Important coverage information

UCare covers a range of health care services including medical care, services, supplies and equipment. These covered services must be medically necessary and needed for the prevention, diagnosis or treatment of a medical condition. They also must meet accepted standards of medical practice. Members receive the highest level of benefits and pay less out of pocket for covered services received from a UCare network provider. There are benefits that UCare doesn't cover, also called "exclusions." Members must pay for the costs of non-covered benefits unless a member appeals, and UCare decides to pay for or cover the benefit because of a specific medical situation.

For more detailed information about covered and non-covered benefits, members should refer to their member documents.

We make every effort to protect our member's personal and health information. There are times that we may share your information for business purposes and to allow you to participate in a health improvement program. The UCare Notice of Privacy Practice explains how UCare protects our members' personal health information as required by state and federal laws.

UCare has an extensive network of doctors and health care providers of all types, including mental health practitioners, specialists, clinics, hospitals, pharmacies and durable medical equipment providers. The best way to get the most up-to-date information about a specific doctor or provider is the Search Network tool. This tool also provides information about the provider's medical school, residency and board certification. Members can also call the customer service number on the back of their member ID card for additional information.

When members enroll in UCare, they should choose a primary care clinic in their UCare plan's network. Within the member's primary care clinic, they can see any primary care provider at this clinic. Primary care providers may be family medicine doctors, general practitioners, internists, geriatricians, doctors in obstetrics/gynecology, nurse midwives, physician assistants and nurse practitioners, or a specialist who is their primary physician. Members can get their routine or basic care from their primary care provider, who will also coordinate the rest of the covered services they get as a plan member. Members also may change their primary care clinic at any time, for any reason, by logging into the member portal or calling UCare Customer Service. Members may refer to their plan documents for more information about primary care providers.

We encourage members to visit their primary care provider at least once a year for a preventive annual visit. Members can call their primary care clinic or go online to their clinic's website to schedule an appointment. UCare Customer Service also can help members schedule appointments.

If you're an Individual and Family plans member between 18 and 21 years old, you may be thinking about changing from a pediatric doctor to adult care. UCare can help you find health care providers in your area, provide contact information and walk you through the process of transferring your medical records. Call the customer service number on the back of your member ID card. We are ready to help make at least one transition into adulthood easier.

A specialist is a health care provider who practices a specific area of medicine. For example, oncologists care for patients with cancer and cardiologists care for patients with heart conditions. A member's primary care provider can help find a specialist in UCare's network, but members don't need a referral to see a specialist in their UCare plan's network.

Members generally have the best coverage (or pay the least amount) when they receive covered services from a specialist in UCare's network. Members should refer to their plan documents for more information about coverage.

Our Search Network tool can help members find behavioral health providers and facilities. UCare Customer Service is also available to help members with their search.

To schedule an appointment, members can contact a specialist or their facility directly. UCare Customer Service can also help members schedule appointments.

If members need care after office hours or on the weekend, they can call their primary care clinic or the 24/7 Nurse Line at the phone number on the back of their member ID card. Some primary care clinics have extended and weekend hours. A list of urgent care providers is included in members' plan provider directories and Search Network tool. Members should refer to their plan documents for more information about urgent care coverage.

When members have an emergency that could be life-threatening or result in hospitalization, they should seek immediate care. Members can get help as quickly as possible by calling 911 or going to the nearest emergency room or hospital. Members may also need to call for an ambulance, which is covered at no additional charge, even when a member is traveling in the United States. Although emergency medical services are covered throughout the United States, members should refer to their plan documents for more information about these services. Emergency coverage outside of the United States varies by plan.

Members who need care when traveling are advised to research the health care providers, clinics and hospitals in the area where they are traveling. Different coverage rules apply to out-of-network health care providers, depending on the members' health plan. Members should refer to their plan documents for more information about out-of-network coverage. See the section above — "What to do in the case of a medical emergency"  — for information about travel coverage in a medical emergency.

Utilization management is what we call our coverage decision-making process. This process refers to how our medical directors review and evaluate the medical necessity, appropriateness and efficiency of the use of health care services, procedures and facilities. This health plan function supports our goal to provide the right care at the right time to our members.

At UCare, utilization management decision making is based on appropriateness of care and service, and existence of coverage. We don't compensate practitioners or individuals for denials of service authorizations; don't offer incentives to encourage denials of service authorizations; and don't encourage decisions that limit use of services. UCare ensures independence and impartiality in making referral decisions that will not influence hiring, compensation, termination or promotion.

We offer members access to utilization review staff during business hours (612-676-6705 or 1-877-447-4384 toll-free, Monday – Friday, 8 am – 5 pm) and a voice mail box to leave messages after hours (phone: 612-676-6705 or fax: 612-884-2499). Hearing impaired members can call our TTY text machine at 612-676-6810 or 1-800-688-2534 toll-free. Collect calls are accepted. Language assistance is available from customer service.

