Members

Members

2010 Preferred Drug List (PDL)

The WINhealth Partners Preferred Drug List (PDL) was developed by your local physicians and is an important part of your prescription drug benefit program. The PDL includes brand name and generic drugs, and the level of your benefit depends on your prescription benefit design and on the status of each drug at the time the prescription is filled.

Inclusion of a particular medication on the PDL is not a guarantee of coverage since medications may be removed or added by the Pharmacy and Therapeutics Committee. Coverage is not based on the Internet version of the PDL. The PDL includes medications that may be subject to specified quantity levels, or may require prior authorization before dispensing. Your pharmacist can initiate these steps for you. The development and maintenance of the PDL is a dynamic process. Our Pharmacy and Therapeutics Committee regularly reviews new and existing medications to ensure the drug list remains responsive to the needs of our members and network providers. Please contact a WINhealth Partners' Customer Service Representative at (307) 773-1300 Ext. 330 if you have any questions about the PDL or coverage of your medication.

There are four co-payment levels.

• Tier 1-lowest co-payment. Unless otherwise excluded from coverage, all generic medications are covered at the lowest co-payment, even if they are not listed in this book
• Tier 2- middle co-payment. If a brand name drug is dispensed when a generic form is available, the member will be responsible for the difference in price between the generic and brand drug plus the applicable co-payment.
• Tier 3- Highest co-payment. Tier 3 medications are listed but the list is not all inclusive. Medications will be added and removed throughout the year based on new information.
• Tier 4- 100% co-payment. These drugs are available to WINhealth members at full price less a discount. These drugs or classes of drugs are not included in the three tier coverage because:
  • There is a therapeutic alternative available or
  • The product is available over the counter (OTC), or
  • The product is available generically

NON-COVERED DRUGS

The following drugs or classes of drugs are not a benefit of the plan. This list is not all inclusive. Future events or circumstances may necessitate non-coverage for a particular drug or class of drugs.

Weight-loss drugs
Smoking cessation drugs
Experimental or investigational drugs
Drugs for cosmetic purposes
Drugs for conditions that are excluded from coverage
New drugs not yet reviewed by the WINhealth Partners Pharmacy and Therapeutics Committee
Nutrients, vitamins, and food supplements
Compounded Medications

PRIOR AUTHORIZATION

Drugs or classes of drugs flagged with (PA) require prior authorization by WINhealth Partners.

The prescribing provider may send a letter or FAX indicating the reason the member requires the drug.

Please send to:
Address: 1200 E. 20th Street, Suite A, Cheyenne, WY 82001
Phone: 307-773-1300 or toll free at 1-800-868-7670
Fax: 307-778-7840

Click on the letter to find your preferred drug:

