2024 Plan Documents and Forms
To find your member documents, select your plan below.
To request a hard copy mailed to you, send us a message through your account in the Member Account or call Customer Service.
Member Newsletters - Catch up on the latest information and tips to help you stay healthy.
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 2/6/2024
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 2/6/2024
UCare Your Choice
Formulary (list of covered drugs)
Provider and Pharmacy Directory (PDF)
Provider and Pharmacy Directory - Spanish (PDF)
Service area map (PDF)
Member Guide (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 PDF
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 Your Choice Enrollment Change Form (PDF)
Online 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)
UCare Your Choice Summary of Benefits - Metro/North (PDF)
UCare Your Choice Summary of Benefits - Metro/North - Hmong (PDF)
UCare Your Choice Summary of Benefits - Metro/North - Spanish (PDF)
UCare Your Choice Summary of Benefits - South (PDF)
UCare Your Choice Summary of Benefits - South - Spanish (PDF)
Plan Comparison Chart - Metro (PDF)
Plan Comparison Chart - North (PDF)
Plan Comparison Chart - South (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)
UCare Your Choice Summary of Benefits - Metro/North (PDF)
UCare Your Choice Summary of Benefits - Metro/North - Hmong (PDF)
UCare Your Choice Summary of Benefits - Metro/North - Spanish (PDF)
Plan Comparison Chart - Metro (PDF)
Plan Comparison Chart - North (PDF)
EssentiaCare
Formulary (list of covered drugs)
Provider and Pharmacy Directory (PDF)
Provider and Pharmacy Directory - Spanish (PDF)
Service area map (PDF)
Medicare Basics (PDF)
Member Guide - Access (PDF)
Member Guide - Grand and Secure (PDF)
Plan Rating Information (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)
Enrollment Forms
Fillable PDFs
2024 EssentiaCare Enrollment Form (PDF)
2024 EssentiaCare Enrollment Form - Spanish (PDF)
2024 EssentiaCare Enrollment Change Form (PDF)
Dental Enrollment Form (PDF)
Dental Enrollment Form - Spanish (PDF)
Online Forms
2024 Dental Enrollment Form
2024 Medicare Enrollment Form - North
UCare Medicare with M Health Fairview & North Memorial
Formulary (list of covered drugs)
Provider and Pharmacy Directory (PDF)
Provider and Pharmacy Directory - Spanish (PDF)
Service area map (PDF)
Member Guide (PDF)
TruHearing Hearing Aid Benefit (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)
Claim Reimbursement Form (PDF)
Online Automatic Payment Form
Advance Directives (PDF)
Enrollment Forms
Fillable PDFs
2024 Medicare Enrollment Form - Metro (PDF)
2024 Medicare Enrollment Form - Metro - Spanish (PDF)
2024 Medicare Enrollment Change Form (PDF)
Online Forms
2024 Medicare Enrollment Form - Metro
UCare Advocate Plans
Formulary (list of covered drugs)
Provider and Pharmacy Directory (PDF)
Provider and Pharmacy Directory - Spanish (PDF)
Plan Rating Information (PDF)
Plan Rating Information - Spanish (PDF)
TruHearing Hearing Aid Benefit (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 PDF
2024 Medicare Enrollment Form (PDF)
UCare Medicare Supplement
Enrollment Form (PDF)
TruHearing Hearing Aid Benefit (PDF)
Online Enrollment Form
UCare Medicare Group Plans
Note: Summary of Benefits and Evidence of Coverage are determined per group. If you are a member and have questions about your particular Group plan, please call UCare Medicare Group Customer Service at 612-676-6840 or 1-877-447-4385 toll free. We are available 8 am – 8 pm , seven days a week.
Plan Documents
Formulary (list of covered drugs)
Provider and Pharmacy Directory (PDF)
Provider and Pharmacy Directory - Spanish (PDF)
To request a bound copy of our Provider/Pharmacy Directory, please call customer service at the number on the back of your member ID card.
Member Guide (PDF)
Medicare Group Classic Dental Plan Overview (PDF)
Dental Enrollment Form (PDF)
Dental Enrollment Form - Spanish (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 Forms
Medicare Claim Reimbursement Form (PDF)
Use this form to be reimbursed for covered health care expenses.
Prescription Drug Claim Form (PDF)
Request for Medicare Prescription Drug Coverage Determination Form (PDF)
Request for Redetermination of Medicare Prescription Drug Denial Form (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
Sign up to have your plan premium automatically deducted from your checking or savings account each month.
