Tier 4 Wellmark Drug List

If you have a 4-Tier benefit design, this is a list of drugs on Tier 4. You can learn more information about the drug by using the searchable Wellmark Drug List. Select the 4-Tier Wellmark Drug List Benefit and enter the name of the drug in the search box. Using the searchable Wellmark Drug List will also provide therapeutically similar, lower cost alternatives(s) on Tier 1, 2, and/or 3.

Label Name
ALLEGRA-D 12 HOUR
ALLEGRA-D 24 HOUR
ALTABAX
AMRIX
APLENZIN
ASTELIN
ASTEPRO
AURALGAN
AZELASTINE HCL
BENZACLIN
BENZACLIN CARE KIT
BENZACLIN WITH PUMP
BENZAMYCINPAK
BENZOYL PEROXIDE CREAMY WASH ACNE KIT
BENZOYL PEROXIDE CREAMY WASH COMPLETE PACK
BENZOYL PEROXIDE WASH
BREVOXYL-4 CREAMY WASH COMPLETE PACK
BREVOXYL-8 CREAMY WASH COMPLETE PACK
BREZE KIT
CARDURA XL
CLARINEX
CLARINEX REDITABS
CLARINEX-D 12 HOUR
CLARINEX-D 24 HOUR
CLEANSE AND TREAT
CLINDAMYCIN/BENZOYL PEROXIDE
CNL8 NAIL KIT
COREG CR
CORZALL-PE
DAYTRANA
DESONIL PLUS CREAM KIT
DESONIL PLUS OINTMENT KIT
DESOWEN CREAM/CETAPHIL LOTION
DESOWEN LOTION/CETAPHIL CREAM
DESOWEN OINTMENT/CETAPHIL LOTION
DUAC CS
DULERA
EDLUAR
EPIDUO
EVAMIST
EXALGO
FENOFIBRIC ACID
FEXOFENADINE/PSEUDOEPHEDRINE
FIBRICOR
FINACEA PLUS
FLECTOR
FLUOXETINE DR
FORTAMET
GELNIQUE
GLUMETZA
INOVA
INVEGA
JALYN
LAMISIL
LIQUADD
LIVALO
LOSEASONIQUE
LUNESTA
LYBREL
MINOCYCLINE HCL ER
MOMEXIN
NATAZIA
NEOBENZ MICRO WASH PLUS PACK
NEOSALUS
NISOLDIPINE
OLEPTRO
OMEPRAZOLE/SODIUM BICARBONATE
OMNARIS
ORACEA
ORAVIG
PAMINE FQ
PATADAY
PATANASE
PEDIADERM HC
PENNSAID
PEXEVA
PRISTIQ
PROZAC WEEKLY
RELHIST
ROSADERM
ROSANIL
SALVAX DUO
SE BPO 3% FOAMING CLOTHS
SE BPO 6% FOAMING CLOTHS
SE BPO 9% FOAMING CLOTHS
SEASONIQUE
SEROQUEL XR
SIMCOR
SOLODYN
SULAR
SUMAVEL DOSEPRO
TREXIMET
TRIAZ FOAMING CLOTHS
TRIBENZOR
TRILIPIX
VERAMYST
VYVANSE
XERESE
XOLEGEL
XYZAL
ZACARE 4% KIT
ZACARE 8% KIT
ZEGERID
ZELAPAR
ZIANA
ZIRGAN
ZODERM
ZODRYL AC ADULT
ZYCLARA

This list is subject to change. The most up-to-date version of the list will always be posted on www.wellmark.com.

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