A

ABILIFY (PA)(Tier 3)
ACCOLATE (Tier 2)
ACCUPRIL (Tier 2)
ACCURETIC (Tier 4)
ACCU-CHEK (Tier 2)
ACETAMINOPHEN/DICHLORALPHENAZONE/ISOMETHEPTENE (Tier 1)
ACETAZOLAMIDE (Tier 1)
ACETIC ACID (Tier 1)
ACETIC ACID/HYDROCORTISONE (Tier 1)
ACIPHEX (Tier 4)
ACTIGALL (Tier 2)
ACTIVELLA (Tier 3)
ACTONEL (PA) (Tier 2)
ACTOS (Tier 2)
ACTOPLUS MET (Tier 2)
ACULAR (Tier 2)
ADALAT CC (Tier 2)
ADDERALL(PA) (Prior Auth required for first time users over age 19) (Tier 2)
ADDERALL XR(Prior Auth required for children up to age 18) (Tier 3)
ADDERALL XR (For adults over 18) (Tier 4)
ADVAIR (Tier 2)
ADVAIR HFA (Tier 2)
AGGRENOX (Tier 2)
ALBUTEROL (Tier 1)
ALDACTAZIDE 25/25 (Tier 2)
ALDACTAZIDE 50/50 (Tier 4)
ALDACTONE (Tier 2)
ALDARA (Tier 2)
ALLEGRA (Tier 2)
ALLEGRA TABLETS (Tier 4)
ALLEGRA-D 12 Hour (Tier 4)
ALLEGRA-D 24 Hour (Tier 4)
ALESSE (Tier 2)
ALKERAN (Tier 2)
ALORA (Tier 2)
ALOXI (Tier 4)
ALPHAGAN P (Tier 2)
ALREX (Tier 2)
ALTACE (Tier 4)
AMANTADINE (Tier 1)
AMBIEN (Tier 2)
AMBIEN CR (Tier 4)
AMERGE (Tier 3)
AMEVIVE (PA) (Tier 3)
AMITRIPTYLINE (Tier 1)
AMITRIPTYLINE/PERPHENAZINE (Tier 1)
AMOXIL (Tier 2)
AMPICILLIN (Tier 1)
ANDROGEL (Tier 3)
ANASPAZ (Tier 2)
ANTABUSE (Tier 2)
ATACAND (Tier 3)
ATACAND HCT (Tier 4)
ANTIVERT (Tier 2)
ANZEMET (Tier 4)
ARALEN (Tier 2)
ARICEPT (Tier 3)
ARIMIDEX (Tier 2)
ARTHROTEC 75 (Tier 3)
ASACOL (Tier 2)
ASTELIN (Tier 3)
ATACAND (Tier 3)
ATACAND HCT (Tier 4)
ATIVAN (Tier 2)
ATROVENT SPRAY (Tier 2)
ATROVENT HFA (Tier 2)
AUGMENTIN (Tier 2)
AUGMENTIN ES 600 (Tier 2)
AVALIDE (Tier 4)
AVANDAMET (Tier 4)
AVANDIA (Tier 2)
AVAPRO (Tier 2)
AVELOX (Tier 3)
AVODART (PA) (Tier 2)
AVONEX (PA)(Plan specific copay) (Tier 2)
AZILECT (Tier 3)
AZMACORT (Tier 3)
AZULFIDINE (Tier 2)
AZULDIFINE EN-TABS (Tier 2)

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B

BACITRACIN (Tier 1)
BACLOFEN (Tier 1)
BACTRIM, SEPTRA (Tier 2)
BACTROBAN (Tier 2)
BACTROBAN NASAL (Tier 2)
BECONASE AQ (Tier 4)
BENICAR (Tier 2)
BENICAR HCT (Tier 4)
BENTYL (Tier 2)
BENZACLIN (Tier 2)
BENZOTIC (Tier 1)
BENZTROPINE (Tier 1)
BETAGAN (Tier 2)
BETAMETHASONE DIPROPIONATE CRM, LOTION, OINT. 0.05% (Tier 1)
BETAMETHASONE VALERATE (Tier 1)
BETAPACE (Tier 2)
BETASERON (PA) (Plan specific copay) (Tier 2)
BETA-VAL (Tier 2)
BETIMOL (Tier 2)
BETOPTIC S (Tier 2)
BIAXIN (Tier 2)
BIAXIN XL (Tier 3)
BLEPH-10 (Tier 2)
BONIVA (PA) (Tier 2)
BRETHINE (Tier 2)
BREVICON (Tier 2)
BRIMONIDINE 0.2% (Tier 1)
BROMFENEX (Tier 2)
BROMFENEX-PD (Tier 2)
BROMPHENIRAMINE/PSEUDOEPHEDRINE (Tier 1)
BUMEX (Tier 2)
BUSPAR (Tier 2)
BUTORPHANOL NASAL SPRAY (PA) (Tier 1)
BYETTA (PA) (Tier 3)

