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Individual & Family Plans UCare Silver HSA and UCare M Health Fairview Silver HSA 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		 25% coinsurance after deductible
Tier 2
Non-preferred generics		 25% coinsurance after deductible
Tier 3
Preferred Brand drugs		 25% coinsurance after deductible;
$25 for a 30-day supply of insulin on the formulary
Tier 4
Non-preferred Brand drugs		 25% coinsurance after deductible
Tier 5
Specialty drugs		 25% coinsurance after deductible