2022 Individual & Family Plans Documents and Information
UCare Individual & Family Plans
New Member Guide (PDF)
Member Release of Information Form (PDF)
Prior Authorization Information (PDF)
Prior Authorization Data
Statement of Representative Form (PDF)
Power of Attorney short form
Deceased Member: Affidavit for the Collection of Personal Property (mncourts.gov)
Member Contract Amendment Letter (PDF)
Formulary
Provider and Pharmacy Directory (PDF)
Network Adequacy Waiver (PDF)
Service Area Map (PDF)
Automatic Payment Form (PDF)
Claim Reimbursement Form (PDF)
Prescription Drug Reimbursement Form (PDF)
A catastrophic plan available to people under 30 years of age or for those who obtain a hardship exemption.
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Bronze
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Bronze A
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Bronze B
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Bronze HSA
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Bronze AH
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Bronze BH
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Silver
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Silver A
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Silver B
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Silver 2
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Silver 3
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Silver 4
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Silver HSA
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Silver AH
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Silver BH
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Silver 2 HSA
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Silver 3H
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Silver 4H
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
UCare Individual & Family Plans with M Health Fairview
New Member Guide (PDF)
Member Release of Information Form (PDF)
Prior Authorization Information (PDF)
Prior Authorization Data
Statement of Representative Form (PDF)
Power of Attorney short form
Deceased Member: Affidavit for the Collection of Personal Property (mncourts.gov)
Member Contract Amendment Letter (PDF)
Formulary
Provider and Pharmacy Directories (PDF)
Network Adequacy Waiver (PDF)
Service Area Map (PDF)
Automatic Payment Form (PDF)
Claim Reimbursement Form (PDF)
Prescription Drug Reimbursement Form (PDF)
A catastrophic plan available to people under 30 years of age or for those who obtain a hardship exemption.
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Bronze
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Bronze A
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Bronze B
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Bronze HSA
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Bronze AH
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Bronze BH
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Silver
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Silver A
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Silver B
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Silver 2
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Silver 3
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Silver 4
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Silver HSA
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Silver AH
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Silver BH
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Silver 2 HSA
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Silver 3H
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Silver 4H
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)