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Not Covered July 2021 In addition to this list, newly marketed prescription medications may not be covered until the Pharmacy & Therapeutics Committee has had an opportunity to review the medication, to determine whether the medication will be covered and if so, which tier will apply based on safety, efficacy and the availability of other products within that class of medications. The current list of newly marketed drugs can be found on our New to Market List.

If available, a generic version of a listed brand product is covered unless the generic is also listed (e.g., Abilify tabs are excluded but aripiprazole tabs are covered).

Abilify tablets Aktipak Anodyne LPT kit Abilify MyCite tablets Ala-Scalp Antara capsules Absorica capsules albuterol HFA (authorized Apadaz tablets Absorica LD capsules generics for ProAir, Proventil, Ventolin Apexicon E Abstral sublingual tablets HFA inhalers) Apidra vials Acanya gel and pump gel Aldactone tablets Apidra SoloStar Accupril tablets Aldara cream Aplenzin tablets acetaminophen 320.5 mg/caffeine 30 Alkindi sprinkle capsules Apriso capsules mg/dihydrocodeine 16 mg Allegra Children’s Allergy ODT Arava tablets capsulesAciphex tablets Allegra ODT, and tablets Arazlo lotion Aciphex Sprinkle capsules Alltizal tablets Arestin microspheres Acticlate tablets alogliptin (authorized generic for Nesina) Aricept tablets Active-Prep kits alogliptin/metformin tablets (authorized Aricept ODT Activella tablets generic for Kazano) Arimidex tablets Actonel tablets alogliptin/pioglitazone (authorized generic Arixtra injection Actoplus Met tablets for Oseni) ArmonAir Digihaler Actos tablets Alphagan P 0.1% eye drops ArmonAir Respiclick inhaler Acuvail eye drops Altace capsules Aromasin tablets acyclovir 5% topical cream Altoprev tablets Arthrotec 50 and 75 tablets Aczone 5% and 7.5% Altreno lotion Asacol HD tablets adapalene 0.1% lotion Alvesco inhaler aspirin/omeprazole DR tablets adapalene 0.1% pads Amaryl tablets (authorized generic for Yosprala) adapalene 0.1% topical Ambien tablets Astepro 0.15% (authorized generic for Plixda) Ambien CR tablets Arymo ER tablets Adasuve amcinonide 0.1% cream and ointment Atacand tablets Adcirca tablets Amerge tablets Atelvia tablets Adderall tablets Amicar tablets Ativan tablets Adderall XR capsules Amitiza capsules Atralin gel Adhansia XR capsules amlodipine/atorvastatin tablets Aurovela 24 Fe tablets Adlyxin injection ER oral suspension Auryxia tablets Admelog vials (authorized generic for Adzenys ER) Auvi-Q injection Admelog SoloStar injection amphetamine sulfate tablets (authorized Avalide tablets Adoxa tablets generic for Evekeo) Avandia tablets Adoxa Pak tablets Ampyra tablets Avapro tablets Adrenaclick injection Amrix ER capsules Avidoxy DK kit Adrenalin nasal spray Amzeeq Avodart capsules Adzenys ER oral suspension Anafranil capsules Azasan tablets Adzenys XR tablets Ana-Lex kit Azasite eye drops Aerospan inhaler Analpram Advanced kit 0.15% nasal spray Aggrenox capsules Analpram E kit azelastine/fluticasone nasal spray AirDuo Digihaler inhaler Androderm patches Azelex cream AirDuo RespiClick inhaler AndroGel 1% and 1.62% gel Azilect tablets Ajovy injection Android capsules azithromycin 1% eye drops Aklief Annovera vaginal ring Azopt eye drops

*Exclusion applies only to plans with Truli Rx Flex and Truli Rx Basic medication guides. 1 Health coverage is offered by Truli for Health, an affiliate of Florida Blue. These companies are Independent Licensees of the Blue Cross and Blue Shield Association.

