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Individual & Family Plans UCare Gold and UCare M Health Fairview Gold 2022 Formulary (List of Covered Drugs)

Download the complete Formulary or search the list of covered drugs below.

Individual & Family Plans Formulary (PDF) Updated 10/1/21

UCare Formulary Exception Criteria (PDF) Updated 9/9/21

Prior Authorization Criteria (PDF) Updated 10/15/21

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
$5 copay per prescription; $10 copay for up to 90-day supply
Tier 2
Non-preferred generics
$15 copay per 30-day supply; $30 copay for up to 90-day supply
Tier 3
Preferred Brand drugs
$125 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