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UCare Medicare Group Plans - Rosemount-Apple Valley Schools High Option 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 5/1/22

Prior Authorization Criteria (PDF) Updated 5/1/22
UCare Formulary Exception Criteria (PDF) Updated 1/21/22

Part B Medical Injectable Drug Authorization List (PDF) Updated 4/27/22








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		 $60 copay Available for two copays through mail order or a preferred network pharmacy
Tier 4
Specialty drugs		 $60 copay Available for two copays through mail order or a preferred network pharmacy