Care Core: M Health Fairview & North Memorial 2023 Formulary (List of Covered Drugs)
Download the complete Formulary or search the list of covered drugs below.
Prior Authorization Criteria (PDF) Updated 9/1/2023
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 8/24/2023
|Tier||Deductible||30 day supply - standard cost share||30 day supply - preferred cost share||90 day supply - preferred mail order|
Preferred generic drugs
|Deductible does not apply to this tier||$12 copay||$3 copay||Available for two preferred copays|
|Deductible does not apply to this tier||$20 copay||$15 copay||Available for two preferred copays|
Preferred brand drugs
|$395||$47 copay||$47 copay||Available for two preferred copays|
|Select insulins||Deductible does not apply to select insulin||$35 copay||$30 copay|
|$395||50% coinsurance||50% coinsurance||Available for 50% coinsurance|
|$395||26% coinsurance||26% coinsurance||Available for 26% coinsurance|
Important Message About What You Pay for Vaccines - Our plan covers most Part D vaccines at no cost to you, even if you haven’t paid your deductible. 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, even if you haven’t paid your deductible.