2025 UCare Individual & Family Plans Plan Documents and Forms
UCare Individual & Family Plans
Member guide (PDF)
Formulary (list of covered drugs)
Plan overview (PDF)
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)
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)
HSA-compatible plan guide (PDF)
Fillable PDFs
2025 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)
Summary of Benefits and Coverage - Spanish (PDF)
Summary of Benefits and Coverage - Off Exchange (PDF)
Summary of Benefits and Coverage - Off-Exchange - Spanish (PDF)
Bronze
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)
Summary of Benefits and Coverage - Off-Exchange (PDF)
Summary of Benefits and Coverage - Off-Exchange - Spanish (PDF)
Bronze A
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)
Bronze B
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)
Bronze HSA
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)
Summary of Benefits and Coverage - Off-Exchange (PDF)
Summary of Benefits and Coverage - Off-Exchange - Spanish (PDF)
Bronze AH
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)
Bronze BH
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)
Bronze Access
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)
Summary of Benefits and Coverage - Off-Exchange (PDF)
Summary of Benefits and Coverage - Off-Exchange - Spanish (PDF)
Bronze Access A
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)
Bronze Access B
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)
Silver
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)
Summary of Benefits and Coverage - Off-Exchange (PDF)
Summary of Benefits and Coverage - Off-Exchange - Spanish (PDF)
Silver A
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)
Silver B
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)
Silver 2
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)
Silver 3
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)
Silver 4
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)
Silver HSA
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)
Summary of Benefits and Coverage - Off-Exchange (PDF)
Summary of Benefits and Coverage - Off-Exchange - Spanish (PDF)
Silver AH
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)
Silver BH
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)
Silver 2H
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)
Silver 3H
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)
Silver 4H
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)
Gold
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)
Summary of Benefits and Coverage - Off-Exchange (PDF)
Summary of Benefits and Coverage - Off-Exchange - Spanish (PDF)
Gold A
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)
Gold B
Member Contract (PDF)
Summary of Benefits and Coverage (PDF)
Summary of Benefits and Coverage - Spanish (PDF)