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2020 Aetna Pharmacy Drug Guide Aetna Small Group ACA Formulary: FL

Aetna.com Health benefits and health insurance plans are offered, administered and/or underwritten by Aetna Health Inc., Aetna Health Insurance Company of New York, Aetna HealthAssurance Pennsylvania Inc., Aetna Health Insurance Company and/or Aetna Life Insurance Company (Aetna). In Florida, by Aetna Health Inc. and/or Aetna Life Insurance Company. In Utah and Wyoming by Aetna Health of Utah Inc. and Aetna Life Insurance Company. In Maryland, by Aetna Health Inc., 151 Farmington Avenue, Hartford, CT 06156. Each insurer has sole financial responsibility for its own products. 2021 Small Group ACA FL Plan

Table of Contents informational...... section...... 144 ANALGESICS - DRUGS TO TREAT PAIN AND INFLAMMATION...... 14 ANTI - INFECTIVES...... 26 ANTI-INFECTIVES - DRUGS TO TREAT INFECTIONS...... 26 ANTINEOPLASTIC AGENTS - DRUGS TO TREAT CANCER...... 40 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES...... 51 CARDIOVASCULAR - DRUGS TO TREAT HEART AND CIRCULATION CONDITIONS...... 51 CENTRAL NERVOUS SYSTEM - DRUGS TO TREAT NERVOUS SYSTEM DISORDERS...... 66 ENDOCRINE AND METABOLIC - DRUGS TO TREAT AND REGULATE HORMONES...... 91 GASTROINTESTINAL - DRUGS TO TREAT STOMACH AND INTESTINAL DISORDERS...... 117 GENITOURINARY - DRUGS TO TREAT GENITAL AND URINARY TRACT CONDITIONS...127 HEMATOLOGIC - DRUGS TO TREAT BLOOD DISORDERS...... 130 IMMUNOLOGIC AGENTS - DRUGS TO TREAT DISORDERS OF THE IMMUNE SYSTEM.....135 MEDICAL DEVICES...... 141 NUTRITIONAL/SUPPLEMENTS - VITAMINS AND SUPPLEMENTS...... 162 OPHTHALMIC - DRUGS TO TREAT EYE CONDITIONS...... 172 OTHER...... 176 PHARMACEUTICAL ADJUVANTS...... 177 RESPIRATORY - DRUGS TO TREAT BREATHING DISORDERS...... 177 TOPICAL - DRUGS TO TREAT EAR AND SKIN CONDITIONS...... 187

TOC-3 How to use this guide

Your guide includes a list of commonly used drugs covered on your pharmacy plan. The amount you pay depends on the drug your doctor prescribes. It’s either a flat fee or a percentage of the prescription’s price after you meet your deductible, if applicable. Preferred generic drugs cost less. Preferred brand drugs will have a higher cost.

Your plan includes You’re covered for all types of medicine — some more expensive, and some less. • Brand and generic drugs that are hand-picked for their quality and effectiveness • Preferred generic: the lowest cost • A specialty pharmacy that fills specialty prescriptions • Preferred brand: a slightly higher cost (ones that are injected, infused or taken by mouth) — • Non-preferred brand and generic: a higher cost and provides services that include personal • Preferred Specialty: lower cost for specialty drugs support, helpful resources and training, and free secure home delivery • Non-preferred Specialty: higher cost for non-preferred specialty drugs • A home delivery pharmacy that delivers maintenance drugs to your home or wherever Your pharmacy plan may not have all the coverage levels you choose (for drugs that are taken regularly to listed above so check your plan documents to see how treat conditions like diabetes or asthma) much you will pay.

What you can expect to pay For your exact coverage and cost, and to learn more about your plan With your pharmacy plan, the amount you pay depends on the drug your doctor prescribes. It’s either a flat fee or Visit the website that’s on your member ID card. a percentage of the drug’s/medicine’s price. Then log in to your account, where you can:

Each drug is grouped as a generic, a brand or a • Find out the coverage* and estimate of cost for specialty drug. The preferred drugs within these specific drugs groups will generally save you money compared • View your deductibles and plan limits to a non-preferred drug. Typically, generic drugs • Order are less expensive than brands. • Check your pharmacy order status Specialty prescription drugs typically include higher-cost • Get a member ID card drugs that require special handling, special storage or • View your claims, Explanation of Benefits and more. monitoring. These types of drugs may include, but are not limited to, drugs that are injected, infused, inhaled or taken by mouth.

* Check your plan documents for coverage information. Your plan may not cover certain drugs such as infertility, erectile dysfunction, weight loss and smoking cessation.

1 Have more questions about your CVS Caremark Mail Service Pharmacy™ pharmacy benefits? You can have maintenance drugs sent right to your home We’re here to help. There are several ways you can or anywhere else you choose by CVS Caremark Mail learn more about your benefits: Service Pharmacy. These are drugs that are taken regularly for chronic conditions like diabetes or asthma. • Check your Plan Design and Benefits Summary in Depending on your plan, you can get up to a 90-day your enrollment kit. supply of medicine for less cost. It’s fast and convenient, • Call the toll-free number on your member ID card. and standard shipping is always free. • Review our pharmacy frequently asked questions (FAQs) and answers. Just visit the website that’s on Get started right away your member ID card to search for the “Pharmacy FAQ.” You can submit your order using one of these options:

Specialty Pharmacy Network 1. Online — Visit your secure member website and An in-network specialty pharmacy can fill your sign in to your account. There you can add or prescriptions for specialty drugs. These are the types remove your prescriptions. of drugs that may be injected, infused or taken by mouth. 2. Phone — Call us toll-free, 24/7 at 1-888-792-3862. They often need special storage and handling. And they If you need the help of a telephone device for the need to be delivered quickly. A nurse or pharmacist may hard of hearing, call 1-877-833-2779. monitor you during your treatment, if needed. With this type of pharmacy, you can get 3. Mail — Get a new prescription from your doctor. Then this medicine sent right to your home. mail it to us with a completed order form. You can find the form on your secure member website. The mailing address is on the form. How to get started with a specialty pharmacy

Ordering your prescriptions through our specialty Your doctor can submit your order using one of pharmacy is easy. And we typically offer a 30-day these options: medicine supply. 1. Online — They can submit your prescriptions using • To transfer your prescription, just call us toll-free the e-prescribe services on our provider website. at 1-866-353-1892. 2. Fax — They can fax your prescription to • For a new prescription, your doctor can send it to 1-877-270-3317. Make sure they include your member us in one of four ways: ID number, date of birth and mailing address on the 1. Electronically: Through e-prescribe fax cover sheet. Only a doctor may fax a prescription. 2. Fax: 1-800-323-2445

3. Phone: 1-800-237-2767

If you mail in your own prescription, please send it with a completed Patient Profile Form. To find this form, just visit the website that’s on your member ID card, to search for the “Patient Profile Form.”

2 Frequently asked questions

How can I save on prescriptions? What is step therapy?

Here are some tips to pay less out of pocket for your Some drugs require step therapy. This means that prescription drugs: you must try one or more prerequisite drug(s) before a step therapy drug is covered. • Ask your doctor to consider prescribing drugs that are on the Pharmacy Drug Guide (formulary). The prerequisite drugs have U.S. Food and Drug • Ask your doctor to consider prescribing generic Administration (FDA) approval and may cost less. They drugs instead of brand-name drugs. treat the same condition as the step therapy drug. • Our home delivery pharmacy may save you money. If you don’t try the appropriate prerequisite drug first, you For more information, visit the website on your may need to pay full cost for the step-therapy drug. member ID card and log in to your account. What are quantity limits? What are generic drugs? Quantity limits help your doctor and pharmacist make Generic drugs are proven to be just as safe and effective sure that you use your drug correctly and safely. We use as brand-name drugs. They contain the same active medical guidelines and FDA-approved recommendations ingredients in the same amounts as the brand-name from drug makers to set these coverage limits. The drugs and work the same way. So they have the same quantity limit program includes: risks and benefits as brand-name drugs. However, they • Dose efficiency edits — Limits prescription coverage typically cost less. to one dose per day for drugs that have approval for When appropriate, your doctor may decide to prescribe once-daily dosing a generic drug or allow the pharmacist to substitute a • Maximum daily dose — If a prescription is lower than generic drug. the minimum or higher than the maximum allowed dose, a message is sent to the pharmacy What is precertification? • Quantity limits over time — Limits prescription Precertification is one way that we can help you and your coverage to a specific number of units over a specific doctor find safe, appropriate drugs and keep costs down. amount of time Precertification means that you or your doctor need to get approval from the plan before certain drugs will be What if I need a drug that requires an exception covered. Generally, precertification applies to drugs that: to the precertification, step therapy or quantity • Are often taken in the wrong way limits requirements? Or what if I need a drug that’s not covered under my plan? • Should only be used for certain conditions • Often cost more than other drugs that are proven In certain cases, you or your prescriber can request a to be just as effective medical exception to the precertification, step therapy or quantity limits requirements or for a drug that’s not Keep in mind that your doctor must contact us to request covered on your plan. You can ask for your request to be approval of coverage for these drugs. expedited. Expedited coverage decisions are made within 24 hours.

We’ll then contact you or your prescriber with our decision. All medically necessary outpatient prescription drugs will be covered. If a medical exception is approved, you only need to pay the copay after the deductible. This amount is based on your pharmacy plan design.

3 How can your provider request a medical Can the formulary change during the year? exception? The formulary can change throughout the year. • Submit their request through our secure provider Some reasons why it can change include: website on www.availity.com. • New drugs are approved. • Call the Aetna Pharmacy Precertification Unit: • Existing drugs are removed from the market. Non-Specialty 1-800-294-5979 or Specialty 1-866-814-5506. • Prescription drugs may become available over the counter (without a prescription). Over-the-counter drugs • Fax the completed request form to: are not generally covered in a formulary. Non-Specialty 1-888-836-0730 or Specialty 1-866-249-6155. • Brand-name drugs lose patent protection and generic versions become available. When this happens, the • Mail the completed request form to: generic drug will be covered in place of the brand- Aetna Pharmacy Management name drug. The brand-name drug is likely to become 1300 East Campbell Road non-formulary or covered at a higher cost. See the Richardson, TX 75081 “What are generic drugs?” section above for more information. Pharmacy and Therapeutics (P&T) committee

The services of an independent National Pharmacy and Therapeutics Committee (“P&T Committee”) are utilized to approve safe and clinically effective drug therapies. The P&T Committee is an external advisory body of clinical professionals from across the United States. The P&T Committee’s voting members include physicians, pharmacists, a pharmacoeconomist and a medical ethicist, all of whom have a broad background of clinical and academic expertise regarding prescription drugs. Voting members of the P&T Committee are not employees of CVS Caremark and must disclose any financial relationship or conflicts of interest with any pharmaceutical manufacturers.

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Civil Rights Coordinator, P.O. Box 14462, Lexington, KY 40512 (CA HMO customers: PO Box 24030 Fresno, CA 93779), 1-800-648-7817, TTY: 711, Fax: 859-425-3379 (CA HMO customers: 860-262-7705), [email protected].

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5 6 7 8 9 Remember to visit the website on your member ID card. Then sign in to your account for the most up-to-date information.

Please note that if your benefits plan changes, the information here may no longer apply. Medications on the Aetna Drug Guide, precertification, step-therapy and quantity limits lists are subject to change. Not all health services are covered. Your plan may not cover certain drugs such as infertility, erectile dysfunction, weight loss and smoking cessation. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by location and are subject to change. The drugs on the Pharmacy Drug Guide (formulary), Formulary Exclusions, Precertification, and Quantity Limit Lists are subject to change. The quantity limits and step therapy drug coverage review programs are not available in all service areas. However, these programs are available to self-funded plans. In accordance with state law, commercial fully insured members in Louisiana and Texas (except Federal Employee Health Benefit Plan members) who are receiving coverage for medications that are added or removed from the Pharmacy Drug Guide (formulary), Precertification, Quantity Limits or Step-Therapy Lists during the plan year will continue to have those medications covered at the same benefit level until their plan’s renewal date. In Texas, precertification approval is known as “pre-service utilization review.” It is not “verification” as defined by Texas law. In accordance with state law, certain fully insured commercial California members (except Federal Employee Health Benefit Plan members) who obtained approval from an Aetna plan for coverage of drugs that are later added to the Preauthorization or Step Therapy Lists or removed from the Pharmacy Drug Guide will continue to have those drugs covered, for as long as the treating in-network provider continues prescribing them, provided that the drug is appropriately prescribed and is considered safe and effective for treating the enrollee’s medical condition. Aetna reserves the right to periodically request clinical information from your provider to assess your medical condition and the appropriateness of your ongoing treatment. Failure to provide clinical information could result in subsequent denial of coverage for this . In accordance with state law, fully insured Commercial Connecticut preferred provider organization (PPO) members (except Federal Employee Health Benefit Plan members) who are receiving coverage for drugs that are added to the Precertification or Step-Therapy Lists will continue to have those drugs covered for as long as the prescriber prescribes them, provided the drug is medically necessary and more medically beneficial than other covered drugs. Nothing in this section shall preclude the prescribing provider from prescribing another drug covered by the plan that is medically appropriate for the enrollee, nor shall anything in this section be construed to prohibit generic drug substitutions. In certain states, including Arkansas, Colorado, Connecticut, Delaware, Georgia, Illinois, Louisiana, Maryland, Minnesota, North Dakota, Pennsylvania and Texas, step therapy programs do not apply to fully insured members utilizing prescription drugs for the treatment of stage-four advanced, metastatic cancer. This material is for information only. It contains only a partial, general description of plan benefits or programs and does not constitute a contract. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by location and are subject to change. Providers are independent contractors and are not agents of Aetna. Provider participation may change without notice. Aetna does not provide care or guarantee access to health services. Information is subject to change. CVS Caremark Mail Service Pharmacy is part of the CVS Health family of companies.

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Drug Details # = Brand-name drug expected to become available generically in the near future. After the generic drug becomes available, the brand- name drug may be covered at a higher non-preferred copay and/or added to the Formulary Exclusion List. The brand-name drug may also be subject to precertification and/or step-therapy. LGC = Lowest Generic Copay Applies N2 = Drug tier when CE does not Drug Status apply CE = Copay Exception: Available OTC = Covered OTC to some members at no cost with a PA = Prior Authorization prescription from your provider QL = Quantity Limit when obtained at an in-network SP Pharmacy = You may pay pharmacy. Certain limitations may higher out of pocket costs and apply. may be required to get these NC = Not Covered products at an Aetna Specialty NP = Non Preferred Pharmacy network provider, like NPSP = Non Preferred Specialty Aetna Specialty Pharmacy. lowercase italics = Generic drugs PB = Preferred Brand Specialty products are limited to a UPPERCASE = Brand name PG = Preferred Generic 30 day supply. drugs PSP = Preferred Specialty ST = Step Therapy Drug Name Drug Status Drug Details GUARDIAN REAL-TIME REPLACE PED (continuous NC blood gluc receiver) GUARDIAN REAL-TIME REPLACEMENT (continuous NC blood gluc receiver) guardian sensor 3 NC GUARDIAN TRANSMITTER (continuous blood gluc NC transmit) ANALGESICS - DRUGS TO TREAT PAIN AND INFLAMMATION COX-2 INHIBITORS CELEBREX (celecoxib) NC celecoxib oral capsule 100 mg, 200 mg, 50 mg NP

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 14 Drug Name Drug Status Drug Details ST; QL (2 capsules per 1 celecoxib oral capsule 400 mg NP day) GOUT - DRUGS TO TREAT GOUT allopurinol oral PG LGC colchicine oral capsule NC colchicine oral tablet NP colchicine-probenecid PG COLCRYS (colchicine) NC DUZALLO (lesinurad-allopurinol) NC febuxostat PG ST GLOPERBA (colchicine) NC MITIGARE (colchicine) NC probenecid oral PG ULORIC (febuxostat) NC ZURAMPIC (lesinurad) NC ZYLOPRIM (allopurinol) NC MISCELLANEOUS duraxin NP RIDAURA (auranofin) NP NON-OPIOID ANALGESICS ALLZITAL (butalbital-acetaminophen) NC butalbital-apap-caffeine (Bac) PG QL (48 tablets per 25 days) butalbital-acetaminophen (Bupap Oral Tablet 50-300 Mg) NP butalbital-acetaminophen oral capsule NC butalbital-acetaminophen oral tablet 25-325 mg NC butalbital-acetaminophen oral tablet 50-300 mg, 50-325 mg NP QL (48 capsules per 1 butalbital-apap-caffeine oral capsule NP month) butalbital-apap-caffeine oral tablet 50-325-40 mg PG QL (48 tablets per 1 month) QL (48 capsules per 1 butalbital-asa-caffeine PG month) butalbital-aspirin-caffeine oral capsule PG butalbital-aspirin-caffeine oral tablet NP capacet NP butalbital-apap-caffeine (Esgic Oral Capsule) NP

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 15 Drug Name Drug Status Drug Details ESGIC ORAL TABLET (butalbital-apap-caffeine) NC FIORICET ORAL CAPSULE (butalbital-apap-caffeine) NC FIORINAL (butalbital-aspirin-caffeine) NC marten-tab NP tencon oral tablet 50-325 mg NC butalbital-apap-caffeine (Vanatol Lq) PG QL (90 ML per 1 day) butalbital-apap-caffeine (Vanatol S) PG QL (90 ML per 1 day) VTOL LQ (butalbital-apap-caffeine) NC zebutal oral capsule 50-325-40 mg NP NSAIDS - DRUGS TO TREAT PAIN AND INFLAMMATION ANAPROX DS (naproxen sodium) NC CAMBIA (diclofenac potassium(migraine)) NC DAYPRO (oxaprozin) NC diclofenac NC diclofenac potassium PG diclofenac sodium er PG diclofenac sodium oral tablet delayed release 25 mg, 50 mg PG diclofenac sodium oral tablet delayed release 75 mg PG LGC EC-NAPROSYN (naproxen) NC equapax/ibuprofen/minrex NC etodolac er PG etodolac oral PG FELDENE (piroxicam) NC fenoprofen calcium oral NP FENORTHO (fenoprofen calcium) NC flurbiprofen oral PG ibuprofen (Ibu Oral Tablet 600 Mg) PG LGC ibuprofen oral suspension PG ibuprofen oral tablet 400 mg, 600 mg, 800 mg PG LGC ILARIS (150MG DELIVERED) (canakinumab) NPSP PA; SP Pharmacy INDOCIN ORAL (indomethacin) NP INDOCIN RECTAL (indomethacin) NP indomethacin er NP indomethacin oral capsule 20 mg NC 2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 16 Drug Name Drug Status Drug Details indomethacin oral capsule 25 mg, 50 mg PG QL (3 capsules per 1 day) ketoprofen er NC ketoprofen oral capsule 50 mg, 75 mg PG ketorolac tromethamine nasal NC ketorolac tromethamine oral NP QL (20 tablets per 5 days) LODINE (etodolac) NC meclofenamate sodium oral PG mefenamic acid oral NP meloxicam oral capsule NC meloxicam oral tablet PG LGC MOBIC ORAL TABLET (meloxicam) NC nabumetone oral PG NALFON ORAL CAPSULE 400 MG (fenoprofen calcium) NC NAPRELAN ORAL TABLET EXTENDED RELEASE 24 NC HOUR 375 MG, 500 MG, 750 MG (naproxen sodium) NAPROSYN ORAL SUSPENSION (naproxen) NC NAPROSYN ORAL TABLET 500 MG (naproxen) NC naproxen dr PG naproxen oral suspension NC naproxen oral tablet PG LGC naproxen oral tablet delayed release PG naproxen sodium er NC naproxen sodium oral tablet 275 mg PG naproxen sodium oral tablet 550 mg PG LGC oxaprozin PG piroxicam oral PG PONSTEL (mefenamic acid) NC QMIIZ ODT (meloxicam) NC nabumetone (Relafen) NC RELAFEN DS (nabumetone) NC SPRIX (ketorolac tromethamine) NC sulindac oral PG TIVORBEX (indomethacin) NC tolmetin sodium oral capsule PG tolmetin sodium oral tablet 200 mg NP 2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 17 Drug Name Drug Status Drug Details tolmetin sodium oral tablet 600 mg PG VIVLODEX (meloxicam) NC ZIPSOR (diclofenac potassium) NC # ZORVOLEX (diclofenac) NC NSAIDS, COMBINATIONS ARTHROTEC ORAL TABLET DELAYED RELEASE NC (diclofenac-misoprostol) diclofenac-misoprostol oral tablet delayed release 50-0.2 mg PG diclofenac-misoprostol oral tablet delayed release 75-0.2 mg NP DUEXIS (ibuprofen-famotidine) NC # ibuprofen-famotidine NC naproxen-esomeprazole NC VIMOVO (naproxen-esomeprazole) NC OPIOID AGONIST/ANTAGONIST BUNAVAIL BUCCAL FILM 2.1-0.3 MG, 4.2-0.7 MG NP ST; QL (3 films per 1 day) (buprenorphine hcl-naloxone hcl) BUNAVAIL BUCCAL FILM 6.3-1 MG (buprenorphine hcl- NP ST; QL (2 films per 1 day) naloxone hcl) buprenorphine hcl-naloxone hcl sublingual film 12-3 mg PG QL (2 films per 1 day) buprenorphine hcl-naloxone hcl sublingual film 2-0.5 mg, 4-1 PG QL (3 films per 1 day) mg, 8-2 mg buprenorphine hcl-naloxone hcl sublingual tablet sublingual PG QL (3 tabs per 1 day) pentazocine-naloxone hcl NP PA; QL (4 tablets per 1 day) SUBOXONE SUBLINGUAL FILM 12-3 MG NP QL (2 films per 1 day) (buprenorphine hcl-naloxone hcl) SUBOXONE SUBLINGUAL FILM 2-0.5 MG, 4-1 MG, 8-2 NP QL (3 films per 1 day) MG (buprenorphine hcl-naloxone hcl) ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 0.7- 0.18 MG, 1.4-0.36 MG, 2.9-0.71 MG, 5.7-1.4 MG PB QL (3 TABLETS per 1 day) (buprenorphine hcl-naloxone hcl) ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 11.4- PB QL (1 TABLET per 1 day) 2.9 MG (buprenorphine hcl-naloxone hcl) ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 8.6- PB QL (2 TABLETS per 1 day) 2.1 MG (buprenorphine hcl-naloxone hcl) OPIOID ANALGESICS - DRUGS TO TREAT PAIN ABSTRAL (fentanyl citrate) NC #

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 18 Drug Name Drug Status Drug Details PA; QL (13 tablets per 1 acetaminophen-codeine #2 PG day) PA; QL (12 tablets per 1 acetaminophen-codeine #3 PG day) PA; QL (10 tablets per 1 acetaminophen-codeine #4 PG day) acetaminophen-codeine oral solution PG PA; QL (90 ml per 1 day) PA; QL (13 tablets per 1 acetaminophen-codeine oral tablet 300-15 mg PG day) PA; QL (10 tablets per 1 acetaminophen-codeine oral tablet 300-60 mg PG day) ACTIQ (fentanyl citrate) NC APADAZ (benzhydrocodone-acetaminophen) NC PA; QL (10 capsules per 1 apap-caff-dihydrocodeine oral capsule NP day) apap-caff-dihydrocodeine oral tablet 325-30-16 mg NC ARYMO ER (morphine sulfate) NC PA; QL (6 capsules per 1 ascomp-codeine PG day) PA; QL (168 tablets per 1 benzhydrocodone-acetaminophen NP month) PA; QL (6 capsules per 1 butalbital-apap-caff-cod PG day) PA; QL (48 tablets per 1 butalbital-asa-caff-codeine PG month) PA; QL (2 bottles per 30 butorphanol tartrate nasal NP days) PA; QL (6 tablets per day codeine sulfate oral tablet 15 mg, 60 mg NP for 7 days only per 90 days) PA; QL (6 tablets per day codeine sulfate oral tablet 30 mg PG for 7 days only per 90 days) CONZIP (tramadol hcl) NC DEMEROL ORAL TABLET 100 MG (meperidine hcl) NC DILAUDID ORAL (hydromorphone hcl) NC DOLOPHINE (methadone hcl) NC DURAGESIC-100 (fentanyl) NC DURAGESIC-12 (fentanyl) NC DURAGESIC-25 (fentanyl) NC 2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 19 Drug Name Drug Status Drug Details DURAGESIC-50 (fentanyl) NC DURAGESIC-75 (fentanyl) NC EMBEDA ORAL CAPSULE EXTENDED RELEASE 100-4 PA; ST; QL (1 capsule per 1 PB MG, 50-2 MG, 60-2.4 MG, 80-3.2 MG (morphine-naltrexone) day) EMBEDA ORAL CAPSULE EXTENDED RELEASE 20- PA; ST; QL (2 capsules per PB 0.8 MG, 30-1.2 MG (morphine-naltrexone) 1 day) endocet oral tablet 10-325 mg PG PA; QL (6 tablets per 1 day) PA; QL (12 tablets per 1 oxycodone-acetaminophen (Endocet Oral Tablet 2.5-325 Mg) PG day) PA; QL (12 tablets per 1 endocet oral tablet 5-325 mg PG day) endocet oral tablet 7.5-325 mg PG PA; QL (8 tablets per 1 day) EXALGO ORAL TABLET ER 24 HOUR ABUSE- NC DETERRENT (hydromorphone hcl) EXALGO ORAL TABLET EXTENDED RELEASE 24 NC HOUR 12 MG, 16 MG, 32 MG, 8 MG (hydromorphone hcl) PA; ST; QL (10 patches per fentanyl NP 30 days) PA; QL (120 lozenges per 30 fentanyl citrate buccal lozenge on a handle NP days) fentanyl citrate buccal tablet 200 mcg, 400 mcg, 600 mcg, 800 PA; QL (120 tablets per 30 NP mcg days) FENTORA BUCCAL TABLET 100 MCG, 200 MCG, 400 NC MCG, 600 MCG, 800 MCG (fentanyl citrate) FIORICET/CODEINE ORAL CAPSULE 50-300-40-30 MG NC (butalbital-apap-caff-cod) FIORINAL/CODEINE #3 (butalbital-asa-caff-codeine) NC HYCET (hydrocodone-acetaminophen) NC hydrocodone bitartrate er oral capsule er 12 hour abuse- PA; QL (2 capsules per 1 PG deterrent day) PA; ST; QL (2 capsules per hydrocodone bitartrate er oral capsule extended release 12 hour PG 1 day) PA; ST; QL (1 tablet per 1 hydrocodone bitartrate er oral tablet er 24 hour abuse-deterrent PG day) hydrocodone-acetaminophen oral solution 10-325 mg/15ml NP QL (90 ml per 1 day) hydrocodone-acetaminophen oral solution 2.5-108 mg/5ml, 5- PA; QL (180 MLS per 1 NP 217 mg/10ml day) hydrocodone-acetaminophen oral solution 7.5-325 mg/15ml NP PA; QL (90 ml per 1 day)

