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Molina Medicare Complete Care (HMO D-SNP) H5628-001 • 2027 • Box Elder County, UT

CMS Rating: ☆☆☆☆☆ (3.0 out of 5 stars*)
Monthly Premium
$45.50Plus Part B premium.
Medical Deductible
$0.00
Maximum Out-of-Pocket
$9850.00In-network
Part B Giveback
Not offered
Prescription Coverage
Enhanced, $700.00 deductible
Additional Benefits
Dental, Vision, Hearing
Service Area
Box Elder County, UT
Local Enrollment
64 beneficiaries in Box Elder County
Last update:

Introduction

CMS Plan ID H5628-001 identifies Molina Medicare Complete Care, a Medicare Advantage Dual-Eligible Special Needs Plan (D-SNP) offered by Molina Healthcare of Utah & Idaho. Its provider network is a Health Maintenance Organization (HMO), and Medicare Part D prescription drug coverage is included. For 2027, the plan has a $45.50 monthly premium, $0.00 medical deductible, and $9850.00 in-network maximum out-of-pocket. The 2027 Part D prescription drug deductible is $700.00.

Enrollment in this plan requires you to live in Box Elder County, Utah. CMS reports 64 beneficiaries enrolled in this plan in Box Elder County. New members can call the plan directly at (844)246-7256 (TTY 711) for assistance.

Eligibility

Molina Medicare Complete Care is a Medicare D-SNP plan for people who qualify for both Medicare and Medicaid.

Special Needs Plan Type
Dual-Eligible Special Needs Plan (D-SNP)
Medicare Requirement
Medicare Part A and Part B
Special Needs Requirement
Must qualify for Medicaid
Service Area Requirement
Must live in the plan's service area
Prescription Drug Coverage
Medicare Part D prescription drug coverage is included.

Compare Similar Plans in Box Elder County

Although no other HMO D-SNP plans meet the comparison criteria in Box Elder County, you may have other Medicare Advantage options. Browse all Medicare Advantage SNP plans available in Box Elder County, or explore our Utah Medicare Special Needs directory for statewide information on plan availability, premiums, out-of-pocket costs, CMS ratings, and enrollment.

Plan Benefits

Molina Medicare Complete Care has cost-sharing, meaning there are out-of-pocket costs when receiving covered healthcare services. The tables below detail the most common in-network out-of-pocket expenses for plan H5628-001.

You can also compare 2027 costs and coverage with last year, side-by-side: Plan H5628-001-0 Cost Compare.

Office Visits

Primary care
In-network: $0 copay
Specialist
In-network: $0 copay

Preventive and Wellness Services

Annual wellness exam
In-network: $0 copay
Telehealth benefit
In-network: $0 copay
Routine chiropractic
Not covered
Fitness benefits
Coming soon
Health education
In-network: $0 copay
Counseling services
Not covered
Over-the-counter drug benefits
In-network: $0 copay
Health transportation (non-emergency)
Coming soon

Diagnostic, Lab, and Imaging Services

Diagnostic radiology services
In-network: $0 copay
Lab services
In-network: $0 copay
Outpatient x-rays
In-network: $0 copay
Diagnostic tests and procedures
In-network: $0 copay

Emergency and Urgent Care Services

Emergency room care
$0 copay
Worldwide emergency care
Coming soon
Urgent care
$0 copay
Inpatient hospital care
Tier 1
$0 per stay
Skilled Nursing Facility
Tier 1
$0 per day for days 1-20
$0 per day for days 21-100
Ground ambulance
In-network: $0 copay

Mental Health Services

Outpatient individual therapy
In-network: $0 copay
Outpatient group therapy
In-network: $0 copay
Inpatient psychiatric hospital care
Tier 1
$0 per stay

Rehabilitation Services

Physical therapy and speech and language therapy
In-network: $0 copay
Occupational therapy
In-network: $0 copay

Medical Equipment and Supplies

Diabetes supplies
In-network: $0 copay
Durable medical equipment
In-network: $0 copay
Prosthetics
In-network: $0 copay

Medicare Part B Drugs

Chemotherapy
In-network: $0 copay
Other Part B drugs (Medicare-covered)
In-network: $0 copay

Dental Services

Oral exam
In-network: $0 copay
Dental x-rays
In-network: $0 copay
Cleaning
In-network: $0 copay
Periodontics
In-network: $0 copay
Endodontics
In-network: $0 copay
Restorative services
In-network: $0 copay
Implant services
Not covered
Orthodontics
Not covered
Oral/Maxillofacial surgery
In-network: $0 copay

Vision Services

Routine eye exam
In-network: $0 copay
Contact lenses
In-network: $0 copay
Eyeglass frames only
In-network: $0 copay
Eyeglass lenses only
In-network: $0 copay
Eyeglasses (frames & lenses)
In-network: $0 copay
Upgrades
In-network: $0 copay

Hearing Services

Hearing exam
In-network: $0 copay
Fitting/evaluation
In-network: $0 copay
Prescription hearing aids
In-network: $0 copay
OTC hearing aids
In-network: $0 copay

Additional and Special Needs Services

Adult day health services
Not covered
Home-based palliative care
Not covered
Personal emergency response system
Coming soon
Weight management programs
Not covered
Wigs for chemotherapy-related hair loss
Coming soon
Alternative therapies
Not covered
Massage therapy
Not covered
Home/bathroom safety devices
Not covered

Certain preventive services are covered 100% by Molina Medicare Complete Care as a Part B benefit.

