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2025 Individual & Family Plans Documents and Information

View the documents below for benefit and coverage information, including deductibles, copays and emergency services. To request a hard copy mailed to you, send us a message through your account in the Member Account or call Customer Service.

2024 Plan Documents

UCare Individual & Family Plans

Member guide (PDF)
Formulary (list of covered drugs)
Plan overview (PDF)

Provider and Pharmacy Directory (PDF)
Coverage Area Map (PDF)

Prior Authorization Data

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: Log on to your online member account to set up your automatic withdrawal.
Claim Reimbursement Form (PDF)
Prescription Drug Reimbursement Form (PDF)

HSA-compatible plan guide (PDF)

Fillable PDFs
2025 Individual & Family Plans Enrollment Form (PDF)

UCare Core

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)
Summary of Benefits and Coverage - Spanish (PDF)
Summary of Benefits and Coverage - Off Exchange (PDF)
Summary of Benefits and Coverage - Off-Exchange - Spanish (PDF)

UCare Bronze and UCare Bronze HSA

Bronze
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)
Summary of Benefits and Coverage - Off-Exchange (PDF)
Summary of Benefits and Coverage - Off-Exchange - Spanish (PDF)

Bronze A
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)

Bronze B
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)

Bronze HSA
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)
Summary of Benefits and Coverage - Off-Exchange (PDF)
Summary of Benefits and Coverage - Off-Exchange - Spanish (PDF)

Bronze AH
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)

Bronze BH
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)

UCare Bronze Access

Bronze Access
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)
Summary of Benefits and Coverage - Off-Exchange (PDF)
Summary of Benefits and Coverage - Off-Exchange - Spanish (PDF)

Bronze Access A
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)

Bronze Access B
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)

UCare Silver and UCare Silver HSA

Silver
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)
Summary of Benefits and Coverage - Off-Exchange (PDF)
Summary of Benefits and Coverage - Off-Exchange - Spanish (PDF)

Silver A
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)

Silver B
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)

Silver 2
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)

Silver 3
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)

Silver 4
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)

Silver HSA
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)
Summary of Benefits and Coverage - Off-Exchange (PDF)
Summary of Benefits and Coverage - Off-Exchange - Spanish (PDF)

Silver AH
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)

Silver BH
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)

Silver 2H
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)

Silver 3H
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)

Silver 4H
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)

UCare Gold

Gold
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)
Summary of Benefits and Coverage - Off-Exchange (PDF)
Summary of Benefits and Coverage - Off-Exchange - Spanish (PDF)

Gold A
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)

Gold B
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)

UCare Individual & Family Plans — Easy Compare Plans

Member guide (PDF)
Formulary (list of covered drugs)

Provider and Pharmacy Directory (PDF)
Coverage Area Map (PDF)

Prior Authorization Data

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: Log on to your online member account to set up your automatic withdrawal.
Claim Reimbursement Form (PDF)
Prescription Drug Reimbursement Form (PDF)

UCare Easy Compare Bronze

Easy Compare Bronze
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)
Summary of Benefits and Coverage - Off-Exchange (PDF)
Summary of Benefits and Coverage - Off-Exchange - Spanish (PDF)

Easy Compare Bronze A
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)

Easy Compare Bronze B
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)

UCare Easy Compare Silver and Rx Copay

Easy Compare Silver and Rx Copay
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)
Summary of Benefits and Coverage - Off-Exchange (PDF)
Summary of Benefits and Coverage - Off-Exchange - Spanish (PDF)

Easy Compare Silver and Rx Copay A
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)

Easy Compare Silver and Rx Copay B
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)

Easy Compare Silver and Rx Copay 2
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)

Easy Compare Silver and Rx Copay 3
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)

Easy Compare Silver and Rx Copay 4
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)

UCare Easy Compare Gold and Rx Copay

Easy Compare Gold and Rx Copay
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)
Summary of Benefits and Coverage - Off-Exchange (PDF)
Summary of Benefits and Coverage - Off-Exchange - Spanish (PDF)

Easy Compare Gold and Rx Copay A
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)

Easy Compare Gold and Rx Copay B
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)

UCare Individual & Family Plans with M Health Fairview

Member guide (PDF)
Formulary (list of covered drugs)
Provider and Pharmacy Directory (PDF)
Coverage Area Map (PDF)

Prior Authorization Data

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: Log on to your online member account to set up your automatic withdrawal.
Claim Reimbursement Form (PDF)
Prescription Drug Reimbursement Form (PDF)

UCare M Health Fairview Core

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)
Summary of Benefits and Coverage - Spanish (PDF)
Summary of Benefits and Coverage - Off-Exchange (PDF)
Summary of Benefits and Coverage - Off-Exchange - Spanish (PDF)

UCare M Health Fairview Bronze and UCare M Health Fairview Bronze HSA

Bronze
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)
Summary of Benefits and Coverage - Off-Exchange (PDF)
Summary of Benefits and Coverage - Off-Exchange - Spanish (PDF)

Bronze A
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)

Bronze B
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)

Bronze HSA
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)
Summary of Benefits and Coverage - Off-Exchange (PDF)
Summary of Benefits and Coverage - Off-Exchange - Spanish (PDF)

Bronze AH
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)

Bronze BH
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)

UCare M Health Fairview Silver and UCare M Health Fairview Silver and HSA

Silver
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)
Summary of Benefits and Coverage - Off-Exchange (PDF)
Summary of Benefits and Coverage - Off-Exchange - Spanish (PDF)

Silver A
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)

Silver B
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)

Silver 2
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)

Silver 3
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)

Silver 4
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)

Silver HSA
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)
Summary of Benefits and Coverage - Off-Exchange (PDF)
Summary of Benefits and Coverage - Off-Exchange - Spanish (PDF)

Silver AH
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)

Silver BH
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)

Silver 2H
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)

Silver 3H
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)

Silver 4H
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)

UCare M Health Fairview Gold

Gold
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)
Summary of Benefits and Coverage - Off-Exchange (PDF)
Summary of Benefits and Coverage - Off-Exchange - Spanish (PDF)

Gold A
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)

Gold B
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)