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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.

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 brand drugs
$480 50% coinsurance 50% coinsurance Available for 50% coinsurance
Tier 5
Specialty drugs
$480 25% coinsurance 25% coinsurance Available for 25% coinsurance