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.
Member Newsletters - Catch up on the latest information and tips to help you stay healthy.
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
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
Formulary
Provider and Pharmacy Directory (PDF)
Provider and Pharmacy Directory - Hmong (PDF)
Provider and Pharmacy Directory - Somali (PDF)
Member Handbook (PDF)
Member Handbook - Hmong (PDF)
Member Handbook - Somali (PDF)
New Member Guide (PDF)
New Member Guide - Hmong (PDF)
New Member Guide - Somali (PDF)
Annual Notice of Changes (PDF)
Annual Notice of Changes - Hmong (PDF)
Annual Notice of Changes - Somali (PDF)
Summary of Benefits (PDF)
Summary of Benefits - Hmong (PDF)
Summary of Benefits - Somali (PDF)
Plan Rating Information (PDF)
Plan Rating Information - Hmong (PDF)
Plan Rating Information - Somali (PDF)
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)
Member Handbook (PDF)
Member Handbook - Hmong (PDF)
Member Handbook - Somali (PDF)
New Member Guide (PDF)
New Member Guide - Hmong (PDF)
New Member Guide - Somali (PDF)
Provider and Pharmacy Directory (PDF)
Provider and Pharmacy Directory - Hmong (PDF)
Provider and Pharmacy Directory - Somali (PDF)
Enrollment Form (PDF)
Online Enrollment Form (external link)
Member Handbook (PDF)
Member Handbook - Hmong (PDF)
Member Handbook - Somali (PDF)
Member Handbook - Spanish (PDF)
New Member Guide (PDF)
New Member Guide - Hmong (PDF)
New Member Guide - Somali (PDF)
New Member Guide - Spanish (PDF)
Provider and Pharmacy Directory (PDF)
Provider and Pharmacy Directory - Arabic (PDF)
Provider and Pharmacy Directory - Hmong (PDF)
Provider and Pharmacy Directory - Russian (PDF)
Provider and Pharmacy Directory - Somali (PDF)
Provider and Pharmacy Directory - Spanish (PDF)
Provider and Pharmacy Directory - Vietnamese (PDF)
Member Handbook (PDF)
Member Handbook - Somali (PDF)
New Member Guide (PDF)
New Member Guide - Somali (PDF)
Provider and Pharmacy Directory (PDF)
Provider and Pharmacy Directory - Arabic (PDF)
Provider and Pharmacy Directory - Hmong (PDF)
Provider and Pharmacy Directory - Russian (PDF)
Provider and Pharmacy Directory - Somali (PDF)
Provider and Pharmacy Directory - Spanish (PDF)
Provider and Pharmacy Directory - Vietnamese (PDF)
Member Handbook (PDF)
Member Handbook - Spanish (PDF)
New Member Guide (PDF)
New Member Guide - Spanish (PDF)
Provider and Pharmacy Directory (PDF)
Provider and Pharmacy Directory - Arabic (PDF)
Provider and Pharmacy Directory - Hmong (PDF)
Provider and Pharmacy Directory - Russian (PDF)
Provider and Pharmacy Directory - Somali (PDF)
Provider and Pharmacy Directory - Spanish (PDF)
Provider and Pharmacy Directory - Vietnamese (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)
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)