Individual & Family Plans UCare Silver HSA and UCare M Health Fairview Silver HSA 2025 Formulary (List of Covered Drugs)
Download the complete Formulary or search the list of covered drugs below.
|
1
|
|
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 |
|
2
|
|
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 copay for up to 30-day supply of insulin on the formulary; $25 copay for up to 30-day supply after deductible on medications for diabetes (except for insulins), asthma, and allergies requiring the use of epinephrine auto-injectors |
| Tier 4 Non-preferred drugs |
25% coinsurance after deductible |
| Tier 5 Specialty drugs |
25% coinsurance after deductible |
Formulary documents and information
| Documents | Last updated date |
|---|---|
| Individual & Family Plans Formulary (PDF) | 12/1/2025 |
| UCare Formulary Exception Criteria (PDF) | 4/28/2025 |
| Prior Authorization Criteria | 1/1/2025 |
| Diabetic Supplies List (PDF) | 10/1/2025 |
| Medical Injectable Drug Authorization List (PDF) | 11/17/2025 |