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 20 Drug Name Drug Status Drug Details hydrocodone-acetaminophen oral tablet 10-300 mg, 7.5-300 mg NP PA; QL (6 tablets per 1 day) hydrocodone-acetaminophen oral tablet 10-325 mg, 7.5-325 mg PG PA; QL (6 tablets per 1 day) PA; QL (12 tablets per 1 hydrocodone-acetaminophen oral tablet 2.5-325 mg NP day) hydrocodone-acetaminophen oral tablet 5-300 mg NP PA; QL (8 tablets per 1 day) hydrocodone-acetaminophen oral tablet 5-325 mg PG PA; QL (8 tablets per 1 day) hydrocodone-ibuprofen oral tablet 10-200 mg PG PA; QL (5 tablets per 1 day) hydrocodone-ibuprofen oral tablet 5-200 mg, 7.5-200 mg NP PA; QL (5 tablets per 1 day) hydromorphone hcl er oral tablet er 24 hour abuse-deterrent NP PA; QL (1 tablet per 1 day) PA; ST; QL (1 tablet per 1 hydromorphone hcl er oral tablet extended release 24 hour NP day) hydromorphone hcl oral liquid NC PA; QL (11 tablets per 1 hydromorphone hcl oral tablet 2 mg PG day) hydromorphone hcl oral tablet 4 mg PG PA; QL (5 tablets per 1 day) hydromorphone hcl oral tablet 8 mg PG PA; QL (2 tablets per 1 day) HYSINGLA ER (hydrocodone bitartrate) NC IBUDONE ORAL TABLET 10-200 MG (hydrocodone- NC ibuprofen) ibudone oral tablet 5-200 mg NP PA; QL (5 tablets per 1 day) KADIAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 100 MG, 20 MG, 30 MG, 50 MG, 60 MG, 80 NC MG (morphine sulfate) KADIAN ORAL CAPSULE EXTENDED RELEASE 24 PA; ST; QL (1 capsule per 1 NP HOUR 200 MG (morphine sulfate) day) KADIAN ORAL CAPSULE EXTENDED RELEASE 24 PA; ST; QL (2 capsules per NP HOUR 40 MG (morphine sulfate) 1 day) LAZANDA (fentanyl citrate) NC levorphanol tartrate oral tablet 2 mg NC levorphanol tartrate oral tablet 3 mg NP PA; QL (2 tablets per 1 day) lorcet PG PA; QL (8 tablets per 1 day) lorcet hd PG PA; QL (6 tablets per 1 day) hydrocodone-acetaminophen (Lorcet Plus Oral Tablet 7.5-325 PG PA; QL (6 tablets per 1 day) Mg) LORTAB ORAL ELIXIR 10-300 MG/15ML (hydrocodone- NC acetaminophen) meperidine hcl oral solution PG QL (90 ml per 1 month)

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 21 Drug Name Drug Status Drug Details PA; QL (18 tablets per 1 meperidine hcl oral tablet NP month) methadone hcl intensol PG PA; QL (3 MLS per 1 day) methadone hcl oral concentrate PG PA; ST; QL (1 ml per 1 day) PA; ST; QL (10 ml per 1 methadone hcl oral solution 10 mg/5ml PG day) PA; ST; QL (15 ml per 1 methadone hcl oral solution 5 mg/5ml PG day) PA; ST; QL (2 tablets per 1 methadone hcl oral tablet 10 mg PG day) PA; ST; QL (6 tablets per 1 methadone hcl oral tablet 5 mg PG day) methadone hcl oral tablet soluble PG QL (9 tablets per 1 month) METHADOSE ORAL CONCENTRATE 10 MG/ML NC (methadone hcl) PA; QL (9 tablets per 1 methadone hcl (Methadose Oral Tablet Soluble) PG month) METHADOSE SUGAR-FREE (methadone hcl) NC MORPHABOND ER (morphine sulfate) NC morphine sulfate (concentrate) oral solution 100 mg/5ml PG PA; QL (4.5 MLS per 1 day) morphine sulfate (concentrate) oral solution 20 mg/ml PG PA; ST; QL (1 capsule per 1 morphine sulfate er beads PG day) morphine sulfate er oral capsule extended release 24 hour 10 mg, PA; ST; QL (2 capsules per PG 20 mg, 30 mg 1 day) morphine sulfate er oral capsule extended release 24 hour 100 PA; QL (2 capsules per 1 PG mg day) PA; ST; QL (2 capsules per morphine sulfate er oral capsule extended release 24 hour 40 mg NP 1 day) morphine sulfate er oral capsule extended release 24 hour 50 mg, PA; ST; QL (1 capsule per 1 PG 60 mg, 80 mg day) PA; ST; QL (2 tablets per 1 morphine sulfate er oral tablet extended release 100 mg, 200 mg PG day) morphine sulfate er oral tablet extended release 15 mg, 30 mg, PA; ST; QL (3 tablets per 1 PG 60 mg day) morphine sulfate oral solution 10 mg/5ml PG PA; QL (30 mls per 1 day) PA; QL (22.5 MLS per 1 morphine sulfate oral solution 20 mg/5ml PG day)

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 22 Drug Name Drug Status Drug Details morphine sulfate oral tablet 15 mg PG PA; QL (6 tablets per 1 day) morphine sulfate oral tablet 30 mg PG PA; QL (3 tablets per 1 day) PA; QL (6 suppositories per morphine sulfate rectal suppository 10 mg, 5 mg PG 1 day) PA; QL (4 suppositories per morphine sulfate rectal suppository 20 mg PG 1 day) PA; QL (3 suppositories per morphine sulfate rectal suppository 30 mg PG 1 day) MS CONTIN ORAL TABLET EXTENDED RELEASE NC (morphine sulfate) PA; QL (12 tablets per 1 nalocet PG day) NORCO (hydrocodone-acetaminophen) NC PA; ST; QL (2 tablets per 1 NUCYNTA ER (tapentadol hcl) NP day) NUCYNTA ORAL TABLET 100 MG (tapentadol hcl) NP QL (2 tablets per 1 day) NUCYNTA ORAL TABLET 50 MG (tapentadol hcl) NP QL (4 tablets per 1 day) NUCYNTA ORAL TABLET 75 MG (tapentadol hcl) NP QL (3 tablets per 1 day) OPANA ER ORAL TABLET ER 12 HOUR ABUSE- PA; ST; QL (2 tablets per 1 NP DETERRENT (oxymorphone hcl) day) OPANA ORAL (oxymorphone hcl) NC OXAYDO ORAL TABLET 5 MG (oxycodone hcl) NP QL (6 tablets per 1 day) OXAYDO ORAL TABLET 7.5 MG (oxycodone hcl) NP PA; QL (6 tablets per 1 day) OXAYDO ORAL TABLET ABUSE-DETERRENT 5 MG NP QL (6 tablets per 1 day) (oxycodone hcl) OXAYDO ORAL TABLET ABUSE-DETERRENT 7.5 MG NP PA; QL (6 tablets per 1 day) (oxycodone hcl) PA; ST; QL (2 tablets per 1 oxycodone hcl er oral tablet er 12 hour abuse-deterrent PG day) PA; QL (6 capsules per 1 oxycodone hcl oral capsule PG day) oxycodone hcl oral concentrate 100 mg/5ml PG PA; QL (3 MLS per 1 day) oxycodone hcl oral solution NP PA; QL (30 mls per 1 day) oxycodone hcl oral tablet 10 mg, 5 mg PG PA; QL (6 tablets per 1 day) oxycodone hcl oral tablet 15 mg PG PA; QL (4 tablets per 1 day) oxycodone hcl oral tablet 20 mg PG PA; QL (3 tablets per 1 day) oxycodone hcl oral tablet 30 mg PG PA; QL (2 tablets per 1 day)

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 23 Drug Name Drug Status Drug Details oxycodone-acetaminophen oral solution NC oxycodone-acetaminophen oral tablet 10-300 mg, 2.5-300 mg, 5- NC 300 mg oxycodone-acetaminophen oral tablet 10-325 mg PG PA; QL (6 tablets per 1 day) PA; QL (12 tablets per 1 oxycodone-acetaminophen oral tablet 2.5-325 mg, 5-325 mg PG day) oxycodone-acetaminophen oral tablet 7.5-325 mg PG PA; QL (8 tablets per 1 day) PA; QL (12 tablets per 1 oxycodone-aspirin oral tablet 4.8355-325 mg PG day) PA; QL (4 tablets per day oxycodone-ibuprofen PG for 7 days per 1 month) OXYCONTIN ORAL TABLET ER 12 HOUR ABUSE- PA; ST; QL (2 tablets per 1 NP DETERRENT (oxycodone hcl) day) PA; ST; QL (2 tablets per 1 oxymorphone hcl er NP day) oxymorphone hcl oral tablet 10 mg NP QL (3 tablets per 1 day) oxymorphone hcl oral tablet 5 mg PG QL (6 tablets per 1 day) panlor NC PERCOCET ORAL TABLET 10-325 MG, 2.5-325 MG, 5- NC 325 MG, 7.5-325 MG (oxycodone-acetaminophen) PRIMLEV (oxycodone-acetaminophen) NC PROLATE (oxycodone-acetaminophen) NC QDOLO (tramadol hcl) NC ROXICODONE ORAL TABLET (oxycodone hcl) NC SUBSYS (fentanyl) NC SYNALGOS-DC (dihydrocodeine compound) NC tramadol hcl er (biphasic) oral tablet extended release 24 hour PA; ST; QL (1 tablet per 1 NP 100 mg, 200 mg, 300 mg day) tramadol hcl er oral capsule extended release 24 hour NC PA; ST; QL (1 tablet per 1 tramadol hcl er oral tablet extended release 24 hour NP day) tramadol hcl oral tablet 100 mg NC tramadol hcl oral tablet 50 mg PG PA; QL (6 tablets per 1 day) PA; QL (40 tablets per 1 tramadol-acetaminophen PG month) TREZIX ORAL CAPSULE 320.5-30-16 MG (apap-caff- NC dihydrocodeine)

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 24 Drug Name Drug Status Drug Details TYLENOL WITH CODEINE #3 (acetaminophen-codeine) NC TYLENOL WITH CODEINE #4 (acetaminophen-codeine) NC PA; QL (40 tablets per 1 ULTRACET (tramadol-acetaminophen) NP month) ULTRAM (tramadol hcl) NC PA; QL (12 tablets per 1 VERDROCET (hydrocodone-acetaminophen) NP day) vicodin es oral tablet 7.5-300 mg NP PA; QL (6 tablets per 1 day) vicodin hp oral tablet 10-300 mg NP PA; QL (6 tablets per 1 day) vicodin oral tablet 5-300 mg NP PA; QL (8 tablets per 1 day) XODOL (hydrocodone-acetaminophen) NC PA; ST; QL (2 tablets per 1 XTAMPZA ER (oxycodone) PB day) hydrocodone-ibuprofen (Xylon) NP PA; QL (5 tablets per 1 day) ZAMICET (hydrocodone-acetaminophen) NC ZOHYDRO ER (hydrocodone bitartrate) NC OPIOID PARTIAL AGONISTS BELBUCA (buprenorphine hcl) NC buprenorphine hcl buccal PG PA; QL (2 films per 1 day) buprenorphine hcl sublingual PG QL (3 tablets per 1 day) PA; ST; QL (4 patches per buprenorphine transdermal PG 28 days) BUTRANS (buprenorphine) NC PA; SP Pharmacy; QL (15 acetate (Sajazir) PSP syringes per 1 month) SUBLOCADE (buprenorphine) PSP SALICYLATES N2 (Not Covered); AL (Min aspirin low dose oral tablet chewable CE 50 Years and Max 69 Years) N2 (Not Covered); AL (Min aspirin oral tablet chewable CE 50 Years and Max 69 Years) N2 (Not Covered); AL (Min aspirin oral tablet delayed release 81 mg CE 50 Years and Max 69 Years) N2 (Not Covered); AL (Min aspirin rectal suppository 120 mg, 200 mg CE 50 Years and Max 69 Years) N2 (Not Covered); AL (Min bayer low dose CE 50 Years and Max 69 Years)

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 25 Drug Name Drug Status Drug Details N2 (Not Covered); AL (Min childrens aspirin CE 50 Years and Max 69 Years) choline-mag trisalicylate NP diflunisal oral PG N2 (Not Covered); AL (Min ecotrin low strength CE 50 Years and Max 69 Years) N2 (Not Covered); AL (Min st joseph aspirin oral tablet delayed release CE 50 Years and Max 69 Years) ANTI - INFECTIVES ERYTHROMYCINS/MACROLIDES - DRUGS TO TREAT INFECTIONS E.E.S. 400 ORAL TABLET (erythromycin ethylsuccinate) PG ANTI-INFECTIVES - DRUGS TO TREAT INFECTIONS ANTI-BACTERIALS - MISCELLANEOUS ARIKAYCE (amikacin sulfate liposome) NC BETHKIS (tobramycin) NC HUMATIN (paromomycin sulfate) NC KITABIS PAK (tobramycin) NC MONUROL (fosfomycin tromethamine) NC neomycin sulfate oral PG paromomycin sulfate oral PG sulfadiazine oral NP TINDAMAX ORAL TABLET 500 MG (tinidazole) NC tinidazole oral NP TOBI (tobramycin) NC TOBI PODHALER (tobramycin) NC SP Pharmacy; QL (224 ML tobramycin inhalation nebulization solution 300 mg/4ml PSP per 1 month) PA; SP Pharmacy; QL (56 tobramycin inhalation nebulization solution 300 mg/5ml PSP vials per 1 fill) ANTIFUNGALS - DRUGS TO TREAT FUNGAL INFECTIONS ANCOBON (flucytosine) NC bio- oral capsule PB bio-statin oral powder PG BREXAFEMME (ibrexafungerp citrate) NC

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 26 Drug Name Drug Status Drug Details CRESEMBA ORAL (isavuconazonium sulfate) NP DIFLUCAN (fluconazole) NC fluconazole oral PG flucytosine oral NP griseofulvin microsize oral NP griseofulvin ultramicrosize NP itraconazole oral NP PA KERYDIN (tavaborole) NP ketoconazole oral NP QL (2 tabs per 1 day) LAMISIL ORAL TABLET (terbinafine hcl) NC NOXAFIL ORAL SUSPENSION (posaconazole) PB NOXAFIL ORAL TABLET DELAYED RELEASE NC (posaconazole) nystatin oral tablet PG ONMEL (itraconazole) NC posaconazole NP PA SPORANOX (itraconazole) NC SPORANOX PULSEPAK (itraconazole) NC terbinafine hcl oral PG tolsura NC VFEND (voriconazole) NC voriconazole oral NP PA ANTI-INFECTIVES - MISCELLANEOUS AEMCOLO (rifamycin sodium) NP QL (12 tablets per 1 fill) QL (336 tablets per 365 albendazole oral NP days) ALINIA ORAL SUSPENSION RECONSTITUTED NP #; QL (180 ml per 3 days) (nitazoxanide) ALINIA ORAL TABLET (nitazoxanide) NC atovaquone oral NP BACTRIM (sulfamethoxazole-trimethoprim) NC BACTRIM DS (sulfamethoxazole-trimethoprim) NC benznidazole NP BILTRICIDE (praziquantel) NP PA; #; SP Pharmacy; QL CAYSTON (aztreonam lysine) PSP (84 vials per 28 days) 2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 27 Drug Name Drug Status Drug Details CLEOCIN ORAL (clindamycin hcl) NC clindamycin hcl oral PG clindamycin palmitate hcl PG dapsone oral PG DARAPRIM (pyrimethamine) NC EMVERM (mebendazole) NP QL (6 tablets per 3 days) FIRVANQ (vancomycin hcl) NP FLAGYL (metronidazole) NC FURADANTIN (nitrofurantoin) NC HIPREX (methenamine hippurate) NC IMPAVIDO (miltefosine) NP PA; #; QL (3 caps per 1 day) ivermectin oral PG KETEK ORAL TABLET 300 MG (telithromycin) NP LAMPIT (nifurtimox) NP linezolid oral PG MACROBID (nitrofurantoin monohyd macro) NC MACRODANTIN (nitrofurantoin macrocrystal) NC methenamine hippurate PG methenamine mandelate oral NP METRONIDAZOLE BENZO+SYRSPEND (metronidazole NC benzoate) metronidazole oral capsule NP metronidazole oral tablet PG NEBUPENT (pentamidine isethionate) NP nitazoxanide oral PG QL (6 tablets per 3 days) nitrofurantoin macrocrystal oral PG PA; AL (Max 70 Years) nitrofurantoin monohyd macro PG PA; AL (Max 70 Years) nitrofurantoin oral suspension NC pentamidine isethionate inhalation PG praziquantel oral PG QL (24 tablets per 365 days) PRIMSOL (trimethoprim hcl) PB pyrimethamine oral NP SIVEXTRO ORAL (tedizolid phosphate) NP ST; QL (6 tabs per 1 fill) SOLOSEC (secnidazole) NC sulfamethoxazole-trimethoprim oral suspension 200-40 mg/5ml PG 2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 28 Drug Name Drug Status Drug Details sulfamethoxazole-trimethoprim oral tablet 400-80 mg PG LGC sulfamethoxazole-trimethoprim oral tablet 800-160 mg PG sulfatrim pediatric PG trimethoprim oral PG trimpex NP VANCOCIN HCL (vancomycin hcl) NC vancomycin hcl oral capsule NP QL (80 capsules per 10 days) XENLETA ORAL (lefamulin acetate) NC XIFAXAN ORAL TABLET 200 MG (rifaximin) PB QL (9 tablets per 25 days) XIFAXAN ORAL TABLET 550 MG (rifaximin) PB PA ZYVOX ORAL (linezolid) NC ANTIMALARIALS - DRUGS TO TREAT MALARIA ARAKODA (tafenoquine succinate) NP atovaquone-proguanil hcl NP chloroquine phosphate oral PG COARTEM (artemether-lumefantrine) NP KRINTAFEL (tafenoquine succinate) NP MALARONE (atovaquone-proguanil hcl) NC mefloquine hcl NP primaquine phosphate oral NP QUALAQUIN (quinine sulfate) NC quinine sulfate oral NP ANTIRETROVIRAL AGENTS - DRUGS TO SUPPRESS HIV/AIDS INFECTION abacavir sulfate oral solution PG QL (4 bottles per 30 days) abacavir sulfate oral tablet PG QL (2 tablets per 1 day) APTIVUS ORAL CAPSULE (tipranavir) PB #; QL (4 capsules per 1 day) APTIVUS ORAL SOLUTION (tipranavir) PB #; QL (4 bottles per 30 days) atazanavir sulfate oral capsule 150 mg, 300 mg PG QL (1 capsule per 1 day) atazanavir sulfate oral capsule 200 mg PG QL (2 capsules per 1 day) #; QL (15 capsules per 1 CRIXIVAN ORAL CAPSULE 200 MG (indinavir sulfate) PB day) CRIXIVAN ORAL CAPSULE 400 MG (indinavir sulfate) PB #; QL (6 capsules per 1 day) didanosine PG QL (1 capsule per 1 day) EDURANT (rilpivirine hcl) PB QL (2 tablets per 1 day)

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 29 Drug Name Drug Status Drug Details oral capsule PG QL (3 capsules per 1 day) efavirenz oral tablet PG QL (1 tablet per 1 day) emtricitabine PG QL (1 capsule per 1 day) EMTRIVA ORAL CAPSULE (emtricitabine) PB QL (1 cap per 1 day) EMTRIVA ORAL SOLUTION (emtricitabine) PB #; QL (4 bottles per 30 days) EPIVIR ORAL SOLUTION (lamivudine) NP QL (30 ML per 1 day) EPIVIR ORAL TABLET 150 MG (lamivudine) NP QL (2 tablets per 1 day) EPIVIR ORAL TABLET 300 MG (lamivudine) NP QL (1 tablet per 1 day) etravirine oral tablet 100 mg PG QL (4 tablets per 1 day) etravirine oral tablet 200 mg PG QL (2 tablets per 1 day) fosamprenavir calcium PG QL (4 tablets per 1 day) FUZEON SUBCUTANEOUS SOLUTION #; SP Pharmacy; QL (2 vials PSP RECONSTITUTED (enfuvirtide) per 1 day) INTELENCE ORAL TABLET 100 MG, 25 MG (etravirine) PB #; QL (4 tabs per 1 day) INTELENCE ORAL TABLET 200 MG (etravirine) PB #; QL (2 tabs per 1 day) INVIRASE ORAL CAPSULE (saquinavir mesylate) PB QL (10 capsules per 1 day) INVIRASE ORAL TABLET (saquinavir mesylate) PB QL (4 tablets per 1 day) ISENTRESS HD (raltegravir potassium) PB QL (2 tablets per 1 Day) ISENTRESS ORAL PACKET (raltegravir potassium) PB QL (2 packets per 1 day) ISENTRESS ORAL TABLET (raltegravir potassium) PB QL (2 tabs per 1 day) ISENTRESS ORAL TABLET CHEWABLE (raltegravir PB QL (6 tablets per 1 day) potassium) lamivudine oral solution PG QL (4 bottles per 30 days) lamivudine oral tablet 150 mg PG QL (2 tablets per 1 day) lamivudine oral tablet 300 mg PG QL (1 tablet per 1 day) LEXIVA ORAL SUSPENSION (fosamprenavir calcium) PB #; QL (8 bottles per 30 days) LEXIVA ORAL TABLET (fosamprenavir calcium) NP QL (4 tablets per 1 day) nevirapine er oral tablet extended release 24 hour 100 mg PG QL (3 tablets per 1 day) nevirapine er oral tablet extended release 24 hour 400 mg PG QL (1 tab per 1 day) nevirapine oral suspension PG QL (5 bottles per 30 days) nevirapine oral tablet PG QL (2 tablets per 1 day) #; QL (12 capsules per 1 NORVIR ORAL CAPSULE (ritonavir) PB day) NORVIR ORAL PACKET (ritonavir) PB QL (12 packets per 1 day) NORVIR ORAL SOLUTION (ritonavir) PB #; QL (2 bottles per 30 days)

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 30 Drug Name Drug Status Drug Details NORVIR ORAL TABLET (ritonavir) NP QL (12 tablets per 1 day) PIFELTRO (doravirine) PB QL (2 tablets per 1 day) PREZISTA ORAL SUSPENSION (darunavir ethanolate) PB QL (2 bottles per 30 days) PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG PB #; QL (2 tabs per 1 day) (darunavir ethanolate) PREZISTA ORAL TABLET 800 MG (darunavir ethanolate) PB #; QL (1 tab per 1 day) RESCRIPTOR ORAL TABLET 100 MG (delavirdine PB QL (30 tablets per 1 day) mesylate) RESCRIPTOR ORAL TABLET 200 MG (delavirdine PB QL (6 tablets per 1 day) mesylate) RETROVIR ORAL CAPSULE (zidovudine) NP QL (6 capsules per 1 day) RETROVIR ORAL SYRUP (zidovudine) NP QL (8 bottles per 30 days) REYATAZ ORAL CAPSULE 150 MG, 300 MG (atazanavir NP QL (1 cap per 1 day) sulfate) REYATAZ ORAL CAPSULE 200 MG (atazanavir sulfate) NP QL (2 caps per 1 day) REYATAZ ORAL PACKET (atazanavir sulfate) PB #; QL (6 packets per 1 day) ritonavir PG QL (12 tablets per 1 day) RUKOBIA (fostemsavir tromethamine) NC SELZENTRY ORAL SOLUTION (maraviroc) PB QL (8 bottles per 1 month) SELZENTRY ORAL TABLET 150 MG (maraviroc) PB #; QL (2 tabs per 1 day) SELZENTRY ORAL TABLET 25 MG (maraviroc) PB #; QL (8 tablets per 1 Day) SELZENTRY ORAL TABLET 300 MG (maraviroc) PB #; QL (4 tablets per 1 day) SELZENTRY ORAL TABLET 75 MG (maraviroc) PB #; QL (2 tablets per 1 Day) stavudine oral capsule PG QL (2 capsules per 1 day) stavudine oral solution reconstituted PG QL (12 bottles per 30 days) SUSTIVA ORAL CAPSULE (efavirenz) NP QL (3 capsules per 1 day) SUSTIVA ORAL TABLET (efavirenz) NP QL (1 tablet per 1 day) tenofovir disoproxil fumarate PG QL (1 tablet per 1 day) TIVICAY ORAL TABLET 10 MG (dolutegravir sodium) PB QL (8 tablets per 1 day) TIVICAY ORAL TABLET 25 MG (dolutegravir sodium) PB QL (2 tablets per 1 day) TIVICAY ORAL TABLET 50 MG (dolutegravir sodium) PB QL (2 tabs per 1 day) TIVICAY PD (dolutegravir sodium) PB QL (12 tablets per 1 day) TYBOST (cobicistat) PB QL (1 tablet per 1 day) VIDEX EC ORAL CAPSULE DELAYED RELEASE 125 PB QL (1 capsule per 1 day) MG (didanosine)