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C

CADUET (Tier 4)
CALAN (Tier 2)
CALAN SR (Tier 2)
CAPEX SHAMPOO (Tier 3)
CAPITROL (Tier 2)
CAPOTEN (Tier 2)
CAPOZIDE (Tier 4)
CARAFATE (Tier 2)
CARBATROL (Tier 2)
CARDENE (Tier 2)
CARDENE SR (Tier 4)
CARDIZEM (Tier 2)
CARDIZEM CD (Tier 2)
CARDIZEM LA (Tier 4)
CARDURA (Tier 2)
CASODEX (Tier 2)
CATAPRES (Tier 2)
CATAPRES-TTS (Tier 3)
CEENU (Tier 2)
CEFTIN (Tier 2)
CEFZIL (Tier 3)
CELEBREX (Tier 2)
CELEXA (Tier 2)
CELLCEPT (Tier 2)
CENSTIN (Tier 2)
CERUMENEX (Tier 2)
CHLORAL HYDRATE (Tier 1)
CHLORPROMAZINE (Tier 1)
CIALIS (Tier 2)
CIPRO (Tier 2)
CIPRO XR (Tier 2)
CIPRODEX (Tier 2)
CLARINEX (Tier 4)
CLEOCIN (Tier 2)
CLEOCIN T (Tier 2)
CLIMARA (Tier 2)
CLIMARA PRO(Tier 2)
CLINORIL (Tier 2)
CODEINE/GUAIFENESIN (Tier 2)
COLCHICINE (Tier 1)
COLCHICINE/PROBENECID (Tier 1)
COLOCORT (Tier 2)
COLYTE (Tier 2)
COMBIPATCH (Tier 2)
COMBIVENT (Tier 2)
COMPAZINE (Tier 2)
CONCERTA (Tier 4)
COPAXONE (PA)(Tier 3)
CORDARONE (Tier 2)
CORGARD (Tier 2)
COREG (Tier 2)
CORTIFOAM (Tier 2)
CORTISPORIN (Tier 2)
CORTISPORIN OTIC (Tier 2)
COSOPT (Tier 2)
COUMADIN (Tier 2)
COVERA HS (Tier 4)
COZAAR (Tier 3)
CREON (Tier 2)
CRESTOR (Tier 2)
CUPRIMINE (Tier 2)
CYMBALTA (PA) (Tier 2)
CYSTOSPAZ (Tier 2)
CYTADREN (Tier 2)
CYTOTEC (Tier 2)
CYTOVENE (Tier 2)
CYTOXAN (Tier 2)

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D

DALMANE (Tier 2)
DANAZOL (Tier 1)
DANOCRINE (Tier 2)
DAPSONE (Tier 2)
DARVOCET-N (Tier 2)
DDAVP (Tier 2)
DECADRON (Tier 2)
DECONAMINE SR (Tier 2)
DEMEROL (Tier 4)
DEMULEN 1/35 (Tier 2)
DEMULEN 1/50 (Tier 2)
DEPAKENE (Tier 2)
DEPAKOTE (Tier 2)
DEPAKOTE ER (Tier 2)
DEPO-PROVERA (PA) (Tier 2)
DERMA-SMOOTHE-FS (Tier 2)
DESOGEN (Tier 2)
DESOGESTREL/EE 0.15/30 (Tier 1)
DESONATE GEL (PA) (Tier 3)
DESQUAM-E (Tier 2)
DESQUAM-X (Tier 2)
DESYREL (Tier 2)
DETROL (Tier 4)
DETROL LA (Tier 2)
DEXAMETHASONE SODIUM PHOSPHATE (Tier 1)
DEXEDRINE (PA) (Prior Auth required for first time users over age 19) (Tier 2)
DEXEDRINE SPANSULE (PA)(Prior Auth required for first time users over age 19) (Tier 2)
DIABETA (Tier 2)
DIAMOX SEQUELS (Tier 2)
DICLOXACILLIN (Tier 1)
DIDRONEL (Tier 4)
DIFFERIN(PA)(Prior Auth required for Members age 25 and older)(Tier 3)
DIFLUCAN (Tier 2)
DIFLUNISAL (Tier 2)
DILANTIN (Tier 2)
DIOVAN (Tier 2)
DIOVAN HCT (Tier 2)
DITROPAN (Tier 2)
DITROPAN XL (Tier 2)
DOLOBID (Tier 2)
DOMEBORO OTIC (Tier 2)
DONNATAL (Tier 2)
DOVONEX (Tier 2)
DOXEPIN (Tier 1)
DUAC (PA) (Prior Auth required for Members 25 years of age and older) (Tier 3)
DUETACT (Tier 2)
DUONEB (Tier 3)
DURADRIN (Tier 2)
DURAGESIC (PA)(Tier 3)
DYNACIRC (Tier 3)
DYNACIRC CR (Tier 4)

