Plan Documents and Information
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 Services.
Use this form to notify UCare of your gender preference if it is different than the sex you were assigned at birth. This will help process your health care claims appropriately.
Get Engaged - Learn about our ambassador, advocacy and feedback programs for members.
Member Newsletters - Catch up on the latest information and tips to help you stay healthy.
2021 Documents
Choose your coverage type, then plan:
We are going green! You can find complete information online about your benefits and coverage in the Evidence of Coverage (EOC), available providers and pharmacies in the Provider Directory, and prescription drugs in the Formulary. If you would like a hard copy mailed to you, send us a message through your account in the Member Account or call Customer Services.
UCare Medicare Plans
Provider and Pharmacy Directory
(PDF)
Formulary
Service Area Map
(PDF)
Welcome Booklet
(PDF)
Travel Benefit
(PDF)
TruHearing Hearing Aid Benefit
UCare Dental Overview
(PDF)
Plan Rating Information
(PDF)
Member Release of Information Form
(PDF)
Statement of Representative Form
(PDF)
Power of Attorney short form (PDF)
Automatic Payment Form
(PDF)
Claim Reimbursement Form
(PDF)
+
–
Prime
Metro/North
Annual Notice of Changes
(PDF)
Evidence of Coverage
(PDF)
Summary of Benefits - Metro
(PDF)
Summary of Benefits - North
(PDF)
South
Evidence of Coverage
(PDF)
Summary of Benefits - South
(PDF)
+
–
Value
Annual Notice of Changes
(PDF)
Evidence of Coverage
(PDF)
Summary of Benefits - Metro
(PDF)
Summary of Benefits - North
(PDF)
Summary of Benefits - South
(PDF)
Part B Medical Injectable Drug Authorization List (PDF) (updated 9/30/20)
+
–
Value Plus
Evidence of Coverage
(PDF)
Summary of Benefits - Metro
(PDF)
Summary of Benefits - North
(PDF)
Summary of Benefits - South
(PDF)
Part B Medical Injectable Drug Authorization List (PDF) (updated 9/30/20)
+
–
Standard
Annual Notice of Changes
(PDF)
Evidence of Coverage
(PDF)
Summary of Benefits - South
(PDF)
+
–
Essentials Rx
Metro
Annual Notice of Changes
(PDF)
Evidence of Coverage
(PDF)
Summary of Benefits - Metro
(PDF)
North
Annual Notice of Changes
(PDF)
Evidence of Coverage
(PDF)
Summary of Benefits - North
(PDF)
+
–
Complete
Metro
Evidence of Coverage
(PDF)
Annual Notice of Changes
(PDF)
Summary of Benefits - Metro
(PDF)
North
Evidence of Coverage
(PDF)
Annual Notice of Changes
(PDF)
Summary of Benefits - North
(PDF)
South
Evidence of Coverage
(PDF)
Annual Notice of Changes
(PDF)
Summary of Benefits - South
(PDF)
+
–
Classic
Metro
Annual Notice of Changes
(PDF)
Evidence of Coverage
(PDF)
Summary of Benefits - Metro
(PDF)
North
Annual Notice of Changes
(PDF)
Evidence of Coverage
(PDF)
Summary of Benefits - North
(PDF)
South
Annual Notice of Changes
(PDF)
Evidence of Coverage
(PDF)
Summary of Benefits - South
(PDF)
+
–
Aware
Evidence of Coverage
(PDF)
Summary of Benefits - Metro
(PDF)
Summary of Benefits - North
(PDF)
+
–
What are the North, Metro and South regions?
Health care costs can vary depending on the area in which you live. Our UCare Medicare coverage area is divided into three regions based on counties: North, Metro and South. Find your county on the list below or view the map of Medicare regions to find out which region you are in.
