Individual & Family Plans UCare Gold and UCare M Health Fairview Gold 2023 Formulary (List of Covered Drugs)
Download the complete Formulary or search the list of covered drugs below.
Individual & Family Plans Formulary (PDF) Updated 12/1/2023
UCare Formulary Exception Criteria (PDF) Updated 10/1/2022
Prior Authorization Criteria (PDF) Updated 12/1/2023
Diabetic Supplies List (PDF) Updated 5/1/2023
Medical Injectable Drug Authorization List (PDF) Updated 11/28/2023
Medication Therapy Management (MTM) – available at no additional cost to members with chronic health conditions who take multiple medicines
| 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 |
40% coinsurance after deductible |
| Tier 5 Specialty drugs |
40% coinsurance after deductible |