Azor tablets Cardizem tablets Conzip capsules baclofen 5 mg tablets Cardizem CD capsules Copaxone injection Baclofen 2% in MaxDerm Base kit Cardizem LA 180, 240, 300, 360, and 420 Cordran cream, lotion, and ointment Bactroban cream mg tablets Coreg tablets Bafiertam capsules Cardura tablets Coreg CR capsules Balcoltra tabletsBaraclude tablets Cardura XL tablets Coremino ER tablets Beconase AQ nasal spray carisoprodol tablets Cortef tablets Belsomra tablets carisoprodol/ASA tablets Cortisporin-TC ear drops Benicar tablets carisoprodol/ASA/codeine tablets Cosopt eye drops Benicar HCT tablets CaroSpir oral suspension Cosopt PF eye drops BenzaClin gel and gel pump Casodex tablets Cotempla XR-ODT benzhydrocodone/acetaminophen tablets Catapres TTS patches Cozaar tablets (authorized generic for Apadaz) Cefaclor ER 500 mg Crestor tablets benzonatate 150 mg capsules Celebrex capsules Crinone 8% vaginal gel benzoyl peroxide foams, kits, pledgets, Celexa tablets Cuprimine capsules and washes cephalexin tablets Cutaquig injection Besivance eye drops Cervidil vaginal insert Cutivate 0.05% lotion Betapace tablets chlordiazepoxide/clidinium capsules Cuvitru injection Betimol 0.25% and 0.5% eye drops chlorzoxazone 250 mg tablet cyclobenzaprine 7.5 mg tablets Betoptic S eye drops chlorzoxazone 500 mg tablet (Axis brand Cyclobenzaprine 2% in Microderm BI-EST progesterone compounding kit ONLY) external cream compounding kit Blisovi 24 Fe tablets Ciclodan 8% solution kit Cyclobenzaprine 5% compounding kit Boniva tablets Ciclopirox 8% solution kit Cymbalta capsules brinzolamide eye drops Ciloxan eye ointment Cytomel tablets Brisdelle capsules cimetidine tablets Daklinza tablets BromSite eye drops Cipro oral suspension dapsone 5% gel Bryhali lotion Cipro tablets Daytrana patches /formoterol 80-4.5 mcg/act, Clarinex tablets Dayvigo tablets 160-4.5 mcg/act (authorized generic for Clarinex-D tablets DDAVP nasal spray Symbicort) Clenpiq oral solution DDAVP tablets Bunavail buccal film Cleocin-T gel Demerol tablets Bupap tablets Climara patches Demser capsules Buphenyl powder for solution Clindacin ETZ pledget kit DermacinRx – all products buprenorphine patches (the authorized Clindacin PAC pledget kit Dermasorb kits generic for Butrans only) Clindagel gel desloratadine ODT bupropion 450 mg ER tablet clindamycin 1% gel (the authorized Desonate gel butalbital 50 mg/acetaminophen 300 mg generic for Clindagel only) DesOwen cream kit capsules and tablets clindamycin 1.2%/benzoyl peroxide 5% desoximetasone 0.05% cream and butalbital 50 mg/acetaminophen 300 gel and pump gel ointment (authorized generic for Topicort) mg/caffeine 40 mg capsules clindamycin foam desvenlafaxine ER tablets (authorized butalbital 50 mg/acetaminophen 325 clindamycin/tretinoin gel generic for Khedezla) mg/caffeine 40 mg capsules clobetasol foams, , , and Detrol tablets Butrans patches Detrol LA capsules Byetta injection Clobex lotion, , and spray 1.5 mg 6-day, 10-day, Caduet tablets Clodan kit and shampoo and 13-day blister packs calcipotriene/betamethasone ointment Clozaril tablets dexchlorpheniramine oral calcipotriene/betamethasone suspension Colazal capsules (authorized generic for RyClora) (authorized generic for Taclonex) colchicine capsules (authorized generic Dexedrine Spansule Cambia powder packets for Mitigare) Dexilant capsules Canasa colchicine tablets DexPac 6-Day, 10-Day, and 13-Day Capex shampoo Colcrys tablets blister packs captopril-hydrochlorothiazide tablets Coly-Mycin S ear drops diclofenac 1% topical gel Carac cream Combigan eye drops diclofenac 3% gel Carafate oral suspension Concerta tablets diclofenac epolamine patch Carafate tablets Conjupri tablets diclofenac sodium ER 100 mg tablets carbinoxamine 6 mg tablet Consensi Differin 0.1% cream, gel, and lotion

