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2022 Plan Documents and Information

To find your member documents, select your plan below.

To request a hard copy mailed to you, send us a message through your account in the Member Account or call Customer Service.

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2023 Plan Documents

Jump to your 2022 plans:

UCare Medicare

EssentiaCare

UCare Medicare with M Health Fairview & North Memorial

UCare Advocate ISNP

UCare Medicare Group

UCare Medicare Supplement

Medicaid + Medicare

Minnesota Health Care Programs

UCare Individual & Family Plans

UCare Individual & Family Plans with M Health Fairview


 

UCare Medicare

Provider and Pharmacy Directory (PDF)
Formulary
Service Area Map (PDF)
Welcome Booklet (PDF)
Travel Benefit (PDF)
TruHearing Hearing Aid Benefit (PDF)
UCare Dental Overview (PDF)
Plan Rating Information (PDF)
Prior Authorization Information (PDF)

Member Release of Information Form (PDF)
Statement of Representative Form (PDF)
Power of Attorney short form
Deceased Member: Affidavit for the Collection of Personal Property (mncourts.gov)
Automatic Payment Form (PDF)
Claim Reimbursement Form (PDF)



 

EssentiaCare

Provider and Pharmacy Directory (PDF)
Formulary
Service Area Map (PDF)
Welcome Booklet (PDF)
Travel Benefit (PDF)
Plan Rating Information (PDF)
Prior Authorization Information (PDF)

Member Release of Information Form (PDF)
Statement of Representative Form (PDF)
Power of Attorney short form
Deceased Member: Affidavit for the Collection of Personal Property (mncourts.gov)
Automatic Payment Form (PDF)
Claim Reimbursement Form (PDF)


 

UCare Medicare with M Health Fairview & North Memorial

Provider and Pharmacy Directory (PDF)
Formulary
Service Area Map (PDF)
Travel Benefit (PDF)
TruHearing Hearing Aid Benefit (PDF)
Care Wise & Care Core Member Programs (PDF)
Plan Rating Information (PDF)
Prior Authorization Information (PDF)

Member Release of Information Form (PDF)
Statement of Representative Form (PDF)
Power of Attorney short form
Deceased Member: Affidavit for the Collection of Personal Property (mncourts.gov)
Automatic Payment Form (PDF)
Claim Reimbursement Form (PDF)


 

UCare Advocate Plans

Provider and Pharmacy Directory (PDF)
Formulary
Service Area Map (PDF)
Welcome Book (PDF)
Prior Authorization Information (PDF)

Member Release of Information Form (PDF)
Statement of Representative Form (PDF)
Power of Attorney short form
Deceased Member: Affidavit for the Collection of Personal Property (mncourts.gov)
Automatic Payment Form (PDF)
Claim Reimbursement Form (PDF)


 

UCare Medicare Group Plans

Note: Summary of Benefits and Evidence of Coverage are determined per group. If you are a member and have questions about your particular Group plan, please call UCare Medicare Group Customer Service at 612-676-6840 or 1-877-447-4385 toll free. We are available 24 hours a day, seven days a week.

Plan Documents

Provider and Pharmacy Directory (PDF)
To request a bound copy of our Provider/Pharmacy Directory, please call customer service at the number on the back of your member ID card.
Formulary
2022 Classic Choice Dental Overview (PDF)
TruHearing Hearing Aid Benefit Information (PDF)
Plan Rating Information (PDF)
Prior Authorization Information (PDF)

Member Forms

Medicare Claim Reimbursement Form (PDF)
Use this form to be reimbursed for covered health care expenses.
Request for Medicare Prescription Drug Coverage Determination Form (PDF)
Request for Redetermination of Medicare Prescription Drug Denial Form (PDF)
Member Release of Information Form (PDF)
Statement of Representative Form (PDF)
Power of Attorney short form
Deceased Member: Affidavit for the Collection of Personal Property (mncourts.gov)
Automatic Payment Form (PDF)
Sign up to have your plan premium automatically deducted from your checking or savings account each month.

Part D Coverage Determinations, Appeals and Grievances
Part C Organizational Determinations, Appeals and Grievances
Instructions for Appointing a Representative (PDF)
Rights and Responsibilities Upon Disenrollment (PDF)
Prescription Drug Transition Policy (PDF)




 

UCare Medicare Supplement

Enrollment Form (PDF)

 

Medicaid + Medicare

Member Release of Information Form (PDF)
Member Release of Information Form - Arabic (PDF)
Member Release of Information Form - Hmong (PDF)
Member Release of Information Form - Russian (PDF)
Member Release of Information Form - Somali (PDF)
Member Release of Information Form - Spanish (PDF)
Member Release of Information Form - Vietnamese (PDF)

Prior Authorization Information (PDF)
Prior Authorization Information - Arabic (PDF)
Prior Authorization Information - Hmong (PDF)
Prior Authorization Information - Russian (PDF)
Prior Authorization Information - Somali (PDF)
Prior Authorization Information - Spanish (PDF)
Prior Authorization Information - Vietnamese (PDF)

Power of Attorney short form
Deceased Member: Affidavit for the Collection of Personal Property (mncourts.gov)

Statement of Representative Form (PDF)
Statement of Representative Form - Arabic (PDF)
Statement of Representative Form - Hmong (PDF)
Statement of Representative Form - Russian (PDF)
Statement of Representative Form - Somali (PDF)
Statement of Representative Form - Spanish (PDF)
Statement of Representative Form - Vietnamese (PDF)

Medicare Coverage Updates


 

Minnesota Health Care Programs

Formulary
Member Release of Information Form (PDF)
Member Release of Information Form - Arabic (PDF)
Member Release of Information Form - Hmong (PDF)
Member Release of Information Form - Russian (PDF)
Member Release of Information Form - Somali (PDF)
Member Release of Information Form - Spanish (PDF)
Member Release of Information Form - Vietnamese (PDF)

Prior Authorization Information (PDF)
Prior Authorization Information - Arabic (PDF)
Prior Authorization Information - Hmong (PDF)
Prior Authorization Information - Russian (PDF)
Prior Authorization Information - Somali (PDF)
Prior Authorization Information - Spanish (PDF)
Prior Authorization Information - Vietnamese (PDF)

Statement of Representative Form (PDF)
Statement of Representative Form - Arabic (PDF)
Statement of Representative Form - Hmong (PDF)
Statement of Representative Form - Russian (PDF)
Statement of Representative Form - Somali (PDF)
Statement of Representative Form - Spanish (PDF)
Statement of Representative Form - Vietnamese (PDF)

Power of Attorney short form
Deceased Member: Affidavit for the Collection of Personal Property (mncourts.gov)
Advance Directives Info (PDF)


 

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)



 

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)