2024 UCare Medicare Plan Documents and Forms
UCare Medicare
Formulary (list of covered drugs)
Provider and Pharmacy Directory (PDF)
Provider and Pharmacy Directory - Spanish (PDF)
Service area map (PDF)
Member Guide (PDF)
Medicare Resource Guide (PDF)
TruHearing Hearing Aid Benefit (PDF)
UCare Dental Overview (PDF)
Dental Enrollment Form (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 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 Medicare Enrollment Form - Metro (PDF)
2024 Medicare Enrollment Form - South (PDF)
2024 Medicare Enrollment Form - North (PDF)
2024 Medicare Enrollment Form - Metro - Spanish (PDF)
2024 Medicare Enrollment Form - South - Spanish (PDF)
2024 Medicare Enrollment Form - North - Spanish (PDF)
2024 UCare Medicare Enrollment Change Form (PDF)
Dental Enrollment Form (PDF)
Dental Enrollment Form - Spanish (PDF)
Online Forms
2024 Dental Enrollment Form
2024 Medicare Enrollment Form - Metro
2024 Medicare Enrollment Form - North
2024 Medicare Enrollment Form - South
UCare Medicare Advantage Plans Overview (PDF)
UCare Medicare Advantage Plans Overview - Spanish (PDF)
Annual Notice of Changes (PDF)
Annual Notice of Changes - Spanish (PDF)
Evidence of Coverage (PDF)
Evidence of Coverage - Spanish (PDF)
Summary of Benefits - Metro (PDF)
Summary of Benefits - North (PDF)
Summary of Benefits - Metro - Spanish (PDF)
Summary of Benefits - North - Spanish (PDF)
Plan Comparison Chart - Metro (PDF)
Plan Comparison Chart - North (PDF)
UCare Medicare Advantage Plans Overview (PDF)
UCare Medicare Advantage Plans Overview - Spanish (PDF)
Metro
Annual Notice of Changes (PDF)
Annual Notice of Changes - Spanish (PDF)
Evidence of Coverage (PDF)
Evidence of Coverage - Spanish (PDF)
Summary of Benefits - Metro (PDF)
Summary of Benefits - Metro - Spanish (PDF)
Plan Comparison Chart - Metro (PDF)
2024 UCare Medicare Advantage Dental Certificate (PDF)
North
Annual Notice of Changes (PDF)
Annual Notice of Changes - Spanish (PDF)
Evidence of Coverage (PDF)
Evidence of Coverage - Spanish (PDF)
Summary of Benefits - North (PDF)
Summary of Benefits - North - Spanish (PDF)
Plan Comparison Chart - North (PDF)
2024 UCare Medicare Advantage Dental Certificate (PDF)
UCare Medicare Advantage Plans Overview (PDF)
UCare Medicare Advantage Plans Overview - Spanish (PDF)
Annual Notice of Changes (PDF)
Annual Notice of Changes - Spanish (PDF)
Evidence of Coverage (PDF)
Evidence of Coverage - Spanish (PDF)
Summary of Benefits - South (PDF)
Summary of Benefits - South - Spanish (PDF)
Plan Comparison Chart - South (PDF)
2024 UCare Medicare Advantage Dental Certificate (PDF)
UCare Medicare Advantage Plans Overview (PDF)
UCare Medicare Advantage Plans Overview - Spanish (PDF)
Metro
Annual Notice of Changes (PDF)
Annual Notice of Changes - Spanish (PDF)
Evidence of Coverage (PDF)
Evidence of Coverage - Spanish (PDF)
Summary of Benefits - Metro (PDF)
Summary of Benefits - Metro - Spanish (PDF)
Plan Comparison Chart - Metro (PDF)
North
Annual Notice of Changes (PDF)
Annual Notice of Changes - Spanish (PDF)
Evidence of Coverage (PDF)
Evidence of Coverage - Spanish (PDF)
Summary of Benefits - North (PDF)
Summary of Benefits - North - Spanish (PDF)
Plan Comparison Chart - North (PDF)
South
Annual Notice of Changes (PDF)
Annual Notice of Changes - Spanish (PDF)
Evidence of Coverage (PDF)
Evidence of Coverage - Spanish (PDF)
Summary of Benefits - South (PDF)
Summary of Benefits - South - Spanish (PDF)
UCare Medicare Advantage Plans Overview (PDF)
UCare Medicare Advantage Plans Overview - Spanish (PDF)
Metro
Annual Notice of Changes (PDF)
Annual Notice of Changes - Spanish (PDF)
Evidence of Coverage (PDF)
Evidence of Coverage - Spanish (PDF)
Summary of Benefits - Metro (PDF)
Summary of Benefits - Metro - Spanish (PDF)
Plan Comparison Chart - Metro (PDF)
2024 UCare Medicare Advantage Dental Certificate (PDF)
North
Annual Notice of Changes (PDF)
Annual Notice of Changes - Spanish (PDF)
Evidence of Coverage (PDF)
Evidence of Coverage - Spanish (PDF)
Summary of Benefits - North (PDF)
Summary of Benefits - North - Spanish (PDF)
Plan Comparison Chart - North (PDF)
2024 UCare Medicare Advantage Dental Certificate (PDF)
South
Annual Notice of Changes (PDF)
Annual Notice of Changes - Spanish (PDF)
Evidence of Coverage (PDF)
Evidence of Coverage - Spanish (PDF)
Summary of Benefits - South (PDF)
Summary of Benefits - South - Spanish (PDF)
Plan Comparison Chart - South (PDF)
2024 UCare Medicare Advantage Dental Certificate (PDF)
UCare Medicare Advantage Plans Overview (PDF)
UCare Medicare Advantage Plans Overview - Spanish (PDF)
Annual Notice of Changes (PDF)
Annual Notice of Changes - Spanish (PDF)
Evidence of Coverage (PDF)
Evidence of Coverage - Spanish (PDF)
Summary of Benefits - Metro (PDF)
Summary of Benefits - North (PDF)
Summary of Benefits - South (PDF)
Summary of Benefits - Metro - Spanish (PDF)
Summary of Benefits - North - Spanish (PDF)
Summary of Benefits - South - Spanish (PDF)
Plan Comparison Chart - Metro (PDF)
Plan Comparison Chart - North (PDF)
Plan Comparison Chart - South (PDF)
2024 UCare Medicare Advantage Dental Certificate (PDF)
Part B Medical Injectable Drug Authorization List (PDF) updated 10/11/2024
UCare Medicare Advantage Plans Overview (PDF)
UCare Medicare Advantage Plans Overview - Spanish (PDF)
Annual Notice of Changes (PDF)
Annual Notice of Changes - Spanish (PDF)
Evidence of Coverage (PDF)
Evidence of Coverage - Spanish (PDF)
Summary of Benefits - Metro (PDF)
Summary of Benefits - North (PDF)
Summary of Benefits - South (PDF)
Summary of Benefits - Metro - Spanish (PDF)
Summary of Benefits - North - Spanish (PDF)
Summary of Benefits - South - Spanish (PDF)
Plan Comparison Chart - Metro (PDF)
Plan Comparison Chart - North (PDF)
Plan Comparison Chart - South (PDF)
Part B Medical Injectable Drug Authorization List (PDF) updated 10/11/2024