North
Aitkin
Becker
Beltrami
Carlton
Cass
Clay
Clearwater
Cook
Crow Wing
Douglas
Grant
Hubbard
Itasca
Kanabec
Kittson
Koochiching
Lake
Lake of the Woods
Mahnomen
Marshall
Morrison
Norman
Otter Tail
Pennington
Pine
Polk
Red Lake
Roseau
St. Louis
Todd
Wadena
Wilkin
Metro
Anoka
Benton
Carver
Chisago
Dakota
Hennepin
Isanti
Mille Lacs
Ramsey
Scott
Sherburne
Stearns
Washington
Wright
South
Big Stone
Blue Earth
Brown
Chippewa
Cottonwood
Dodge
Faribault
Fillmore
Freeborn
Goodhue
Houston
Jackson
Kandiyohi
Lac qui Parle
Le Sueur
Lincoln
Lyon
Martin
McLeod
Meeker
Mower
Murray
Nicollet
Nobles
Olmsted
Pipestone
Pope
Redwood
Renville
Rice
Rock
Sibley
Steele
Stevens
Swift
Traverse
Wabasha
Waseca
Watonwan
Winona
Yellow Medicine
UCare Medicare Group Plans
Note: Summary of Benefits and Evidence of Coverage are determined per group.
Provider and Pharmacy Directories
(PDF)
Formulary
TruHearing Hearing Aid Benefit Information
Plan Rating Information
(PDF)
Member Release of Information Form
(PDF)
Statement of Representative Form
(PDF)
Power of Attorney short form (PDF)
Automatic Payment Form
(PDF)
UCare Advocate Plans
Provider and Pharmacy Directory
(PDF)
Formulary
Service Area Map
(PDF)
Member Release of Information Form
(PDF)
Statement of Representative Form
(PDF)
Power of Attorney short form (PDF)
Automatic Payment Form
(PDF)
Claim Reibursement Form
(PDF)
+
–
UCare Advocate Choice
Evidence of Coverage
(PDF)
Summary of Benefits
(PDF)
+
–
UCare Advocate Plus
Evidence of Coverage
(PDF)
Summary of Benefits
(PDF)
EssentiaCare
Provider and Pharmacy Directory
(PDF)
Formulary
Service Area Map
(PDF)
Travel Benefit
(PDF)
Plan Rating Information
(PDF)
Member Release of Information Form
(PDF)
Member Release of Information Form
(PDF)
Power of Attorney short form (PDF)
Automatic Payment Form
(PDF)
Claim Reimbursement Form
(PDF)
+
–
Secure
Evidence of Coverage
(PDF)
Annual Notice of Changes
(PDF)
Summary of Benefits
(PDF)
+
–
Grand
Evidence of Coverage
(PDF)
Annual Notice of Changes
(PDF)
Summary of Benefits
(PDF)
+
–
Access
Evidence of Coverage
(PDF)
Summary of Benefits
(PDF)
UCare Medicare with M Health Fairview & North Memorial
Provider and Pharmacy Directory
(PDF)
Formulary
Service Area Map
(PDF)
Travel Benefit
(PDF)
TruHearing Hearing Aid Benefit
Medicare Advantage Member Programs
(PDF)
Plan Rating Information
(PDF)
Member Release of Information Form
(PDF)
Statement of Representative Form
(PDF)
Power of Attorney short form (PDF)
Automatic Payment Form
(PDF)
Claim Reimbursement Form
(PDF)
+
–
Care Core with M Health Fairview & North Memorial
Evidence of Coverage
(PDF)
Annual Notice of Changes
(PDF)
Summary of Benefits
(PDF)
+
–
Care Advantage with M Health Fairview & North Memorial
Evidence of Coverage
(PDF)
Annual Notice of Changes
(PDF)
Summary of Benefits
(PDF)
UCare Medicare Supplement
+
–
Basic
Policy
(PDF)
Outline of Coverage
(PDF)
Part A Deductible Rider
(PDF)
Part B Deductible
(PDF)
Part B Excess Charges Rider
(PDF)
Preventive Care Rider
(PDF)
+
–
Extended Basic
Policy
(PDF)
Outline of Coverage
(PDF)
+
–
$20/$50 Copay
Policy
(PDF)
Outline of Coverage
(PDF)
How to Enroll