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E

E.E.S. (Tier 1)
ECONAZOLE (Tier 2)
EFFEXOR (Tier 2)
EFFEXOR XR (Tier 3)
EFUDEX (Tier 2)
ELDEPRYL (Tier 2)
ELESTAT (Tier 3)
ELIDEL (PA) (Tier 2)
ELMIRON (PA) (Tier 3)
ELIMITE (Tier 2)
ENABLEX (PA) (Tier 2)
ENTOCORT EC (Tier 2)
ENULOSE (Tier 2)
EPIPEN (Tier 2)
EPIPEN JR. (Tier 2)
EPOGEN (PA) (Tier 3)
ERYC (Tier 3)
ERYGEL (Tier 2)
ERYTHROMYCIN SOLN (Tier 1)
ERYTHROMYCIN (Tier 1)
ERYTHROMYCIN STEARATE (Tier 1)
ESTRACE (Tier 2)
ESTRADIOL (Tier 1)
ESTROSTEP FE (Tier 2)
ETODOLAC (Tier 2)
EULEXIN (Tier 2)
EURAX (Tier 2)
EVISTA (Tier 2)
EXELDERM (Tier 2)
EXELON (Tier 2)
EXFORGE (Tier 2)

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F

FAMVIR (Tier 4)
FANSIDAR (Tier 2)
FEMARA (Tier 2)
FELDENE (Tier 2)
FEMHRT (Tier 2)
FIORICET (Tier 2)
FIORINAL (Tier 2)
FLAGYL (Tier 2)
FLAGYL ER (Tier 2)
FLECTOR (Tier 2)
FLEXERIL (Tier 2)
FLOMAX (Tier 2)
FLONASE (Tier 3)
FLORINEF (Tier 2)
FLOVENT HFA (Tier 2)
FLUMADINE (Tier 2)
FLUPHENAZINE (Tier 1)
FLUPHENAXINE DECANOATE (PA) (Tier 1)
FLUVOXAMINE (Tier 1)
FML (Tier 2)
FOCALIN (Tier 3)
FORADIL (Tier 3)
FORTOVASE (Tier 2)
FOSAMAX (Tier 2)
FOSAMAX PLUS D (Tier 4)
FREESTYLE FREEDOM (Tier 2)
FREESTYLE TEST STRIPS (Tier 2)
FREESTYLE LITE STRIPS (Tier 2)
FROVA (Tier 3)
FUROXONE (Tier 2)

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G

GANCICLOVIR (Tier 2)
GANTRISIN (Tier 2)
GARDASIL (Tier 2)
GENTAMICIN (Tier 1)
GEODON (PA) (Tier 2)
GLEEVEC (Tier 2)
GLUCOGAN EMERGENCY KIT (Tier 2)
GLUCOPHAGE (Tier 2)
GLUCOPHAGE XR (Tier 2)
GLUCOTROL (Tier 2)
GLUCOTROL XL (Tier 2)
GRANULEX (Tier 2)
GRIFULVIN V (Tier 2)
GRIS-PEG (Tier 2)
GUAIFENEX MD (Tier 2)
GUIATUSS AC (Tier 2)

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H

HALOPERIDOL (Tier 1)
HIPREX, UREX (Tier 2)
HISTUSSIN D (Tier 2)
HISTUSSIN HC (Tier 2)
HIVID (Tier 2)
HUMALOG (Tier 2)
HUMALOG MIX (Tier 2)
HUMIBID L.A. (Tier 3)
HUMULIN 50/50 (Tier 2)
HUMULIN 70/30 (Tier 2)
HUMULIN N (Tier 2)
HUMULIN R (Tier 2)
HYDRALAZINE (Tier 1)
HYDROCHLOROTHIAZIDE (Tier 1)
HYTONE (Tier 2)
HYTRIN (Tier 2)
HYZARR (Tier 4)

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I

IMITREX (Tier 2)
IMURAN (Tier 2)
INDERAL(Tier 2)
INDERAL LA (Tier 2)
INDOCIN (Tier 2)
INFLAMASE FORTE (Tier 2)
INFLAMASE MILD (Tier 2)
INTAL (Tier 2)
INTRON A (Tier 2)
INVIRASE (Tier 2)
IPRATROPIUM SOLN (Tier 1)
ISONIAZID (Tier 1)
ISOPTO ATROPINE (Tier 2)
ISOPTO CARBACHOL (Tier 2)
ISORDIL (Tier 2)

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J

Januvia (PA) (Tier 3)