*Exclusion applies only to plans with Truli Rx Flex and Truli Rx Basic medication guides. 2 Health coverage is offered by Truli for Health, an affiliate of Florida Blue. These companies are Independent Licensees of the Blue Cross and Blue Shield Association.

Differin 0.3% gel and gel pump Estrostep Fe tablets Fortamet tablets diflorasone cream and ointment Eucrisa ointment Fortesta gel Diflucan tablets Evekeo ODT Fosamax Plus D tablets Dilaudid tablets Evekeo tablets Frova tablets Diovan tablets Evista tablets Gastrocrom oral solution Diovan HCT tablets Evoclin foam Gelnique gel and gel pump Dipentocaine cream compounding kit Evoxac capsules Genotropin injection Dipentum capsules Evzio 2 mg/0.4 mL Geodon capsules diphenhydramine Exalgo tablets Gimoti nasal spray Ditropan XL tablets Exforge HCT tablets Glatopa injection Doral tablets Exforge tablets Gleevec tablets Doryx tablets Extavia injection Gloperba Doryx MPC tablets Extina foam Glucophage tablets doxycycline (all non-generic products) Eysuvis eye drops tablets doxycycline biphasic-release 40 mg Ezallor Sprinkle capsules Glucotrol tablets Fabior foam Glucotrol XL tablets doxycycline hyclate 50 mg tablets Falessa kit Glumetza tablets (generic for Targadox) famotidine oral suspension Glycate tablets doxycycline monohydrate 75 and 150 mg Femara tablets glycopyrrolate 1.5 mg tablets capsules Femring vaginal ring Gocovri capsules Drizalma Sprinkle capsules fenofibrate 40 and 120 mg tablets GoNitro sublingual powder packets Duaklir Pressair inhaler fenofibrate 50 and 150 mg capsules Gralise tablets Duetact tablets (authorized generic for Lipofen) Granix injection Duexis tablets fenofibric acid tablets (authorized generic Hailey 24 Fe tablets duloxetine 40 mg enteric-coated capsules for Fibricor) Halcion tablets (generic for Irenka) Fenoglide tablets halobetasol propionate 0.05% foam Duobrii lotion fenoprofen 200 and 400 mg capsules (authorized generic for Lexette) Duragesic patches Fenortho 200 and 400 mg capsules Halog cream Durlaza capsules 37.5, 62.5, and 87.5 mcg patches Hemady tablets Dutoprol tablets fentanyl buccal tablets (authorized Hemangeol 4.28 mg/mL oral solution Dyanavel XR oral suspension generic for Fentora) Hepsera tablet Dymista nasal spray Fentora buccal tabletsFerriprox Twice-a- HIV drugs (certain products only – see Dxevo tablets Day tablets Appendix) EC-naprosyn tablets Fexmid tablets Horizant ER tablets EC-naproxen tablets Fibricor tablets Humalog vials Ecoza foam Finacea foam Humalog Junior KwikPen injection Edarbi tablets Fioricet capsules and tablets Humalog KwikPen injection Edarbyclor tablets Fioricet with Codeine capsules Humalog KwikPen Mix 50/50 injection Edluar sublingual tablets Fiorinal capsules Humalog KwikPen Mix 75/50 injection Effexor XR capsules Fiorinal with Codeine capsules Humalog Mix 50/50 vials Effient tablets Firazyr injection Humalog Mix 75/25 vials Elavil tablets Firdapse tablets Humatrope injection Elidel cream Flector topical patches Humulin 70/30 vials Elocon cream Flomax capsules Humulin 70/30 KwikPen injection Empricaine cream kit Flonase nasal spray Humulin N vials Enstilar foam Flolipid oral suspension Humulin N KwikPen injection Entocort EC capsules fluocinonide 0.1% cream Humulin R 100 units/mL vials Epiduo Forte gel fluorouracil 0.5% cream (authorized Hycet oral solution EpiPen injection generic of Carac) hydrocortisone butyrate lipid cream EpiPen Jr injection fluoxetine tablets (lipocream) EPIsnap kit flurandrenolide cream, lotion, and hydrocortisone butyrate lotion Ergomar sublingual tablets ointment hydromorphone ER tablets (generic for Esgic tablets lotion Exalgo) esomeprazole magnesium 20 mg fluvoxamine ER capsules Hysingla ER tablets capsules Focalin XR capsules Hyzaar tablets esomeprazole strontium capsules Forfivo XL tablets Ibudone tablets

