2024 UCare Medicare Group Plan Documents and Forms

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