+
–
Mail-in forms
To enroll by mail:
Medicare Advantage
Enrollment Form - Metro
(PDF)
Enrollment Form - South
(PDF)
Enrollment Form - North
(PDF) (Includes EssentiaCare)
Dental Enrollment Form
(PDF)
UCare Medicare Enrollment Change Form
(PDF)
EssentiaCare Enrollment Change Form
(PDF)
Medicare Supplement
Enrollment Form - Medicare Supplement
(PDF)
Additional Links and Documents
Medicaid + Medicare
Member Release of Information Form
(PDF)
Prior Authorization Information
(PDF)
Power of Attorney short form (PDF)
Statement of Representative Form
(PDF)
Medicare Coverage Updates
+
–
UCare's Minnesota Senior Health Options (MSHO)
+
–
UCare Connect + Medicare
Minnesota Health Care Programs
Member Release of Information Form
(PDF)
Prior Authorization Information
(PDF)
Statement of Representative Form
(PDF)
Power of Attorney short form (PDF)
+
–
UCare Connect
+
–
Prepaid Medical Assistance Program (PMAP)
+
–
Minnesota Senior Care Plus (MSC+)
+
–
MinnesotaCare (MnCare)
UCare Individual & Family Plans
New Member Guide
(PDF)
Member Release of Information Form
(PDF)
Prior Authorization Information
(PDF)
Statement of Representative Form
(PDF)
Power of Attorney short form (PDF)
Formulary
Provider and Pharmacy Directory
(PDF)
Service Area Map
(PDF)
Automatic Payment Form
(PDF)
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)
Quick Reference Guide
(PDF)
+
–
UCare Bronze and UCare Bronze HSA
Bronze
Member Contract
(PDF)
Summary of Benefits and Coverage
(PDF)
Quick Reference Guide
(PDF)
Bronze A
Member Contract
(PDF)
Summary of Benefits and Coverage
(PDF)
Quick Reference Guide
(PDF)
Bronze B
Member Contract
(PDF)
Summary of Benefits and Coverage
(PDF)
Quick Reference Guide
(PDF)
Bronze HSA
Member Contract
(PDF)
Summary of Benefits and Coverage
(PDF)
Quick Reference Guide
(PDF)
Bronze AH
Member Contract
(PDF)
Summary of Benefits and Coverage
(PDF)
Quick Reference Guide
(PDF)
Bronze BH
Member Contract
(PDF)
Summary of Benefits and Coverage
(PDF)
Quick Reference Guide
(PDF)
+
–
UCare Silver and UCare Silver HSA
Silver
Member Contract
(PDF)
Summary of Benefits and Coverage
(PDF)
Quick Reference Guide
(PDF)
Silver A
Member Contract
(PDF)
Summary of Benefits and Coverage
(PDF)
Quick Reference Guide
(PDF)
Silver B
Member Contract
(PDF)
Summary of Benefits and Coverage
(PDF)
Quick Reference Guide
(PDF)
Silver 2
Member Contract
(PDF)
Summary of Benefits and Coverage
(PDF)
Quick Reference Guide
(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)
Quick Reference Guide
(PDF)
Silver AH
Member Contract
(PDF)
Summary of Benefits and Coverage
(PDF)
Quick Reference Guide
(PDF)
Silver BH
Member Contract
(PDF)
Summary of Benefits and Coverage
(PDF)
Quick Reference Guide
(PDF)
Silver 2 HSA
Member Contract
(PDF)
Summary of Benefits and Coverage
(PDF)
Quick Reference Guide
(PDF)
Silver 3H
Member Contract
(PDF)
Summary of Benefits and Coverage
(PDF)
Silver 4H
Member Contract
(PDF)
Summary of Benefits and Coverage
(PDF)
+
–
UCare Gold
Gold
Member Contract
(PDF)
Summary of Benefits and Coverage
(PDF)
Quick Reference Guide
(PDF)
Gold A
Member Contract
(PDF)