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K

K-DUR 10 (Tier 2)
K-DUR 20 (Tier 2)
KADIAN (Tier 4)
KEFLEX (Tier 2)
KENALOG (Tier 2)
KEPPRA (Tier 3)
KLONOPIN (Tier 2)
KLOR-CON 8 (Tier 2)
KLOTRIX 10 (Tier 2)
K-LYTE DS (Tier 2)
K-LYTE/CL (Tier 2)
K-LYTE/CL 50 (Tier 2)
KYTRIL (Tier 4)

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L

LAC-HYDRIN (Tier 2)
LACRISERT (Tier 2)
LACTULOSE (Tier 2)
LAMICTAL (PA) (Tier 3)
LAMISIL (PA) (Tier 3)
LANOXIN (Tier 2)
LANTUS SOLOSTAR (Tier 2)
LARIAM (Tier 2)
LASIX (Tier 2)
LESCOL (Tier 4)
LESCOL XL (Tier 4)
LEUKERAN (Tier 2)
LEVAQUIN (Tier 2)
LEVEMIR (Tier 2)
LEVLEN (Tier 2)
LEVOTHYROXINE (Tier 1)
LEVOXYL, SYNTHROID (Tier 2)
LEVSIN (Tier 2)
LEXAPRO (Tier 4)
LIBRIUM (Tier 2)
LIDEX (Tier 2)
LIFESCAN ONETOUCH BASIC SYSTEM (Tier 2)
LIFESCAN ONETOUCH TEST STRIPS (Tier 2)
LIFESCAN ONETOUCH ULTRA TEST STRIPS (Tier 2)
LIFESCAN SURESTEP TEST STRIPS (Tier 2)
LIPITOR (Tier 2)
LITHIUM CARBONATE (Tier 1)
LITHOBID (Tier 2)
LIVOSTIN (Tier 2)
LO/OVRAL (Tier 2)
LODINE (Tier 2)
LODINE XL (Tier 2)
LOESTRIN 1.5/30 (Tier 2)
LOESTRIN 1/20 (Tier 2)
LOESTRIN FE 1.5/30 (Tier 2)
LOESTRIN FE 1/20 (Tier 2)
LOPID (Tier 2)
LOPRESSOR (Tier 2)
LOTEMAX (Tier 2)
LOTENSIN (Tier 2)
LOTENSIN HCT (Tier 4)
LOVAZA (Tier 2)
LOVENOX (PA) (Tier 3)
LOXITANE (Tier 2)
LUMIGAN (Tier 3)
LUNESTA (Tier 4)
LYRICA (PA) (Tier 2)

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M

MACROBID (Tier 2)
MACRODANTIN (Tier 2)
MATULAN (Tier 2)
MAVIK (Tier 2)
MAXAIR (Tier 2)
MAXALT (Tier 3)
MAXALT-MLT (PA) (Tier 3)
MAXITROL (Tier 2)
MEBENDAZOLE (Tier 1)
MECLIZINE (Tier 1)
MEDROL (Tier 2)
MEDROL DOSEPAK (Tier 2)
MENEST (Tier 2)
MEPERIDINE (Tier 4)
MEPYTHON (Tier 2)
MESTINON (Tier 2)
METADATE CD (PA)(Prior Auth required for first time users over age 19) (Tier 3)
METADATE ER (PA) (Prior Auth required for first time users over age 19) (Tier 2)
METHADONE TABS (Tier 1)
METHAZOLAMIDE (Tier 1)
METHERGINE (Tier 2)
METHOTREXATE (Tier 1)
METHYLDOPA (Tier 1)
METROCREAM (Tier 2)
METROGEL (Tier 2)
METROGEL VAGINAL (Tier 2)
METROLOTION (Tier 4)
MEVACOR (Tier 2)
MEXILETINE (Tier 2)
MEXITIL (Tier 2)
MIACALCIN (Tier 2)
MICARDIS HCT (Tier 4)
MIGRANAL (PA) (Tier 3)
MINIPRESS (Tier 2)
MINOCIN (Tier 3)
MINOCYCLINE TABLETS (Tier 4)
MINTEZOL (Tier 2)
MIRAPEX (Tier 2)
MOBAN (PA) (Tier 3)
MOBIC (Tier 3)
MONOPRIL (Tier 2)
MONOPRIL HCT (Tier 4)
MS CONTIN (PA) (Tier 2)
MUSE (PA) (Tier 3)
MYAMBUTOL (Tier 2)
MYCOLOG-II (Tier 2)
MYCOSTATIN (Tier 2)
MYLERAN (Tier 2)
MYSOLINE (Tier 2)

