Molina Medicare Complete Care Select (HMO D-SNP)
Available to residents of Millard County, UT for 2026. Contract H5628, plan 012, segment 0.
- ✉ Email a copy of the plan benefit details
- Plan health benefits
- Benefits in plain text
- Rx cost-sharing for all pharmacies and tiers
- Other plans in Millard County
- Plan website
- Browse the Molina Medicare Complete Care Select (HMO D-SNP) formulary
Renewed for 2026. CMS carries this plan forward from 2025.
Plan details
| Monthly premium (Part C + D) | $0.00 |
|---|---|
| — medical (Part C) part | $0.00 |
| — drug (Part D) part | $0.00? |
| Monthly premium with full Extra Help (LIS) | $0.00? |
| Part B premium reduction (giveback) | None |
| In-network out-of-pocket maximum | $9,250.00? |
| Drug deductible | $375.00Tier 1 and 6 exempt |
| Drug out-of-pocket threshold | $2,100.00 |
| Plan type | HMO D-SNP? |
| Special needs plan | Dual-eligible SNP |
| Contract / plan | H5628-012-0 |
| Offered by | Molina Healthcare of Utah & Idaho |
| Parent organization | Molina Healthcare, Inc. |
| Formulary drugs | 3,522 |
| Formulary exception tier | 4? |
| Pharmacy search | www.molinahealthcare.com/medicare |
| Member services | (844)246-7256TTY 711 |
CMS star ratings
- Overall
- 3 out of 5 stars for Overall
- Health plan (Part C)
- 3 out of 5 stars for Health plan (Part C)
- Drug plan (Part D)
- 3.5 out of 5 stars for Drug plan (Part D)
Published per contract — every plan under contract H5628 shares this rating.
Plan health benefits
| Service | In-network |
|---|---|
| Doctor visits | |
| Primary care doctor | $0 copay |
| Specialist | $30 copay |
| Other health care professional | $0–$15 copay(authorization required) |
| Additional telehealth services | $0–$45 copay; 0%–20% coinsurance |
| Preventive care | |
| Medicare-covered preventive services | $0 copay |
| Annual physical exam | $0 copay |
| Kidney disease education | $0 copay |
| Glaucoma screening | $0 copay |
| Diabetes self-management training | $0 copay |
| Diagnostic tests, labs and imaging | |
| Diagnostic tests and procedures | 0%–20% coinsurance(authorization required) |
| Lab services | 0%–20% coinsurance(authorization required) |
| Diagnostic radiology (e.g. MRI, CT) | 0%–20% coinsurance(authorization required) |
| Therapeutic radiology | 20% coinsurance(authorization required) |
| Outpatient x-rays | $0 copay(authorization required) |
| Emergency and urgent care | |
| Emergency room | $100 copay |
| Urgent care | $30 copay |
| Worldwide emergency coverage | $0 copay · $10,000 plan limit |
| Worldwide urgent care | $0 copay · $10,000 plan limit |
| Worldwide emergency transportation | $0 copay |
| Hospital care | |
| Inpatient hospital stay | $325 per day for days 1–6; $0 per day for days 7–90(authorization required) |
| Outpatient hospital services | 20% coinsurance(authorization required) |
| Outpatient observation | $325 copay(authorization required) |
| Ambulatory surgical center | $50 copay(authorization required) |
| Outpatient blood services | 20% coinsurance |
| Skilled nursing and home health | |
| Skilled nursing facility | $0 per day for days 1–20; $200 per day for days 21–100(authorization required) |
| Home health care | $0 copay(authorization required) |
| Kidney dialysis | 20% coinsurance |
| Rehabilitation | |
| Occupational therapy | 0%–20% coinsurance(authorization required) |
| Physical therapy and speech-language therapy | 0%–20% coinsurance(authorization required) |
| Cardiac rehabilitation | $30 copay(authorization required) |
| Pulmonary rehabilitation | $15 copay(authorization required) |
| Mental health and substance use | |
| Inpatient psychiatric hospital stay | Original Medicare cost-sharing(authorization required) |
| Outpatient mental health, individual session | $45 copay(authorization required) |
| Outpatient mental health, group session | $45 copay(authorization required) |
