UCare Medicare Group Plans - Dakota County 2023 Formulary (List of Covered Drugs)
Download the complete Formulary or search the list of covered drugs below.
Group Medicare Formulary (List of Covered Drugs) (PDF) Updated 12/1/2023
Group Medicare Formulary (List of Covered Drugs) - Spanish (PDF) Updated 12/13/2023
Prior Authorization Criteria (PDF) Updated 12/1/2023
Step Therapy Criteria (PDF) Updated 3/1/2023
UCare Formulary Exception Criteria (PDF) Updated 10/1/2022
Formulary Change Notice (PDF) Updated 8/1/2023
Part B Medical Injectable Drug Authorization List (PDF) Updated 11/28/2023
| Tier | 30 day supply cost share | 90 day supply cost share |
| Tier 1 Generic drugs |
$10 copay | Available for two copays through mail order or a preferred network pharmacy |
| Tier 2 Preferred brand-name drugs |
$30 copay | Available for two copays through mail order or a preferred network pharmacy |
| Tier 3 Non-preferred drugs |
$50 copay | Available for two copays through mail order or a preferred network pharmacy |
| Tier 4 Specialty drugs |
$50 copay | Available for two copays through mail order or a preferred network pharmacy |
Important Message About What You Pay for Vaccines - Our plan covers most Part D vaccines at no cost to you. Call Customer Service for more information.
Important Message About What You Pay for Insulin - You won’t pay more than $35 for a one-month supply of each insulin product covered by our plan, no matter what cost-sharing tier it’s on.