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2024 UCare Medicare Plan Documents and Forms

UCare Medicare

Formulary (list of covered drugs)
Provider and Pharmacy Directory (PDF)
Provider and Pharmacy Directory - Spanish (PDF)
Service area map (PDF)
Member Guide (PDF)
Medicare Resource Guide (PDF)

TruHearing Hearing Aid Benefit (PDF)
UCare Dental Overview (PDF)
Dental Enrollment Form (PDF)

Plan Rating Information (PDF)
Plan Rating Information - Spanish (PDF)

Prior Authorization List (PDF)
Prior Authorization List - Arabic (PDF)
Prior Authorization List - Hmong (PDF)
Prior Authorization List - Russian (PDF)
Prior Authorization List - Somali (PDF)
Prior Authorization List - Spanish (PDF)
Prior Authorization List - Vietnamese (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)
Online Automatic Payment Form
Claim Reimbursement Form (PDF)
Advance Directives (PDF)

Enrollment Forms

Fillable PDFs
2024 Medicare Enrollment Form - Metro (PDF)
2024 Medicare Enrollment Form - South (PDF)
2024 Medicare Enrollment Form - North (PDF)
2024 Medicare Enrollment Form - Metro - Spanish (PDF)
2024 Medicare Enrollment Form - South - Spanish (PDF)
2024 Medicare Enrollment Form - North - Spanish (PDF)
2024 UCare Medicare Enrollment Change Form (PDF)

Dental Enrollment Form (PDF)
Dental Enrollment Form - Spanish (PDF)

Online Forms
2024 Dental Enrollment Form
2024 Medicare Enrollment Form - Metro
2024 Medicare Enrollment Form - North
2024 Medicare Enrollment Form - South