Prescription Drug Coverage

Molina Medicare Complete Care includes a Medicare Part D prescription drug plan (PDP). Plan type and coverage level are defined by CMS and may vary between basic and enhanced benefit designs.

Prescription Drug Plan Premium

The Part D prescription drug plan premium is included in the overall Medicare Advantage plan cost. Additional adjustments may apply through the Low-Income Subsidy (LIS) program, also known as Extra Help, administered by Social Security. LIS benefits are separate from Medicare Special Needs Plan coverage.

Molina Medicare Complete Care (H5628-001-0) Prescription Drug Plan Premium Details
Part D Premium Component Amount
Basic Part D Premium:$45.50
Supplemental Part D Premium:$0.00
Total Part D Premium:$45.50
Low-Income Premium Subsidy:$45.51
Low-Income Premium Subsidy Paid by CMS:$45.50
Low-Income Subsidy Premium:$0.00

For more details, visit the Social Security Extra Help program .

Prescription Drug Plan Deductible

This plan has a $700.00 annual Part D deductible. You'll pay this deductible at the pharmacy before Molina Healthcare of Utah & Idaho starts contributing towards your prescription costs.

Prescription Drug Plan Out-of-Pocket Costs

Beyond premiums and deductibles, Molina Medicare Complete Care may have additional costs at pharmacies. The table below outlines out-of-pocket expenses by drug tier.

Molina Medicare Complete Care (H5628-001-0) Pharmacy Out-of-Pocket Costs by Drug Tier
Drug Tier Retail Mail Order
Preferred Generic$0.00 copay$0.00 copay
Generic25% coinsurance10% coinsurance
Preferred Brand25% coinsurance20% coinsurance
Non-Preferred Drug26% coinsurance30% coinsurance
Specialty Tier25% coinsurance25% coinsurance
Select Care Drugs$0.00 copay$0.00 copay
*Deductible does not apply.

CMS 5-Star Performance Ratings (Contract ID: H5628)

CMS star ratings reflect how well a Medicare plan performs across key quality measures, such as managing chronic conditions, member satisfaction, and customer service. Ratings range from 1 to 5 stars and are updated each year by Medicare.

2027 Medicare Star Ratings for Contract H5628
CMS Measure Star Rating
2027 Overall Rating ☆☆☆☆☆
Staying Healthy: Screenings, Tests, Vaccines ☆☆☆☆☆
Managing Chronic (Long Term) Conditions ☆☆☆☆☆
Member Experience with Health Plan ☆☆☆☆☆
Complaints and Changes in Plans Performance ☆☆☆☆☆
Health Plan Customer Service ☆☆☆☆☆
Drug Plan Customer Service ☆☆☆☆☆
Complaints and Changes in the Drug Plan ☆☆☆☆☆
Member Experience with the Drug Plan ☆☆☆☆☆
Drug Safety and Accuracy of Drug Pricing ☆☆☆☆☆

Contact Information for Molina Healthcare of Utah & Idaho

Website
Molina Healthcare of Utah & Idaho Plan Page
Providers
Molina Healthcare of Utah & Idaho Providers Page
Formulary
Molina Healthcare of Utah & Idaho Formulary Page
Pharmacy
Molina Healthcare of Utah & Idaho Pharmacy Page
New Member Health Plan Help
(844)246-7256
New Member Health Plan TTY
711
New Member Part D Help
(844)246-7256
New Member Part D TTY Users
711

Enrollment status and eligibility information are available through the Social Security Administration. Additional information about Medicare Advantage is available at Medicare.gov.

Medicare Plan Data Sources and Methodology
Primary CMS datasets used for this Medicare Advantage Plan resource.
Data Source Publisher Last Accessed
Landscape Source Files Centers for Medicare & Medicaid Services November 10, 2026
Medicare Part C & D Performance Centers for Medicare & Medicaid Services November 10, 2026
Plan Benefits Package Centers for Medicare & Medicaid Services November 10, 2026
Monthly Enrollment by Contract/Plan/State/County Centers for Medicare & Medicaid Services November 10, 2026

Data sources and methodology documentation.

Official plan information and secondary Medicare references.
Publisher Reference Last Accessed
Molina Healthcare of Utah & Idaho (official source) http://www.molinahealthcare.com/medicare October 4, 2026
CMS.gov Dual Eligible Special Needs Plans (D-SNPs) April 28, 2026
Medicare.gov Understanding Medicare Advantage Plans April 28, 2026
Medicare.gov Joining a plan April 28, 2026

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Provenance documentation for this data is maintained under the U.S. Core Data for Interoperability (USCDI) Provenance standard.