2024 Medical Assistance + Medicare Plan Documents and Forms
Medical Assistance + 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 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)
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
Formulary (list of covered drugs)
Provider and Pharmacy Directory (PDF)
Provider and Pharmacy Directory - Hmong (PDF)
Provider and Pharmacy Directory - Somali (PDF)
Annual Notice of Changes (PDF)
Annual Notice of Changes - Hmong (PDF)
Annual Notice of Changes - Somali (PDF)
Annual Notice of Changes - Spanish (PDF)
Summary of Benefits (PDF)
Summary of Benefits - Hmong (PDF)
Summary of Benefits - Somali (PDF)
Member Handbook (PDF)
Member Guide (PDF)
Member Guide - Hmong (PDF)
Member Guide - Somali (PDF)
Plan Rating Information (PDF)
Plan Rating Information - Hmong (PDF)
Plan Rating Information - Somali (PDF)
Plan Rating Information - Spanish (PDF)
Advance Directives Info (PDF)
Formulary (list of covered drugs)
Provider and Pharmacy Directory (PDF)
Provider and Pharmacy Directory - Hmong (PDF)
Provider and Pharmacy Directory - Somali (PDF)
Member Handbook (PDF)
Member Guide (PDF)
Annual Notice of Changes (PDF)
Annual Notice of Changes - Spanish (PDF)
Summary of Benefits (PDF)
Summary of Benefits - Hmong (PDF)
Summary of Benefits - Somali (PDF)
Plan Rating Information (PDF)
Advance Directive Info (PDF)