicare-covered Chiropractic Services $0

Chiropractic Services:
Copayment for Medicare-covered Chiropractic Services $0
Diabetes Supplies, Training, Nutrition Therapy and Monitoring

Diabetic Supplies and Services:
Copayment for Medicare-covered Diabetic Supplies $0
Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0
Prior authorization may be required. Prior authorization required for diabetic shoes and inserts. Prior authorization is not required for preferred manufacturer.
Durable Medical Equipment (DME)

Durable Medical Equipment:
Copayment for Medicare-covered Durable Medical Equipment $0
Prior authorization may be required. Prior authorization is not required for preferred manufacturers.
Diagnostic Tests, Lab and Radiology Services, and X-Rays

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $0
Copayment for Medicare-covered Lab Services $0
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $0
Copayment for Medicare-covered Therapeutic Radiological Services $0
Copayment for Medicare-covered X-Ray Services $0

Prior authorization may be required for some services. No authorization is required for outpatient lab services and outpatient x-ray services. Genetic lab testing requires prior authorization.
Home Health Care

Home Health Services:
Copayment for Medicare-covered Home Health Services $0
Prior Authorization Required for Home Health Services
Mental Health Inpatient Care

Psychiatric Hospital Services:
Copayment for Psychiatric Hospital Services per Stay $0
Prior Authorization Required for Psychiatric Hospital Services
Mental Health Outpatient Care

Outpatient Mental Health Services:
Copayment for Medicare-covered Individual Sessions $0
Copayment for Medicare-covered Group Sessions $0
Prior authorization may be required. 
Outpatient Services / Surgery

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0
Prior Authorization Required for Outpatient Hospital Services

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services $0
Prior Authorization Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $0
Prior Authorization Required for Ambulatory Surgical Center Services
Outpatient Substance Abuse Care

Outpatient Substance Abuse Services:
Copayment for Medicare-covered Individual Sessions $0
Copayment for Medicare-covered Group Sessions $0
Prior Authorization Required for Outpatient Substance Abuse Services

Outpatient Substance Abuse Services:
Copayment for Medicare-covered Individual Sessions $0
Copayment for Medicare-covered Group Sessions $0
Prior Authorization Required for Outpatient Substance Abuse Services
Over-the-counter (OTC) Items

$75 combined allowance every month for OTC items.  

OTC hearing aids are covered and included in the combined OTC allowance.

Unused allowance does not carry over to the next month.

Please see the Flexible Extras section for a complete list of benefits and services that are included in the combined allowance.
Podiatry Services

Podiatry Services:
Copayment for Medicare-Covered Podiatry Services $0
Prior Authorization Required for Podiatry Services

Podiatry Services:
Copayment for Medicare-Covered Podiatry Services $0
Prior Authorization Required for Podiatry Services
Skilled Nursing Facility Care

Skilled Nursing Facility Services:
Copayment for Skilled Nursing Facility Services per Stay $0
Prior Authorization Required for Skilled Nursing Facility Services

Dental Benefits

The following dental services are covered from in-network providers.

Coverage Cost
Dental Care

Medicare Covered Preventive Dental:
Copayment for Office Visit $0

Non-Medicare Covered Preventive Dental:
Copayment for Non-medicare preventive $0
Copayment for Oral exams $0

  • Maximum 2 visits (Please see Evidence of Coverage for details)

Copayment for Dental x-rays $0

  • Maximum 1 visit (Please see Evidence of Coverage for details)

Copayment for Prophylaxis $0

  • Maximum 2 visits every year

Copayment for Fluoride treatment $0

  • Maximum 2 visits every year


Non-Medicare Covered Comprehensive Dental:
Copayment for Non-medicare comprehensive $0
Copayment for Restorative services $0

  • Maximum 1 visit (Please see Evidence of Coverage for details)

Copayment for Endodontics $0

  • Maximum 1 visit (Please see Evidence of Coverage for details)

Copayment for Periodontics $0

  • Maximum 1 visit (Please see Evidence of Coverage for details)

Copayment for Prothodontics, removable $0

  • Maximum 1 visit (Please see Evidence of Coverage for details)

Copayment for Maxillofacial surgery $0

  • Maximum 1 visit (Please see Evidence of Coverage for details)

Copayment for Adjunctive general services $0

  • Maximum 1 visit (Please see Evidence of Coverage for details)

Maximum Plan Benefit of $1,000 every year

Vision Benefits

The following vision services are covered from in-network providers.

Coverage Cost
Vision Benefits

Eye Exams:
Copayment for Medicare Covered Benefits $0
Copayment for Routine Eye Exams $0

  • Maximum 1 Routine Eye Exams every year


Eyewear:
Copayment for Medicare-Covered Benefits $0
Copayment for Contact Lenses $0
Copayment for Eyeglasses (lenses and frames) $0
Copayment for Eyeglass Lenses $0
Copayment for Eyeglass Frames $0
Copayment for Upgrades $0
Maximum Plan Benefit of $250 every year

Hearing Benefits

The following hearing services are covered from in-network providers.

Coverage Cost
Hearing Benefits

Hearing Exams:
Copayment for Medicare Covered Benefits $0
Copayment for Routine Hearing Exams $0

  • Maximum 1 visit every year

Copayment for Fitting/Evaluation for Hearing Aid $0

  • Maximum 1 visit every year


Hearing Aids:
Copayment for Hearing Aids $0

  • Maximum 2 Hearing Aids every two years

Preventive Services and Health/Wellness Education Programs

The following services are covered from in-network providers.

Coverage Cost
Preventive Services and Health/Wellness Education Programs

$0.00 copay for Medicare Covered Preventive Services:

Abdominal aortic aneurysm screening
Alcohol misuse screenings & counseling
Bone mass measurements (bone density)
Cardiovascular disease screenings
Cardiovascular disease (behavioral therapy)
Cervical & vaginal cancer screening
Colorectal cancer screenings
Depression screenings
Diabetes screenings
Diabetes self-management training
Glaucoma tests
Hepatitis B (HBV) infection screening
Hepatitis C screening test
HIV screening
Lung cancer screening
Mammograms (screening)
Nutrition therapy services
Obesity screenings & counseling
One-time Welcome to Medicare preventive visit
Prostate cancer screenings(PSA)
Sexually transmitted infections screening & counseling
Shots:

  • COVID-19 shots

  • Flu shots

  • Hepatitis B shots

  • Pneumococcal shots

Tobacco use cessation
Yearly "Wellness" visit

Prescription Drug Costs and Coverage

The Molina Medicare Complete Care (HMO D-SNP) plan offers the following prescription drug coverage, with an annual drug deductible of $0 (excludes Tiers 1 and 6) per year.

Coverage Cost
Coverage & Cost
Annual Drug Deductible $0 (excludes Tiers 1 and 6)
Preferred Generic
  • Standard retail $0.00
  • Standard mail order $0.00
Select Care Drugs
  • Standard retail $0.00
  • Standard mail order $0.00
Annual Drug Deductible $0 (excludes Tiers 1 and 6)
Preferred Generic
  • Standard retail $0.00
  • Standard mail order $0.00
Select Care Drugs
  • Standard retail $0.00
  • Standard mail order $0.00
Annual Drug Deductible $0 (excludes Tiers 1 and 6)
Preferred Generic
  • Standard retail $0.00
  • Standard mail order $0.00
Select Care Drugs
  • Standard retail $0.00
  • Standard mail order $0.00
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