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N

NAMENDA (Tier 2)
NASACORT AQ (Tier 4)
NASAREL (Tier 3)
NASONEX (Tier 4)
NAVANE (Tier 2)
NEBUPENT (Tier 2)
NEFAZODONE (Tier 1)
NEORAL (Tier 2)
NEOSPORIN (Tier 2)
NEUPOGEN (PA) (Tier 3)
NEURONTIN (Tier 2)
NEXIUM (Tier 2)
NIASPAN (Tier 2)
NITREK (Tier 2)
NITRO-DUR (Tier 2)
NITROGLYCERIN (Tier 2)
NITROGLYCERIN EXT. REL (Tier 1)
NITROSTAT (Tier 2)
NIZORAL (Tier 2)
NOLVADEX (Tier 2)
NORDETTE (Tier 2)
NORINYL 1+35 (Tier 2)
NORINYL 1+50 (Tier 2)
NORPACE CR (Tier 2)
NORPRAMIN (Tier 2)
NOR-QD (Tier 2)
NORVASC (Tier 2)
NORVIR (Tier 2)
NoVOFIN 32 (Tier 2)
NOVOLIN 70/30 (Tier 2)
NOVOLIN N (Tier 2)
NOVOLIN R (Tier 2)
NOVOLOG (Tier 2)
NOVOLOG MIX 70/30 (Tier 2)
NOXAFIL (Tier 3)
NUVARING (Tier 3)

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O

OCUFEN (Tier 2)
OCUFLOX (Tier 2)
OMACOR (Tier 4)
OMNICEF (Tier 3)
ONETOUCH (Tier 2)
ORTHO-CEPT (Tier 2)
ORTHO EVRA (Tier 2)
ORTHO TRI-CYCLEN (Tier 2)
ORTHO TRI-CYCLEN LO (Tier 2)
ORTHO-CYCLEN (Tier 2)
OVCON 35 (Tier 2)
OVCON 50 (Tier 2)
OVIDE (Tier 2)
OXYCONTIN (PA) (Tier 3)

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P

PAMELOR (Tier 2)
PANCREASE (Tier 2)
PANCREASE MT (Tier 2)
PARLODEL (Tier 2)
PARNATE (Tier 3)
PATANOL (Tier 3)
PAXIL (Tier 2)
PAXIL CR (Tier 4)
PAXIL SUSPENSION (Tier 4)
PEDIAZOLE (Tier 2)
PENICILLIN VK (Tier 1)
PERCOCET (Tier 2)
PERCODAN (Tier 2)
PEN NEEDLE (Tier 2)
PERMAX (Tier 2)
PERPHENAZINE (Tier 1)
PHENERGAN (Tier 2)
PHENOBARBITAL (Tier 1)
PHRENILIN (Tier 2)
PHRENILIN FORTE (Tier 4)
PILOCARPINE (Tier 1)
PINDOLOL (Tier 1)
PLAQUENIL (Tier 2)
PLAVIX (Tier 2)
PLENDIL (Tier 3)
POLYMYXIN B/BACITRACIN (Tier 2)
POLYSPORIN (Tier 2)
POLYTRIM (Tier 2)
PONSTEL (Tier 2)
POTASSIUM CHLORIDE LIQUID (Tier 1)
PRANDIN (Tier 3)
PRAVACHOL (Tier 2)
PRAZOSIN (Tier 1)
PRECOSE (Tier 2)
PRED FORTE (Tier 2)
PRED MILD (Tier 2)
PRED-G (Tier 2)
PREDNISOLONE PHOSPHATE (Tier 2)
PREDNISONE (Tier 1)
PRELONE (Tier 2)
PREMARIN (Tier 2)
PREMARIN crm (Tier 2)
PREMPHASE (Tier 2)
PREMPRO (Tier 2)
PRENATE ELITE (Tier 2)
PREVACID (Tier 4)
PRIMAQUINE (Tier 2)
PRINZIDE (Tier 4)
PROAMATINE (Tier 2)
PROBENECID (Tier 1)
PROCAINAMIDE EXT-REL (Tier 1)
PROCHLORPERAZINE (Tier 2)
PROCTOCREAM-HC 2.5% (Tier 2)
PROGRAF (Tier 2)
PROMETHAZINE (Tier 2)
PROMETHAZINE w/ CODEINE (Tier 1)
PROMETRIUM (Tier 2)
PRONESTYL (Tier 2)
PROPINE (Tier 2)
PROPYLTHIOURACIL (Tier 1)
PROSCAR (Tier 2)
PROTONIX (Tier 3)
PROTOPIC (PA) (Tier 2)
PROVENTIL (Tier 2)
PROVENTIL HFA (Tier 3)
PROVERA (Tier 2)
PROVIGIL (PA) (Tier 2)
PROZAC (Tier 2)
PROZAC WEEKLY (Tier 4)
PULMICORT RESPULES (Tier 2)
PULMICORT FLEXHALER (Tier 2)
PURINETHOL (Tier 2)
PYRAZINAMIDE (Tier 1)
PYRIDIUM (Tier 2)

