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UCare Medicare Group Plans - Dakota County 2022 Formulary (List of Covered Drugs)

Download the complete Formulary or search the list of covered drugs below.

Group Medicare Formulary (List of Covered Drugs) (PDF) Updated 12/1/22

Prior Authorization Criteria (PDF) Updated 12/1/22
UCare Formulary Exception Criteria (PDF) Updated 1/21/22
Formulary Change Notice (PDF) Updated 8/18/22

Part B Medical Injectable Drug Authorization List (PDF) Updated 11/15/22





Tier 30 day supply cost share 90 day supply cost share
Tier 1
Generic drugs		 $10 copay Available for two copays through mail order or a preferred network pharmacy
Tier 2
Preferred brand-name drugs		 $30 copay Available for two copays through mail order or a preferred network pharmacy
Tier 3
Non-preferred drugs		 $50 copay Available for two copays through mail order or a preferred network pharmacy
Tier 4
Specialty drugs		 $50 copay Available for two copays through mail order or a preferred network pharmacy