*Exclusion applies only to plans with Truli Rx Flex and Truli Rx Basic medication guides. 3 Health coverage is offered by Truli for Health, an affiliate of Florida Blue. These companies are Independent Licensees of the Blue Cross and Blue Shield Association.

Ibuprofen Comfort Pac lansoprazole 15 mg capsules Maxalt MLT tablets imipramine pamoate capsules lansoprazole ODT Melodetta 24 Fe chewable tablets imiquimod 3.75% cream pump lansoprazole/amoxicillin/clarithromycin Medolor Pak kit Imitrex injection, nasal spray, and tablets triple therapy blister pack (generic for mefenamic acid capsules Imitrex Statdose injection Prevpac) meloxicam capsules (authorized generic Impeklo lotion Larin 24 Fe tablets for Vivlodex) Impoyz cream Lazanda nasal spray memantine ER capsules Inderal LA capsules Lescol XL tablets meperidine 50 mg, 100 mg tablets Inderal XL capsules levalbuterol inhaler meprobamate tablets Indocin suppositories levorphanol 3 mg tablets mesalamine kit Indocin suspension Lexapro tablets Mestinon syrup and tablets indomethacin 20 mg capsules (authorized Lexette foam metformin ER (generic Fortamet) generic for Tivorbex) Lialda tablets metformin ER (generic Glumetza) Innopran XL capsules Librax capsules methotrexate 2.5 mg tablet (antirheumatic Inova pads Licart 1.3% patch version only) Inspra tablets lidocaine 2% mucosal/urethral gel and methylphenidate ER capsules (generic for insulin lispro KwikPen injection prefilled Aptensio XR only) (authorized generic for Humalog) lidocaine 5% ointment methylphenidate 72 mg ER tablets insulin lispro vials (authorized generic for lidocaine HCl 3% lotion metoclopramide ODT Humalog) lidocaine/hydrocortisone kits metoprolol succinate/ hydrochlorothiazide Intermezzo sublingual tablets lidocaine/prilocaine kits tablets Intuniv tablets lidocaine/tetracaine cream Metozolv ODT Inveltys eye drops Lidoderm patch MetroCream 0.75% cream Ionsys system Linzess capsules metyrosine capsules Irenka capsules Lipitor tablets Mibelas 24 Fe chewable tablets Isordil tablets Lipofen capsules Micardis tablets Istalol eye drops Locoid cream and lotion Micardis HCT tablets Jatenzo Locoid lipocream MiCort-HC cream Jentadueto tablets Loestrin 1.5/30 21-day tablets Migranal nasal spray Jentadueto XR tablets Loestrin 1/20 21-day tablets Millipred oral solution and tablets Jornay PM capsules Loestrin Fe 1/20 28-day tablets Millipred DP tablet packs Jublia topical solution Lofibra 160 mg tablet Minastrin 24 Fe chewable tablets Junel Fe 24 tablets Lomedia 24 Fe tablets Minivelle patches Kadian capsules Lonhala Magnair inhalation solution Minocin capsules Kapspargo Sprinkle capsules Loprox cream kit minocycline ER tablets Kapvay tablets Loprox shampoo minocycline 50 mg, 75 mg, and 100 mg Karbinal ER oral suspension Lortab elixir tablets Katerzia oral suspension Lorzone tablets Minolira tablets Kazano tablets LoSeasonique tablets Mirapex tablets K.B.G.L. in TeroDerm cream kit Lotrel capsules Mirapex ER tablets Keflex capsules Lotronex tablets Mircette 28-day tablets Kenalog topical spray Lovaza capsules Mirvaso gel and gel pump Kerydin topical solution Lovenox injections Mobic tablets ketoconazole foam luliconazole cream (authorized generic for nasal spray Ketodan foam Luzu) Mondoxyne NL capsules ketoprofen 25 mg capsules Lunesta tablets Monodox capsules nasal spray Luzu cream montelukast oral granules packet Khedezla tablets Lyrica capsules Morgidox capsules and kits Klonopin tablets Lyrica CR tablets Morphabond ER tablets Klor-Con 20 mEq powder packets Lyumjev vials 100 units/mL morphine sulfate ER capsules (generic for Kombiglyze XR tablets Lyumjev Kwikpen 100 units/mL Kadian) Kristalose powder packets Lyumjev Kwikpen 200 units/mL Motegrity tablets lactulose powder packets Malarone tablets Motofen tablets Lamisil AT spray Malarone Pediatric tablets Moxeza 0.5% eye drops Lancets (certain high-cost brands not Marinol capsules MS Contin tablets covered) Maxalt tablets mupirocin 2% cream

