2024 EssentiaCare Plan Documents and Forms

EssentiaCare

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

Member Guide - Access (PDF)
Member Guide - Grand and Secure (PDF)

Plan Rating Information (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)
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 EssentiaCare Enrollment Form (PDF)
2024 EssentiaCare Enrollment Form - Spanish (PDF)
2024 EssentiaCare Enrollment Change Form (PDF)
Dental Enrollment Form (PDF)
Dental Enrollment Form - Spanish (PDF)

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