Individual & Family Plans UCare Bronze HSA and UCare M Health Fairview Bronze HSA 2025 Formulary (List of Covered Drugs)
Download the complete Formulary or search the list of covered drugs below.
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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 |
0% coinsurance after deductible |
| Tier 2 Non-preferred generics |
0% coinsurance after deductible |
| Tier 3 Preferred Brand drugs |
0% coinsurance after deductible; $25 copay for up to 30-day supply of insulin on the formulary |
| Tier 4 Non-preferred drugs |
0% coinsurance after deductible |
| Tier 5 Specialty drugs |
0% coinsurance after deductible |
Formulary documents and information
| Documents | Last updated date |
|---|---|
| Individual & Family Plans Formulary (PDF) | 9/1/2025 |
| UCare Formulary Exception Criteria (PDF) | 4/28/2025 |
| Prior Authorization Criteria | 1/1/2025 |
| Diabetic Supplies List (PDF) | 5/1/2024 |
| Medical Injectable Drug Authorization List (PDF) | 8/12/2025 |
| Medication Therapy Management (MTM) — available at no additional cost to members with chronic health conditions who take multiple medicines |