| Psychiatrist, individual session | $45 copay(authorization required) |
| Psychiatrist, group session | $45 copay(authorization required) |
| Partial hospitalization | $70 copay(authorization required) |
| Intensive outpatient program | $70 copay(authorization required) |
| Outpatient substance use, individual session | $30 copay(authorization required) |
| Outpatient substance use, group session | $30 copay(authorization required) |
| Opioid treatment program | $0 copay(authorization required) |
| Ambulance and transportation | |
| Ground ambulance | 20% coinsurance(authorization required) |
| Air ambulance | 20% coinsurance(authorization required) |
| Transportation to plan-approved locations | $0 copay |
| Medical equipment and supplies | |
| Durable medical equipment (e.g. wheelchairs, oxygen) | 20% coinsurance(authorization required) |
| Prosthetics (e.g. braces, artificial limbs) | 20% coinsurance(authorization required) |
| Medical supplies | 20% coinsurance(authorization required) |
| Diabetes supplies | $0 copay(authorization required) |
| Diabetic therapeutic shoes or inserts | $0 copay(authorization required) |
| Chiropractic, acupuncture and foot care | |
| Chiropractic (Medicare-covered) | $15 copay |
| Routine chiropractic care | Not covered |
| Acupuncture | $15 copay(limits apply) |
| Foot exams and treatment (Medicare-covered) | $30 copay(authorization required) |
| Routine foot care | Not covered |
| Dental? | |
| Medicare-covered dental services | $0 copay |
| Oral exams | $0 copay(limits apply) |
| Cleanings | $0 copay(limits apply) |
| Fluoride treatment | $0 copay(limits apply) |
| Dental x-rays | $0 copay(limits apply) |
| Other diagnostic dental services | Not covered |
| Other preventive dental services | Not covered |
| Comprehensive dental plan limit | $1,200 plan limit every year |
| Restorative services (fillings, crowns) | $0 copay(authorization required, limits apply) |
| Endodontics (root canals) | $0 copay(authorization required, limits apply) |
| Periodontics (gum disease) | $0 copay(authorization required, limits apply) |
| Dentures and other removable prosthodontics | $0 copay(authorization required, limits apply) |
| Maxillofacial prosthetics | Not covered |
| Implants | Not covered |
| Bridges and other fixed prosthodontics | Not covered |
| Oral and maxillofacial surgery | $0 copay(authorization required, limits apply) |
| Orthodontics | Not covered |
| Adjunctive general services | $0 copay(authorization required, limits apply) |
| Vision? | |
| Eye exam (Medicare-covered) | $0 copay |
| Routine eye exam | $0 copay(limits apply) |
| Eyewear after cataract surgery (Medicare-covered) | 20% coinsurance(limits apply) |
| Eyewear plan limit | $250 plan limit every year |
| Contact lenses | $0 copay(limits apply) |
| Eyeglasses (frames and lenses) | $0 copay(limits apply) |
| Eyeglass lenses | $0 copay(limits apply) |
| Eyeglass frames | $0 copay(limits apply) |
| Eyewear upgrades | $0 copay(limits apply) |
| Hearing? | |
| Hearing exam (Medicare-covered) | $30 copay |
| Routine hearing exam | $0 copay(limits apply) |
| Hearing aid fitting and evaluation | $0 copay(limits apply) |
| Hearing aids (all types) | $0 copay(limits apply) |
| Hearing aids, inner ear | Not covered |
| Hearing aids, outer ear | Not covered |
| Hearing aids, over the ear | Not covered |
| Medicare Part B drugs | |
| Part B insulin | 0%–20% coinsurance(authorization required, step therapy may apply) |
| Chemotherapy and radiation drugs | 0%–20% coinsurance(authorization required, step therapy may apply) |
| Other Part B drugs | 0%–20% coinsurance(authorization required, step therapy may apply) |
| Other extra benefits? | |
| Over-the-counter (OTC) allowance | Covered (allowance not stated) |
| Meals after a hospital stay or for a chronic condition | $0 copay(authorization required) |
| Fitness benefit | $0 copay(authorization required) |