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Q

QUESTRAN/QUESTRAN-LIGHT (Tier 2)
QUINIDINE GLUCONATE EXT. REL (Tier 1)
QUINIDINE SULFATE (Tier 1)

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R

REBIF (PA)(Tier 3)
REGLAN (Tier 2)
RELPAX (Tier 2)
RENVELA (PA) (Prior Auth required except when prescribed by a Nephrologist)(Tier 3)
REQUIP (Tier 3)
RESERPINE (Tier 1)
RESTASIS (Tier 3)
RESTORIL (Tier 2)
RETIN-A (PA) (Tier 2)
RETIN-A MICRO (Tier 4)
RETINOIC POWDER (Tier 4)
RETROVIR (Tier 2)
RHINOCORT AQUA (Tier 2)
RIDAURA (Tier 2)
RIFADIN (Tier 2)
RISPERDAL (PA) (Tier 2)
RITALIN (PA) (Prior Auth required for first time users over age 19) (Tier 2)
RIATALIN LA ( Tier 4)
RITALIN-SR (PA)(Prior Auth required for first time users over age 19) (Tier 2)
ROWASA (Tier 2)
RYTHMOL (Tier 2)

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S

SAIZEN (PA)
SALSALATE (Tier 1)
SANCTURA (PA) (Tier 3)
SANDIMMUNE (Tier 2)
SEASONALE (Tier 2)
SEASONIQUE (Tier 4)
SELSUN (Tier 2)
SERAX (Tier 2)
SEREVENT (Tier 2)
SEROQUEL (PA)(Tier 2)
SILVADENE (Tier 2)
SINEMET (Tier 2)
SINEQUAN (Tier 2)
SINGULAIR(Tier 2)
SKELAXIN (Tier 3)
SONATA (Tier 4)
SPECTAZOLE (Tier 2)
SPIRIVA (Tier 2) (PA)
STRATERRA (PA)(Prior Auth required for first time users over age 19) (Tier 2)
SULAR (Tier 4)
SULFACET-R (Tier 2)
SUMYCIN (Tier 2)
SURESTEP (Tier 2)
SURE COMFORT (Tier 2)
SYMBICORT (Tier 2)
SYMBYAX (Tier 4)
SYNALAR (Tier 2)
SYNAREL (Tier 2)
SYNTHROID (Tier 2)

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T

TAMIFLU (Tier 2)
TAPAZOLE (Tier 2)
TARKA (Tier 4)
TAZORAC (PA) (Tier 2)
TEGRETOL (Tier 2)
TEGRETOL-XR (Tier 2)
TEMOVATE (Tier 2)
TEKRTURNA (PA)(Prior Auth required unless prescribed by a Nephrologists) (Tier 2)
TENEX (Tier 2)
TENORMIN (Tier 2)
TESTRED (Tier 2)
TETRACYCLINE (Tier 2)
TEVETEN HCT (Tier 4)
THEOCHRON (Tier 2)
THEOPHYLLINE EXT-REL (Tier 1)
TEVETE HCT (Tier 4)
THIABENDAZOLE (Tier 3)
THIOGUANINE (Tier 2)
THIORIDAZINE (Tier 1)
TIAZAC (Tier 4)
TICLID (Tier 2)
TILADE (Tier 2)
TOBRADEX (Tier 2)
TOBREX (Tier 2)
TOFRANIL (Tier 2)
TOPAMAX (Tier 3)
TOPROL-XL (Tier 2)
TRANDATE (Tier 2)
TRENTAL (Tier 2)
TRETINOIN POWDER (Tier 4)
TRETIN-X COMBO PACKS (Tier 4)
TRICOR (Tier 2)
TRIHEXYPHENIDYL (Tier 1)
TRILEPTAL (Tier 2)
TRI-LEVLEN (Tier 2)
TRI-NORINYL (Tier 2)
TRIPHASIL (Tier 2)
TUSSIONEX (Tier 2)
TYLENOL w/CODEINE (Tier 2)