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 31 Drug Name Drug Status Drug Details VIDEX EC ORAL CAPSULE DELAYED RELEASE 200 NP QL (1 capsule per 1 day) MG, 250 MG, 400 MG (didanosine) VIDEX ORAL SOLUTION RECONSTITUTED 2 GM PB QL (12 bottles per 30 days) (didanosine) VIDEX ORAL SOLUTION RECONSTITUTED 4 GM PB QL (6 bottles per 30 days) (didanosine) VIRACEPT ORAL TABLET 250 MG (nelfinavir mesylate) PB QL (10 tablets per 1 day) VIRACEPT ORAL TABLET 625 MG (nelfinavir mesylate) PB QL (4 tablets per 1 day) VIRAMUNE ORAL SUSPENSION (nevirapine) NP QL (5 bottles per 30 days) VIRAMUNE ORAL TABLET (nevirapine) NP QL (2 tablets per 1 day) VIRAMUNE XR ORAL TABLET EXTENDED RELEASE NP QL (3 tabs per 1 day) 24 HOUR 100 MG (nevirapine) VIRAMUNE XR ORAL TABLET EXTENDED RELEASE NP QL (1 tab per 1 day) 24 HOUR 400 MG (nevirapine) VIREAD ORAL POWDER (tenofovir disoproxil fumarate) PB #; QL (4 bottles per 30 days) VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG PB #; QL (1 tab per 1 day) (tenofovir disoproxil fumarate) VIREAD ORAL TABLET 300 MG (tenofovir disoproxil NP QL (1 tab per 1 day) fumarate) ZERIT ORAL CAPSULE (stavudine) NP QL (2 capsules per 1 day) ZERIT ORAL SOLUTION RECONSTITUTED (stavudine) PB QL (12 bottles per 30 days) ZIAGEN ORAL SOLUTION (abacavir sulfate) NP QL (4 bottles per 30 days) ZIAGEN ORAL TABLET (abacavir sulfate) NP QL (2 tablets per 1 day) zidovudine oral capsule PG QL (6 capsules per 1 day) zidovudine oral syrup PG QL (8 bottles per 30 days) zidovudine oral tablet PG QL (2 tablets per 1 day) ANTIRETROVIRAL COMBINATION AGENTS - DRUGS TO SUPPRESS HIV/AIDS INFECTION abacavir sulfate-lamivudine PG QL (1 tablet per 1 day) abacavir-lamivudine-zidovudine PG QL (2 tablets per 1 day) ATRIPLA (efavirenz-emtricitab-tenofovir) PB QL (1 tablet per 1 day) BIKTARVY (bictegravir-emtricitab-tenofov) PB QL (1 tablet per 1 day) CIMDUO (lamivudine-tenofovir) PB QL (1 tablet per 1 Day) COMBIVIR (lamivudine-zidovudine) NP QL (2 tablets per 1 day) COMPLERA (emtricitab-rilpivir-tenofovir) PB QL (1 tab per 1 day) DELSTRIGO (doravirin-lamivudin-tenofov df) PB QL (1 tablet per 1 day)

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 32 Drug Name Drug Status Drug Details DESCOVY (emtricitabine-tenofovir af) PB QL (1 tablet per 1 day) DOVATO (dolutegravir-lamivudine) PB QL (1 tablet per 1 day) efavirenz-emtricitab-tenofovir PG QL (1 tablet per 1 day) efavirenz-lamivudine-tenofovir PG QL (1 tablet per 1 day) emtricitabine-tenofovir df oral tablet 100-150 mg, 133-200 mg, PG QL (1 TABLET per 1 Day) 167-250 mg emtricitabine-tenofovir df oral tablet 200-300 mg PG QL (1 tablet per 1 day) EPZICOM (abacavir sulfate-lamivudine) NP QL (1 tablet per 1 day) EVOTAZ (atazanavir-cobicistat) PB QL (1 tablet per 1 day) GENVOYA (elviteg-cobic-emtricit-tenofaf) PB QL (1 tablet per 1 day) JULUCA (dolutegravir-rilpivirine) PB QL (1 tablet per 1 day) KALETRA ORAL SOLUTION (lopinavir-ritonavir) NP QL (3 bottles per 30 days) KALETRA ORAL TABLET 100-25 MG (lopinavir-ritonavir) PB #; QL (8 tablets per 1 day) KALETRA ORAL TABLET 200-50 MG (lopinavir-ritonavir) PB #; QL (4 tablets per 1 day) lamivudine-zidovudine PG QL (2 tablets per 1 day) lopinavir-ritonavir oral solution PG QL (3 bottles per 30 days) lopinavir-ritonavir oral tablet 100-25 mg PG QL (8 tablets per 1 day) lopinavir-ritonavir oral tablet 200-50 mg PG QL (4 tablets per 1 day) ODEFSEY (emtricitab-rilpivir-tenofov af) PB QL (1 tablet per 1 day) PREZCOBIX (darunavir-cobicistat) PB QL (1 tablet per 1 day) STRIBILD (elviteg-cobic-emtricit-tenofdf) PB QL (1 tab per 1 day) SYMFI (efavirenz-lamivudine-tenofovir) PB QL (1 tablet per 1 day) SYMFI LO (efavirenz-lamivudine-tenofovir) PB QL (1 tablet per 1 day) SYMTUZA (darun-cobic-emtricit-tenofaf) PB QL (1 tablet per 1 day) TEMIXYS (lamivudine-tenofovir) PB QL (1 tablet per 1 day) TRIUMEQ (abacavir-dolutegravir-lamivud) PB QL (1 tablet per 1 day) TRIZIVIR (abacavir-lamivudine-zidovudine) NP QL (2 tablets per 1 day) TRUVADA (emtricitabine-tenofovir df) PB QL (1 tablet per 1 day) ANTITUBERCULAR AGENTS - DRUGS TO TREAT TUBERCULOSIS cycloserine oral NP ethambutol hcl oral PG isoniazid oral PG MYAMBUTOL (ethambutol hcl) NC MYCOBUTIN (rifabutin) NC

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 33 Drug Name Drug Status Drug Details PASER (aminosalicylic acid) NP pretomanid NP PA; QL (1 tablet per 1 day) PRIFTIN (rifapentine) PB pyrazinamide oral PG rifabutin NP RIFADIN ORAL (rifampin) NC RIFAMATE (isoniazid-rifampin) PB rifampin oral PG RIFAMPIN+SYRSPEND SF PH4 (rifampin) NC RIFATER (isoniazid-rifamp-pyrazinamide) PB SIRTURO (bedaquiline fumarate) NPSP PA; SP Pharmacy TRECATOR (ethionamide) PB ANTIVIRALS - DRUGS TO TREAT VIRAL INFECTIONS acyclovir oral capsule PG LGC acyclovir oral suspension PG acyclovir oral tablet 400 mg PG LGC acyclovir oral tablet 800 mg PG adefovir dipivoxil PSP BARACLUDE ORAL SOLUTION (entecavir) NP BARACLUDE ORAL TABLET (entecavir) NC diclofenac sodium external gel 3 % NC SP Pharmacy; QL (1 tablet entecavir PSP per 1 day) EPIVIR HBV ORAL SOLUTION (lamivudine) PB #; SP Pharmacy EPIVIR HBV ORAL TABLET (lamivudine) NP SP Pharmacy famciclovir oral NP favipiravir NP FLUMADINE (rimantadine hcl) NC HEPSERA (adefovir dipivoxil) NC lamivudine oral tablet 100 mg PG QL (20 capsules per 365 oseltamivir phosphate oral capsule PG Days) oseltamivir phosphate oral suspension reconstituted PG QL (480 MLS per 365 Days) PREVYMIS ORAL (letermovir) NC RELENZA DISKHALER (zanamivir) PB QL (2 inhalers per 90 days)

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 34 Drug Name Drug Status Drug Details ribavirin inhalation PG rimantadine hcl PG SITAVIG (acyclovir) NC SYNAGIS (palivizumab) PSP PA; SP Pharmacy TAMIFLU ORAL CAPSULE (oseltamivir phosphate) NC TAMIFLU ORAL SUSPENSION RECONSTITUTED 6 NC MG/ML (oseltamivir phosphate) valacyclovir hcl oral PG VALCYTE ORAL TABLET (valganciclovir hcl) NC PA; SP Pharmacy; QL (1000 valganciclovir hcl oral solution reconstituted PSP milliliters per 30 days) PA; SP Pharmacy; QL (120 valganciclovir hcl oral tablet PSP tablets per 30 days) VALTREX (valacyclovir hcl) NC VEMLIDY (tenofovir alafenamide fumarate) NP PA; QL (1 tablet per 1 day) XERESE (acyclovir-hydrocortisone) NC # XOFLUZA (40 MG DOSE) ORAL TABLET THERAPY NC PACK 1 X 40 MG (baloxavir marboxil) XOFLUZA (40 MG DOSE) ORAL TABLET THERAPY NP QL (4 tablets per 365 days) PACK 2 X 20 MG (baloxavir marboxil) XOFLUZA (80 MG DOSE) ORAL TABLET THERAPY NC PACK 1 X 80 MG (baloxavir marboxil) XOFLUZA (80 MG DOSE) ORAL TABLET THERAPY NP QL (4 tablets per 365 days) PACK 2 X 40 MG (baloxavir marboxil) ZOVIRAX ORAL (acyclovir) NC CEPHALOSPORINS - DRUGS TO TREAT INFECTIONS CEDAX ORAL CAPSULE (ceftibuten) NC CEDAX ORAL SUSPENSION RECONSTITUTED 180 NC MG/5ML (ceftibuten) cefaclor PG cefaclor er NP cefadroxil PG cefdinir PG cefditoren pivoxil NP cefixime oral capsule PG cefixime oral suspension reconstituted NP

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 35 Drug Name Drug Status Drug Details cefpodoxime proxetil NP cefprozil PG ceftibuten PG CEFTIN ORAL SUSPENSION RECONSTITUTED NC (cefuroxime axetil) cefuroxime axetil oral tablet PG cephalexin PG DAXBIA (cephalexin) NC KEFLEX (cephalexin) NC SPECTRACEF ORAL TABLET 400 MG (cefditoren pivoxil) NC SUPRAX ORAL CAPSULE (cefixime) NP SUPRAX ORAL SUSPENSION RECONSTITUTED 100 NC MG/5ML, 200 MG/5ML (cefixime) SUPRAX ORAL SUSPENSION RECONSTITUTED 500 PB MG/5ML (cefixime) SUPRAX ORAL TABLET CHEWABLE (cefixime) PB # ERYTHROMYCINS/MACROLIDES - DRUGS TO TREAT INFECTIONS azithromycin oral packet PG azithromycin oral suspension reconstituted PG azithromycin oral tablet 250 mg, 500 mg, 600 mg PG BIAXIN ORAL TABLET (clarithromycin) NC clarithromycin er PG clarithromycin oral PG DIFICID (fidaxomicin) PB PA E.E.S. GRANULES (erythromycin ethylsuccinate) NP ERYPED 200 (erythromycin ethylsuccinate) NP ERYPED 400 (erythromycin ethylsuccinate) NP ERY-TAB (erythromycin base) PG ERYTHROCIN STEARATE ORAL TABLET 250 MG NC (erythromycin stearate) erythromycin base oral capsule delayed release particles PG erythromycin base oral tablet PG erythromycin ethylsuccinate oral PG erythromycin stearate oral tablet 250 mg NC PCE (erythromycin base coated) NP 2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 36 Drug Name Drug Status Drug Details ZITHROMAX ORAL (azithromycin) NC ZITHROMAX TRI-PAK (azithromycin) NC ZITHROMAX Z-PAK (azithromycin) NC ZMAX (azithromycin) NP FLUOROQUINOLONES - DRUGS TO TREAT INFECTIONS AVELOX ORAL (moxifloxacin hcl) NC BAXDELA ORAL (delafloxacin meglumine) NP CIPRO ORAL SUSPENSION RECONSTITUTED 250 NC MG/5ML (5%) (ciprofloxacin) CIPRO ORAL SUSPENSION RECONSTITUTED 500 NP MG/5ML (10%) (ciprofloxacin) CIPRO ORAL TABLET 250 MG, 500 MG (ciprofloxacin hcl) NC CIPRO XR (ciprofloxacin-ciproflox hcl) NC ciprofloxacin hcl oral PG ciprofloxacin oral PG ciprofloxacin-ciproflox hcl er NP FACTIVE (gemifloxacin mesylate) NP # LEVAQUIN ORAL TABLET (levofloxacin) NC levofloxacin oral PG moxifloxacin hcl oral NP ofloxacin oral tablet 300 mg, 400 mg PG HEPATITIS C COPEGUS (ribavirin) NC PA; ST; SP Pharmacy; QL DAKLINZA (daclatasvir dihydrochloride) NPSP (1 tablet per 1 day) EPCLUSA ORAL TABLET 200-50 MG, 400-100 MG PA; SP Pharmacy; QL (1 PSP (sofosbuvir-velpatasvir) tablet per 1 day) PA; SP Pharmacy; QL (1 HARVONI ORAL PACKET (ledipasvir-sofosbuvir) PSP packet per 1 day) HARVONI ORAL TABLET 45-200 MG (ledipasvir- PA; SP Pharmacy; QL (1 PSP sofosbuvir) tablet per 1 day) HARVONI ORAL TABLET 90-400 MG (ledipasvir- PSP PA; SP Pharmacy sofosbuvir) ledipasvir-sofosbuvir NC MAVYRET (glecaprevir-pibrentasvir) NC

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 37 Drug Name Drug Status Drug Details MODERIBA 1200 DOSE PACK (ribavirin) NP MODERIBA 800 DOSE PACK (ribavirin) NP moderiba oral tablet 200 mg PG SP Pharmacy PA; ST; SP Pharmacy; QL OLYSIO (simeprevir sodium) NPSP (1 tablet per 1 day) PEGASYS PROCLICK (peginterferon alfa-2a) PB PA; SP Pharmacy PEGASYS SUBCUTANEOUS SOLUTION (peginterferon PSP PA; SP Pharmacy alfa-2a) PEGINTRON SUBCUTANEOUS KIT 50 MCG/0.5ML NPSP (peginterferon alfa-2b) REBETOL ORAL CAPSULE (ribavirin) NC REBETOL ORAL SOLUTION (ribavirin) PB SP Pharmacy ribasphere oral capsule PG SP Pharmacy ribasphere oral tablet 200 mg PG SP Pharmacy ribasphere oral tablet 400 mg, 600 mg NP SP Pharmacy RIBASPHERE RIBAPAK ORAL TABLET 400 MG, 600 PG MG (ribavirin) ribavirin oral capsule PG PA; SP Pharmacy ribavirin oral tablet 200 mg PG PA; SP Pharmacy sofosbuvir-velpatasvir NC PA; ST; SP Pharmacy; QL SOVALDI ORAL PACKET (sofosbuvir) NPSP (1 packet per 1 day) PA; ST; SP Pharmacy; QL SOVALDI ORAL TABLET 200 MG (sofosbuvir) NPSP (1 tablet per 1 day) PA; ST; SP Pharmacy; QL SOVALDI ORAL TABLET 400 MG (sofosbuvir) NPSP (1 tab per 1 day) PA; ST; QL (2 tablets per 1 TECHNIVIE (ombitasvir-paritaprev-ritonav) NPSP day) PA; ST; SP Pharmacy; QL VIEKIRA PAK (ombitas-paritapre-ritona-dasab) NPSP (1 pak per 28 days) PA; ST; SP Pharmacy; QL VIEKIRA XR (ombitas-paritapre-ritona-dasab) NPSP (1 carton per 28 days) PA; SP Pharmacy; QL (1 VOSEVI (sofosbuv-velpatasv-voxilaprev) PSP tablet per 1 Day) PA; ST; SP Pharmacy; QL ZEPATIER (elbasvir-grazoprevir) NPSP (1 tablet per 1 day)

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 38 Drug Name Drug Status Drug Details PENICILLINS - DRUGS TO TREAT INFECTIONS amoxicillin oral capsule 250 mg PG LGC amoxicillin oral capsule 500 mg PG amoxicillin oral suspension reconstituted PG amoxicillin oral tablet PG amoxicillin oral tablet chewable 125 mg, 250 mg PG amoxicillin-pot clavulanate er PG amoxicillin-pot clavulanate oral PG ampicillin oral capsule 500 mg PG AUGMENTIN ES-600 (amoxicillin-pot clavulanate) NC AUGMENTIN ORAL SUSPENSION RECONSTITUTED 125-31.25 MG/5ML, 250-62.5 MG/5ML (amoxicillin-pot NC clavulanate) AUGMENTIN ORAL TABLET 500-125 MG, 875-125 MG NC (amoxicillin-pot clavulanate) AUGMENTIN XR (amoxicillin-pot clavulanate) NC dicloxacillin sodium PG MOXATAG (amoxicillin) NC penicillin v potassium PG TETRACYCLINES - DRUGS TO TREAT INFECTIONS ACTICLATE (doxycycline hyclate) NC ADOXA ORAL CAPSULE (doxycycline monohydrate) NC avidoxy PG minocycline hcl (Coremino) NC demeclocycline hcl oral NP DORYX MPC (doxycycline hyclate) NC # DORYX ORAL TABLET DELAYED RELEASE 200 MG, NC 50 MG (doxycycline hyclate) doxycycline hyclate oral capsule PG doxycycline hyclate oral tablet 100 mg PG LGC doxycycline hyclate oral tablet 150 mg, 75 mg NC doxycycline hyclate oral tablet 20 mg, 50 mg PG doxycycline hyclate oral tablet delayed release 100 mg, 200 mg, NC 50 mg, 80 mg doxycycline hyclate oral tablet delayed release 150 mg, 75 mg PG doxycycline monohydrate oral capsule 100 mg, 50 mg PG 2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 39 Drug Name Drug Status Drug Details doxycycline monohydrate oral capsule 150 mg, 75 mg NC doxycycline monohydrate oral suspension reconstituted PG doxycycline monohydrate oral tablet 100 mg NC doxycycline monohydrate oral tablet 150 mg, 50 mg, 75 mg PG MINOCIN ORAL CAPSULE 100 MG, 50 MG (minocycline NC hcl) minocycline hcl er NC minocycline hcl oral PG MINOLIRA (minocycline hcl) NC doxycycline monohydrate (Mondoxyne Nl Oral Capsule 100 PG Mg, 50 Mg) doxycycline monohydrate (Mondoxyne Nl Oral Capsule 75 NC Mg) MONODOX ORAL CAPSULE 100 MG, 75 MG NC (doxycycline monohydrate) doxycycline hyclate (Morgidox Oral) PG NUZYRA ORAL TABLET 150 MG (omadacycline tosylate) NC SEYSARA (sarecycline hcl) NC SOLODYN ORAL TABLET EXTENDED RELEASE 24 HOUR 105 MG, 115 MG, 55 MG, 65 MG, 80 MG NC (minocycline hcl) doxycycline hyclate (Targadox) NC tetracycline hcl oral PG LGC VIBRAMYCIN ORAL CAPSULE (doxycycline hyclate) NC VIBRAMYCIN ORAL SUSPENSION RECONSTITUTED NC (doxycycline monohydrate) VIBRAMYCIN ORAL SYRUP (doxycycline calcium) NP XIMINO (minocycline hcl) NC ANTINEOPLASTIC AGENTS - DRUGS TO TREAT CANCER ALKYLATING AGENTS - CHEMOTHERAPY DRUGS ALKERAN ORAL (melphalan) CE N2 (Not Covered) cyclophosphamide injection PSP cyclophosphamide oral capsule CE N2 (PG) EMCYT ( phosphate sodium) CE N2 (PSP) GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG CE N2 (PSP) (lomustine) 2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 40 Drug Name Drug Status Drug Details GLEOSTINE ORAL CAPSULE 5 MG (lomustine) PB PA HEXALEN (altretamine) NPSP LEUKERAN (chlorambucil) CE N2 (PB) melphalan CE N2 (PG) MYLERAN (busulfan) CE N2 (NP) TEMODAR ORAL (temozolomide) CE N2 (Not Covered) temozolomide CE PA; SP Pharmacy; N2 (PSP) ANTIMETABOLITES - CHEMOTHERAPY DRUGS PA; SP Pharmacy; N2 capecitabine oral tablet 150 mg CE (PSP); QL (4 tablets per 1 day) PA; SP Pharmacy; N2 capecitabine oral tablet 500 mg CE (PSP); QL (10 tablets per 1 day) floxuridine injection PG mercaptopurine oral CE N2 (PG) methotrexate oral CE N2 (PG) methotrexate sodium (pf) injection solution 200 mg/8ml NC methotrexate sodium injection solution reconstituted PG methotrexate sodium oral CE N2 (PG) ONUREG (azacitidine) NC PA; ST; #; SP Pharmacy; PURIXAN (mercaptopurine) CE N2 (NPSP) TABLOID (thioguanine) CE N2 (PB) TREXALL (methotrexate sodium) CE N2 (NP) XATMEP (methotrexate) CE PA; N2 (NP) XELODA (capecitabine) CE N2 (Not Covered) BIOLOGIC RESPONSE MODIFIERS DAURISMO (glasdegib maleate) CE N2 (Not Covered) PA; SP Pharmacy; N2 ERIVEDGE (vismodegib) CE (PSP); QL (1 cap per 1 day) PA; N2 (PSP); QL (6 FARYDAK (panobinostat lactate) CE capsules per 21 days) PA; SP Pharmacy; N2 IBRANCE ORAL CAPSULE (palbociclib) CE (PSP); QL (21 capsules per 28 days)

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 41 Drug Name Drug Status Drug Details PA; SP Pharmacy; N2 IBRANCE ORAL TABLET (palbociclib) CE (PSP); QL (21 tablets per 28 days) PA; SP Pharmacy; QL (21 KISQALI (200 MG DOSE) (ribociclib succinate) PSP tablets per 28 days) PA; SP Pharmacy; QL (42 KISQALI (400 MG DOSE) (ribociclib succinate) PSP tablets per 28 days) PA; SP Pharmacy; QL (63 KISQALI (600 MG DOSE) (ribociclib succinate) PSP tablets per 28 days) KISQALI 200 DOSE (ribociclib succinate) CE N2 (Not Covered) KISQALI 400 DOSE (ribociclib succinate) CE N2 (Not Covered) KISQALI 600 DOSE (ribociclib succinate) CE N2 (Not Covered) KISQALI FEMARA (400 MG DOSE) (ribociclib-letrozole) CE N2 (Not Covered) KISQALI FEMARA (600 MG DOSE) (ribociclib-letrozole) CE N2 (Not Covered) KISQALI FEMARA(200 MG DOSE) (ribociclib-letrozole) CE N2 (Not Covered) LYNPARZA ORAL TABLET (olaparib) CE PA; N2 (PSP) PA; SP Pharmacy; N2 RUBRACA ORAL TABLET 200 MG, 300 MG (rucaparib CE (NPSP); QL (4 tablets per 1 camsylate) day) PA; SP Pharmacy; N2 RUBRACA ORAL TABLET 250 MG (rucaparib camsylate) CE (NPSP); QL (4 tablets per 1 Day) PA; N2 (NPSP); QL (8 RYDAPT (midostaurin) CE capsules per 1 day) TALZENNA (talazoparib tosylate) CE N2 (Not Covered) VERZENIO (abemaciclib) CE N2 (Not Covered) PA; SP Pharmacy; N2 ZEJULA (niraparib tosylate) CE (PSP); QL (3 capsules per 1 day) PA; SP Pharmacy; N2 ZOLINZA (vorinostat) CE (PSP); QL (4 caps per 1 day) HORMONAL ANTINEOPLASTIC AGENTS SP Pharmacy; N2 (Not oral tablet 250 mg CE Covered) PA; SP Pharmacy; N2 abiraterone acetate oral tablet 500 mg CE (PSP); QL (2 tablets per 1 day) anastrozole oral CE N2 (PG)

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 42 Drug Name Drug Status Drug Details ARIMIDEX (anastrozole) CE N2 (Not Covered) AROMASIN (exemestane) CE N2 (Not Covered) bicalutamide CE N2 (PG) CASODEX (bicalutamide) CE N2 (Not Covered) DEPO-PROVERA INTRAMUSCULAR SUSPENSION 400 NP MG/ML (medroxyprogesterone acetate) ELIGARD SUBCUTANEOUS KIT 22.5 MG (leuprolide PSP PA acetate (3 month)) ELIGARD SUBCUTANEOUS KIT 30 MG (leuprolide PSP PA acetate (4 month)) ELIGARD SUBCUTANEOUS KIT 45 MG (leuprolide PSP PA acetate (6 month)) ELIGARD SUBCUTANEOUS KIT 7.5 MG (leuprolide PSP PA; SP Pharmacy acetate) ERLEADA (apalutamide) CE PA; N2 (PSP) exemestane CE N2 (NP) FARESTON ( citrate) CE N2 (Not Covered) FEMARA (letrozole) CE N2 (Not Covered) FENSOLVI (leuprolide acetate (6 month)) NC FIRMAGON (240 MG DOSE) (degarelix acetate) NPSP PA FIRMAGON SUBCUTANEOUS SOLUTION NPSP PA RECONSTITUTED 120 MG (degarelix acetate) FIRMAGON SUBCUTANEOUS SOLUTION NPSP PA; SP Pharmacy RECONSTITUTED 80 MG (degarelix acetate) flutamide CE N2 (PG) PSP PA letrozole oral CE N2 (PG) leuprolide acetate injection PSP PA LUPRON DEPOT (1-MONTH) (leuprolide acetate) NPSP PA; #; SP Pharmacy LUPRON DEPOT (3-MONTH) (leuprolide acetate (3 NPSP PA; #; SP Pharmacy month)) LUPRON DEPOT (4-MONTH) (leuprolide acetate (4 NPSP PA; #; SP Pharmacy month)) LUPRON DEPOT (6-MONTH) (leuprolide acetate (6 NPSP PA; #; SP Pharmacy month)) LUPRON DEPOT-PED (1-MONTH) (leuprolide acetate) PSP PA; #; SP Pharmacy