Summary of Benefits and Coverage
(PDF)
Quick Reference Guide
(PDF)
Gold B
Member Contract
(PDF)
Summary of Benefits and Coverage
(PDF)
Quick Reference Guide
(PDF)
Additional Links and Documents
UCare Individual & Family Plans with M Health Fairview
New Member Guide
(PDF)
Member Release of Information Form
(PDF)
Prior Authorization Information
(PDF)
Statement of Representative Form
(PDF)
Power of Attorney short form (PDF)
Formulary
Provider and Pharmacy Directories
(PDF)
Service Area Map
(PDF)
Automatic Payment Form
(PDF)
Claim Reimbursement Form
(PDF)
Prescription Drug Reimbursement Form
(PDF)
+
–
UCare M Health Fairview Bronze and UCare M Health Fairview Bronze HSA
Bronze
Member Contract
(PDF)
Summary of Benefits and Coverage
(PDF)
Quick Reference Guide
(PDF)
Bronze A
Member Contract
(PDF)
Summary of Benefits and Coverage
(PDF)
Quick Reference Guide
(PDF)
Bronze B
Member Contract
(PDF)
Summary of Benefits and Coverage
(PDF)
Quick Reference Guide
(PDF)
Bronze HSA
Member Contract
(PDF)
Summary of Benefits and Coverage
(PDF)
Quick Reference Guide
(PDF)
Bronze AH
Member Contract
(PDF)
Summary of Benefits and Coverage
(PDF)
Quick Reference Guide
(PDF)
Bronze BH
Member Contract
(PDF)
Summary of Benefits and Coverage
(PDF)
Quick Reference Guide
(PDF)
+
–
UCare M Health Fairview Silver and UCare M Health Fairview Silver HSA
Silver
Member Contract
(PDF)
Summary of Benefits and Coverage
(PDF)
Quick Reference Guide
(PDF)
Silver A
Member Contract
(PDF)
Summary of Benefits and Coverage
(PDF)
Quick Reference Guide
(PDF)
Silver B
Member Contract
(PDF)
Summary of Benefits and Coverage
(PDF)
Quick Reference Guide
(PDF)
Silver 2
Member Contract
(PDF)
Summary of Benefits and Coverage
(PDF)
Quick Reference Guide
(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)
Quick Reference Guide
(PDF)
Silver AH
Member Contract
(PDF)
Summary of Benefits and Coverage
(PDF)
Quick Reference Guide
(PDF)
Silver BH
Member Contract
(PDF)
Summary of Benefits and Coverage
(PDF)
Quick Reference Guide
(PDF)
Silver 2 HSA
Member Contract
(PDF)
Summary of Benefits and Coverage
(PDF)
Quick Reference Guide
(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)
Quick Reference Guide
(PDF)
Gold A
Member Contract
(PDF)
Summary of Benefits and Coverage
(PDF)
Quick Reference Guide
(PDF)
Gold B
Member Contract
(PDF)
Summary of Benefits and Coverage
(PDF)
Quick Reference Guide
(PDF)
+
–
2020 Documents
We are going green! You can find complete information online about your benefits and coverage in the Evidence of Coverage (EOC), available providers and pharmacies in the Provider Directory, and prescription drugs in the Formulary. If you would like a hard copy mailed to you, send us a message through your account in the Member Portal or call Customer Services.
UCare Medicare Plans
Service Area Map
(PDF)
Welcome Booklet
(PDF)
Formulary
Travel Benefit
(PDF)
Member Release of Information Form
(PDF)
Statement of Representative Form
(PDF)
Power of Attorney short form (PDF)
Automatic Payment Form
(PDF)
Claim Reimbursement Form
(PDF)
+
–
Prime
+
–
Value
Annual Notice of Changes
(PDF)
Evidence of Coverage
(PDF)