*Exclusion applies only to plans with Truli Rx Flex and Truli Rx Basic medication guides. 4 Health coverage is offered by Truli for Health, an affiliate of Florida Blue. These companies are Independent Licensees of the Blue Cross and Blue Shield Association.

Mydayis capsules Olux foam penicillamine capsules Mysoline tablets Olux E foam Penlac nail lacquer naftifine cream Omeclamox-Pak blister packet Pennsaid 2% solution Naftin cream and gel Omega-3/D-3 kit Pentasa capsules Nalfon 400 mg capsules omeprazole/sodium bicarbonate capsules Pepcid AC tablets Nalfon 600 mg tablets and powder for suspension (generic Pepcid solution and tablets Nalocet tablets Zegerid) Percocet tablets Namenda tablets Omnaris nasal spray Perforomist solution Namenda XR capsules Omnitrope injection Pertzye capsules Namzaric ER capsules/titration pack Onexton gel Pexeva tablets Naprelan tablets Ongentys capsules phendimetrazine tablets Naprosyn oral suspension Onglyza tablets Phexxi gel Naproxen Comfort Pac Onmel tablets Physicians EZ Use B-12 Compliance Naproxen DR tablets Onzetra Xsail nasal powder Injection Kit naproxen oral suspension Opana ER tablets pioglitazone/glimepiride tablets naproxen sodium ER / CR tablets Opana tablets Plavix tablets (generic for Naprelan) Oracea capsules Plexion 9.8%-4.8% cleansing clothes naproxen/esomeprazole magnesium Oralair sublingual tablets Pliaglis cream delayed-release tablets Orapred ODT disintegrating tablets Plixda topical solution Nasacort Allergy 24HR nasal spray Orbivan capsules Ponstel capsules Nasacort AQ nasal spray Orphengesic Forte tablets Port-Prep kit Nascobal nasal spray Ortho Tri-Cyclen Lo 28-day tablets potassium chloride (KCl) 20 mEq powder Nasonex nasal spray Ortikos capsules packets Natesto nasal gel Oseni tablets Praluent injection Neomycin/polymyxin/hydrocortisone Osmolex ER tablets Pramosone cream suspension eye drops OsmoPrep tablets Prandin tablets Nesina tablets Otovel ear drops Pravachol tablets Neuac kit Ovace 10% wash Pred Forte eye drops Neupogen injection Ovace Plus 9.8% foam and lotion pregabalin ER Nevanac eye drops Ovace Plus 10% gel and liquid wash prenatal vitamins (certain products only - Nexium capsules Ovcon-35 tablets see Appendix) Nexium 10 mg, 20 mg, and 40 mg Ovcon-50 tablets PreGenna granules Oxaydo tablets Prepidil vaginal gel Niacor tablets Oxecta tablets Prestalia tablets Niaspan tablets Oxistat cream and lotion Prevacid capsules Niravam ODT oxycodone ER tablets (authorized generic Prevacid 24H capsules Nocdurna sublingual tablets for OxyContin) Prevacid Solutab tablets Noctiva nasal spray oxycodone/acetaminophen 5-300,10-300 mg Prevpac blister packet Nolix cream and lotion tablets Prikaan kits Norco tablets oxycodone/acetaminophen oral solution 10- Prilolid kits norethindrone acetate 1 mg/ethinyl 300mg/5mlOxyContin tablets Prilovix kits 20 mcg/ferrous fumarate (24) oxymorphone ER tablets Priloxx LP kits chewable tablets oxymorphone tablets Prilosec capsules and granules for Norgesic Forte tablets Oxytrol patch suspension Noritate cream Oxytrol for Women patch Primlev tablets Northera capsules Ozobax oral solution Prinivil tablets Norvasc tablets Pancreaze capsules Pristiq tablets Nucynta IR tablets Pancelipase 5,000 unit DR capsule ProAir Digihaler inhaler Nudroxipak kits Pandel cream Proair HFA inhaler Nutropin AQ injection paroxetine ER tablets Proair Respiclick inhaler Nuvessa gel Pataday eye drops Procardia XL tablets Nuvigil tablets Patanase nasal spray Proctocort rectal cream Obredon oral solution Patanol eye drops Progesterone in HRT 10% cream Okebo capsules Paxil tablets compounding kit olanzapine/fluoxetine capsules Paxil CR tablets Prolate oral solution 0.2% eye drops Pazeo eye drops Prolate tablets

*Exclusion applies only to plans with Truli Rx Flex and Truli Rx Basic medication guides. 5 Health coverage is offered by Truli for Health, an affiliate of Florida Blue. These companies are Independent Licensees of the Blue Cross and Blue Shield Association.