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 43 Drug Name Drug Status Drug Details LUPRON DEPOT-PED (3-MONTH) (leuprolide acetate (3 PSP PA; #; SP Pharmacy month)) LYSODREN (mitotane) CE N2 (PB) megestrol acetate oral suspension 40 mg/ml, 400 mg/10ml CE N2 (PG) megestrol acetate oral suspension 625 mg/5ml CE N2 (NP) megestrol acetate oral tablet CE N2 (PG) NILANDRON (nilutamide) CE N2 (Not Covered) nilutamide CE N2 (PG) NUBEQA (darolutamide) CE PA; N2 (PSP) ORGOVYX (relugolix) CE N2 (Not Covered) SOLTAMOX ( citrate) CE #; N2 (Not Covered) N2 (PG); AL (Min 35 tamoxifen citrate oral CE Years) toremifene citrate CE N2 (PG) TRELSTAR MIXJECT (triptorelin pamoate) NPSP PA; #; SP Pharmacy PA; SP Pharmacy; N2 XTANDI ORAL CAPSULE (enzalutamide) CE (PSP); QL (4 caps per 1 day) PA; SP Pharmacy; N2 XTANDI ORAL TABLET 40 MG (enzalutamide) CE (PSP); QL (4 tablets per 1 day) PA; SP Pharmacy; N2 XTANDI ORAL TABLET 80 MG (enzalutamide) CE (PSP); QL (2 tablets per 1 day) #; N2 (PSP); QL (4 tablets YONSA (abiraterone acetate) CE per 1 day) ZYTIGA (abiraterone acetate) CE N2 (Not Covered) KINASE INHIBITORS AFINITOR DISPERZ ORAL TABLET SOLUBLE 2 MG, 5 PA; #; N2 (PSP); QL (2 CE MG () tablets per 1 day) AFINITOR DISPERZ ORAL TABLET SOLUBLE 3 MG PA; #; N2 (PSP); QL (3 CE (everolimus) tablets per 1 day) PA; #; SP Pharmacy; N2 AFINITOR ORAL TABLET 10 MG (everolimus) CE (PSP); QL (1 tab per 1 day) AFINITOR ORAL TABLET 2.5 MG, 5 MG, 7.5 MG SP Pharmacy; N2 (Not CE (everolimus) Covered) ALECENSA (alectinib hcl) CE PA; N2 (PSP) ALUNBRIG (brigatinib) CE N2 (Not Covered)

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 44 Drug Name Drug Status Drug Details BALVERSA (erdafitinib) NC PA; SP Pharmacy; N2 BOSULIF ORAL TABLET 100 MG (bosutinib) CE (PSP); QL (3 tablets per 1 day) PA; SP Pharmacy; N2 BOSULIF ORAL TABLET 400 MG (bosutinib) CE (PSP); QL (1 tablet per 1 day) PA; SP Pharmacy; N2 BOSULIF ORAL TABLET 500 MG (bosutinib) CE (PSP); QL (1 tab per 1 day) BRUKINSA (zanubrutinib) CE N2 (Not Covered) PA; SP Pharmacy; N2 CABOMETYX (cabozantinib s-malate) CE (PSP); QL (1 tablet per 1 day) CALQUENCE (acalabrutinib) CE PA; N2 (NPSP) PA; #; SP Pharmacy; N2 CAPRELSA ORAL TABLET 100 MG (vandetanib) CE (PSP); QL (2 tabs per 1 day) PA; #; SP Pharmacy; N2 CAPRELSA ORAL TABLET 300 MG (vandetanib) CE (PSP); QL (1 tab per 1 day) PA; SP Pharmacy; N2 COMETRIQ (100 MG DAILY DOSE) ORAL KIT 80 & 20 CE (PSP); QL (2 capsules per 1 MG (cabozantinib s-malate) day) PA; SP Pharmacy; N2 COMETRIQ (140 MG DAILY DOSE) ORAL KIT 3 X 20 CE (PSP); QL (4 capsules per 1 MG & 80 MG (cabozantinib s-malate) day) PA; SP Pharmacy; N2 COMETRIQ (60 MG DAILY DOSE) (cabozantinib s-malate) CE (PSP); QL (3 capsules per 1 day) COPIKTRA (duvelisib) CE N2 (Not Covered) COTELLIC (cobimetinib fumarate) CE N2 (Not Covered) PA; N2 (PSP); QL (1 tablet erlotinib hcl oral tablet 100 mg, 150 mg CE per 1 day) PA; N2 (PSP); QL (2 tablets erlotinib hcl oral tablet 25 mg CE per 1 day) PA; SP Pharmacy; N2 everolimus oral tablet 2.5 mg, 5 mg, 7.5 mg CE (PSP); QL (1 tablet per 1 day) FOTIVDA (tivozanib hcl) CE N2 (Not Covered) GLEEVEC (imatinib mesylate) CE N2 (Not Covered)

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 45 Drug Name Drug Status Drug Details PA; SP Pharmacy; N2 ICLUSIG ORAL TABLET 10 MG, 30 MG (ponatinib hcl) CE (PSP); QL (1 TABLET per 1 Day) PA; SP Pharmacy; N2 ICLUSIG ORAL TABLET 15 MG (ponatinib hcl) CE (PSP); QL (1 tablet per 1 day) PA; SP Pharmacy; N2 ICLUSIG ORAL TABLET 45 MG (ponatinib hcl) CE (PSP); QL (1 tab per 1 day) PA; N2 (PSP); QL (1 tablet IDHIFA (enasidenib mesylate) CE per 1 day) PA; SP Pharmacy; N2 imatinib mesylate oral tablet 100 mg CE (PSP); QL (3 tablets per 1 day) PA; SP Pharmacy; N2 imatinib mesylate oral tablet 400 mg CE (PSP); QL (2 tablets per 1 day) PA; N2 (PSP); QL (3 IMBRUVICA ORAL CAPSULE 140 MG (ibrutinib) CE capsules per 1 day) IMBRUVICA ORAL CAPSULE 70 MG (ibrutinib) CE PA; N2 (PSP) IMBRUVICA ORAL TABLET (ibrutinib) CE PA; N2 (PSP) PA; SP Pharmacy; N2 INLYTA ORAL TABLET 1 MG (axitinib) CE (PSP); QL (8 tablets per 1 day) PA; SP Pharmacy; N2 INLYTA ORAL TABLET 5 MG (axitinib) CE (PSP); QL (4 tabs per 1 day) SP Pharmacy; N2 (NPSP); INREBIC (fedratinib hcl) CE QL (4 capsules per 1 day) IRESSA (gefitinib) CE #; N2 (Not Covered) PA; SP Pharmacy; N2 JAKAFI ORAL TABLET 10 MG (ruxolitinib phosphate) CE (PSP); QL (2 tablets per 1 day) JAKAFI ORAL TABLET 15 MG, 20 MG, 25 MG, 5 MG PA; SP Pharmacy; N2 CE (ruxolitinib phosphate) (PSP); QL (2 tabs per 1 day) PA; SP Pharmacy; N2 KOSELUGO ORAL CAPSULE 10 MG (selumetinib sulfate) CE (NPSP); QL (8 capsules per 1 day) PA; SP Pharmacy; N2 KOSELUGO ORAL CAPSULE 25 MG (selumetinib sulfate) CE (NPSP); QL (4 capsules per 1 day)

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 46 Drug Name Drug Status Drug Details N2 (PSP); QL (1 capsule per LENVIMA (10 MG DAILY DOSE) (lenvatinib mesylate) CE 1 day) LENVIMA (12 MG DAILY DOSE) (lenvatinib mesylate) CE N2 (PSP) N2 (PSP); QL (2 capsules LENVIMA (14 MG DAILY DOSE) (lenvatinib mesylate) CE per 1 day) N2 (PSP); QL (3 capsules LENVIMA (18 MG DAILY DOSE) (lenvatinib mesylate) CE per 1 day) N2 (PSP); QL (2 capsules LENVIMA (20 MG DAILY DOSE) (lenvatinib mesylate) CE per 1 day) N2 (PSP); QL (3 capsules LENVIMA (24 MG DAILY DOSE) (lenvatinib mesylate) CE per 1 day) LENVIMA (4 MG DAILY DOSE) (lenvatinib mesylate) CE N2 (PSP) N2 (PSP); QL (2 capsules LENVIMA (8 MG DAILY DOSE) (lenvatinib mesylate) CE per 1 day) LORBRENA (lorlatinib) CE PA; N2 (NPSP) LUMAKRAS (sotorasib) CE N2 (Not Covered) MEKINIST ORAL TABLET 0.5 MG (trametinib dimethyl PA; SP Pharmacy; N2 CE sulfoxide) (PSP); QL (3 tabs per 1 day) MEKINIST ORAL TABLET 2 MG (trametinib dimethyl PA; SP Pharmacy; N2 CE sulfoxide) (PSP); QL (1 tab per 1 day) NERLYNX (neratinib maleate) CE N2 (Not Covered) PA; SP Pharmacy; N2 NEXAVAR (sorafenib tosylate) CE (PSP); QL (4 tabs per 1 day) N2 (Not Covered); QL (1 PIQRAY (200 MG DAILY DOSE) (alpelisib) CE tablet per 1 day) N2 (Not Covered); QL (2 PIQRAY (250 MG DAILY DOSE) (alpelisib) CE tablets per 1 day) N2 (Not Covered); QL (2 PIQRAY (300 MG DAILY DOSE) (alpelisib) CE tablets per 1 day) RETEVMO (selpercatinib) CE N2 (Not Covered) ROZLYTREK (entrectinib) NC PA; SP Pharmacy; N2 SPRYCEL ORAL TABLET 100 MG, 140 MG (dasatinib) CE (PSP); QL (1 tab per 1 day) PA; SP Pharmacy; N2 SPRYCEL ORAL TABLET 20 MG (dasatinib) CE (PSP); QL (3 tablets per 1 day) PA; SP Pharmacy; N2 SPRYCEL ORAL TABLET 50 MG, 70 MG, 80 MG CE (PSP); QL (1 tablet per 1 (dasatinib) day) 2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 47 Drug Name Drug Status Drug Details PA; SP Pharmacy; N2 STIVARGA (regorafenib) CE (PSP); QL (3 tablets per 1 day) PA; SP Pharmacy; N2 sunitinib malate CE (PSP); QL (1 capsule per 1 day) PA; #; SP Pharmacy; N2 SUTENT ORAL CAPSULE 12.5 MG, 25 MG (sunitinib CE (PSP); QL (1 capsule per 1 malate) day) SUTENT ORAL CAPSULE 37.5 MG, 50 MG (sunitinib PA; #; SP Pharmacy; N2 CE malate) (PSP); QL (1 cap per 1 day) PA; SP Pharmacy; N2 TAFINLAR (dabrafenib mesylate) CE (PSP); QL (4 caps per 1 day) TAGRISSO (osimertinib mesylate) CE N2 (Not Covered) PA; SP Pharmacy; N2 (Not TARCEVA ORAL TABLET 100 MG, 150 MG (erlotinib hcl) CE Covered); QL (1 tablet per 1 day) PA; SP Pharmacy; N2 (Not TARCEVA ORAL TABLET 25 MG (erlotinib hcl) CE Covered); QL (2 tablets per 1 day) PA; ST; SP Pharmacy; N2 TASIGNA ORAL CAPSULE 150 MG, 200 MG (nilotinib CE (NPSP); QL (4 caps per 1 hcl) day) PA; ST; SP Pharmacy; N2 TASIGNA ORAL CAPSULE 50 MG (nilotinib hcl) CE (NPSP); QL (4 capsules per 1 Day) TEPMETKO (tepotinib hcl) CE N2 (Not Covered) TRUSELTIQ (100MG DAILY DOSE) (infigratinib CE N2 (Not Covered) phosphate) TRUSELTIQ (125MG DAILY DOSE) (infigratinib CE N2 (Not Covered) phosphate) TRUSELTIQ (50MG DAILY DOSE) (infigratinib phosphate) CE N2 (Not Covered) TRUSELTIQ (75MG DAILY DOSE) (infigratinib phosphate) CE N2 (Not Covered) PA; SP Pharmacy; N2 TUKYSA (tucatinib) CE (NPSP); QL (4 tablets per 1 day) TURALIO (pexidartinib hcl) NC PA; SP Pharmacy; N2 (Not TYKERB (lapatinib ditosylate) CE Covered); QL (6 tablets per 1 day) 2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 48 Drug Name Drug Status Drug Details UKONIQ (umbralisib tosylate) CE N2 (Not Covered) VITRAKVI (larotrectinib sulfate) CE PA; N2 (NPSP) VIZIMPRO (dacomitinib) CE N2 (Not Covered) PA; SP Pharmacy; N2 VOTRIENT (pazopanib hcl) CE (PSP); QL (4 tabs per 1 day) PA; SP Pharmacy; N2 XALKORI (crizotinib) CE (PSP); QL (4 CAPSULES per 1 day) XOSPATA (gilteritinib fumarate) CE N2 (Not Covered) PA; SP Pharmacy; N2 ZELBORAF (vemurafenib) CE (PSP); QL (8 tabs per 1 day) PA; SP Pharmacy; N2 ZYDELIG (idelalisib) CE (PSP); QL (2 tablets per 1 day) PA; SP Pharmacy; N2 ZYKADIA ORAL TABLET (ceritinib) CE (PSP); QL (3 tablets per 1 day) MISCELLANEOUS ALFERON N (interferon alfa-n3) PSP SP Pharmacy; N2 (Not AYVAKIT (avapritinib) CE Covered); QL (1 tablet per 1 day) bexarotene CE PA; N2 (PSP) BRAFTOVI (encorafenib) CE N2 (Not Covered) PA; SP Pharmacy; N2 COMETRIQ (100 MG DAILY DOSE) ORAL KIT 1 X 80 & CE (NPSP); QL (2 capsules per 1 X 20 MG (cabozantinib s-malate) 1 day) PA; SP Pharmacy; N2 COMETRIQ (140 MG DAILY DOSE) ORAL KIT 1 X 80 & CE (NPSP); QL (4 capsules per 3 X 20 MG (cabozantinib s-malate) 1 day) DROXIA (hydroxyurea) PB GAVRETO (pralsetinib) CE N2 (Not Covered) PA; SP Pharmacy; N2 GILOTRIF (afatinib dimaleate) CE (NPSP); QL (1 tab per 1 day) HYDREA (hydroxyurea) CE N2 (Not Covered) hydroxyurea oral CE N2 (PG) INQOVI (decitabine-cedazuridine) NC

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 49 Drug Name Drug Status Drug Details PA; SP Pharmacy; N2 LONSURF ORAL TABLET 15-6.14 MG (trifluridine- CE (NPSP); QL (100 tablets per tipiracil) 28 days) PA; SP Pharmacy; N2 LONSURF ORAL TABLET 20-8.19 MG (trifluridine- CE (NPSP); QL (80 tablets per tipiracil) 28 days) LYNPARZA ORAL CAPSULE (olaparib) NC MATULANE (procarbazine hcl) CE SP Pharmacy; N2 (PSP) MEKTOVI (binimetinib) CE N2 (Not Covered) PA; N2 (PSP); QL (1 ODOMZO (sonidegib phosphate) CE capsule per 1 day) ONCASPAR INJECTION (pegaspargase) PSP PA PEMAZYRE (pemigatinib) CE N2 (Not Covered) QINLOCK (ripretinib) CE N2 (Not Covered) SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, PA; SP Pharmacy; QL (4 NPSP 600 MCG (peginterferon alfa-2b) injections per 1 month) TABRECTA (capmatinib hcl) CE N2 (Not Covered) TARGRETIN ORAL (bexarotene) CE N2 (Not Covered) SP Pharmacy; N2 (Not TAZVERIK (tazemetostat hbr) CE Covered); QL (8 tablets per 1 day) TIBSOVO (ivosidenib) CE N2 (Not Covered) TICE BCG (bcg live) PB tretinoin oral CE SP Pharmacy; N2 (PG) SP Pharmacy; QL (20 VISTOGARD (uridine triacetate) PSP packets per 1 prescription) PA; SP Pharmacy; N2 (Not XPOVIO (100 MG ONCE WEEKLY) ORAL TABLET CE Covered); QL (16 tablets per THERAPY PACK 20 MG (selinexor) 28 days) XPOVIO (100 MG ONCE WEEKLY) ORAL TABLET CE N2 (Not Covered) THERAPY PACK 50 MG (selinexor) XPOVIO (40 MG ONCE WEEKLY) (selinexor) CE N2 (Not Covered) XPOVIO (40 MG TWICE WEEKLY) (selinexor) CE N2 (Not Covered) PA; SP Pharmacy; N2 (Not XPOVIO (60 MG ONCE WEEKLY) ORAL TABLET CE Covered); QL (16 tablets per THERAPY PACK 20 MG (selinexor) 28 days) XPOVIO (60 MG ONCE WEEKLY) ORAL TABLET CE N2 (Not Covered) THERAPY PACK 60 MG (selinexor)

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 50 Drug Name Drug Status Drug Details XPOVIO (60 MG TWICE WEEKLY) (selinexor) CE N2 (Not Covered) PA; SP Pharmacy; N2 (Not XPOVIO (80 MG ONCE WEEKLY) ORAL TABLET CE Covered); QL (16 tablets per THERAPY PACK 20 MG (selinexor) 28 days) XPOVIO (80 MG ONCE WEEKLY) ORAL TABLET CE N2 (Not Covered) THERAPY PACK 40 MG (selinexor) PA; SP Pharmacy; N2 (Not XPOVIO (80 MG TWICE WEEKLY) (selinexor) CE Covered); QL (16 tablets per 28 days) PA; SP Pharmacy; N2 ZYKADIA ORAL CAPSULE (ceritinib) CE (NPSP); QL (3 capsules per 1 day) PROTEASOME INHIBITORS NINLARO (ixazomib citrate) CE N2 (Not Covered) PROTECTIVE AGENTS leucovorin calcium injection solution reconstituted 500 mg PG leucovorin calcium oral CE N2 (PG) MESNEX ORAL (mesna) CE N2 (PSP) TOPOISOMERASE INHIBITORS etoposide oral CE N2 (PG) PA; SP Pharmacy; N2 HYCAMTIN ORAL (topotecan hcl) CE (NPSP) ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES ANTINEOPLASTIC, BCL-2 INHIBITORS PA; N2 (PSP); QL (4 tablets VENCLEXTA ORAL TABLET 10 MG, 50 MG (venetoclax) CE per 1 day) VENCLEXTA ORAL TABLET 100 MG (venetoclax) CE PA; N2 (PSP) PA; N2 (PSP); QL (1 pack VENCLEXTA STARTING PACK (venetoclax) CE per 1 month) CARDIOVASCULAR - DRUGS TO TREAT HEART AND CIRCULATION CONDITIONS ACE INHIBITOR COMBINATIONS - DRUGS TO TREAT HIGH BLOOD PRESSURE ACCURETIC (quinapril-hydrochlorothiazide) NC amlodipine besy-benazepril hcl PG benazepril-hydrochlorothiazide PG captopril-hydrochlorothiazide PG

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 51 Drug Name Drug Status Drug Details enalapril-hydrochlorothiazide PG LGC fosinopril sodium-hctz PG lisinopril-hydrochlorothiazide PG LGC LOTENSIN HCT ORAL TABLET 10-12.5 MG, 20-12.5 NC MG, 20-25 MG (benazepril-hydrochlorothiazide) LOTREL ORAL CAPSULE 10-20 MG, 10-40 MG, 5-10 NC MG, 5-20 MG (amlodipine besy-benazepril hcl) moexipril-hydrochlorothiazide PG PRESTALIA (perindopril arg-amlodipine) NP # quinapril-hydrochlorothiazide PG TARKA (trandolapril-verapamil hcl) NC trandolapril-verapamil hcl er PG VASERETIC (enalapril-hydrochlorothiazide) NC ZESTORETIC (lisinopril-hydrochlorothiazide) NC ACE INHIBITORS - DRUGS TO TREAT HIGH BLOOD PRESSURE ACCUPRIL (quinapril hcl) NC ACEON ORAL TABLET 4 MG, 8 MG (perindopril NC erbumine) ALTACE ORAL CAPSULE (ramipril) NC benazepril hcl oral PG LGC captopril oral PG enalapril maleate oral solution PG QL (5 ml per 1 day) enalapril maleate oral tablet PG LGC EPANED ORAL SOLUTION (enalapril maleate) NP #; QL (5 ml per 1 day) fosinopril sodium PG lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg PG LGC lisinopril oral tablet 30 mg, 40 mg PG LOTENSIN ORAL TABLET 20 MG, 40 MG (benazepril hcl) NC moexipril hcl PG perindopril erbumine PG PRINIVIL (lisinopril) NC QBRELIS (lisinopril) NC quinapril hcl PG ramipril PG trandolapril PG 2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 52 Drug Name Drug Status Drug Details VASOTEC (enalapril maleate) NC ZESTRIL (lisinopril) NC RECEPTOR ANTAGONISTS - DRUGS TO TREAT HIGH BLOOD PRESSURE eplerenone NP INSPRA (eplerenone) NC ALPHA BLOCKERS - DRUGS TO TREAT HIGH BLOOD PRESSURE CARDURA (doxazosin mesylate) NC doxazosin mesylate oral PG MINIPRESS (prazosin hcl) NC prazosin hcl oral PG terazosin hcl oral PG LGC ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS - DRUGS TO TREAT HIGH BLOOD PRESSURE amlodipine besylate-valsartan PG amlodipine-olmesartan NP amlodipine-valsartan-hctz NP ATACAND HCT (candesartan cilexetil-hctz) NC AVALIDE ORAL TABLET 150-12.5 MG, 300-12.5 MG NC (irbesartan-hydrochlorothiazide) AZOR (amlodipine-olmesartan) NC BENICAR HCT (olmesartan medoxomil-hctz) NC BYVALSON (nebivolol-valsartan) NC candesartan cilexetil-hctz PG CLORPRES (clonidine-chlorthalidone) NP DIOVAN HCT (valsartan-hydrochlorothiazide) NC EDARBYCLOR (azilsartan-chlorthalidone) NP ST; QL (1 tab per 1 day) EXFORGE (amlodipine besylate-valsartan) NC EXFORGE HCT (amlodipine-valsartan-hctz) NC HYZAAR (losartan potassium-hctz) NC irbesartan-hydrochlorothiazide PG losartan potassium-hctz PG LGC MICARDIS HCT (telmisartan-hctz) NC olmesartan medoxomil-hctz NP 2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 53 Drug Name Drug Status Drug Details olmesartan-amlodipine-hctz NP telmisartan-amlodipine NP telmisartan-hctz PG TRIBENZOR (olmesartan-amlodipine-hctz) NC TWYNSTA (telmisartan-amlodipine) NC valsartan-hydrochlorothiazide PG ANGIOTENSIN II RECEPTOR ANTAGONISTS - DRUGS TO TREAT HIGH BLOOD PRESSURE ATACAND (candesartan cilexetil) NC AVAPRO (irbesartan) NC BENICAR (olmesartan medoxomil) NC candesartan cilexetil PG COZAAR (losartan potassium) NC DIOVAN (valsartan) NC EDARBI (azilsartan medoxomil) NP ST eprosartan mesylate NP irbesartan PG losartan potassium oral PG LGC MICARDIS (telmisartan) NC olmesartan medoxomil oral NP telmisartan PG valsartan PG ANTIARRHYTHMICS - DRUGS TO CONTROL HEART RHYTHM amiodarone hcl oral PG disopyramide phosphate oral PG dofetilide NP PA flecainide acetate PG mexiletine hcl oral PG MULTAQ (dronedarone hcl) NP PA NORPACE (disopyramide phosphate) NC NORPACE CR (disopyramide phosphate) PB pacerone oral tablet 100 mg, 200 mg, 400 mg PG propafenone hcl PG propafenone hcl er NP

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 54 Drug Name Drug Status Drug Details quinidine gluconate er NP quinidine sulfate oral PG RYTHMOL SR (propafenone hcl) NC sorine oral tablet 120 mg, 80 mg PG LGC sorine oral tablet 160 mg, 240 mg PG sotalol hcl (af) oral tablet 120 mg PG LGC sotalol hcl (af) oral tablet 160 mg, 80 mg PG sotalol hcl oral tablet 120 mg, 80 mg PG LGC sotalol hcl oral tablet 160 mg, 240 mg PG TIKOSYN (dofetilide) NC ANTILIPEMICS, ACL INHIBITORS/COMBINATIONS NEXLETOL (bempedoic acid) NC NEXLIZET (bempedoic acid-ezetimibe) NC ANTILIPEMICS, BILE ACID RESINS cholestyramine light PG cholestyramine oral PG colesevelam hcl PG COLESTID (colestipol hcl) NC COLESTID FLAVORED (colestipol hcl) NC colestipol hcl PG prevalite PG QUESTRAN (cholestyramine) NC QUESTRAN LIGHT ORAL POWDER (cholestyramine NC light) WELCHOL (colesevelam hcl) NC ANTILIPEMICS, ABSORPTION INHIBITOR ezetimibe PG ZETIA (ezetimibe) NC ANTILIPEMICS, FIBRATES ANTARA ORAL CAPSULE 30 MG, 90 MG (fenofibrate NC # micronized) fenofibrate micronized oral capsule 130 mg NC fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg PG QL (1 cap per 1 day) fenofibrate micronized oral capsule 43 mg PG

