Individual & Family Plans UCare Silver HSA and UCare M Health Fairview Silver HSA 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 |
25% coinsurance after deductible |
| Tier 2 Non-preferred generics |
25% coinsurance after deductible |
| Tier 3 Preferred Brand drugs |
25% coinsurance after deductible; $25 for a 30-day supply of insulin on the formulary |
| Tier 4 Non-preferred Brand drugs |
25% coinsurance after deductible |
| Tier 5 Specialty drugs |
25% coinsurance after deductible |
More formulary information
| Documents | Last Updated Date |
| Individual & Family Plans Formulary (PDF) | 4/1/2024 |
| UCare Formulary Exception Criteria (PDF) | 4/1/2024 |
| Prior Authorization Criteria | 10/1/2023 |
| Diabetic Supplies List (PDF) | 5/1/2023 |
| Medical Injectable Drug Authorization List (PDF) | 4/1/2024 |
| Medication Therapy Management (MTM) – available at no additional cost to members with chronic health conditions who take multiple medicines |