Prolensa eye drops RyClora oral solution Tazorac 0.1% cream Prometrium capsules Rytary capsules Tecfidera capsules Promiseb Complete kit Rythmol SR capsules Tekturna HCT tablets Prostin E-2 vaginal RyVent tablets Tenormin tablets Protonix granules for suspension and Ryzolt tablets Testim gel tablets Saizen injection Testone CIK kit Protopic ointment Samsca 30 mg tablets testosterone 1% gel and gel pump Proventil HFA inhaler Sanctura tablets (generics for Testim and Vogelxo only) Provigil tablets Sarafem tablets testosterone 2% (10 mg/actuation) gel Prozac capsules Savaysa tablets (generic for Fortesta) Prozac Weekly capsules Seebri Neohaler inhaler testosterone 30 mg buccal tablet Psorcon cream Semglee pen injection Testred capsules Pulmicort Flexhaler inhaler Semglee vials Texacort topical solution Pulmicort Respules Semprex-D capsules Tiazac capsules Pylera blister packet Sernivo topical spray Tikosyn capsules pyridostigmine 30 mg tablets Seroquel tablets Timoptic Ocudose eye drops Qbrelis oral solution Seroquel XR tablets Tirosint capsules Qbrexza topical cloth Seysara tablets Tirosint-Sol oral solution Qdolo oral solution Siklos tablets Tivorbex capsules Qmiiz ODT Singulair chewable tablets, granules, and tizanidine capsules Qnasl nasal spray tablets Tizanidine Comfort Pac kit Qnasl Children’s nasal spray Sitavig buccal tablet Tobi nebulizer solution Quartette extended-cycle tablets Skelaxin tablets Tofranil tablets Quazepam tablets Solaraze 3% gel Tofranil PM capsules ranitidine (all dosage forms) Solosec oral granules Tolsura capsules Rasuvo Soluline kit Topicort 0.05% cream and ointment Rayaldee capsules SoluPICC kit Topicort spray Rayos tablets Solodyn tablets Tosymra nasal spray Relador Pak kit Soma tablets Toviaz tablets Relador Pak Plus kit Sorilux foam Tradjenta tablets Relexxii tablets Sotilyze oral solution tramadol 100 mg tablets Relistor injection and tablets Spritam ODT tramadol ER capsules Relafen DS tablets Sprix nasal spray Tranxene T-Tab tablets Relpax tablets Steglujan tablets trazodone 300 mg tablets Reltone capsules Strattera capsules Tretin-X cream Remeron tablets Striant buccal system tretinoin microsphere gel Remeron Soltab tablets Suboxone oral film tretinoin 0.05% gel Renvela powder packets and tablets Subsys sublingual spray Trexall tablets Reprexain tablets sucralfate oral suspension Treximet tablets Requip XL tablets /naproxen sodium tablets Trezix 320.5-30-16 mg capsules Restoril capsules Sumavel Dosepro injection triamcinolone 0.05% ointment Retin-A creams Symbyax capsules Trianex ointment Retin-A Micro gel and gel pump Sympazan oral film triazolam tablets Revatio tablets Synalar cream, ointment, and topical Tribenzor tablets Rhinocort AQ nasal spray solution Tridesilon cream Rhofade cream Synalar cream kit Triglide tablets Riax foam Synalar TS kit Trilipix capsules Riomet oral solution Synalgos-DC capsules Tudorza Pressair inhaler Riomet extended release oral suspension Syndros oral solution TussiCaps capsules Risperdal oral solution and tablets Taclonex ointment and topical suspension Tuxarin ER tablets Risperdal M-Tab ODT Talicia Tuzistra XR oral suspension Ritalin LA capsules TaperDex 6-Day and 12-Day blister packs Twirla patches Rosadan gel kit Targadox tablets Tyzine Pediatric 0.05% nasal drops Rowasa enema kit Targiniq ER Uceris rectal foam Roxicodone tablets Tarina 24 Fe tablets Uceris tablets RoxyBond tablets Taytulla capsules Uloric tablets

*Exclusion applies only to plans with Truli Rx Flex and Truli Rx Basic medication guides. 6 Health coverage is offered by Truli for Health, an affiliate of Florida Blue. These companies are Independent Licensees of the Blue Cross and Blue Shield Association.

