Individual & Family Plans UCare Bronze and UCare M Health Fairview Bronze 2022 Formulary (List of Covered Drugs)
Download the complete Formulary or search the list of covered drugs below.
Individual & Family Plans Formulary (PDF) Updated 12/1/22
UCare Formulary Exception Criteria (PDF) Updated 9/9/21
Prior Authorization Criteria (PDF) Updated 12/1/22
Medical Injectable Drug Authorization List (PDF) Updated 11/15/22
Medication Therapy Management (MTM) – available at no additional cost to members with chronic health conditions who take multiple medicines
| Tier | What you pay when using in-network pharmacy |
| Tier 1 Preferred generic drugs |
$15 copay per 30-day supply; $30 copay for up to 90-day supply |
| Tier 2 Non-preferred generics |
$25 copay per 30-day supply; $50 copay for up to 90-day supply |
| Tier 3 Preferred Brand drugs |
$200 copay per prescription; $25 for a 30-day supply of insulin on the formulary; $25 for a 30-day supply of select diabetes drugs |
| Tier 4 Non-preferred Brand drugs |
40% coinsurance after deductible |
| Tier 5 Specialty drugs |
40% coinsurance after deductible |