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 55 Drug Name Drug Status Drug Details fenofibrate oral capsule 134 mg, 150 mg, 200 mg, 67 mg PG fenofibrate oral capsule 50 mg NC fenofibrate oral tablet 120 mg, 40 mg NC fenofibrate oral tablet 145 mg, 48 mg, 54 mg PG fenofibrate oral tablet 160 mg NP fenofibric acid oral capsule delayed release PG fenofibric acid oral tablet NP FENOGLIDE (fenofibrate) NC FIBRICOR (fenofibric acid) NC gemfibrozil oral PG LGC LIPOFEN (fenofibrate) NC LOFIBRA ORAL CAPSULE 134 MG, 67 MG (fenofibrate NC micronized) LOFIBRA ORAL TABLET 54 MG (fenofibrate) NC LOPID (gemfibrozil) NC TRICOR (fenofibrate) NC TRIGLIDE ORAL TABLET 160 MG (fenofibrate) NC TRILIPIX (choline fenofibrate) NC ANTILIPEMICS, HMG-COA REDUCTASE INHIBITORS ALTOPREV (lovastatin) NP ST; #; QL (2 tabs per 1 day) N2 (Not Covered); AL (Min atorvastatin calcium oral tablet 10 mg, 20 mg CE 40 Years and Max 75 Years) atorvastatin calcium oral tablet 40 mg, 80 mg NC CRESTOR (rosuvastatin calcium) NC EZALLOR SPRINKLE (rosuvastatin calcium) NC flolipid NC fluvastatin sodium PG fluvastatin sodium er PG LESCOL XL (fluvastatin sodium) NC LIPITOR (atorvastatin calcium) NC LIVALO (pitavastatin calcium) NP ST; QL (1 tab per 1 day) lovastatin oral PG LGC MEVACOR ORAL TABLET 40 MG (lovastatin) NC PRAVACHOL ORAL TABLET 20 MG, 40 MG, 80 MG NC (pravastatin sodium)

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 56 Drug Name Drug Status Drug Details pravastatin sodium PG LGC rosuvastatin calcium PG simvastatin oral suspension NC LGC; N2 (PG); AL (Min 40 simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg CE Years and Max 75 Years) simvastatin oral tablet 80 mg PG LGC ZOCOR (simvastatin) NC ZYPITAMAG (pitavastatin magnesium) NC ANTILIPEMICS, HMG-COA REDUCTASE INHIBITORS/COMBINATIONS ezetimibe-simvastatin NP ROSZET (ezetimibe-rosuvastatin) NC VYTORIN (ezetimibe-simvastatin) NC ANTILIPEMICS, MISCELLANEOUS - DRUGS TO TREAT HIGH CHOLESTEROL icosapent ethyl PG PA; ST; SP Pharmacy; QL JUXTAPID (lomitapide mesylate) NPSP (1 capsule per 1 day) KYNAMRO SUBCUTANEOUS SOLUTION PREFILLED NC SYRINGE (mipomersen sodium) LOVAZA (omega-3-acid ethyl esters) NC (antihyperlipidemic) NP niacin er (antihyperlipidemic) PG NIACOR (niacin (antihyperlipidemic)) NC NIASPAN (niacin (antihyperlipidemic)) NC ANTILIPEMICS, OMEGA-3 FATTY ACIDS omega-3-acid ethyl esters NP VASCEPA ORAL CAPSULE 0.5 GM (icosapent ethyl) PB # VASCEPA ORAL CAPSULE 1 GM (icosapent ethyl) PB ANTILIPEMICS, PCSK9 INHIBITORS PRALUENT SUBCUTANEOUS SOLUTION AUTO- PSP INJECTOR (alirocumab) PRALUENT SUBCUTANEOUS SOLUTION PEN- NC INJECTOR (alirocumab) PRALUENT SUBCUTANEOUS SOLUTION PREFILLED PSP SYRINGE (alirocumab)

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 57 Drug Name Drug Status Drug Details REPATHA (evolocumab) NC PA REPATHA PUSHTRONEX SYSTEM (evolocumab) NC PA REPATHA SURECLICK (evolocumab) NC PA BETA-BLOCKER/DIURETIC COMBINATIONS - DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONS atenolol-chlorthalidone PG LGC bisoprolol-hydrochlorothiazide PG LGC CORZIDE (nadolol-bendroflumethiazide) NC LOPRESSOR HCT ORAL TABLET 50-25 MG (metoprolol- NC hydrochlorothiazide) metoprolol-hctz er NC metoprolol-hydrochlorothiazide PG nadolol-bendroflumethiazide PG propranolol-hctz PG TENORETIC 100 (atenolol-chlorthalidone) NC TENORETIC 50 (atenolol-chlorthalidone) NC ZIAC (bisoprolol-hydrochlorothiazide) NC BETA-BLOCKERS - DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONS acebutolol hcl oral PG atenolol oral PG LGC ATENOLOL+SYRSPEND SF PH4 (atenolol) NC BETAPACE AF (sotalol hcl af) NC BETAPACE ORAL TABLET 120 MG, 160 MG, 80 MG NC (sotalol hcl) betaxolol hcl oral PG bisoprolol fumarate oral PG LGC BYSTOLIC (nebivolol hcl) NP # carvedilol PG LGC carvedilol phosphate er NP COREG (carvedilol) NC COREG CR (carvedilol phosphate) NC CORGARD (nadolol) NC HEMANGEOL (propranolol hcl) NP PA INDERAL LA (propranolol hcl) NC 2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 58 Drug Name Drug Status Drug Details INDERAL XL (propranolol hcl sr beads) NC INNOPRAN XL (propranolol hcl sr beads) NC # KAPSPARGO SPRINKLE (metoprolol succinate) NP labetalol hcl oral PG LEVATOL (penbutolol sulfate) NP LOPRESSOR ORAL (metoprolol tartrate) NC metoprolol succinate er PG metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg PG LGC metoprolol tartrate oral tablet 37.5 mg, 75 mg PG nadolol oral tablet 20 mg, 40 mg, 80 mg PG pindolol PG propranolol hcl er PG propranolol hcl oral solution PG propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 80 mg PG LGC propranolol hcl oral tablet 60 mg PG SOTYLIZE (sotalol hcl) NC TENORMIN (atenolol) NC timolol maleate oral PG TOPROL XL (metoprolol succinate) NC CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS amlodipine-atorvastatin PG CADUET ORAL TABLET 10-10 MG, 10-20 MG, 10-40 MG, 10-80 MG, 5-10 MG, 5-20 MG, 5-40 MG, 5-80 MG NC (amlodipine-atorvastatin) CALCIUM CHANNEL BLOCKERS - DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONS ADALAT CC (nifedipine) NC afeditab cr oral tablet extended release 24 hour 30 mg PG QL (1 tab per 1 day) afeditab cr oral tablet extended release 24 hour 60 mg PG QL (2 tabs per 1 day) AMLODIPINE BES+SYRSPEND SF (amlodipine besylate) NC amlodipine besylate oral PG LGC CALAN ORAL TABLET 120 MG, 80 MG (verapamil hcl) NC CALAN SR (verapamil hcl) NC

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 59 Drug Name Drug Status Drug Details CARDIZEM CD ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 360 MG NC (diltiazem hcl coated beads) CARDIZEM LA ORAL TABLET EXTENDED RELEASE NP 24 HOUR 120 MG (diltiazem hcl coated beads) CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 180 MG, 240 MG, 300 MG, 360 MG, 420 MG NC (diltiazem hcl coated beads) CARDIZEM ORAL TABLET 120 MG, 30 MG, 60 MG NC (diltiazem hcl) cartia xt PG CONJUPRI (levamlodipine maleate) NC CONSENSI (amlodipine besylate-celecoxib) NC diltiazem cd oral capsule extended release 24 hour 120 mg, 180 PG QL (1 capsule per 1 day) mg diltiazem cd oral capsule extended release 24 hour 240 mg PG QL (2 capsules per 1 day) diltiazem cd oral capsule extended release 24 hour 300 mg PG QL (1 cap per 1 day) diltiazem hcl er beads PG diltiazem hcl er coated beads oral capsule extended release 24 PG hour diltiazem hcl er coated beads oral tablet extended release 24 PG QL (1 tab per 1 day) hour 180 mg, 300 mg, 360 mg diltiazem hcl er coated beads oral tablet extended release 24 PG QL (2 tabs per 1 day) hour 240 mg diltiazem hcl er coated beads oral tablet extended release 24 PG hour 420 mg diltiazem hcl er oral capsule extended release 12 hour PG diltiazem hcl er oral capsule extended release 24 hour 120 mg, PG 180 mg diltiazem hcl er oral capsule extended release 24 hour 240 mg PG QL (2 cap per 1 day) diltiazem hcl oral PG LGC dilt-xr PG felodipine er PG isradipine PG KATERZIA (amlodipine benzoate) NC matzim la PG nicardipine hcl oral NC

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 60 Drug Name Drug Status Drug Details nifediac cc oral tablet extended release 24 hour 30 mg PG QL (1 tablet per 1 day) nifedical xl oral tablet extended release 24 hour 60 mg PG QL (2 tabs per 1 day) nifedipine er PG nifedipine er osmotic release PG nifedipine oral PG nimodipine oral PG nisoldipine er PG NORVASC (amlodipine besylate) NC NYMALIZE ORAL SOLUTION 6 MG/ML (nimodipine) NP NYMALIZE ORAL SOLUTION 60 MG/20ML (nimodipine) NC # PROCARDIA (nifedipine) NC PROCARDIA XL (nifedipine) NC SULAR ORAL TABLET EXTENDED RELEASE 24 NC HOUR 17 MG, 34 MG, 8.5 MG (nisoldipine) taztia xt PG diltiazem hcl er beads (Tiadylt Er Oral Capsule Extended PG Release 24 Hour 120 Mg, 180 Mg, 240 Mg, 300 Mg, 360 Mg) TIAZAC (diltiazem hcl er beads) NC verapamil hcl er oral capsule extended release 24 hour PG verapamil hcl er oral tablet extended release 120 mg PG LGC verapamil hcl er oral tablet extended release 180 mg, 240 mg PG verapamil hcl oral PG LGC VERELAN (verapamil hcl) NC VERELAN PM (verapamil hcl) NC DIGITALIS GLYCOSIDES - DRUGS TO TREAT HEART CONDITIONS digoxin (Digitek) PG digoxin (Digox) PG digoxin oral PG LANOXIN ORAL TABLET 125 MCG, 187.5 MCG, 250 NC MCG (digoxin) LANOXIN ORAL TABLET 62.5 MCG (digoxin) PB DIRECT RENIN INHIBITORS/COMBINATIONS - DRUGS TO TREAT HEART CONDITIONS aliskiren fumarate PG TEKTURNA (aliskiren fumarate) NC 2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 61 Drug Name Drug Status Drug Details TEKTURNA HCT (aliskiren-hydrochlorothiazide) NP ST; QL (1 tab per 1 day) DIURETICS - DRUGS TO TREAT HEART CONDITIONS acetazolamide er PG acetazolamide oral PG ALDACTAZIDE ORAL TABLET 25-25 MG NC (-hctz) ALDACTAZIDE ORAL TABLET 50-50 MG PB (spironolactone-hctz) ALDACTONE (spironolactone) NC amiloride hcl oral PG amiloride-hydrochlorothiazide PG LGC bumetanide oral PG BUMEX (bumetanide) NC CAROSPIR (spironolactone) NC chlorothiazide oral PG chlorthalidone oral tablet 25 mg, 50 mg PG DEMADEX ORAL TABLET 10 MG, 20 MG (torsemide) NC DIAMOX SEQUELS (acetazolamide) NC DIURIL (chlorothiazide) NP DYAZIDE (triamterene-hctz) NC DYRENIUM (triamterene) NP EDECRIN (ethacrynic acid) NC ethacrynic acid oral NP furosemide oral solution 10 mg/ml, 8 mg/ml PG furosemide oral tablet PG LGC hydrochlorothiazide oral capsule PG LGC hydrochlorothiazide oral tablet 12.5 mg PG hydrochlorothiazide oral tablet 25 mg, 50 mg PG LGC indapamide oral PG KEVEYIS (dichlorphenamide) NC # LASIX (furosemide) NC MAXZIDE (triamterene-hctz) NC MAXZIDE-25 (triamterene-hctz) NC methazolamide oral PG methyclothiazide oral PG

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 62 Drug Name Drug Status Drug Details metolazone PG MICROZIDE (hydrochlorothiazide) NC NEPTAZANE (methazolamide) NC spironolactone oral tablet 100 mg, 50 mg PG spironolactone oral tablet 25 mg PG LGC spironolactone-hctz PG torsemide oral PG triamterene oral PG triamterene-hctz oral capsule 37.5-25 mg PG LGC triamterene-hctz oral capsule 50-25 mg NP triamterene-hctz oral tablet PG LGC HEART FAILURE VERQUVO (vericiguat) NC MISCELLANEOUS BIDIL (isosorb dinitrate-hydralazine) NP # CATAPRES (clonidine hcl) NC CATAPRES-TTS-1 (clonidine) NC CATAPRES-TTS-2 (clonidine) NC CATAPRES-TTS-3 (clonidine) NC clonidine hcl oral PG LGC clonidine hcl transdermal NP CORLANOR (ivabradine hcl) PB DEMSER (metyrosine) NPSP ST; SP Pharmacy desmopressin ace rhinal tube NC DIBENZYLINE (phenoxybenzamine hcl) NC droxidopa NC ENTRESTO (-valsartan) PB guanfacine hcl oral PG hydralazine hcl oral tablet 10 mg, 100 mg, 50 mg PG hydralazine hcl oral tablet 25 mg PG LGC methyldopa oral PG methyldopa-hydrochlorothiazide NP metyrosine NP midodrine hcl PG minoxidil oral PG 2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 63 Drug Name Drug Status Drug Details NORTHERA (droxidopa) NC PA; QL (12 capsules per 1 phenoxybenzamine hcl oral PSP day) RANEXA ORAL TABLET EXTENDED RELEASE 12 NC HOUR 1000 MG (ranolazine) ranolazine er PG ST reserpine oral NP VECAMYL (mecamylamine hcl) NC VYNDAMAX (tafamidis) NC VYNDAQEL (tafamidis meglumine (cardiac)) NC NITRATES - DRUGS TO TREAT HEART CONDITIONS DILATRATE-SR (isosorbide dinitrate) NP GONITRO (nitroglycerin) NC ISORDIL TITRADOSE ORAL TABLET 40 MG (isosorbide NP dinitrate) ISORDIL TITRADOSE ORAL TABLET 5 MG (isosorbide NC dinitrate) isosorbide dinitrate er PG isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 5 mg PG isosorbide dinitrate oral tablet 40 mg NC isosorbide mononitrate PG isosorbide mononitrate er PG nitroglycerin (Minitran) PG NITRO-BID (nitroglycerin) NP NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.1 MG/HR, 0.2 MG/HR, 0.4 MG/HR, 0.6 MG/HR NC (nitroglycerin) NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.3 PB MG/HR, 0.8 MG/HR (nitroglycerin) nitroglycerin sublingual PG nitroglycerin transdermal patch 24 hour PG nitroglycerin translingual NP NITROLINGUAL (nitroglycerin) NC NITROMIST (nitroglycerin) NC NITROSTAT (nitroglycerin) NC

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 64 Drug Name Drug Status Drug Details RANEXA ORAL TABLET EXTENDED RELEASE 12 NC HOUR 500 MG (ranolazine) PULMONARY ARTERIAL HYPERTENSION - DRUGS TO TREAT PULMONARY HYPERTENSION PA; ST; SP Pharmacy; QL ADCIRCA (tadalafil (pah)) NPSP (2 tabs per 1 day) PA; SP Pharmacy; QL (3 ADEMPAS (riociguat) NPSP tabs per 1 day) PA; SP Pharmacy; QL (2 tadalafil (pah) (Alyq) PSP tablets per 1 day) PA; SP Pharmacy; QL (1 PSP tablet per 1 day) PA; SP Pharmacy; QL (2 PSP tablets per 1 day) epoprostenol sodium NC PA; SP Pharmacy FLOLAN (epoprostenol sodium) NC LETAIRIS (ambrisentan) PSP PA; SP Pharmacy PA; SP Pharmacy; QL (2 OPSUMIT () PSP tablets per 1 day) ORENITRAM (treprostinil diolamine) PSP PA; SP Pharmacy REMODULIN INJECTION SOLUTION 1 MG/ML, 10 NC # MG/ML, 2.5 MG/ML, 5 MG/ML (treprostinil sodium) REMODULIN INJECTION SOLUTION 100 MG/20ML, 20 NPSP MG/20ML, 200 MG/20ML, 50 MG/20ML (treprostinil) REVATIO ORAL (sildenafil citrate) NC PA; SP Pharmacy; QL (3 sildenafil citrate oral tablet 20 mg PSP tabs per 1 day) PA; SP Pharmacy; QL (2 tadalafil (pah) NPSP tablets per 1 day) TRACLEER ORAL TABLET (bosentan) NC TRACLEER ORAL TABLET SOLUBLE (bosentan) PSP QL (4 tablets per 1 day) treprostinil PG PA; SP Pharmacy TYVASO (treprostinil) NC TYVASO REFILL (treprostinil) NC TYVASO STARTER (treprostinil) PSP UPTRAVI ORAL TABLET 1000 MCG, 1200 MCG, 1400 MCG, 1600 MCG, 400 MCG, 600 MCG, 800 MCG PSP (selexipag)

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 65 Drug Name Drug Status Drug Details UPTRAVI ORAL TABLET 200 MCG (selexipag) PSP QL (5 tablets per 1 day) UPTRAVI ORAL TABLET THERAPY PACK (selexipag) PSP QL (1 pack per 1 month) VELETRI (epoprostenol sodium) NC PA; SP Pharmacy; QL (9 VENTAVIS (iloprost) PSP ampules per 1 day) CENTRAL NERVOUS SYSTEM - DRUGS TO TREAT NERVOUS SYSTEM DISORDERS ANTIANXIETY - DRUGS TO TREAT ANXIETY alprazolam er NP QL (2 tabs per 1 day) ALPRAZOLAM INTENSOL (alprazolam) PB QL (10 ml per 1 day) alprazolam oral PG QL (5 tablets per 1 day) alprazolam xr NP QL (2 tabs per 1 day) ATIVAN ORAL (lorazepam) NC chlordiazepoxide hcl oral capsule 10 mg, 25 mg NC chlordiazepoxide hcl oral capsule 5 mg PG QL (12 capsules per 1 day) lorazepam (Lorazepam Intensol) NC lorazepam oral concentrate 2 mg/ml PG QL (5 ml per 1 day) lorazepam oral tablet PG QL (5 tablets per 1 day) meprobamate PG oxazepam PG QL (4 capsules per 1 day) XANAX (alprazolam) NC XANAX XR (alprazolam) NC ANTICONVULSANTS - DRUGS TO TREAT SEIZURES APTIOM (eslicarbazepine acetate) NP PA; # BANZEL ORAL SUSPENSION (rufinamide) NP BANZEL ORAL TABLET (rufinamide) NP #; QL (8 tabs per 1 day) BRIVIACT ORAL (brivaracetam) NP PA carbamazepine er oral capsule extended release 12 hour 100 mg, PG 300 mg carbamazepine er oral capsule extended release 12 hour 200 mg NC carbamazepine er oral tablet extended release 12 hour PG carbamazepine oral suspension PG carbamazepine oral tablet PG LGC carbamazepine oral tablet chewable PG CARBATROL (carbamazepine) NC

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 66 Drug Name Drug Status Drug Details CELONTIN (methsuximide) NP clobazam PG PA clonazepam oral tablet PG clonazepam oral tablet dispersible NP clorazepate dipotassium PG QL (6 tablets per 1 day) DEPAKENE ORAL CAPSULE (valproic acid) NC DEPAKENE ORAL SOLUTION (valproate sodium) NC DEPAKOTE (divalproex sodium) NC DEPAKOTE ER (divalproex sodium) NC DEPAKOTE SPRINKLES ORAL CAPSULE DELAYED NC RELEASE SPRINKLE (divalproex sodium) SP Pharmacy; QL (12 DIACOMIT ORAL CAPSULE 250 MG (stiripentol) NPSP capsules per 1 day) SP Pharmacy; QL (6 DIACOMIT ORAL CAPSULE 500 MG (stiripentol) NPSP capsules per 1 day) SP Pharmacy; QL (12 DIACOMIT ORAL PACKET 250 MG (stiripentol) NPSP packets per 1 day) SP Pharmacy; QL (6 packets DIACOMIT ORAL PACKET 500 MG (stiripentol) NPSP per 1 day) DIASTAT ACUDIAL (diazepam) NC DIASTAT PEDIATRIC (diazepam) NC diazepam intensol PG QL (8 ml per 1 day) diazepam oral concentrate PG diazepam oral solution 1 mg/ml PG diazepam oral solution 5 mg/5ml PG QL (40 ml per 1 day) diazepam oral tablet PG QL (4 tablets per 1 day) diazepam rectal NP QL (1 pack per 1 fill) DILANTIN INFATABS () NC DILANTIN ORAL CAPSULE 100 MG (phenytoin sodium NC extended) DILANTIN ORAL CAPSULE 30 MG (phenytoin sodium NP extended) DILANTIN ORAL SUSPENSION (phenytoin) NC divalproex sodium er oral tablet extended release 24 hour PG divalproex sodium oral capsule delayed release sprinkle PG divalproex sodium oral tablet delayed release PG

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 67 Drug Name Drug Status Drug Details ELEPSIA XR (levetiracetam) NC PA; SP Pharmacy; QL (800 EPIDIOLEX (cannabidiol) NPSP ML per 1 month) epitol PG LGC ethosuximide oral PG felbamate oral suspension PG felbamate oral tablet NP FELBATOL (felbamate) NC PA; SP Pharmacy; QL (12 FINTEPLA (fenfluramine hcl) NPSP ML per 1 day) FYCOMPA (perampanel) PB gabapentin oral PG GABITRIL (tiagabine hcl) NC KEPPRA ORAL (levetiracetam) NC KEPPRA XR (levetiracetam) NC KLONOPIN (clonazepam) NC LAMICTAL ODT (lamotrigine) NC LAMICTAL ORAL TABLET (lamotrigine) NC LAMICTAL ORAL TABLET CHEWABLE 25 MG, 5 MG NC (lamotrigine) LAMICTAL XR ORAL KIT (lamotrigine) NP LAMICTAL XR ORAL TABLET EXTENDED RELEASE NC 24 HOUR (lamotrigine) lamotrigine er NP lamotrigine oral kit 21 x 25 mg & 7 x 50 mg, 25 & 50 & 100 mg, NP 42 x 50 mg & 14x100 mg lamotrigine oral tablet PG lamotrigine oral tablet chewable NP lamotrigine oral tablet dispersible NP lamotrigine starter kit-blue PG lamotrigine starter kit-green PG lamotrigine starter kit-orange PG levetiracetam er PG levetiracetam oral PG LYRICA (pregabalin) NC MYSOLINE (primidone) NC 2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 68 Drug Name Drug Status Drug Details NAYZILAM (midazolam (anticonvulsant)) NC NEURONTIN (gabapentin) NC ONFI ORAL SUSPENSION (clobazam) NC ONFI ORAL TABLET 10 MG, 20 MG (clobazam) NC oxcarbazepine PG OXTELLAR XR ORAL TABLET EXTENDED RELEASE NP ST; QL (2 tabs per 1 day) 24 HOUR 150 MG, 300 MG (oxcarbazepine) OXTELLAR XR ORAL TABLET EXTENDED RELEASE NP ST; QL (4 tabs per 1 day) 24 HOUR 600 MG (oxcarbazepine) PEGANONE (ethotoin) NP phenobarbital oral PG PHENYTEK (phenytoin sodium extended) NC phenytoin infatabs PG phenytoin oral suspension 125 mg/5ml PG phenytoin oral tablet chewable PG phenytoin sodium extended PG POTIGA ORAL TABLET 200 MG, 300 MG, 400 MG NP QL (3 tablets per 1 Day) (ezogabine) POTIGA ORAL TABLET 50 MG (ezogabine) NP QL (6 tablets per 1 Day) pregabalin er NC pregabalin oral PG ST primidone oral PG QUDEXY XR (topiramate) NC levetiracetam (Roweepra Oral Tablet 500 Mg) PG rufinamide oral suspension PG rufinamide oral tablet PG QL (8 tablets per 1 day) SABRIL ORAL PACKET (vigabatrin) NC PA; SP Pharmacy; QL (6 SABRIL ORAL TABLET (vigabatrin) NPSP tablets per 1 day) SECONAL (secobarbital sodium) NP SPRITAM (levetiracetam) NC SYMPAZAN (clobazam) NC TEGRETOL ORAL SUSPENSION (carbamazepine) NC TEGRETOL ORAL TABLET (carbamazepine) NC TEGRETOL-XR (carbamazepine) NC tiagabine hcl oral tablet 12 mg, 16 mg, 4 mg PG 2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 69 Drug Name Drug Status Drug Details tiagabine hcl oral tablet 2 mg NP TOPAMAX (topiramate) NC TOPAMAX SPRINKLE (topiramate) NC topiramate er NC topiramate oral PG TRANXENE-T ORAL TABLET 7.5 MG (clorazepate NC dipotassium) TRILEPTAL (oxcarbazepine) NC TROKENDI XR (topiramate) NC # VALIUM (diazepam) NC valproate sodium oral solution PG valproic acid oral capsule PG valproic acid oral solution PG VALTOCO 10 MG DOSE (diazepam) NC VALTOCO 15 MG DOSE (diazepam) NC VALTOCO 20 MG DOSE (diazepam) NC VALTOCO 5 MG DOSE (diazepam) NC PA; SP Pharmacy; QL (6 vigabatrin oral packet PSP packets per 1 Day) PA; SP Pharmacy; QL (6 vigabatrin oral tablet PSP tablets per 1 day) PA; SP Pharmacy; QL (6 vigabatrin (Vigadrone) PSP packets per 1 Day) VIMPAT ORAL (lacosamide) NP # XCOPRI (cenobamate) NC XCOPRI (250 MG DAILY DOSE) (cenobamate) NC XCOPRI (350 MG DAILY DOSE) (cenobamate) NC ZARONTIN (ethosuximide) NC ZONEGRAN (zonisamide) NC zonisamide oral PG ANTIDEMENTIA - DRUGS TO TREAT DEMENTIA AND MEMORY LOSS ARICEPT (donepezil hcl) NC donepezil hcl oral tablet 10 mg, 5 mg PG donepezil hcl oral tablet 23 mg NP donepezil hcl oral tablet dispersible PG 2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 70 Drug Name Drug Status Drug Details ergoloid mesylates oral NP EXELON TRANSDERMAL (rivastigmine) NC galantamine hydrobromide NP galantamine hydrobromide er NP memantine hcl er PG PA memantine hcl oral solution 2 mg/ml PG PA memantine hcl oral tablet PG PA NAMENDA ORAL TABLET (memantine hcl) NC NAMENDA TITRATION PAK (memantine hcl) NC NAMENDA XR (memantine hcl) NC NAMENDA XR TITRATION PACK (memantine hcl) PB # NAMZARIC (memantine hcl-donepezil hcl) PB PA RAZADYNE ER (galantamine hydrobromide) NC RAZADYNE ORAL TABLET (galantamine hydrobromide) NC rivastigmine NP PA rivastigmine tartrate NP PA ANTIDEPRESSANTS - DRUGS TO TREAT DEPRESSION LGC; QL (5 tablets per 1 amitriptyline hcl oral tablet 10 mg PG day) PA; LGC; AL (Max 70 amitriptyline hcl oral tablet 100 mg, 75 mg PG Years) amitriptyline hcl oral tablet 150 mg PG PA; AL (Max 70 Years) LGC; QL (2 tablets per 1 amitriptyline hcl oral tablet 25 mg PG day) LGC; QL (1 tablet per 1 amitriptyline hcl oral tablet 50 mg PG day) amoxapine oral tablet 100 mg, 25 mg, 50 mg PG QL (3 tablets per 1 day) amoxapine oral tablet 150 mg PG QL (2 tablets per 1 day) ANAFRANIL (clomipramine hcl) NC APLENZIN (bupropion hbr) NC BRISDELLE (paroxetine mesylate) NC bupropion hcl er (sr) PG bupropion hcl er (xl) oral tablet extended release 24 hour 150 PG mg, 300 mg