Ultracet tablets Xembify injection Zyvox oral suspension and tablets Ultram tablets Xenazine tablets Ultram ER tablets Xepi cream Ultravate lotion Xerese cream Ultravate X kit Ximino capsules Uroxatral tablets Xodol tablets Urso 250 tablets Xolegel CorePak, Duo Kit, and topical gel Urso Forte tablets Xopenex nebulizer solution Utibron Neohaler inhaler Xopenex HFA inhaler Valcyte oral solution and tablets Xyosted Valium tablets Yosprala tablets Valtrex tablets Yupelri nebulizer solution Vanatol LQ oral solution Zanaflex capsules Vanatol S oral solution Zantac syrup and tablets vancomycin 250 mg/5 mL oral solution Zecuity transdermal system Vanos cream Zegerid capsules and powder for Vantrela ER suspension Vaseretic tablets Zelapar ODT Vasotec tablets Zelnorm tablets Veltin gel Zembrace SymTouch injection venlafaxine ER tablets Zenzedi tablets Veramyst nasal spray Zepatier tablets Verdeso foam Zestoretic tablets Veregen ointment Zestril tablets Vibramycin capsules and powder for Zetia tablets suspension Zetonna nasal spray Vicodin tablets Ziac tablets Vicodin ES tablets Ziana gel Vicoprofen tablets Zilxi foam Viekira Pak tablets Zinbryta injection Vigamox eye drops Zipsor capsules Vimovo tablets Zithromax tablets Viokace tablets Zocor tablets Vivelle Dot patches Zofran ODT Vivlodex capsules Zofran tablets Vogelxo gel and gel pump Zohydro ER capsules Voltaren 1% topical gel Zoloft tablets Vumerity capsules zolpidem sublingual tablets Vusion ointment Zolpimist oral spray Vytorin tablets Zomacton injection Vyzulta eye drops Zomig tablets Welchol tablets Zomig-ZMT ODT Wellbutrin tablets Zorbtive injection Wellbutrin SR tablets Zorvolex capsules Wellbutrin XL tablets Zovirax cream and ointment Winlevi cream ZTlido patch Wymzya Fe chewable tablet Zuplenz oral film Wynzora cream Zyclara cream and cream pump Xadago tablets Zyflo tablets Xalatan eye drops Zylet eye drops Xanax tablets Zyloprim tablets Xanax XR tablets Zypitamag tablets Xartemis XR tablets Zyprexa Xatmep oral solution Zyprexa tablets Xeloda tablets Zyprexa Zydis ODT Xelpros eye drops Zytiga 250 mg and 500 mg tablets

