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2024 UCare Individual & Family Plans with M Health Fairview Plan Documents and Forms

UCare Individual & Family Plans with M Health Fairview

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)

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)

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

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)

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

Silver
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)

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

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

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

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

Silver 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)

UCare M Health Fairview Gold

Gold
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)

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

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