Part D Coverage Determinations, Appeals and Grievances
Part C Organizational Determinations, Appeals and Grievances
Instructions for Appointing a Representative (PDF)
Rights and Responsibilities Upon Disenrollment (PDF)
Prescription Drug Transition Policy (PDF)
Advance Directives (PDF)
Enrollment Forms
2024 Online Enrollment Form
2024 Online Dental Enrollment Form
Medicaid + Medicare
Member Release of Information Form (PDF)
Member Release of Information Form - Arabic (PDF)
Member Release of Information Form - Hmong (PDF)
Member Release of Information Form - Russian (PDF)
Member Release of Information Form - Somali (PDF)
Member Release of Information Form - Spanish (PDF)
Member Release of Information Form - Vietnamese (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)
Deceased Member: Affidavit for the Collection of Personal Property (mncourts.gov)
Statement of Representative Form (PDF)
Statement of Representative Form - Arabic (PDF)
Statement of Representative Form - Hmong (PDF)
Statement of Representative Form - Russian (PDF)
Statement of Representative Form - Somali (PDF)
Statement of Representative Form - Spanish (PDF)
Statement of Representative Form - Vietnamese (PDF)
Medicare Coverage Updates
Formulary (list of covered drugs)
Provider and Pharmacy Directory (PDF)
Provider and Pharmacy Directory - Hmong (PDF)
Provider and Pharmacy Directory - Somali (PDF)
Annual Notice of Changes (PDF)
Annual Notice of Changes - Hmong (PDF)
Annual Notice of Changes - Somali (PDF)
Annual Notice of Changes - Spanish (PDF)
Summary of Benefits (PDF)
Summary of Benefits - Hmong (PDF)
Summary of Benefits - Somali (PDF)
Member Handbook (PDF)
Member Guide (PDF)
Plan Rating Information (PDF)
Plan Rating Information - Hmong (PDF)
Plan Rating Information - Somali (PDF)
Plan Rating Information - Spanish (PDF)
Advance Directives Info (PDF)
Formulary (list of covered drugs)
Provider and Pharmacy Directory (PDF)
Provider and Pharmacy Directory - Hmong (PDF)
Provider and Pharmacy Directory - Somali (PDF)
Member Handbook (PDF)
Member Guide (PDF)
Annual Notice of Changes (PDF)
Annual Notice of Changes - Spanish (PDF)
Summary of Benefits (PDF)
Summary of Benefits - Hmong (PDF)
Summary of Benefits - Somali (PDF)
Plan Rating Information (PDF)
Advance Directive Info (PDF)
Minnesota Health Care Programs
Formulary
Member Release of Information Form (PDF)
Member Release of Information Form - Arabic (PDF)
Member Release of Information Form - Hmong (PDF)
Member Release of Information Form - Russian (PDF)
Member Release of Information Form - Somali (PDF)
Member Release of Information Form - Spanish (PDF)
Member Release of Information Form - Vietnamese (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)
Statement of Representative Form (PDF)
Statement of Representative Form - Arabic (PDF)
Statement of Representative Form - Hmong (PDF)
Statement of Representative Form - Russian (PDF)
Statement of Representative Form - Somali (PDF)
Statement of Representative Form - Spanish (PDF)
Statement of Representative Form - Vietnamese (PDF)
Power of Attorney short form
Deceased Member: Affidavit for the Collection of Personal Property (mncourts.gov)
Advance Directives Info (PDF)
Parent/Guardian Authorization Form for Unaccompanied Minors (PDF)
Provider and Pharmacy Directory (PDF)
Provider and Pharmacy Directory - Arabic (PDF)
Provider and Pharmacy Directory - Hmong (PDF)
Provider and Pharmacy Directory - Russian (PDF)
Provider and Pharmacy Directory - Somali (PDF)
Provider and Pharmacy Directory - Spanish (PDF)
Provider and Pharmacy Directory - Vietnamese (PDF)
Provider and Pharmacy Directory (PDF)
Provider and Pharmacy Directory - Arabic (PDF)
Provider and Pharmacy Directory - Hmong (PDF)
Provider and Pharmacy Directory - Russian (PDF)
Provider and Pharmacy Directory - Somali (PDF)
Provider and Pharmacy Directory - Spanish (PDF)
Provider and Pharmacy Directory - Vietnamese (PDF)
Provider and Pharmacy Directory (PDF)
Provider and Pharmacy Directory - Arabic (PDF)
Provider and Pharmacy Directory - Hmong (PDF)
Provider and Pharmacy Directory - Russian (PDF)
Provider and Pharmacy Directory - Somali (PDF)
Provider and Pharmacy Directory - Spanish (PDF)
Provider and Pharmacy Directory - Vietnamese (PDF)
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)
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)
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)
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)
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)