*Exclusion applies only to plans with Truli Rx Flex and Truli Rx Basic medication guides. 7 Health coverage is offered by Truli for Health, an affiliate of Florida Blue. These companies are Independent Licensees of the Blue Cross and Blue Shield Association.

Appendix Excluded HIV Products* Excluded Prenatal Vitamins Atripla tab Azeschew Combivir tablet 150-300 mg Azesco Emtriva capsule 200 mg CitraNatal Assure Epivir solution 100 mg/mL CitraNatal Bloom Epivir tablet 150 mg and 300 mg CitraNatal DHA Epzicom tablet 600-300 mg CitraNatal Harmony Kaletra solution Duet DHA 400 Lexiva tablet 700 mg Duet DHA Balanced Norvir tablet 100 mg Enbrace HR Retrovir capsule 100 mg Kosher Prentate Plus Iron Retrovir syrup 50 mg/5 mL Natachew Reyataz capsule 150 mg, 200mg, and Neevo DHA 300 mg Nestabs ABC Sustiva capsule 50 mg and 200 mg Nestabs DHA Sustiva tablet 600 mg Nestabs One Symfi tablet OB Complete Gold Symfi Lo tablet OB Complete One Trizivir tablet OB Complete Petite Videx EC capsule 200 mg, 250 mg, and OB Complete Premier 400 mg Prefera OB One Viramune suspension 50 mg/5 mL Pregen DHA Viramune tablet 200 mg Prenara Viramune XR tablet 100 mg and 400 mg Prenate Viread tablet 300 mg Prenate AM Zerit capsule 15 mg, 20 mg, 30 mg, and Prenate DHA 40 mg Prenate Elite Ziagen solution 20 mg/mL Prenate Enhance Ziagen tablet 300 mg Prenate Essential Prenate Mini

Prenate Pixie

Prenate Restore Prenatrix Primacare Select-OB Select-OB + DHA Trinaz Tristart DHA Tristart Free Tristart One Vitafol Gummies Vitafol Ultra Vitafol Nano Vitafol-OB Vitafol-OB+ DHA Vitafol-One VitaMedMD One Rx VitaMedMD Rx RediChew Rx Vitapearl Vitatrue

*Exclusion applies only to plans with Truli Rx Flex and Truli Rx Basic medication guides. 8 Health coverage is offered by Truli for Health, an affiliate of Florida Blue. These companies are Independent Licensees of the Blue Cross and Blue Shield Association.