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Care Wise: M Health Fairview & North Memorial 2022 Formulary (List of Covered Drugs)

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

UCare Medicare and EssentiaCare 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

Part D Information
EssentiaCare Part D Information

Prescription Drug Calculator










Tier Deductible 30 day supply - standard cost share 30 day supply - preferred cost share 90 day supply - preferred mail order
Tier 1
Preferred generic drugs		 Deductible does not apply to this tier
 $12 copay $3 copay Available for two preferred copays
Tier 2
Generic drugs		 $480 $20 copay $15 copay Available for two preferred copays
Tier 3
Preferred brand drugs		 $480 25% coinsurance
 17% coinsurance Available for 17% coinsurance
Select insulins Deductible does not apply to select insulin $35 copay $30 copay
Tier 4
Non-preferred drugs		 $480 50% coinsurance 50% coinsurance Available for 50% coinsurance
Tier 5
Specialty drugs		 $480 25% coinsurance 25% coinsurance Available for 25% coinsurance