Summary of Benefits - Metro
(PDF)
Summary of Benefits - North
(PDF)
Summary of Benefits - South
(PDF)
Provider and Pharmacy Directory
(PDF)
TruHearing Hearing Aid Benefit Information
Part B Medical Injectable Drug Authorization List
(PDF) (updated 7/24/20)
Plan Rating Information
(PDF)
+
–
Standard
+
–
Essentials Rx
Metro
Annual Notice of Changes - Metro
(PDF)
Evidence of Coverage
(PDF)
Summary of Benefits - Metro
(PDF)
North
Annual Notice of Change - North
(PDF)
Evidence of Coverage
(PDF)
Summary of Benefits - North
(PDF)
Provider and Pharmacy Directory
(PDF)
TruHearing Hearing Aid Benefit Information
Plan Rating Information (PDF)
+
–
Complete
Metro
Evidence of Coverage
(PDF)
Annual Notice of Changes
(PDF)
Summary of Benefits - Metro
(PDF)
North
Evidence of Coverage
(PDF)
Annual Notice of Changes
(PDF)
Summary of Benefits - North
(PDF)
South
Evidence of Coverage
(PDF)
Annual Notice of Changes
(PDF)
Summary of Benefits - South
(PDF)
Provider and Pharmacy Directories
(PDF)
TruHearing Hearing Aid Benefit Information
Plan Rating Information (PDF)
+
–
Classic
Metro
Annual Notice of Changes - Metro
(PDF)
Evidence of Coverage
(PDF)
Summary of Benefits - Metro
(PDF)
North
Annual Notice of Changes - North
(PDF)
Evidence of Coverage
(PDF)
Summary of Benefits - North
(PDF)
South
Annual Notice of Changes - South
(PDF)
Evidence of Coverage
(PDF)
Summary of Benefits - South
(PDF)
Provider and Pharmacy Directories
(PDF)
TruHearing Hearing Aid Benefit Information
Plan Rating Information (PDF)
+
–
Total
Metro
Evidence of Coverage - Metro
(PDF)
Annual Notice of Changes
(PDF)
Summary of Benefits - Metro
(PDF)
North
Evidence of Coverage - North
(PDF)
Annual Notice of Changes
(PDF)
Summary of Benefits - North
(PDF)
South
Evidence of Coverage - South
(PDF)
Annual Notice of Changes
(PDF)
Summary of Benefits - South
(PDF)
Provider and Pharmacy Directories
(PDF)
TruHearing Hearing Aid Benefit Information
Plan Rating Information (PDF)
+
–
What are the North, Metro and South regions?
Health care costs can vary depending on the area in which you live. Our UCare Medicare coverage area is divided into three regions based on counties: North, Metro and South. Find your county on the list below or view the map of Medicare regions to find out which region you are in.
North
Aitkin
Becker
Beltrami
Carlton
Cass
Clay
Clearwater
Cook
Crow Wing
Douglas
Grant
Hubbard
Itasca
Kanabec
Kittson
Koochiching
Lake
Lake of the Woods
Mahnomen
Marshall
Morrison
Norman
Otter Tail
Pennington
Pine
Polk
Red Lake
Roseau
St. Louis
Todd
Wadena
Wilkin
Metro
Anoka
Benton
Carver
Chisago
Dakota
Hennepin
Isanti
Mille Lacs
Ramsey
Scott
Sherburne
Stearns
Washington
Wright
South
Big Stone
Blue Earth
Brown
Chippewa
Cottonwood
Dodge
Faribault
Fillmore
Freeborn
Goodhue
Houston
Jackson
Kandiyohi
Lac qui Parle
Le Sueur
Lincoln
Lyon
Martin
McLeod
Meeker
Mower
Murray
Nicollet
Nobles
Olmsted
Pipestone
Pope
Redwood
Renville
Rice
Rock
Sibley
Steele
Stevens
Swift
Traverse
Wabasha
Waseca
Watonwan
Winona
Yellow Medicine
UCare Medicare Group Plans
Note: Summary of Benefits and Evidence of Coverage are determined per group.
