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2024 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.

Member Newsletters - Catch up on the latest information and tips to help you stay healthy.




 

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







 

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

Formulary (list of covered drugs)
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.
Member Guide (PDF)

Medicare Group Classic Dental Plan Overview (PDF)
Dental Enrollment Form (PDF)
Dental Enrollment Form - Spanish (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 Forms

Medicare Claim Reimbursement Form (PDF)
Use this form to be reimbursed for covered health care expenses.

Prescription Drug Claim Form (PDF)
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)
Online Automatic Payment Form
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)
Advance Directives (PDF)

Enrollment Forms

2024 Online Enrollment Form
2024 Online Dental Enrollment Form

 




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)





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)