2023 Plan Documents and Forms

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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Jump to your 2023 plans:

UCare Medicare

EssentiaCare

UCare Medicare with M Health Fairview & North Memorial

UCare Advocate ISNP

UCare Your Choice

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

Formulary (list of covered drugs)
Provider and Pharmacy Directory (PDF)
Provider and Pharmacy Directory - Spanish (PDF)
Service Area Map (PDF)
Welcome booklet (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 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)
Online Automatic Payment Form
Claim Reimbursement Form (PDF)
Advance Directives (PDF)

Enrollment Forms

Fillable PDFs
2023 Medicare Enrollment Form - Metro (PDF)
2023 Medicare Enrollment Form - South (PDF)
2023 Medicare Enrollment Form - North (PDF)
2023 UCare Medicare Enrollment Change Form (PDF)
Dental Enrollment Form (PDF)

Online Forms
2023 Medicare Enrollment Form - Metro
2023 Medicare Enrollment Form - South
2023 Medicare Enrollment Form - North
2023 Medicare Enrollment Change Form
2023 Dental Enrollment Form

EssentiaCare

Formulary (list of covered drugs)
Service Area Map (PDF)
Provider and Pharmacy Directory (PDF)
Welcome booklet (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)

Enrollment Forms

Fillable PDFs
2023 EssentiaCare Enrollment Form (PDF)
2023 EssentiaCare Enrollment Change Form (PDF)
Dental Enrollment Form (PDF)

Online Forms
2023 EssentiaCare Enrollment Form
2023 EssentiaCare Enrollment Change Form
2023 Dental Enrollment Form

UCare Medicare with M Health Fairview & North Memorial

Formulary (list of covered drugs)
Provider and Pharmacy Directory (PDF)
Provider and Pharmacy Directory - Spanish (PDF)
Service Area Map (PDF)
Welcome booklet (PDF)
TruHearing Hearing Aid Benefit (PDF)
Plan Rating Information (PDF)
Plan Rating Information - Spanish (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)
Advance Directives (PDF)

Enrollment Forms

Fillable PDFs
2023 Medicare Enrollment Form - Metro (PDF)
2023 Medicare Enrollment Change Form (PDF)

Online Forms
2023 Medicare Enrollment Form - Metro
2023 Medicare Enrollment Change Form

UCare Advocate Plans

Formulary (list of covered drugs)
Provider and Pharmacy Directory (PDF)
Provider and Pharmacy Directory - Spanish (PDF)
Plan Rating Information (PDF)
Plan Rating Information - Spanish (PDF)
Prior Authorization Information (PDF)
TruHearing Hearing Aid Benefit (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 PDF
2023 Medicare Enrollment Form (PDF)

Online Form
2023 Medicare Enrollment Form

UCare Your Choice

Formulary (list of covered drugs)
Provider and Pharmacy Directory (PDF)
Service Area Map (PDF)
Welcome booklet (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)
Online Automatic Payment Form
Claim Reimbursement Form (PDF)
Advance Directives (PDF)

Enrollment Forms

Fillable PDF
2023 Medicare Enrollment Form - Metro (PDF)
2023 Your Choice Enrollment Change Form (PDF)

Online Form
2023 Medicare Enrollment 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 8 am – 8 pm , seven days a week.

Plan Documents

Provider and Pharmacy Directory (PDF)
Provider and Pharmacy Directory - Spanish (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 (list of covered drugs)
2023 Classic Choice Dental Overview (PDF)
Dental Enrollment Form (PDF)
Plan Rating Information (PDF)
Plan Rating Information - Spanish (PDF)
Prior Authorization Information (PDF)
Welcome booklet (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) (updated 10/2022)
Advance Directives (PDF)

Enrollment Forms

Online Enrollment Form
Online Dental Enrollment Form

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)
Parent/Guardian Authorization Form for Unaccompanied Minors (PDF)

UCare Individual & Family Plans

New Member Guide (PDF)
Formulary (list of covered drugs)
Provider and Pharmacy Directory (PDF)
Network Adequacy Waiver (PDF)
ECP Network Adequacy Waiver (PDF)
Coverage Area Map (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)

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)
Formulary (list of covered drugs)
Provider and Pharmacy Directory (PDF)
Network Adequacy Waiver (PDF)
Coverage Area Map (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)

Automatic Payment Form (PDF)
Claim Reimbursement Form (PDF)
Prescription Drug Reimbursement Form (PDF)