Formulary
Provider and Pharmacy Directories
(PDF)
TruHearing Hearing Aid Benefit Information
Plan Rating Information
(PDF)
Member Release of Information Form
(PDF)
Statement of Representative Form
(PDF)
Power of Attorney short form (PDF)
Automatic Payment Form
(PDF)
EssentiaCare
Service Area Map
(PDF)
Formulary
Travel Benefit
(PDF)
Member Release of Information Form
(PDF)
Statement of Representative Form
(PDF)
Power of Attorney short form (PDF)
Automatic Payment Form
(PDF)
Claim Reimbursement Form
(PDF)
+
–
Secure
+
–
Grand
UCare Medicare with M Health Fairview & North Memorial
Service Area Map
(PDF)
Formulary
Travel Benefit
(PDF)
Medicare Advantage Member Programs
(PDF)
Member Release of Information Form
(PDF)
Statement of Representative Form
(PDF)
Power of Attorney short form (PDF)
Automatic Payment Form
(PDF)
Claim Reibursement Form
(PDF)
+
–
Care Core with M Health Fairview & North Memorial
+
–
Care Advantage with M Health Fairview & North Memorial
How to Enroll
+
–
Mail-in forms
To enroll by mail:
Enrollment Form - Metro
(PDF)
Enrollment Form - South
(PDF)
Enrollment Form - North
(PDF) (Includes EssentiaCare)
Dental Enrollment Form
(PDF)
Additional Links and Documents
Medicaid + Medicare
Member Release of Information Form
(PDF)
Prior Authorization Information
(PDF)
Power of Attorney short form (PDF)
Medicare Coverage Updates
+
–
UCare's Minnesota Senior Health Options (MSHO)
+
–
UCare Connect + Medicare
Minnesota Health Care Programs
Member Release of Information Form
(PDF)
Prior Authorization Information
(PDF)
Statement of Representative Form
(PDF)
Power of Attorney short form (PDF)
+
–
UCare Connect
+
–
Prepaid Medical Assistance Program (PMAP)
+
–
Minnesota Senior Care Plus (MSC+)
+
–
MinnesotaCare (MnCare)
UCare Individual & Family Plans
New Member Guide
(PDF)
Member Release of Information Form
(PDF)
Prior Authorization Information
(PDF)
Statement of Representative Form
(PDF)
Power of Attorney short form (PDF)
Formulary
Provider and Pharmacy Directory
(PDF)
Service Area Map
(PDF)
Automatic Payment Form
(PDF)
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)
Quick Reference Guide
(PDF)
+
–
UCare Bronze and UCare Bronze HSA
Bronze
Member Contract
(PDF)
Summary of Benefits and Coverage
(PDF)
Quick Reference Guide
(PDF)
Bronze A
Member Contract
(PDF)
Summary of Benefits and Coverage
(PDF)
Quick Reference Guide
(PDF)
Bronze B
Member Contract
(PDF)
Summary of Benefits and Coverage
(PDF)
Quick Reference Guide
(PDF)
Bronze HSA
Member Contract
(PDF)
Summary of Benefits and Coverage
(PDF)
Quick Reference Guide
(PDF)
Bronze AH
Member Contract
(PDF)
Summary of Benefits and Coverage
(PDF)
Quick Reference Guide
(PDF)
Bronze BH
Member Contract
(PDF)
Summary of Benefits and Coverage
(PDF)
Quick Reference Guide
(PDF)
+
–
UCare Silver and UCare Silver HSA
Silver
Member Contract
(PDF)
Summary of Benefits and Coverage
(PDF)
Quick Reference Guide
(PDF)
Silver A
Member Contract
(PDF)
Summary of Benefits and Coverage
(PDF)
Quick Reference Guide
(PDF)
Silver B
Member Contract
(PDF)
Summary of Benefits and Coverage
(PDF)
Quick Reference Guide
(PDF)
Silver 2
Member Contract
(PDF)
Summary of Benefits and Coverage
(PDF)
Quick Reference Guide
(PDF)
Silver 3
Member Contract
(PDF)
Summary of Benefits and Coverage
(PDF)
Quick Reference Guide
(PDF)
Silver 4
Member Contract
(PDF)
Summary of Benefits and Coverage
(PDF)
Quick Reference Guide
(PDF)
Silver HSA
Member Contract
(PDF)
Summary of Benefits and Coverage
(PDF)
Quick Reference Guide
(PDF)
Silver AH
Member Contract
(PDF)
Summary of Benefits and Coverage
(PDF)
Quick Reference Guide
(PDF)
Silver BH