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U

ULTRAM (Tier 2)
ULTRAVATE (Tier 2)
UNIPHYL (Tier 4)
UNIRETIC (Tier 4)
URECHOLINE (Tier 2)
URISED (Tier 2)
URSODIOL (Tier 1)

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V

VALCYTE (Tier 2)
VALIUM (Tier 2)
VALTREX (Tier 2)
VANTIN TABS (Tier 2)
VASERETIC (Tier 4)
VASOTEC (Tier 2)
VENLAFAXINE HCL ER (Tier 2) VENTOLIN HFA (Tier 2)
VERELAN PM (Tier 4)
VERAMYST (Tier 2)
VESICARE (PA) (Tier 2)
VEXOL (Tier 2)
VIAGRA (PA) (QL) (Quantity limit, maximum of 6 tablets every 30 days) (Tier 2)
VIBRAMYCIN (Tier 2)
VICODIN (Tier 2)
VIGAMOX (Tier 3)
VIRACEPT (Tier 2)
VIRAMUNE (Tier 2)
VIROPTIC (Tier 2)
VISTARIL (Tier 2)
VIVELLE-DOT (Tier 3)
VOLTAREN (Tier 2)
VOLTAREN-XR (Tier 2)
VOSPIRE ER (Tier 2)
VYTORIN (Tier 3)

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W

WELLBUTRIN SR (Tier 2)
WELLBURTRIN XL (Tier 4)

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X

XALATAN (Tier 2)
XANAX (Tier 2)
XOLAIR (PA) (Tier 2)
XOPENEX (PA) (Tier 3)
XYLOCAINE VISCOUS (Tier 2)

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Y

YASMIN 28 (Tier 3) YAZ (Tier 2)

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Z

ZARONTIN (Tier 2)
ZAROXOLYN (Tier 2)
ZELNORM (Tier 4)
ZEPHREX LA (Tier 2)
ZERIT (Tier 2)
ZESTORETIC (Tier 4)
ZESTRIL (Tier 2)
ZETIA (PA) (Tier 3)
ZITHROMAX (Tier 2)
ZMAX (Tier 4)
ZOCOR (Tier 2)
ZOFRAN (Tier 2)
ZOFRAN ODT (Tier 3)
ZOLOFT (Tier 2)
ZOLINKA (Tier 3)
ZOMIG (Tier 2)
ZOVIRAX (Tier 2)
ZYLOPRIM (Tier 2)
ZYMAR (Tier 3)
ZYPREXA (PA) (Tier 2)
ZYPREXA ZYDIS (Tier 4)

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*The information contained in this formulary and its appendices is provided by WINhealth Partners, solely for the convenience of medical providers and members. WINhealth Partners does not warrant or assure accuracy of such information nor is it intended to be comprehensive in nature. This formulary is not inteded to be a substitute for the knowledge, expertise, skill, and judgement of the medical provider in their choice of prescription drugs. WINhealth Partners assumes no responsibility for the actions or omissions of any medical provider based upon reliance, in whole or in part, on the information contained herein. The medical provider should consult the drug manufacturer's product literature or standard references for more detailed information.

The information contained in this document is proprietary information. The information may not be copied in whole or in part without the written permission of WINhealth Partners. All rights reserved.

The drug names listed here are the registered and/or unregistered trademarks of third party pharmaceutical compaines unrelated to and unaffiliated with WINhealth Partners. These trademarked brand names are included for informational purposes only and are not intended to imply or suggest any affiliation between WINhealth Partners and such third-party pharmaceutical companies.