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 |