UCare Medicare Group Plans - Basic 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 | Deductible | 30 day supply cost share | 90 day supply cost share |
Tier 1 Generic drugs |
Deductible does not apply to this tier | $12 copay | Available for two copays through mail order or a preferred network pharmacy |
Tier 2 Preferred brand-name drugs |
$395 | $45 copay | Available for two copays through mail order or a preferred network pharmacy |
Tier 3 Non-preferred drugs |
$395 | $100 copay | Available for two copays through mail order or a preferred network pharmacy |
Tier 4 Specialty Drugs |
$395 | 25% coinsurance | Available for 25% coinsurance |