UCare Medicare Group Plans - Allina Executive Plan 2025 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 | 30 day supply cost share | 90 day supply cost share |
| Tier 1 Preferred generic drugs |
$0 copay | Available for two copays through mail order or a preferred network pharmacy |
| Tier 2 Generic drugs |
$0 copay | Available for two copays through mail order or a preferred network pharmacy |
| Tier 3 Preferred brand-name drugs |
$30 copay | Available for two copays through mail order or a preferred network pharmacy |
| Tier 4 Non-preferred drugs |
$30 copay | Available for two copays through mail order or a preferred network pharmacy |
| Tier5 Specialty drugs |
$30 copay | Available for two copays through mail order or a preferred network pharmacy |
Important Message About What You Pay for Vaccines - Our plan covers most Part D vaccines at no cost to you. Call Customer Service for more information.
Important Message About What You Pay for Insulin - You won’t pay more than $35 for a one-month supply of each insulin product covered by our plan, no matter what cost-sharing tier it’s on.
More formulary information
| Document | Last Updated Date |
|---|---|
| Group Medicare Formulary (List of Covered Drugs) (PDF) | 10/1/2024 |
| Prior Authorization Criteria (PDF) | 1/1/2025 |
| UCare Formulary Exception Criteria (PDF) | 4/1/2024 |
| Formulary Change Notice (PDF) | Coming soon |
| Diabetic Supply List (PDF) | 12/4/2024 |
| Non-Preferred CGM and Testing Criteria (PDF) | 10/1/2024 |
| Part B Medical Injectable Drug Authorization List (PDF) | 12/18/2024 |
| Part D Information |