2024 UCare Individual & Family Plans Plan Documents and Forms
UCare Individual & Family Plans
New Member Guide (PDF)
Formulary (list of covered drugs)
Provider and Pharmacy Directory (PDF)
Coverage Area Map (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)
Prior Authorization Data
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)
Fillable PDFs
2024 Individual & Family Plans Enrollment Form (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)
Bronze
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Bronze A
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Bronze B
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Bronze HSA
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Bronze AH
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Bronze BH
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Bronze Access
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Bronze Access A
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Bronze Access B
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Silver StandardRx
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Silver StandardRx A
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Silver StandardRx B
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Silver StandardRx 2
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Silver StandardRx 3
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Silver StandardRx 4
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Silver HSA
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Silver AH
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Silver BH
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Silver 2H
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Silver 3H
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Silver 4H
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Gold StandardRx
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Gold StandardRx A
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Gold StandardRx B
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)