2023 Individual & Family Plans Documents and Information

View the documents below for benefit and coverage information, including deductibles, copays and emergency services. To request a hard copy mailed to you, send us a message through your account in the Member Account or call Customer Service.

UCare Individual & Family Plans

New Member Guide (PDF)
Formulary (list of covered drugs)
Provider and Pharmacy Directory (PDF)
Network Adequacy Waiver (PDF)
ECP Network Adequacy Waiver (PDF)
Coverage Area Map (PDF)

Member Release of Information Form (PDF)
Prior Authorization Information (PDF)
Prior Authorization Data
Statement of Representative Form (PDF)
Power of Attorney short form
Deceased Member: Affidavit for the Collection of Personal Property (mncourts.gov)

Online Automatic Payment Form
Claim Reimbursement Form (PDF)
Prescription Drug Reimbursement Form (PDF)

UCare 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 Individual & Family Plans with M Health Fairview

New Member Guide (PDF)
Formulary (list of covered drugs)
Provider and Pharmacy Directory (PDF)
Network Adequacy Waiver (PDF)
Coverage Area Map (PDF)

Online Automatic Payment Form
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 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 2 HSA
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)