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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.

Follow these steps to see the coverage and cost of your medication.

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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


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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) 5/1/2024
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) 5/2/2024
Medication Therapy Management (MTM) – available at no additional cost to members with chronic health conditions who take multiple medicines
 

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