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 71 Drug Name Drug Status Drug Details bupropion hcl er (xl) oral tablet extended release 24 hour 450 NC mg bupropion hcl oral PG CELEXA ORAL TABLET (citalopram hydrobromide) NC citalopram hydrobromide oral solution NP citalopram hydrobromide oral tablet PG LGC CYMBALTA (duloxetine hcl) NC desipramine hcl oral tablet 10 mg, 25 mg, 50 mg PG QL (3 tablets per 1 day) desipramine hcl oral tablet 100 mg, 150 mg PG QL (1 tablet per 1 day) desipramine hcl oral tablet 75 mg PG QL (2 tablets per 1 day) desvenlafaxine er NC desvenlafaxine succinate er NP ST; QL (1 tablet per 1 day) doxepin hcl oral capsule 10 mg, 25 mg, 50 mg PG QL (3 capsules per 1 day) doxepin hcl oral capsule 100 mg, 150 mg PG QL (1 capsule per 1 day) doxepin hcl oral capsule 75 mg PG QL (2 capsules per 1 day) doxepin hcl oral concentrate PG QL (15 ml per 1 day) DRIZALMA SPRINKLE (duloxetine hcl) NC duloxetine hcl oral PG EFFEXOR XR (venlafaxine hcl) NC ELAVIL (amitriptyline hcl) NC EMSAM (selegiline) NP PA; # escitalopram oxalate PG FETZIMA (levomilnacipran hcl) NP ST; QL (1 cap per 1 day) ST; QL (1 capsule per 1 FETZIMA TITRATION (levomilnacipran hcl) NP Day) fluoxetine hcl (pmdd) oral capsule PG LGC fluoxetine hcl (pmdd) oral tablet NP fluoxetine hcl oral capsule PG fluoxetine hcl oral capsule delayed release PG fluoxetine hcl oral solution PG fluoxetine hcl oral tablet 10 mg, 20 mg PG fluoxetine hcl oral tablet 60 mg NP QL (1 tablet per 1 day) FORFIVO XL (bupropion hcl) NC imipramine hcl oral tablet 10 mg, 25 mg PG QL (4 tablets per 1 day) imipramine hcl oral tablet 50 mg PG QL (2 tablets per 1 day)

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 72 Drug Name Drug Status Drug Details imipramine pamoate oral capsule 100 mg, 75 mg NP QL (1 capsule per 1 day) imipramine pamoate oral capsule 125 mg, 150 mg NP PA KHEDEZLA (desvenlafaxine) NC LEXAPRO ORAL TABLET (escitalopram oxalate) NC maprotiline hcl PG MARPLAN (isocarboxazid) NP mirtazapine oral PG NARDIL (phenelzine sulfate) NC nefazodone hcl NP NORPRAMIN ORAL TABLET 10 MG, 25 MG NC (desipramine hcl) LGC; QL (5 capsules per 1 nortriptyline hcl oral capsule 10 mg PG day) LGC; QL (2 capsules per 1 nortriptyline hcl oral capsule 25 mg PG day) nortriptyline hcl oral capsule 50 mg PG QL (1 capsule per 1 day) nortriptyline hcl oral capsule 75 mg PG nortriptyline hcl oral solution PG QL (750 ml per 1 month) PAMELOR ORAL CAPSULE (nortriptyline hcl) NC PARNATE (tranylcypromine sulfate) NC paroxetine hcl er NP paroxetine hcl oral tablet PG LGC paroxetine mesylate NC PAXIL (paroxetine hcl) NC PAXIL CR (paroxetine hcl) NC PEXEVA (paroxetine mesylate) NC phenelzine sulfate oral PG PRISTIQ (desvenlafaxine succinate) NC protriptyline hcl oral tablet 10 mg NP QL (2 tablets per 1 day) protriptyline hcl oral tablet 5 mg NP QL (3 tablets per 1 day) PROZAC ORAL CAPSULE (fluoxetine hcl) NC REMERON (mirtazapine) NC REMERON SOLTAB (mirtazapine) NC SARAFEM ORAL TABLET 10 MG, 20 MG (fluoxetine hcl NC (pmdd)) sertraline hcl oral concentrate PG 2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 73 Drug Name Drug Status Drug Details sertraline hcl oral tablet PG LGC SURMONTIL (trimipramine maleate) NC TOFRANIL (imipramine hcl) NC tranylcypromine sulfate NP trazodone hcl oral PG trimipramine maleate oral capsule 100 mg NP QL (1 capsule per 1 day) trimipramine maleate oral capsule 25 mg, 50 mg NP QL (2 capsules per 1 day) TRINTELLIX (vortioxetine hbr) NP ST venlafaxine hcl PG venlafaxine hcl er oral capsule extended release 24 hour PG venlafaxine hcl er oral tablet extended release 24 hour 150 mg, NP 37.5 mg, 75 mg venlafaxine hcl er oral tablet extended release 24 hour 225 mg NP QL (1 tab per 1 day) VIIBRYD ORAL TABLET (vilazodone hcl) NP ST; # VIIBRYD STARTER PACK (vilazodone hcl) NP ST; # WELLBUTRIN SR (bupropion hcl) NC WELLBUTRIN XL (bupropion hcl) NC ZOLOFT (sertraline hcl) NC ANTIPARKINSONIAN AGENTS - DRUGS TO TREAT PARKINSONS DISEASE amantadine hcl oral PG APOKYN SUBCUTANEOUS SOLUTION CARTRIDGE PA; QL (20 cartridges per 30 PSP (apomorphine hcl) days) AZILECT (rasagiline mesylate) NC benztropine mesylate oral PG LGC mesylate oral PG carbidopa oral PG carbidopa-levodopa PG carbidopa-levodopa er oral tablet extended release 25-100 mg, PG 50-200 mg carbidopa-levodopa-entacapone NP COMTAN (entacapone) NC DUOPA ENTERAL (carbidopa-levodopa) NC ELDEPRYL (selegiline hcl) NC entacapone PG GOCOVRI (amantadine hcl) NC 2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 74 Drug Name Drug Status Drug Details INBRIJA (levodopa) NC KYNMOBI (apomorphine hcl) NC LODOSYN (carbidopa) NC MIRAPEX (pramipexole dihydrochloride) NC MIRAPEX ER (pramipexole dihydrochloride) NC NEUPRO (rotigotine) PB # NOURIANZ (istradefylline) NC ONGENTYS (opicapone) NC OSMOLEX ER (amantadine hcl) NC PARLODEL (bromocriptine mesylate) NC pramipexole dihydrochloride PG pramipexole dihydrochloride er NP rasagiline mesylate oral tablet 0.5 mg PG rasagiline mesylate oral tablet 1 mg NP REQUIP (ropinirole hcl) NC REQUIP XL (ropinirole hcl) NC ropinirole hcl PG ropinirole hcl er oral tablet extended release 24 hour 12 mg NP QL (2 tabs per 1 day) ropinirole hcl er oral tablet extended release 24 hour 2 mg, 4 mg, NP QL (1 tab per 1 day) 6 mg, 8 mg RYTARY (carbidopa-levodopa) NC # selegiline hcl oral PG SINEMET (carbidopa-levodopa) NC SINEMET CR (carbidopa-levodopa) NC STALEVO 100 (carbidopa-levodopa-entacapone) NC STALEVO 125 (carbidopa-levodopa-entacapone) NC STALEVO 150 (carbidopa-levodopa-entacapone) NC STALEVO 200 (carbidopa-levodopa-entacapone) NC STALEVO 50 (carbidopa-levodopa-entacapone) NC TASMAR ORAL TABLET 100 MG (tolcapone) NC tolcapone NP trihexyphenidyl hcl oral elixir PG trihexyphenidyl hcl oral tablet 2 mg PG LGC trihexyphenidyl hcl oral tablet 5 mg PG XADAGO (safinamide mesylate) NC 2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 75 Drug Name Drug Status Drug Details ZELAPAR (selegiline hcl) NP ST; QL (2 tabs per 1 day) ANTIPSYCHOTICS - DRUGS TO TREAT PSYCHOSES ABILIFY MAINTENA INTRAMUSCULAR PREFILLED NP SYRINGE (aripiprazole) ABILIFY MAINTENA INTRAMUSCULAR NP SUSPENSION RECONSTITUTED ER (aripiprazole) ABILIFY ORAL TABLET (aripiprazole) NC aripiprazole PG ARISTADA (aripiprazole lauroxil) NP ARISTADA INITIO (aripiprazole lauroxil) PB asenapine maleate PG CAPLYTA (lumateperone tosylate) NC chlorpromazine hcl injection NP chlorpromazine hcl oral concentrate NC chlorpromazine hcl oral tablet 10 mg, 200 mg, 50 mg PG chlorpromazine hcl oral tablet 100 mg, 25 mg NP clozapine PG CLOZARIL ORAL TABLET 100 MG, 25 MG (clozapine) NC EQUETRO (carbamazepine (antipsychotic)) NP FANAPT (iloperidone) NP ST; QL (2 tabs per 1 day) FANAPT TITRATION PACK (iloperidone) NP ST FAZACLO (clozapine) NC fluphenazine decanoate injection PG fluphenazine hcl injection PG fluphenazine hcl oral PG GEODON (ziprasidone hcl) NC HALDOL (haloperidol lactate) NP HALDOL DECANOATE (haloperidol decanoate) NP haloperidol decanoate intramuscular solution 100 mg/ml, 50 PG mg/ml haloperidol lactate oral PG haloperidol oral PG INVEGA (paliperidone) NC INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE (paliperidone NP palmitate) 2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 76 Drug Name Drug Status Drug Details INVEGA TRINZA INTRAMUSCULAR SUSPENSION NC PREFILLED SYRINGE (paliperidone palmitate) LATUDA (lurasidone hcl) NP PA; # LITHOBID (lithium carbonate) NC loxapine succinate oral PG NUPLAZID (pimavanserin tartrate) NC olanzapine intramuscular PG olanzapine oral tablet PG olanzapine oral tablet dispersible NP paliperidone er NP perphenazine oral PG PERSERIS () NC prochlorperazine edisylate injection solution 10 mg/2ml, 50 PG mg/10ml quetiapine fumarate PG quetiapine fumarate er NP REXULTI (brexpiprazole) NP ST RISPERDAL (risperidone) NC RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED (risperidone NP # microspheres) RISPERDAL M-TAB ORAL TABLET DISPERSIBLE 0.5 NC MG, 1 MG, 3 MG, 4 MG (risperidone) risperidone PG risperidone m-tab oral tablet dispersible 0.5 mg, 1 mg, 2 mg NP QL (2 tabs per 1 day) risperidone m-tab oral tablet dispersible 3 mg NP QL (3 tabs per 1 day) risperidone m-tab oral tablet dispersible 4 mg NP QL (4 tabs per 1 day) SAPHRIS (asenapine maleate) NC SECUADO (asenapine) NC SEROQUEL (quetiapine fumarate) NC SEROQUEL XR (quetiapine fumarate) NC thioridazine hcl oral PG thiothixene oral PG trifluoperazine hcl oral PG VERSACLOZ (clozapine) NC

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 77 Drug Name Drug Status Drug Details PA; ST; QL (4 capsule per 1 VRAYLAR ORAL CAPSULE 1.5 MG (cariprazine hcl) NP day) PA; ST; QL (2 capsule per 1 VRAYLAR ORAL CAPSULE 3 MG (cariprazine hcl) NP day) VRAYLAR ORAL CAPSULE 4.5 MG, 6 MG (cariprazine PA; ST; QL (1 capsule per 1 NP hcl) day) VRAYLAR ORAL CAPSULE THERAPY PACK NP PA; ST (cariprazine hcl) ziprasidone hcl PG ziprasidone mesylate PG ZYPREXA INTRAMUSCULAR (olanzapine) NP ZYPREXA ORAL (olanzapine) NC ZYPREXA RELPREVV (olanzapine pamoate) NP ZYPREXA ZYDIS (olanzapine) NC ATTENTION DEFICIT HYPERACTIVITY DISORDER - DRUGS TO TREAT ADHD ADDERALL (amphetamine-dextroamphetamine) NC ADDERALL XR (amphetamine-dextroamphetamine) NC ADHANSIA XR (methylphenidate hcl) NC ADZENYS ER (amphetamine) NC ADZENYS XR-ODT (amphetamine) NC amphetamine er PG QL (15 ml per 1 day) amphetamine sulfate NP PA; QL (4 tablets per 1 day) amphetamine-dextroamphet er oral capsule extended release 24 PG QL (3 capsules per 1 day) hour 10 mg, 5 mg amphetamine-dextroamphet er oral capsule extended release 24 PG QL (1 capsule per 1 day) hour 15 mg, 20 mg, 25 mg, 30 mg amphetamine-dextroamphetamine oral tablet 10 mg, 12.5 mg, 5 PG QL (3 tablets per 1 day) mg, 7.5 mg amphetamine-dextroamphetamine oral tablet 15 mg, 20 mg PG QL (2 tablets per 1 day) amphetamine-dextroamphetamine oral tablet 30 mg PG QL (1 tablet per 1 day) APTENSIO XR (methylphenidate hcl) NC atomoxetine hcl oral capsule 10 mg, 18 mg, 40 mg PG QL (2 capsules per 1 day) atomoxetine hcl oral capsule 100 mg, 60 mg, 80 mg PG QL (1 capsule per 1 day) atomoxetine hcl oral capsule 25 mg PG QL (4 capsules per 1 day) AZSTARYS (serdexmethylphen-dexmethylphen) NC

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 78 Drug Name Drug Status Drug Details clonidine hcl er NP QL (4 tabs per 1 day) CONCERTA ORAL TABLET EXTENDED RELEASE 18 NC MG, 27 MG (methylphenidate hcl) CONCERTA ORAL TABLET EXTENDED RELEASE 36 NP QL (2 tablets per 1 day) MG (methylphenidate hcl) CONCERTA ORAL TABLET EXTENDED RELEASE 54 NP QL (1 capsule per 1 day) MG (methylphenidate hcl) COTEMPLA XR-ODT (methylphenidate) NC ST; #; QL (1 patch per 1 DAYTRANA (methylphenidate) NP day) DESOXYN (methamphetamine hcl) NC DEXEDRINE ORAL CAPSULE EXTENDED RELEASE NC 24 HOUR (dextroamphetamine sulfate) dexmethylphenidate hcl er NC dexmethylphenidate hcl oral tablet 10 mg PG QL (2 tablets per 1 day) dexmethylphenidate hcl oral tablet 2.5 mg, 5 mg PG QL (4 tablets per 1 day) dextroamphetamine sulfate er oral capsule extended release 24 NP QL (4 capsules per 1 day) hour 10 mg, 5 mg dextroamphetamine sulfate er oral capsule extended release 24 NP QL (2 capsules per 1 day) hour 15 mg dextroamphetamine sulfate oral solution PG QL (40 ML per 1 day) dextroamphetamine sulfate oral tablet 10 mg, 5 mg NP QL (4 tabs per 1 day) DYANAVEL XR (amphetamine) NC EVEKEO (amphetamine sulfate) NC EVEKEO ODT (amphetamine sulfate) NC FOCALIN ORAL TABLET 10 MG (dexmethylphenidate hcl) NP QL (2 tablets per 1 day) FOCALIN ORAL TABLET 2.5 MG, 5 MG NC (dexmethylphenidate hcl) FOCALIN XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 15 MG, 20 MG, 5 MG NC (dexmethylphenidate hcl) FOCALIN XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 25 MG, 30 MG, 35 MG, 40 MG NP QL (1 capsule per 1 day) (dexmethylphenidate hcl) guanfacine hcl er NP QL (1 tablet per 1 day) INTUNIV (guanfacine hcl) NC JORNAY PM (methylphenidate hcl) NC

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 79 Drug Name Drug Status Drug Details KAPVAY ORAL TABLET EXTENDED RELEASE 12 NC HOUR (clonidine hcl) metadate er oral tablet extended release 20 mg PG QL (3 tabs per 1 day) methamphetamine hcl NP QL (5 tablets per 1 day) METHYLIN ORAL SOLUTION (methylphenidate hcl) NC methylphenidate hcl er (cd) oral capsule extended release 10 NP QL (2 capsules per 1 day) mg, 20 mg, 30 mg methylphenidate hcl er (cd) oral capsule extended release 40 NP QL (1 cap per 1 day) mg, 50 mg, 60 mg methylphenidate hcl er (la) oral capsule extended release 24 NP QL (2 capsules per 1 day) hour 10 mg, 20 mg methylphenidate hcl er (la) oral capsule extended release 24 NP QL (1 cap per 1 day) hour 30 mg, 40 mg methylphenidate hcl er (la) oral capsule extended release 24 NP QL (1 capsule per 1 Day) hour 60 mg methylphenidate hcl er (xr) oral capsule extended release 24 NP QL (2 capsules per 1 day) hour 10 mg, 15 mg, 20 mg, 30 mg methylphenidate hcl er (xr) oral capsule extended release 24 NP QL (1 capsule per 1 day) hour 40 mg, 50 mg, 60 mg methylphenidate hcl er oral tablet extended release 10 mg, 20 PG QL (3 tabs per 1 day) mg methylphenidate hcl er oral tablet extended release 18 mg, 27 PG QL (2 tablets per 1 day) mg, 36 mg methylphenidate hcl er oral tablet extended release 24 hour NC methylphenidate hcl er oral tablet extended release 54 mg PG QL (1 capsule per 1 day) methylphenidate hcl er oral tablet extended release 72 mg NP QL (1 tablet per 1 Day) methylphenidate hcl oral solution 10 mg/5ml NP QL (30 ML per 1 day) methylphenidate hcl oral solution 5 mg/5ml NP QL (60 ML per 1 day) methylphenidate hcl oral tablet 10 mg, 5 mg PG QL (6 tablets per 1 day) methylphenidate hcl oral tablet 20 mg PG QL (3 tablets per 1 day) methylphenidate hcl oral tablet chewable NP QL (6 tablets per 1 Day) MYDAYIS (amphetamine-dextroamphetamine) NC # dextroamphetamine sulfate (Procentra) NC QELBREE (viloxazine hcl) NC QUILLICHEW ER ORAL TABLET CHEWABLE NP QL (2 tablets per 1 day) EXTENDED RELEASE 20 MG (methylphenidate hcl)

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 80 Drug Name Drug Status Drug Details QUILLICHEW ER ORAL TABLET CHEWABLE EXTENDED RELEASE 30 MG, 40 MG (methylphenidate NC hcl) QUILLIVANT XR ORAL SUSPENSION PA; ST; #; QL (1 bottle per NP RECONSTITUTED (methylphenidate hcl) 1 fill) QUILLIVANT XR ORAL SUSPENSION NP QL (20 ML per 1 day) RECONSTITUTED ER (methylphenidate hcl) RELEXXII (methylphenidate hcl) NP QL (1 tablet per 1 Day) RITALIN LA (methylphenidate hcl) NC RITALIN ORAL TABLET 10 MG, 5 MG (methylphenidate NC hcl) RITALIN ORAL TABLET 20 MG (methylphenidate hcl) NP QL (3 tablets per 1 day) STALEVO 75 (carbidopa-levodopa-entacapone) NC STRATTERA ORAL CAPSULE 10 MG, 100 MG, 18 MG, NC 25 MG, 40 MG, 80 MG (atomoxetine hcl) STRATTERA ORAL CAPSULE 60 MG (atomoxetine hcl) NP QL (1 capsule per 1 day) VYVANSE ORAL CAPSULE 10 MG, 20 MG, 30 MG ST; QL (2 capsules per 1 NP (lisdexamfetamine dimesylate) day) VYVANSE ORAL CAPSULE 40 MG, 50 MG, 60 MG, 70 NP ST; QL (1 capsule per 1 day) MG (lisdexamfetamine dimesylate) VYVANSE ORAL TABLET CHEWABLE 10 MG, 20 MG, NP ST; QL (2 tablets per 1 day) 30 MG (lisdexamfetamine dimesylate) VYVANSE ORAL TABLET CHEWABLE 40 MG, 50 MG, NP ST; QL (1 capsule per 1 day) 60 MG (lisdexamfetamine dimesylate) dextroamphetamine sulfate (Zenzedi Oral Tablet 10 Mg, 5 Mg) NP QL (4 tablets per 1 day) dextroamphetamine sulfate (Zenzedi Oral Tablet 15 Mg, 20 NC Mg, 30 Mg) ZENZEDI ORAL TABLET 2.5 MG, 7.5 MG NC (dextroamphetamine sulfate) HYPNOTICS - DRUGS TO TREAT INSOMNIA AMBIEN (zolpidem tartrate) NC AMBIEN CR (zolpidem tartrate) NC BELSOMRA ORAL TABLET 10 MG () NP PA; QL (1 tablet per 1 day) BELSOMRA ORAL TABLET 15 MG, 20 MG, 5 MG NP PA; QL (1 tablet per 1 Day) (suvorexant) BUTISOL SODIUM ORAL TABLET 30 MG (butabarbital NP sodium) cvs ultra sleep PG

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 81 Drug Name Drug Status Drug Details DAYVIGO () NC DORAL (quazepam) NC doxepin hcl oral tablet NP QL (1 tablet per 1 day) EDLUAR (zolpidem tartrate) NC eql sleep aid oral tablet PG estazolam NP eszopiclone PG QL (15 tablets per 1 month) flurazepam hcl PG HALCION (triazolam) NC PA; SP Pharmacy; QL (1 HETLIOZ (tasimelteon) NPSP capsule per 1 day) HETLIOZ LQ (tasimelteon) NC hm sleep aid PG INTERMEZZO (zolpidem tartrate) NC kls sleep aid PG LUNESTA (eszopiclone) NC midazolam hcl oral NP MIDAZOLAM+SYRSPEND SF PH4 (midazolam) NC quazepam NP ra sleep aid oral tablet PG ramelteon PG QL (15 tablets per 1 month) RESTORIL (temazepam) NC ROZEREM (ramelteon) NC SILENOR (doxepin hcl) NP ST; QL (1 tablet per 1 day) sleep-aid oral tablet PG sm sleep aid PG SONATA (zaleplon) NC QL (15 capsules per 1 temazepam oral capsule 15 mg, 30 mg PG month) temazepam oral capsule 22.5 mg, 7.5 mg PG QL (1 cap per 1 day) triazolam PG QL (10 tablets per 30 days) wal-som oral tablet PG zaleplon PG QL (1 capsule per 1 day) PA; QL (15 tablets per 1 zolpidem tartrate er NP month)

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 82 Drug Name Drug Status Drug Details zolpidem tartrate oral PG QL (2 tabs per 1 day) zolpidem tartrate sublingual NC ZOLPIMIST (zolpidem tartrate) NC # MIGRAINE - DRUGS TO TREAT SEVERE HEADACHES AIMOVIG (-aooe) PB ST AIMOVIG (140 MG DOSE) (erenumab-aooe) PB AJOVY SUBCUTANEOUS SOLUTION AUTO- PB ST; QL (1 pen per 1 month) INJECTOR (-vfrm) AJOVY SUBCUTANEOUS SOLUTION PREFILLED ST; QL (1 injection per 1 PB SYRINGE (fremanezumab-vfrm) month) almotriptan malate NP QL (12 tablets per 30 days) AMERGE (naratriptan hcl) NC AXERT (almotriptan malate) NC D.H.E. 45 (dihydroergotamine mesylate) NC dihydroergotamine mesylate injection NP dihydroergotamine mesylate nasal NP ST; QL (8 vials per 1 fill) eletriptan hydrobromide NP QL (12 tablets per 30 days) ST; QL (2 injections per 1 EMGALITY (-gnlm) PB month) EMGALITY (300 MG DOSE) (galcanezumab-gnlm) PB ST ERGOMAR (ergotamine tartrate) NP ergotamine-caffeine NP FROVA (frovatriptan succinate) NC frovatriptan succinate NP QL (18 tablets per 30 days) IMITREX (sumatriptan succinate) NC IMITREX STATDOSE REFILL SUBCUTANEOUS NC SOLUTION CARTRIDGE (sumatriptan succinate) IMITREX STATDOSE SYSTEM SUBCUTANEOUS NC SOLUTION AUTO-INJECTOR (sumatriptan succinate) MAXALT (rizatriptan benzoate) NC MAXALT-MLT (rizatriptan benzoate) NC MIGERGOT (ergotamine-caffeine) NC MIGRANAL (dihydroergotamine mesylate) NC naratriptan hcl PG QL (9 tablets per 30 days) ST; QL (16 tablets per 30 NURTEC ( sulfate) PB days)