| Health education | $0 copay(authorization required) |
| Nutritional / dietary benefit | $0 copay(authorization required) |
| Extra smoking and tobacco cessation counseling | $0 copay(authorization required) |
| Enhanced disease management | Not covered |
| Telemonitoring | Not covered |
| Remote access technologies (web/phone, nurse line) | $0 copay(authorization required) |
| Home and bathroom safety devices | Not covered |
| Counseling services | Not covered |
| In-home safety assessment | Not covered |
| Personal emergency response system (PERS) | $0 copay(authorization required) |
| Medical nutrition therapy | Not covered |
| Post-discharge in-home medication reconciliation | Not covered |
| Re-admission prevention | Not covered |
| Wigs for hair loss from chemotherapy | Not covered |
| Weight management programs | Not covered |
| Alternative therapies | Not covered |
| Therapeutic massage | Not covered |
| Adult day health services | Not covered |
| Home-based palliative care | Not covered |
| In-home support services | Not covered |
| Support for caregivers | Not covered |
In-network cost-sharing as the plan filed it with CMS (CMS plan benefit package (PBP) files, CY2026). A range means the cost depends on the service or setting. Rows the filing does not state are left out rather than guessed. Contact the plan for the full Evidence of Coverage.
Drug tiers — preferred pharmacy, initial coverage
| Tier | Cost-sharing |
|---|---|
| Tier 1 | $0.00 |
| Tier 2 | $4.00 |
| Tier 3 | 20% |
| Tier 4 | 30% |
| Tier 5 | 27% |
| Tier 6 | $0.00 |
Rx cost-sharing by coverage phase
| Tier | 30-day supply | 90-day supply | ||||
|---|---|---|---|---|---|---|
| Preferred | Standard | Mail Order | Preferred | Standard | Mail Order | |
| Initial deductible phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 6: Select Care Drugs | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Initial coverage phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 2: Generic | $4.00 | $4.00 | $4.00 | $8.00 | $8.00 | $8.00 |
| Tier 3: Preferred Brand | 20% | 20% | 20% | 20% | 20% | 20% |
| Tier 4: Non-Preferred Drug | 30% | 30% | 30% | 30% | 30% | 30% |
| Tier 5: Specialty Tier | 27% | 27% | 27% | n/a | n/a | n/a |
| Tier 6: Select Care Drugs | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Catastrophic coverage phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 2: Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 3: Preferred Brand | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 4: Non-Preferred Drug | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 5: Specialty Tier | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 6: Select Care Drugs | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
Also available in 22 other UT counties
Benefits in plain text
Molina Medicare Complete Care Select (HMO D-SNP) (H5628-012-0) is a 2026 HMO D-SNP Medicare Advantage plan offered by Molina Healthcare of Utah & Idaho, available to residents of Millard County, UT.
The monthly premium is $0.00 (Part C and Part D together).
With full Extra Help (the Low-Income Subsidy), the total monthly premium is $0.00.
Its in-network out-of-pocket maximum is $9,250.00.
The drug deductible is $375.00. Tier 1 and 6 exempt.
It is a special needs plan (Dual-eligible SNP).
The plan's formulary lists 3,522 drugs.
At a preferred pharmacy in the initial coverage phase, a 30-day supply costs tier 1: $0.00; tier 2: $4.00; tier 3: 20%; tier 4: 30%; tier 5: 27%; tier 6: $0.00.
CMS gives the plan's contract (H5628) an overall rating of 3 out of 5 stars.
Email a copy of the plan benefit details
Plan facts come from the CMS quarterly prescription drug plan public use files; the premium split, Extra Help premium, MOOP and plan type from the CMS Landscape file; the Part B giveback and health benefits from the CMS plan benefit package (PBP) files.