Member Contract
(PDF)
Summary of Benefits and Coverage
(PDF)
Quick Reference Guide
(PDF)
Silver 2 HSA
Member Contract
(PDF)
Summary of Benefits and Coverage
(PDF)
Quick Reference Guide
(PDF)
Silver 3H
Member Contract
(PDF)
Summary of Benefits and Coverage
(PDF)
Quick Reference Guide
(PDF)
Silver 4H
Member Contract
(PDF)
Summary of Benefits and Coverage
(PDF)
Quick Reference Guide
(PDF)
+
–
UCare Gold
Gold
Member Contract
(PDF)
Summary of Benefits and Coverage
(PDF)
Quick Reference Guide
(PDF)
Gold A
Member Contract
(PDF)
Summary of Benefits and Coverage
(PDF)
Quick Reference Guide
(PDF)
Gold B
Member Contract
(PDF)
Summary of Benefits and Coverage
(PDF)
Quick Reference Guide
(PDF)
Additional Links and Documents
UCare Individual & Family Plans with M Health Fairview
New Member Guide
(PDF)
Member Release of Information Form
(PDF)
Prior Authorization Information
(PDF)
Statement of Representative Form
(PDF)
Power of Attorney short form (PDF)
Formulary
Provider and Pharmacy Directories
(PDF)
Service Area Map
(PDF)
Automatic Payment Form
(PDF)
Claim Reimbursement Form
(PDF)
Prescription Drug Reimbursement Form
(PDF)
+
–
UCare M Health Fairview Bronze and UCare M Health Fairview Bronze HSA
Bronze
Member Contract
(PDF)
Summary of Benefits and Coverage
(PDF)
Quick Reference Guide
(PDF)
Bronze A
Member Contract
(PDF)
Summary of Benefits and Coverage
(PDF)
Quick Reference Guide
(PDF)
Bronze B
Member Contract
(PDF)
Summary of Benefits and Coverage
(PDF)
Quick Reference Guide
(PDF)
Bronze HSA
Member Contract
(PDF)
Summary of Benefits and Coverage
(PDF)
Quick Reference Guide
(PDF)
Bronze AH
Member Contract
(PDF)
Summary of Benefits and Coverage
(PDF)
Quick Reference Guide
(PDF)
Bronze BH
Member Contract
(PDF)
Summary of Benefits and Coverage
(PDF)
Quick Reference Guide
(PDF)
+
–
UCare M Health Fairview Silver and UCare M Health Fairview Silver HSA
Silver
Member Contract
(PDF)
Summary of Benefits and Coverage
(PDF)
Quick Reference Guide
(PDF)
Silver A
Member Contract
(PDF)
Summary of Benefits and Coverage
(PDF)
Quick Reference Guide
(PDF)
Silver B
Member Contract
(PDF)
Summary of Benefits and Coverage
(PDF)
Quick Reference Guide
(PDF)
Silver 2
Member Contract
(PDF)
Summary of Benefits and Coverage
(PDF)
Quick Reference Guide
(PDF)
Silver 3
Member Contract
(PDF)
Summary of Benefits and Coverage
(PDF)
Quick Reference Guide
(PDF)
Silver 4
Member Contract
(PDF)
Summary of Benefits and Coverage
(PDF)
Quick Reference Guide
(PDF)
Silver HSA
Member Contract
(PDF)
Summary of Benefits and Coverage
(PDF)
Quick Reference Guide
(PDF)
Silver AH
Member Contract
(PDF)
Summary of Benefits and Coverage
(PDF)
Quick Reference Guide
(PDF)
Silver BH
Member Contract
(PDF)
Summary of Benefits and Coverage
(PDF)
Quick Reference Guide
(PDF)
Silver 2 HSA
Member Contract
(PDF)
Summary of Benefits and Coverage
(PDF)
Quick Reference Guide
(PDF)
Silver 3H
Member Contract
(PDF)
Summary of Benefits and Coverage
(PDF)
Quick Reference Guide
(PDF)
Silver 4H
Member Contract
(PDF)
Summary of Benefits and Coverage
(PDF)
Quick Reference Guide
(PDF)
Cost sharing reduction (CSR) plans
CSR plans help reduce your out-of-pocket costs by lowering your deductibles and coinsurance. You must meet certain income levels (determined by MNsure) to enroll in a CSR plan.
“A” plans have 100% cost sharing reductions; “B” plans have limited cost sharing variations; Silver “2” plans have 73% cost sharing reduction; Silver “3” plans have 87% cost sharing reduction; and Silver “4” plans have 94% cost sharing reduction. If you are unsure which plan you qualify for, please call us at 1-855-307-6985.