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 83 Drug Name Drug Status Drug Details ONZETRA XSAIL (sumatriptan succinate) NC RELPAX (eletriptan hydrobromide) NC REYVOW (lasmiditan succinate) NC rizatriptan benzoate oral tablet PG QL (12 tablets per 30 days) rizatriptan benzoate oral tablet dispersible PG QL (9 tablets per 30 days) sumatriptan nasal NP QL (6 sprays per 30 days) sumatriptan succinate oral PG QL (9 tablets per 30 days) QL (10 carts/30 days per 48 sumatriptan succinate refill subcutaneous solution cartridge NP max in 365 days) QL (10 vials/30 days per 48 sumatriptan succinate subcutaneous solution 6 mg/0.5ml NP max in 365 days) sumatriptan succinate subcutaneous solution auto-injector 4 QL (10 carts/30 days per 48 NP mg/0.5ml, 6 mg/0.5ml max in 365 days) sumatriptan-naproxen sodium NP ST SUMAVEL DOSEPRO SUBCUTANEOUS SOLUTION NC JET-INJECTOR (sumatriptan succinate) TOSYMRA (sumatriptan) NC TREXIMET ORAL TABLET 10-60 MG (sumatriptan- NC # naproxen sodium) TREXIMET ORAL TABLET 85-500 MG (sumatriptan- NC naproxen sodium) UBRELVY () NC ZEMBRACE SYMTOUCH (sumatriptan succinate) NC QL (12 SPRAYS per 1 zolmitriptan nasal PG month) zolmitriptan oral PG QL (12 tablets per 30 days) ZOMIG (zolmitriptan) NC ZOMIG ZMT (zolmitriptan) NC MISCELLANEOUS AUSTEDO (deutetrabenazine) NC PA; ST; QL (2 tablets per 1 BELVIQ (lorcaserin hcl) NP day) buspirone hcl oral tablet 10 mg, 5 mg PG LGC buspirone hcl oral tablet 15 mg, 30 mg, 7.5 mg PG caffeine citrate oral NC clomipramine hcl oral capsule 25 mg, 50 mg NP QL (5 capsules per 1 day)

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 84 Drug Name Drug Status Drug Details clomipramine hcl oral capsule 75 mg NP QL (3 capsules per 1 day) PA; SP Pharmacy; QL (200 EVRYSDI (risdiplam) NPSP ML per 1 month) EXSERVAN (riluzole) NC PA; SP Pharmacy; QL (8 FIRDAPSE (amifampridine phosphate) NPSP tablets per 1 day) fluvoxamine maleate PG fluvoxamine maleate er PG guanidine hcl oral NP IMCIVREE (setmelanotide acetate) NC INGREZZA ORAL CAPSULE 40 MG, 60 MG, 80 MG PA; SP Pharmacy; QL (1 NPSP (valbenazine tosylate) capsule per 1 day) INGREZZA ORAL CAPSULE THERAPY PACK NC (valbenazine tosylate) lithium NP lithium carbonate er PG lithium carbonate oral PG MESTINON ORAL SYRUP (pyridostigmine bromide) NP MESTINON ORAL TABLET (pyridostigmine bromide) NC MESTINON ORAL TABLET EXTENDED RELEASE NC (pyridostigmine bromide) NUEDEXTA (dextromethorphan-quinidine) NP PA ORAP (pimozide) NC phendimetrazine tartrate PG QL (6 tablets per 1 day) phendimetrazine tartrate er NC phentermine hcl oral capsule 15 mg PG QL (2 tablets per 1 day) phentermine hcl oral capsule 30 mg, 37.5 mg PG QL (1 tablet per 1 day) pimozide NP pyridostigmine bromide er PG pyridostigmine bromide oral solution PG pyridostigmine bromide oral tablet PG RILUTEK (riluzole) NC riluzole PG RUZURGI (amifampridine) NC SAVELLA (milnacipran hcl) NP ST SAVELLA TITRATION PACK (milnacipran hcl) NP ST 2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 85 Drug Name Drug Status Drug Details tetrabenazine oral tablet 12.5 mg PSP PA; QL (8 tablets per 1 day) tetrabenazine oral tablet 25 mg PSP PA; QL (4 tablets per 1 day) TIGLUTIK (riluzole) NC XENAZINE (tetrabenazine) NC MULTIPLE SCLEROSIS AGENTS - DRUGS TO TREAT MULTIPLE SCLEROSIS AMPYRA (dalfampridine) NC PA; SP Pharmacy; QL (1 AUBAGIO (teriflunomide) PSP tab per 1 day) PA; ST; SP Pharmacy; QL AVONEX (interferon beta-1a) NPSP (1 kit per 30 days) AVONEX PEN INTRAMUSCULAR AUTO-INJECTOR PA; ST; SP Pharmacy; QL NPSP KIT (interferon beta-1a) (4 pens per 28 days) AVONEX PREFILLED INTRAMUSCULAR PREFILLED PA; ST; SP Pharmacy; QL NPSP SYRINGE KIT (interferon beta-1a) (4 syringes per 28 days) BAFIERTAM (monomethyl fumarate) NC PA; SP Pharmacy; QL (1 kit BETASERON SUBCUTANEOUS KIT (interferon beta-1b) PSP per 1 month) COPAXONE SUBCUTANEOUS SOLUTION PA; SP Pharmacy; QL (1 PSP PREFILLED SYRINGE 20 MG/ML (glatiramer acetate) syringe per 1 day) COPAXONE SUBCUTANEOUS SOLUTION PA; SP Pharmacy; QL (12 PSP PREFILLED SYRINGE 40 MG/ML (glatiramer acetate) syringes per 28 days) PA; SP Pharmacy; QL (2 dalfampridine er NPSP tablets per 1 day) PA; SP Pharmacy; QL (2 dimethyl fumarate oral PSP capsules per 1 day) PA; ST; SP Pharmacy; QL EXTAVIA SUBCUTANEOUS KIT (interferon beta-1b) NPSP (1 kit per 1 month) PA; #; SP Pharmacy; QL (1 GILENYA (fingolimod hcl) PSP capsule per 1 day) glatiramer acetate subcutaneous solution prefilled syringe 20 PA; SP Pharmacy; QL (1 PG mg/ml syringe per 1 day) glatiramer acetate subcutaneous solution prefilled syringe 40 PA; SP Pharmacy; QL (12 PB mg/ml syringes per 28 days) glatiramer acetate (Glatopa Subcutaneous Solution Prefilled PA; SP Pharmacy; QL (1 PB Syringe 20 Mg/Ml) syringe per 1 day) glatiramer acetate (Glatopa Subcutaneous Solution Prefilled PA; SP Pharmacy; QL (12 PG Syringe 40 Mg/Ml) syringes per 28 days)

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 86 Drug Name Drug Status Drug Details MAVENCLAD (10 TABS) (cladribine) NC MAVENCLAD (4 TABS) (cladribine) NC MAVENCLAD (5 TABS) (cladribine) NC MAVENCLAD (6 TABS) (cladribine) NC MAVENCLAD (7 TABS) (cladribine) NC MAVENCLAD (8 TABS) (cladribine) NC MAVENCLAD (9 TABS) (cladribine) NC MAYZENT (siponimod fumarate) NC MAYZENT STARTER PACK (siponimod fumarate) NC PA; ST; SP Pharmacy; QL PLEGRIDY INTRAMUSCULAR (peginterferon beta-1a) NPSP (2 SYRINGES per 1 month) PLEGRIDY STARTER PACK SUBCUTANEOUS PA; ST; SP Pharmacy; QL NPSP SOLUTION PEN-INJECTOR (peginterferon beta-1a) (1 kit per 365 days) PLEGRIDY STARTER PACK SUBCUTANEOUS PA; ST; SP Pharmacy; QL NPSP SOLUTION PREFILLED SYRINGE (peginterferon beta-1a) (2 syringes per 28 days) PA; ST; SP Pharmacy; QL PLEGRIDY SUBCUTANEOUS (peginterferon beta-1a) NPSP (2 syringes per 28 days) PONVORY (ponesimod) NC PONVORY STARTER PACK (ponesimod) NC REBIF REBIDOSE SUBCUTANEOUS SOLUTION PA; SP Pharmacy; QL (12 PSP AUTO-INJECTOR (interferon beta-1a) syringes per 28 days) REBIF REBIDOSE TITRATION PACK PA; SP Pharmacy; QL (1 SUBCUTANEOUS SOLUTION AUTO-INJECTOR PSP titration pack per 1 month) (interferon beta-1a) REBIF SUBCUTANEOUS SOLUTION PREFILLED PA; SP Pharmacy; QL (12 PSP SYRINGE (interferon beta-1a) syringes per 28 days) REBIF TITRATION PACK SUBCUTANEOUS PA; SP Pharmacy; QL (1 PSP SOLUTION PREFILLED SYRINGE (interferon beta-1a) titration pack per 1 month) TECFIDERA (dimethyl fumarate) NC PA; SP Pharmacy; QL (4 VUMERITY (diroximel fumarate) NPSP capsules per 1 day) PA; SP Pharmacy; QL (1 VUMERITY (STARTER) (diroximel fumarate) NPSP pack per 1 month) ZEPOSIA (ozanimod hcl) NC ZEPOSIA 7-DAY STARTER PACK (ozanimod hcl) NC ZEPOSIA STARTER KIT (ozanimod hcl) NC

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 87 Drug Name Drug Status Drug Details MUSCULOSKELETAL THERAPY AGENTS - DRUGS TO TREAT MUSCLE SPASMS AMRIX (cyclobenzaprine hcl) NC baclofen oral tablet 10 mg PG LGC baclofen oral tablet 20 mg, 5 mg PG carisoprodol oral tablet 250 mg NC carisoprodol oral tablet 350 mg PG PA; AL (Max 70 Years) carisoprodol-aspirin NP carisoprodol-aspirin-codeine NP PA chlorzoxazone oral tablet 250 mg, 500 mg NC chlorzoxazone oral tablet 375 mg, 750 mg NP cyclobenzaprine hcl er NP cyclobenzaprine hcl oral tablet 10 mg NC LGC PA; LGC; AL (Max 70 cyclobenzaprine hcl oral tablet 5 mg PG Years) cyclobenzaprine hcl oral tablet 7.5 mg NP DANTRIUM ORAL CAPSULE 25 MG, 50 MG (dantrolene NC sodium) dantrolene sodium oral PG FEXMID (cyclobenzaprine hcl) NC chlorzoxazone (Lorzone) NC metaxalone (Metaxall) NP metaxalone oral tablet 400 mg PG PA; AL (Max 70 Years) metaxalone oral tablet 800 mg NP PA; AL (Max 70 Years) methocarbamol oral NC norgesic forte NC orphenadrine citrate er PG PA; AL (Max 70 Years) orphenadrine-asa-caffeine NC orphenadrine-aspirin-caffeine (Orphengesic Forte Oral Tablet NC 50-770-60 Mg) OZOBAX (baclofen) NC PARAFON FORTE DSC (chlorzoxazone) NC ROBAXIN ORAL (methocarbamol) NC ROBAXIN-750 (methocarbamol) NC SKELAXIN (metaxalone) NC SOMA (carisoprodol) NC 2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 88 Drug Name Drug Status Drug Details tizanidine hcl oral capsule NC tizanidine hcl oral tablet PG carisoprodol (Vanadom) NC ZANAFLEX (tizanidine hcl) NC NARCOLEPSY/CATAPLEXY - DRUGS FOR SLEEP DISORDERS armodafinil oral tablet 150 mg, 200 mg, 250 mg PG PA; QL (1 tablet per 1 day) armodafinil oral tablet 50 mg PG PA; QL (2 tablets per 1 day) modafinil NP PA; QL (2 tablets per 1 day) NUVIGIL (armodafinil) NC PROVIGIL (modafinil) NC SUNOSI (solriamfetol hcl) NC WAKIX (pitolisant hcl) NC PA; SP Pharmacy; QL (540 XYREM (sodium oxybate) NPSP ml per 1 month) XYWAV (ca, mg, k, and na oxybates) NC POLYNEUROPATHY PA; SP Pharmacy; QL (4 TEGSEDI (inotersen sodium) NPSP injections per 1 month) POSTHERPETIC NEURALGIA (PHN) GRALISE ORAL TABLET 300 MG (gabapentin (once- NP ST; QL (1 tab per 1 day) daily)) GRALISE ORAL TABLET 600 MG (gabapentin (once- NP ST; QL (3 tabs per 1 day) daily)) GRALISE STARTER (gabapentin (once-daily)) NP ST; QL (1 pack per 1 fill) HORIZANT ORAL TABLET EXTENDED RELEASE 300 NP ST; QL (1 tablet per 1 day) MG (gabapentin enacarbil) HORIZANT ORAL TABLET EXTENDED RELEASE 600 NP ST; QL (1 tablet per 2 days) MG (gabapentin enacarbil) LYRICA CR ORAL TABLET EXTENDED RELEASE 24 PA; ST; QL (3 tablets per 1 NP HOUR 165 MG, 82.5 MG (pregabalin) Day) LYRICA CR ORAL TABLET EXTENDED RELEASE 24 PA; ST; QL (2 tablets per 1 NP HOUR 330 MG (pregabalin) Day) PSYCHOTHERAPEUTIC-MISC acamprosate calcium NP PA ADDYI (flibanserin) NP PA; QL (1 tablet per 1 day) ANTABUSE (disulfiram) NC 2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 89 Drug Name Drug Status Drug Details N2 (PG); QL (180 day bupropion hcl er (smoking det) CE supply per 365 days) #; N2 (NP); QL (180 day CHANTIX (varenicline tartrate) CE supply per 365 days) CHANTIX CONTINUING MONTH PAK (varenicline #; N2 (NP); QL (180 day CE tartrate) supply per 365 days) #; N2 (NP); QL (180 day CHANTIX STARTING MONTH PAK (varenicline tartrate) CE supply per 365 days) chlordiazepoxide-amitriptyline NP disulfiram oral PG EVZIO INJECTION SOLUTION AUTO-INJECTOR 0.4 NP ST MG/0.4ML (naloxone hcl) EVZIO INJECTION SOLUTION AUTO-INJECTOR 2 NP ST; # MG/0.4ML (naloxone hcl) N2 (Not Covered); QL (180 goodsense nicotine mouth/throat gum 4 mg CE day supply per 365 days) KLOXXADO (naloxone hcl) NC QL (192 tablets per 3 LUCEMYRA (lofexidine hcl) NP courses in 1 years) naloxone hcl injection solution 0.4 mg/ml, 4 mg/10ml PG naloxone hcl injection solution auto-injector NC naloxone hcl injection solution cartridge PG naloxone hcl injection solution prefilled syringe PG naltrexone hcl oral PG #; QL (4 sprays per 180 NARCAN (naloxone hcl) PB days) N2 (Not Covered); QL (180 nicotine polacrilex mouth/throat CE day supply per 365 days) N2 (Not Covered); QL (180 nicotine transdermal kit NP day supply per 365 days) N2 (Not Covered); QL (180 nicotine transdermal patch 24 hour CE day supply per 365 days) N2 (NP); QL (180 day NICOTROL (nicotine) CE supply per 365 days) N2 (NP); QL (180 day NICOTROL NS (nicotine) CE supply per 365 days) olanzapine-fluoxetine hcl oral capsule 12-25 mg, 12-50 mg, 6-25 NP QL (1 capsule per 1 day) mg, 6-50 mg

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 90 Drug Name Drug Status Drug Details olanzapine-fluoxetine hcl oral capsule 3-25 mg NP perphenazine-amitriptyline NP SYMBYAX (olanzapine-fluoxetine hcl) NC THRIVE MOUTH/THROAT GUM 2 MG (nicotine N2 (Not Covered); QL (180 CE polacrilex) day supply per 365 days) VIVITROL (naltrexone) PSP PA; QL (1 vial per 1 month) VYLEESI (bremelanotide acetate) NC ENDOCRINE AND METABOLIC - DRUGS TO TREAT DIABETES AND REGULATE HORMONES ANDROGENS - DRUGS TO REGULATE MALE HORMONES ANADROL-50 () NP PA ANDRODERM TRANSDERMAL PATCH 24 HOUR NC () ANDROGEL (testosterone) NC ANDROGEL PUMP TRANSDERMAL GEL 20.25 NC MG/ACT (1.62%) (testosterone) DEPO-TESTOSTERONE INTRAMUSCULAR NC SOLUTION () FORTESTA (testosterone) NC INTRAROSA () NP JATENZO () NC METHITEST NP oral PG PA NATESTO (testosterone) NC OXANDRIN ORAL TABLET 10 MG (oxandrolone) NC oxandrolone oral NP PA TESTIM (testosterone) NC testosterone cypionate intramuscular solution 100 mg/ml, 200 PG PA mg/ml intramuscular solution PG PA testosterone transdermal gel 10 mg/act (2%), 25 mg/2.5gm PG PA (1%) testosterone transdermal gel 12.5 mg/act (1%), 50 mg/5gm PA; QL (10 grams per 1 PG (1%) day) testosterone transdermal gel 20.25 mg/1.25gm (1.62%), 20.25 PG QL (5 grams per 1 day) mg/act (1.62%), 40.5 mg/2.5gm (1.62%)

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 91 Drug Name Drug Status Drug Details PA; QL (6 milliliters per 1 testosterone transdermal solution PG Day) VOGELXO PUMP (testosterone) NC VOGELXO TRANSDERMAL GEL 50 MG/5GM (1%) NC (testosterone) XYOSTED (testosterone enanthate) NC ANTIDIABETICS, ALPHA-GLUCOSIDASE INHIBITORS oral PG GLYSET () NC miglitol PG PRECOSE (acarbose) NC ANTIDIABETICS, ANALOGS SYMLINPEN 120 SUBCUTANEOUS SOLUTION PEN- NP ST; # INJECTOR ( acetate) SYMLINPEN 60 SUBCUTANEOUS SOLUTION PEN- NP ST; # INJECTOR (pramlintide acetate) ANTIDIABETICS, FORTAMET ( hcl) NC GLUCOPHAGE (metformin hcl) NC GLUCOPHAGE XR (metformin hcl) NC GLUMETZA (metformin hcl) NC metformin hcl er (mod) NC metformin hcl er (osm) oral tablet extended release 24 hour NP ST; QL (2 tablets per 1 day) 1000 mg metformin hcl er (osm) oral tablet extended release 24 hour 500 NP ST; QL (3 tablets per 1 day) mg metformin hcl er oral tablet extended release 24 hour 500 mg PG LGC metformin hcl er oral tablet extended release 24 hour 750 mg PG metformin hcl oral solution NC metformin hcl oral tablet PG LGC RIOMET (metformin hcl) NC RIOMET ER (metformin hcl) NC ANTIDIABETICS, BIGUANIDE/ COMBINATIONS -metformin hcl NP QL (2 tablets per 1 day)

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 92 Drug Name Drug Status Drug Details ANTIDIABETICS, BIGUANIDE/ COMBINATIONS -metformin hcl PG GLUCOVANCE ORAL TABLET 2.5-500 MG, 5-500 MG NC (glyburide-metformin) glyburide-metformin PG ANTIDIABETICS, DIPEPTIDYL PEPTIDASE-4 INHIBITORS benzoate NP ST JANUVIA ( phosphate) PB ST NESINA (alogliptin benzoate) NC ONGLYZA ( hcl) NP ST; QL (1 tab per 1 day) TRADJENTA () NP ST; QL (1 tab per 1 day) ANTIDIABETICS, DOPAMINE RECEPTOR AGONISTS CYCLOSET (bromocriptine mesylate) NP ANTIDIABETICS, DPP-4 INHIBITOR COMBINATIONS alogliptin-metformin hcl NP ST; QL (2 tablets per 1 day) alogliptin- NP QL (1 tablet per 1 day) JANUMET (sitagliptin-metformin hcl) PB ST JANUMET XR (sitagliptin-metformin hcl) PB ST JENTADUETO (linagliptin-metformin hcl) NP ST; QL (2 tabs per 1 day) JENTADUETO XR (linagliptin-metformin hcl) NP ST KAZANO (alogliptin-metformin hcl) NC KOMBIGLYZE XR ORAL TABLET EXTENDED NP ST; QL (2 tabs per 1 day) RELEASE 24 HOUR 2.5-1000 MG (saxagliptin-metformin) KOMBIGLYZE XR ORAL TABLET EXTENDED RELEASE 24 HOUR 5-1000 MG, 5-500 MG (saxagliptin- NP ST; QL (1 tab per 1 day) metformin) OSENI (alogliptin-pioglitazone) NC TRIJARDY XR (-linaglip-metform) NC ANTIDIABETICS, INCRETIN MIMETIC AGENTS ADLYXIN () NC ADLYXIN STARTER PACK (lixisenatide) NC PA; ST; QL (4 pens per 1 BYDUREON BCISE () NP month)

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 93 Drug Name Drug Status Drug Details BYDUREON SUBCUTANEOUS PEN-INJECTOR PA; ST; QL (4 pens per 1 NP (exenatide) month) BYDUREON SUBCUTANEOUS SUSPENSION PA; ST; QL (4 pens per 1 NP RECONSTITUTED ER (exenatide) month) BYETTA 10 MCG PEN SUBCUTANEOUS SOLUTION PA; ST; #; QL (1 pen per 1 NP PEN-INJECTOR (exenatide) fill) BYETTA 5 MCG PEN SUBCUTANEOUS SOLUTION PA; ST; #; QL (1 pen per 1 NP PEN-INJECTOR (exenatide) fill) OZEMPIC (0.25 OR 0.5 MG/DOSE) () PB ST OZEMPIC (1 MG/DOSE) (semaglutide) PB ST RYBELSUS (semaglutide) NC TRULICITY () PB ST VICTOZA SUBCUTANEOUS SOLUTION PEN- NP ST INJECTOR () ANTIDIABETICS, INCRETIN MIMETIC COMBINATION AGENTS SOLIQUA ( glargine-lixisenatide) PB ST XULTOPHY (-liraglutide) NP ST ANTIDIABETICS, INSULIN ADMELOG () NC ADMELOG SOLOSTAR (insulin lispro) NC AFREZZA INHALATION POWDER 12 UNIT, 4 & 8 & 12 UNIT, 4 UNIT, 8 UNIT, 90 X 4 UNIT & 90X8 UNIT, 90 X 8 NP ST UNIT & 90X12 UNIT (insulin regular human) AFREZZA INHALATION POWDER 30 X 4 UNIT & 60X8 UNIT, 60 X 4 UNIT & 30X8 UNIT, 60 X 8 UNIT & 30X12 NC UNIT (insulin regular human) APIDRA () NP ST APIDRA SOLOSTAR SUBCUTANEOUS SOLUTION NP ST PEN-INJECTOR (insulin glulisine) BASAGLAR KWIKPEN () PB FIASP ( (w/niacinamide)) PB FIASP FLEXTOUCH (insulin aspart (w/niacinamide)) PB FIASP PENFILL (insulin aspart (w/niacinamide)) PB HUMALOG (insulin lispro) NP ST HUMALOG JUNIOR KWIKPEN (insulin lispro) NP ST

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 94 Drug Name Drug Status Drug Details HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML, 200 UNIT/ML (insulin NP ST lispro) HUMALOG MIX 50/50 (insulin lispro prot & lispro) NP ST HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS NP ST SUSPENSION PEN-INJECTOR (insulin lispro prot & lispro) HUMALOG MIX 75/25 (insulin lispro prot & lispro) NP ST HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS NP ST SUSPENSION PEN-INJECTOR (insulin lispro prot & lispro) HUMULIN 70/30 (insulin nph isophane & regular) NP HUMULIN 70/30 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (insulin nph isophane & NP regular) HUMULIN N (insulin nph human (isophane)) NP HUMULIN N KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (insulin nph human NP (isophane)) HUMULIN R (insulin regular human) NP HUMULIN R U-500 (CONCENTRATED) (insulin regular PB human) HUMULIN R U-500 KWIKPEN SUBCUTANEOUS PB SOLUTION PEN-INJECTOR (insulin regular human) insulin asp prot & asp flexpen NC insulin aspart NC insulin aspart flexpen NC insulin aspart penfill NC insulin aspart prot & aspart NC insulin lispro (1 unit dial) NP insulin lispro junior kwikpen NC insulin lispro prot & lispro NC insulin lispro subcutaneous solution NP ST LANTUS (insulin glargine) NC LANTUS SOLOSTAR SUBCUTANEOUS SOLUTION NC PEN-INJECTOR (insulin glargine) LEVEMIR () PB LEVEMIR FLEXTOUCH (insulin detemir) PB LYUMJEV (insulin lispro-aabc) NC

