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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