UCare provides extra support when needed by members with short-term or complex health needs and social service needs. We call this support case management. Case management is a collaboration between the member (or family member if appropriate), provider(s) and case manager to assess, plan, facilitate, evaluate and advocate for options and services to meet a member’s comprehensive health needs.

UCare provides complex case management services for members with multiple complex conditions. Our goal is to help members improve their health and quality of life and become more self-reliant in managing their healthcare. UCare complex case managers are registered nurses and help our members by providing education, supporting them to achieve their health goals, short term coordination of care and access to services.

Members or their caregivers are encouraged to contact UCare to be screened for the complex case management program. They can call or email the program with the contact information listed below. If the member meets the program criteria, they are offered the option to enroll in our complex case management program. If the member doesn't meet the program criteria, they may be referred to one of the UCare disease management programs.


Call 612-676-6538, Monday – Friday, 8 am – 5 pm, or email us at ccmteam@ucare.org to ask about participating in complex case management.


Some health care services are covered only if the member's doctor or other provider gets approval in advance from UCare. This is called prior authorization. Some examples that require prior authorization are inpatient rehabilitation services, spine surgery, bone growth stimulators and spinal cord stimulators. Members should refer to their member documents for more information about services requiring prior authorization.

UCare health plans each have a formulary or list of covered drugs that we cover for that plan. The formulary is developed by a team of health care providers to ensure the list represents the drug therapies believed to be a necessary part of a quality treatment program. Formularies can change during the course of the year, so members should check online for the most current formulary. Generally, we cover drugs listed in the formulary as long as the drug is medically necessary, the prescription is filled at a UCare network pharmacy, and other plan rules are followed. We will also cover prescriptions for medical emergencies.

The formulary covers both brand-name drugs and generic drugs. A generic drug is approved by the Federal Drug Administration (FDA) as having the same active ingredient as the brand-name drug. Generic drugs usually cost less than brand-name drugs. Some covered drugs may have additional requirements or limits on coverage, including:

• Prior Authorizations: A member's health care provider must get approval from UCare in advance for a prescription drug before the member fills the prescription.
• Quantity Limits: For certain drugs, we limit the amount of the drug UCare will cover.
• Step Therapy: In some cases, UCare requires the member to first try certain drugs to treat their medical condition before UCare will cover another drug for that condition.
• Members can request an exception to the formulary following the process outlined in their plan's formulary or list of covered drugs. 

Individual and Family Plans Formulary

Medical Assistance (Medicaid) List of Covered Drugs (Formulary)

Medical procedures can be expensive, and it’s important to have as much available information as possible to make an informed decision. New Choice Health is a free tool to help you find and compare costs for common medical procedures across the United States. Costs may vary depending on use of in-network versus out-of-network physicians. Members may be responsible for charges above approved rate. Call the UCare Customer Service number on the back of your member ID card for additional information.

If you’re an Individual & Family Plan member, you can also use the free cost estimator located in your online member account. This tool provides a good faith estimate of your total out-of-pocket costs for a specific service from a specific in-network provider. You can find it and learn more on your account dashboard's plan benefits overview. You'll need to have or create an account for access. The cost estimator tool is located in the "Resources" section.

Remember, staying in your plan’s network helps you save money. That’s because we negotiate rates with providers and places in our network so you get care at a lower cost. You'll usually pay quite a bit more if you visit an out-of-network provider. Use our Search Network to quickly find doctors, specialists, hospitals, clinics and pharmacies within your plan’s network.

When new technologies enter the marketplace (devices, procedures, and medications), UCare medical leaders carefully evaluate them for effectiveness. They use information gathered from many sources and standard-setting organizations in our evaluation.

• UCare clinical and quality committees and medical directors carefully research and review new technologies before determining their medical necessity and/or appropriateness.
• UCare uses information gathered from many sources in our evaluation efforts, including the Winifred S. Hayes, Inc. Technology Assessment Reports, published peer-reviewed medical literature, consensus statements or guidelines from national medical associations and physician specialty societies, the U.S. Food and Drug Administration (FDA), other regulatory bodies, and internal and external expert consultative sources.
• Medical policies don't constitute coverage authorization or explain benefits.
• UCare encourages your health care providers and health care team to talk openly with you. We don't restrict providers from talking with you about care options, regardless of cost.

To learn about our specific medical policies including initiating medical policy requests and the process to develop them, visit the UCare Medical Policy site.

Note: the level of coverage may vary depending on regulations or the benefits outlined in member's plan documents. When regulations and/or the plan documents are not specific enough, you or your provider can contact us to start the coverage determination process.

When a state of disaster or emergency is declared in your geographic area, UCare generally allows you to receive care from out-of-network providers at in-network cost-sharing. If you can't use a network pharmacy during a disaster, you may be able to fill your prescription drugs at an out-of-network pharmacy.