Individual & Family Plans UCare Gold StandardRx and UCare M Health Fairview Gold 2024 Formulary (List of Covered Drugs)
Download the complete Formulary or search the list of covered drugs below.
Find out what tier your medication is
Use the drug search tool below to see whether your medication is covered and what tier it is
Find out how much your medication costs
Use this tier table to see how much your medication costs
| Tier | What you pay when using in-network pharmacy |
| Tier 1 Preferred generic drugs |
$5 copay per prescription; $10 copay for up to 90-day supply |
| Tier 2 Non-preferred generics |
$15 copay per 30-day supply; $30 copay for up to 90-day supply |
| Tier 3 Preferred Brand drugs |
$125 copay per prescription; $25 for a 30-day supply of insulin on the formulary; $25 for a 30-day supply of select diabetes drugs |
| Tier 4 Non-preferred Brand drugs |
$250 copay per prescription |
| Tier 5 Specialty drugs |
$550 copay per prescription |
More formulary information
| Documents | Last Updated Date |
| Individual & Family Plans Formulary (PDF) | 10/1/2024 |
| UCare Formulary Exception Criteria (PDF) | 4/1/2024 |
| Prior Authorization Criteria | 10/1/2023 |
| Diabetic Supplies List (PDF) | 5/1/2024 |
| Medical Injectable Drug Authorization List (PDF) | 9/23/2024 |
| Medication Therapy Management (MTM) – available at no additional cost to members with chronic health conditions who take multiple medicines |