2024 UCare Your Choice Plan Documents and Forms

UCare Your Choice

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

Medicare Coverage Updates

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)

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 PDF
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 Your Choice Enrollment Change Form (PDF)

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