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 95 Drug Name Drug Status Drug Details LYUMJEV KWIKPEN (insulin lispro-aabc) NC NOVOLIN 70/30 (insulin nph isophane & regular) PB NOVOLIN 70/30 FLEXPEN RELION (insulin nph isophane PB & regular) NOVOLIN 70/30 RELION (insulin nph isophane & regular) PB NOVOLIN N (insulin nph human (isophane)) PB NOVOLIN N FLEXPEN (insulin nph human (isophane)) PB NOVOLIN N FLEXPEN RELION (insulin nph human NC (isophane)) NOVOLIN N RELION (insulin nph human (isophane)) PB NOVOLIN R (insulin regular human) PB NOVOLIN R FLEXPEN (insulin regular human) PB NOVOLIN R FLEXPEN RELION (insulin regular human) NC NOVOLIN R RELION (insulin regular human) PB NOVOLOG (insulin aspart) PB NOVOLOG 70/30 FLEXPEN RELION (insulin aspart prot & NC aspart) NOVOLOG FLEXPEN RELION (insulin aspart) NC NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION PB PEN-INJECTOR (insulin aspart) NOVOLOG MIX 70/30 (insulin aspart prot & aspart) PB NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (insulin aspart prot & PB aspart) NOVOLOG MIX 70/30 RELION (insulin aspart prot & NC aspart) NOVOLOG PENFILL SUBCUTANEOUS SOLUTION PB CARTRIDGE (insulin aspart) NOVOLOG RELION (insulin aspart) NC SEMGLEE (insulin glargine) NC PA; ST; QL (4 pens per 1 TANZEUM () NP month) TOUJEO MAX SOLOSTAR (insulin glargine) NC TOUJEO SOLOSTAR (insulin glargine) NC TRESIBA (insulin degludec) NP TRESIBA FLEXTOUCH (insulin degludec) NP

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 96 Drug Name Drug Status Drug Details ANTIDIABETICS, INSULIN SENSITIZER ACTOS (pioglitazone hcl) NC AVANDIA ORAL TABLET 2 MG, 4 MG ( NP QL (1 tab per 1 day) maleate) pioglitazone hcl PG ANTIDIABETICS, INSULIN SENSITIZER/BIGUANIDE COMBINATION ACTOPLUS MET (pioglitazone hcl-metformin hcl) NC ACTOPLUS MET XR (pioglitazone hcl-metformin hcl) NP ST; QL (1 tablet per 1 day) pioglitazone hcl-metformin hcl PG ANTIDIABETICS, INSULIN SENSITIZER/SULFONYLUREA COMBINATION pioglitazone hcl- PG ANTIDIABETICS, MEGLITINIDE PG PRANDIN ORAL TABLET 1 MG, 2 MG (repaglinide) NC repaglinide NP STARLIX (nateglinide) NC ANTIDIABETICS, SODIUM-GLUC CO-TRANSPOR2 (SGLT2) INHIB QTERN ORAL TABLET 10-5 MG (-saxagliptin) NC QTERN ORAL TABLET 5-5 MG (dapagliflozin-saxagliptin) PB ST; QL (1 tablet per 1 day) STEGLUJAN (-sitagliptin) NC ANTIDIABETICS, SODIUM-GLUC CO-TRANSPOR2 INHIB SYNJARDY (empagliflozin-metformin hcl) NP ST SYNJARDY XR (empagliflozin-metformin hcl) NP ST XIGDUO XR (dapagliflozin-metformin hcl) PB ST ANTIDIABETICS, SODIUM-GLUC CO-TRANSPOR2 INHIB (SGTL2) COMBO INVOKAMET (-metformin hcl) NP QL (2 tablets per 1 day) INVOKAMET XR (canagliflozin-metformin hcl) NP QL (2 tablets per 1 day) SEGLUROMET (ertugliflozin-metformin hcl) NC ANTIDIABETICS, SODIUM-GLUC CO-TRANSPOR2 INHIB(SGLT2)/DPP-4 INHIBITOR COMBINATIONS GLYXAMBI (empagliflozin-linagliptin) NP ST

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 97 Drug Name Drug Status Drug Details ANTIDIABETICS, SODIUM-GLUCOSE COTRANSPORTER2 (SGLT2) INHIB FARXIGA (dapagliflozin propanediol) PB ST INVOKANA (canagliflozin) NP QL (1 tab per 1 day) JARDIANCE (empagliflozin) NP ST STEGLATRO (ertugliflozin l-pyroglutamicac) NC ANTIDIABETICS, SULFONYLUREA AMARYL (glimepiride) NC oral tablet 100 mg PG LGC chlorpropamide oral tablet 250 mg PG glimepiride PG LGC glipizide er PG glipizide oral PG LGC glipizide xl PG GLUCOTROL (glipizide) NC GLUCOTROL XL (glipizide) NC glyburide micronized oral tablet 1.5 mg PG glyburide micronized oral tablet 3 mg, 6 mg PG LGC glyburide oral tablet 1.25 mg PG glyburide oral tablet 2.5 mg, 5 mg PG LGC GLYNASE (glyburide micronized) NC PG PG ANTIDIABETICS, SULFONYLUREA/ COMBINATIONS DUETACT (pioglitazone hcl-glimepiride) NC BISPHOSPHONATES - DRUGS TO TREAT BONE LOSS ACTONEL ORAL TABLET 150 MG, 30 MG, 35 MG, 5 NC MG (risedronate sodium) alendronate sodium oral solution PG alendronate sodium oral tablet 10 mg, 35 mg, 5 mg, 70 mg PG alendronate sodium oral tablet 40 mg PG QL (1 tab per 1 day) ATELVIA (risedronate sodium) NC BINOSTO (alendronate sodium) NC BONIVA ORAL TABLET 150 MG (ibandronate sodium) NC

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 98 Drug Name Drug Status Drug Details etidronate disodium NP FOSAMAX ORAL TABLET 70 MG (alendronate sodium) NC FOSAMAX PLUS D (alendronate-) NP ST ibandronate sodium oral NP risedronate sodium oral tablet 150 mg, 30 mg, 35 mg, 5 mg NP risedronate sodium oral tablet delayed release NP CALCIUM RECEPTOR AGONISTS calcitriol oral PG cinacalcet hcl oral tablet 30 mg, 60 mg PSP PA; QL (2 tablets per 1 day) cinacalcet hcl oral tablet 90 mg PSP PA; QL (4 tablets per 1 day) doxercalciferol oral PG SP Pharmacy paricalcitol oral PG SP Pharmacy PA; ST; QL (1 cap per 1 RAYALDEE (calcifediol) NP day) ROCALTROL (calcitriol) NC PA; SP Pharmacy; QL (2 SENSIPAR (cinacalcet hcl) NP tablets per 1 day) STRENSIQ (asfotase alfa) NC ZEMPLAR ORAL CAPSULE 1 MCG, 2 MCG (paricalcitol) NC CARNITINE DEFICIENCY AGENTS CARNITOR ORAL (levocarnitine) NC CARNITOR SF (levocarnitine) NC levocarnitine oral solution PG levocarnitine oral tablet PG CHELATING AGENTS CHEMET (succimer) NP CUPRIMINE ORAL CAPSULE 250 MG (penicillamine) NC deferasirox granules NC deferasirox oral tablet NC deferasirox oral tablet soluble PSP PA; SP Pharmacy deferiprone PSP PA; SP Pharmacy DEPEN TITRATABS (penicillamine) NPSP PA d-penamine NPSP PA; SP Pharmacy EXJADE (deferasirox) NPSP PA; SP Pharmacy FERRIPROX ORAL SOLUTION (deferiprone) NC

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 99 Drug Name Drug Status Drug Details FERRIPROX ORAL TABLET 1000 MG (deferiprone) PSP PA; #; SP Pharmacy FERRIPROX ORAL TABLET 500 MG (deferiprone) NC FERRIPROX TWICE-A-DAY (deferiprone) PSP PA; #; SP Pharmacy JADENU (deferasirox) NC JADENU SPRINKLE (deferasirox) NC kionex PG LOKELMA (sodium zirconium cyclosilicate) NC penicillamine oral capsule PSP PA; SP Pharmacy penicillamine oral tablet PG PA sodium polystyrene sulfonate oral PG sodium polystyrene sulfonate rectal PG SPS (sodium polystyrene sulfonate) PG SYPRINE (trientine hcl) NC trientine hcl PSP PA; SP Pharmacy PA; ST; QL (1 packet per 1 VELTASSA (patiromer sorbitex calcium) NP day) CONTRACEPTIVES - PRODUCTS FOR BIRTH CONTROL levonorgestrel-ethinyl estrad (Afirmelle) CE N2 (PG) AFTERA (levonorgestrel) CE N2 (Not Covered) altavera CE N2 (PG) alyacen 1/35 CE N2 (PG) alyacen 7/7/7 CE N2 (PG) amethia CE N2 (PG) amethia lo CE N2 (PG) N2 (NPB); QL (1 ring per ANNOVERA (segesterone-ethinyl ) CE 365 days) apri CE N2 (PG) aranelle CE N2 (PG) levonorgest-eth estrad 91-day (Ashlyna) CE N2 (PG) levonorgestrel-ethinyl estrad (Aubra) CE N2 (PG) levonorgestrel-ethinyl estrad (Aubra Eq) CE N2 (PG) norethindrone acet-ethinyl est (Aurovela 1.5/30) CE N2 (PG) norethindrone acet-ethinyl est (Aurovela 1/20) CE N2 (PG) norethin ace-eth estrad-fe (Aurovela 24 Fe) CE N2 (PG)

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 100 Drug Name Drug Status Drug Details norethin ace-eth estrad-fe (Aurovela Fe 1/20) CE N2 (PG) aviane CE N2 (PG) levonorgestrel-ethinyl estrad (Ayuna) CE N2 (PG) azurette CE N2 (PG) BALCOLTRA (levonorgest-eth estrad-fe bisg) CE #; N2 (NP) balziva CE N2 (PG) desogestrel-ethinyl estradiol (Bekyree) CE N2 (PG) BEYAZ (drospiren-eth estrad-levomefol) NP norethin ace-eth estrad-fe (Blisovi 24 Fe) CE N2 (PG) norethin ace-eth estrad-fe (Blisovi Fe 1.5/30) CE N2 (PG) norethin ace-eth estrad-fe (Blisovi Fe 1/20) CE N2 (PG) briellyn CE N2 (PG) camila CE N2 (PG) camrese CE N2 (PG) camrese lo CE N2 (PG) caziant CE N2 (PG) cesia CE N2 (PG) chateal CE N2 (PG) levonorgestrel-ethinyl estrad (Chateal Eq) CE N2 (PG) cryselle-28 CE N2 (PG) cyclafem 1/35 CE N2 (PG) cyclafem 7/7/7 CE N2 (PG) desogestrel-ethinyl estradiol (Cyred) CE N2 (PG) dasetta 1/35 CE N2 (PG) dasetta 7/7/7 CE N2 (PG) daysee CE N2 (PG) deblitane CE N2 (PG) levonorgestrel-ethinyl estrad (Delyla) CE N2 (PG) DEPO-SUBQ PROVERA 104 SUBCUTANEOUS #; N2 (NP); QL (1 syringe SUSPENSION PREFILLED SYRINGE CE per 90 days) (medroxyprogesterone acetate) desogestrel-ethinyl estradiol CE N2 (PG) drospiren-eth estrad-levomefol oral tablet 3-0.02-0.451 mg CE N2 (PG) drospirenone-ethinyl estradiol CE N2 (PG) ECONTRA EZ (levonorgestrel) CE N2 (Not Covered)

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 101 Drug Name Drug Status Drug Details elinest CE N2 (PG) ELLA (ulipristal acetate) CE #; N2 (NP) etonogestrel-ethinyl estradiol (Eluryng) CE N2 (PG) emoquette CE N2 (PG) enpresse-28 CE N2 (PG) enskyce oral tablet 0.15-30 mg-mcg CE N2 (PG) errin CE N2 (PG) estarylla CE N2 (PG) ethynodiol diac-eth estradiol oral tablet 1-50 mg-mcg CE N2 (PG) FALESSA ORAL KIT 20-1-0.1 MCG-MG (levonorgestrel-eth CE N2 (NP) estrad & fa) falmina CE N2 (PG) levonorgest-eth estrad 91-day (Fayosim) CE N2 (PG) norgestimate-eth estradiol (Femynor) CE N2 (PG) norethin ace-eth estrad-fe (Gemmily) CE N2 (PG) gianvi CE N2 (PG) gildagia CE N2 (PG) gildess fe 1.5/30 CE N2 (PG) gildess fe 1/20 CE N2 (PG) norethin ace-eth estrad-fe (Hailey 24 Fe) CE N2 (PG) heather CE N2 (PG) introvale CE N2 (PG) desogestrel-ethinyl estradiol (Isibloom) CE N2 (PG) drospirenone-ethinyl estradiol (Jasmiel) CE N2 (PG) jencycla CE N2 (PG) jolessa CE N2 (PG) jolivette CE N2 (PG) desogestrel-ethinyl estradiol (Juleber) CE N2 (PG) junel 1.5/30 CE N2 (PG) junel 1/20 CE N2 (PG) junel fe 1.5/30 CE N2 (PG) junel fe 1/20 CE N2 (PG) norethin ace-eth estrad-fe (Junel Fe 24) CE N2 (PG) norethin-eth estradiol-fe (Kaitlib Fe) CE N2 (PG) kariva CE N2 (PG) 2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 102 Drug Name Drug Status Drug Details kelnor 1/35 CE N2 (PG) desogestrel-ethinyl estradiol (Kimidess) CE N2 (PG) kurvelo CE N2 (PG) KYLEENA (levonorgestrel) CE N2 (NP) norethindrone acet-ethinyl est (Larin 1.5/30) CE N2 (PG) norethindrone acet-ethinyl est (Larin 1/20) CE N2 (PG) norethin ace-eth estrad-fe (Larin 24 Fe) CE N2 (PG) larin fe 1.5/30 CE N2 (PG) larin fe 1/20 CE N2 (PG) levonorgestrel-ethinyl estrad (Larissia) CE N2 (PG) norethin-eth estradiol-fe (Layolis Fe) CE N2 (PG) leena CE N2 (PG) lessina CE N2 (PG) levonest CE N2 (PG) levonorgest-eth estrad 91-day CE N2 (PG) levonorgestrel oral tablet 1.5 mg CE N2 (Not Covered) levonorgestrel-ethinyl estrad CE N2 (PG) levonorg-eth estrad triphasic oral tablet CE N2 (PG) levora 0.15/30 (28) CE N2 (PG) LILETTA (52 MG) INTRAUTERINE INTRAUTERINE CE N2 (NP) DEVICE 19.5 MCG/DAY (levonorgestrel) LO LOESTRIN FE (norethin-eth estrad-fe biphas) CE N2 (NP) norethindrone acet-ethinyl est (Loestrin 1.5/30 (21)) NP norethindrone acet-ethinyl est (Loestrin 1/20 (21)) NP lomedia 24 fe CE N2 (PG) loryna CE N2 (PG) low-ogestrel CE N2 (PG) drospirenone-ethinyl estradiol (Lo-Zumandimine) CE N2 (PG) lutera CE N2 (PG) lyza CE N2 (PG) marlissa CE N2 (PG) medroxyprogesterone acetate intramuscular suspension CE N2 (PG) medroxyprogesterone acetate intramuscular suspension prefilled N2 (PG); QL (1 syringe per CE syringe 90 days) norethin ace-eth estrad-fe (Mibelas 24 Fe) CE N2 (PG)

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 103 Drug Name Drug Status Drug Details microgestin 1.5/30 CE N2 (PG) microgestin 1/20 CE N2 (PG) microgestin fe 1.5/30 CE N2 (PG) microgestin fe 1/20 CE N2 (PG) MINASTRIN 24 FE (norethin ace-eth estrad-fe) NP MIRENA (52 MG) (levonorgestrel) CE #; N2 (NP) mono-linyah CE N2 (PG) mononessa CE N2 (PG) my way CE N2 (Not Covered) myzilra CE N2 (PG) NATAZIA (-dienogest) CE N2 (NP) necon 0.5/35 (28) CE N2 (PG) necon 1/35 (28) CE N2 (PG) necon 1/50 (28) CE N2 (PG) necon 7/7/7 CE N2 (PG) NEXPLANON (etonogestrel) CE N2 (NP) next choice one dose CE N2 (Not Covered) NEXTSTELLIS (drospirenone-) NC nikki CE N2 (PG) nora-be CE N2 (PG) norethin ace-eth estrad-fe oral capsule CE N2 (PG) norethin ace-eth estrad-fe oral tablet 1-20 mg-mcg, 1-20 mg- CE N2 (PG) mcg(24) norethin ace-eth estrad-fe oral tablet chewable CE N2 (PG) norethindrone acet-ethinyl est oral tablet 1-20 mg-mcg CE N2 (PG) norethindrone oral CE N2 (PG) norethin-eth estradiol-fe CE N2 (PG) norgestimate-eth estradiol oral tablet 0.25-35 mg-mcg CE N2 (PG) norgestim-eth estrad triphasic CE N2 (PG) norlyroc CE N2 (PG) nortrel 0.5/35 (28) CE N2 (PG) nortrel 1/35 (21) CE N2 (PG) nortrel 1/35 (28) CE N2 (PG) nortrel 7/7/7 CE N2 (PG) NUVARING (etonogestrel-ethinyl estradiol) NP 2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 104 Drug Name Drug Status Drug Details ocella CE N2 (PG) ogestrel CE N2 (PG) OPCICON ONE-STEP (levonorgestrel) CE N2 (Not Covered) OPTION 2 (levonorgestrel) CE N2 (Not Covered) orsythia CE N2 (PG) ORTHO TRI-CYCLEN LO (norgestim-eth estrad triphasic) NP ORTHO-NOVUM 7/7/7 (28) (norethin-eth estrad triphasic) NP PARAGARD INTRAUTERINE COPPER (copper) CE N2 (NP) philith CE N2 (PG) pimtrea CE N2 (PG) pirmella 1/35 CE N2 (PG) pirmella 7/7/7 CE N2 (PG) portia-28 CE N2 (PG) previfem CE N2 (PG) QUARTETTE (levonorgest-eth estrad 91-day) NP quasense CE N2 (PG) drospiren-eth estrad-levomefol (Rajani) CE N2 (PG) REACT (levonorgestrel) CE N2 (Not Covered) reclipsen CE N2 (PG) levonorgest-eth estrad 91-day (Rivelsa) CE N2 (PG) SAFYRAL (drospiren-eth estrad-levomefol) NP levonorgest-eth estrad 91-day (Setlakin) CE N2 (PG) sharobel CE N2 (PG) desogestrel-ethinyl estradiol (Simliya) CE N2 (PG) levonorgest-eth estrad 91-day (Simpesse) CE N2 (PG) SKYLA (levonorgestrel) CE N2 (NP) SLYND (drospirenone) CE N2 (NPB) solia CE N2 (PG) sprintec 28 CE N2 (PG) sronyx CE N2 (PG) syeda CE N2 (PG) take action CE N2 (Not Covered) norethin ace-eth estrad-fe (Tarina 24 Fe) CE N2 (PG) norethin ace-eth estrad-fe (Tarina Fe 1/20) CE N2 (PG) TAYTULLA (norethin ace-eth estrad-fe) NC 2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 105 Drug Name Drug Status Drug Details tilia fe CE N2 (PG) norgestim-eth estrad triphasic (Tri Femynor) CE N2 (PG) tri-estarylla CE N2 (PG) tri-legest fe CE N2 (PG) tri-linyah CE N2 (PG) norgestim-eth estrad triphasic (Tri-Lo-Estarylla) CE N2 (PG) norgestim-eth estrad triphasic (Tri-Lo-Marzia) CE N2 (PG) norgestim-eth estrad triphasic (Tri-Lo-Sprintec) CE N2 (PG) norgestim-eth estrad triphasic (Tri-Mili) CE N2 (PG) trinessa (28) CE N2 (PG) norgestim-eth estrad triphasic (Trinessa Lo) CE N2 (PG) TRI-NORINYL (28) (norethin-eth estrad triphasic) NP tri-previfem CE N2 (PG) tri-sprintec CE N2 (PG) trivora (28) CE N2 (PG) norgestim-eth estrad triphasic (Tri-Vylibra Lo) CE N2 (PG) norethindrone (Tulana) CE N2 (PG) TWIRLA (levonorgestrel-eth estradiol) NC drospiren-eth estrad-levomefol (Tydemy) CE N2 (PG) velivet CE N2 (PG) vestura CE N2 (PG) levonorgestrel-ethinyl estrad (Vienva) CE N2 (PG) viorele CE N2 (PG) vyfemla CE N2 (PG) wera CE N2 (PG) wymzya fe CE N2 (PG) xulane CE N2 (PG) zarah CE N2 (PG) zenchent CE N2 (PG) zovia 1/35e (28) CE N2 (PG) zovia 1/50e (28) CE N2 (PG) drospirenone-ethinyl estradiol (Zumandimine) CE N2 (PG) ENDOMETRIOSIS oral PG ORILISSA (elagolix sodium) PB 2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 106 Drug Name Drug Status Drug Details SYNAREL (nafarelin acetate) NPSP PA; SP Pharmacy TRIPTODUR (triptorelin pamoate) NPSP PA; SP Pharmacy REPLACEMENTS - DRUGS TO TREAT ENZYME DEFICIENCIES ADAGEN (pegademase bovine) NPSP PA; SP Pharmacy BUPHENYL ORAL POWDER 3 GM/TSP (sodium NC phenylbutyrate) BUPHENYL ORAL TABLET (sodium phenylbutyrate) NC CARBAGLU (carglumic acid) PSP PA; #; SP Pharmacy PA; SP Pharmacy; QL (2 CERDELGA (eliglustat tartrate) PSP caps per 1 day) CYSTADANE (betaine) PSP PA; SP Pharmacy CYSTAGON (cysteamine bitartrate) PSP PA; SP Pharmacy KUVAN (sapropterin dihydrochloride) NC PA; ST; SP Pharmacy; QL miglustat PSP (3 capsules per 1 Day) PA; SP Pharmacy; QL (1 MYALEPT () PSP vial per 1 day) nitisinone PSP PA; SP Pharmacy NITYR (nitisinone) NC ORFADIN ORAL CAPSULE 10 MG, 2 MG, 5 MG NPSP PA; SP Pharmacy (nitisinone) ORFADIN ORAL CAPSULE 20 MG (nitisinone) PSP PA ORFADIN ORAL SUSPENSION (nitisinone) PSP PA; SP Pharmacy PALYNZIQ (pegvaliase-pqpz) NC PA; ST; SP Pharmacy; QL RAVICTI (glycerol phenylbutyrate) NPSP (20 bottles per 30 days) sapropterin dihydrochloride oral packet 100 mg PSP PA sapropterin dihydrochloride oral packet 500 mg PSP PA; SP Pharmacy sapropterin dihydrochloride oral tablet PSP PA sapropterin dihydrochloride oral tablet soluble PSP PA; SP Pharmacy PA; SP Pharmacy; QL (20 sodium phenylbutyrate oral powder 3 gm/tsp PSP grams per 1 day) PA; SP Pharmacy; QL (40 sodium phenylbutyrate oral tablet PSP tablets per 1 day) PA; ST; SP Pharmacy; QL ZAVESCA (miglustat) NPSP (3 caps per 1 day)

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 107 Drug Name Drug Status Drug Details - DRUGS TO REGULATE FEMALE HORMONES ACTIVELLA (estradiol-norethindrone acet) NC ALORA (estradiol) NC estradiol-norethindrone acet (Amabelz Oral Tablet 0.5-0.1 Mg) NP QL (1 tablet per 1 Day) estradiol-norethindrone acet (Amabelz Oral Tablet 1-0.5 Mg) PG ANGELIQ (drospirenone-estradiol) NP BIEST/ (estradiol--progesterone) NC BIJUVA (estradiol-progesterone) NC CLIMARA (estradiol) NC CLIMARA PRO (estradiol-levonorgestrel) PB # COMBIPATCH (estradiol-norethindrone acet) NP QL (8 patch per 1 month) DELESTROGEN (estradiol valerate) NC DEPO-ESTRADIOL () NP DIVIGEL (estradiol) NP PA; AL (Max 70 Years) DUAVEE (conj estrogens-) PB ELESTRIN (estradiol) NP PA; AL (Max 70 Years) ESTRACE ORAL (estradiol) NC PA; LGC; AL (Max 70 estradiol oral PG Years) estradiol transdermal PG PA; AL (Max 70 Years) estradiol vaginal cream PG estradiol vaginal tablet NP estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml PG estradiol-norethindrone acet PG ESTRING (estradiol) NP ESTROGEL (estradiol) NP PA; AL (Max 70 Years) oral PG EVAMIST (estradiol) NP PA; #; AL (Max 70 Years) FEMRING () NP #; QL (1 ring per 90 days) norethindrone-eth estradiol (Fyavolv Oral Tablet 0.5-2.5 Mg- NP Mcg) norethindrone-eth estradiol (Fyavolv Oral Tablet 1-5 Mg-Mcg) PG IMVEXXY (estradiol) NC IMVEXXY MAINTENANCE PACK VAGINAL INSERT NC 10 MCG (estradiol) 2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 108 Drug Name Drug Status Drug Details IMVEXXY STARTER PACK VAGINAL INSERT 10 NC MCG (estradiol) jevantique lo NP jinteli PG estradiol-norethindrone acet (Lopreeza Oral Tablet 1-0.5 Mg) PG MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG NP PA; AL (Max 70 Years) () #; QL (4 patches per 28 MENOSTAR (estradiol) NP days) mimvey PG estradiol-norethindrone acet (Mimvey Lo) NP QL (1 tablet per 1 day) MINIVELLE (estradiol) NC norethindrone-eth estradiol NP ORIAHNN (elagolix-estradiol-norethind) NC PREFEST (estradiol-norgestimate) NP QL (1 tab per 1 day) PREMARIN ORAL (estrogens conjugated) NP PA; AL (Max 70 Years) PREMARIN VAGINAL (estrogens, conjugated) NP PREMPHASE (conj estrog-medroxyprogest ace) NP PREMPRO (conj estrog-medroxyprogest ace) NP VAGIFEM VAGINAL TABLET 10 MCG (estradiol) NC VIVELLE-DOT (estradiol) NC estradiol (Yuvafem) NP FERTILITY REGULATORS chorionic gonadotropin intramuscular PSP PA; SP Pharmacy GONAL-F (follitropin alfa) PSP PA; SP Pharmacy GONAL-F RFF (follitropin alfa) PSP PA; SP Pharmacy GONAL-F RFF REDIJECT (follitropin alfa) PSP PA; SP Pharmacy NOVAREL INTRAMUSCULAR SOLUTION PSP PA; SP Pharmacy RECONSTITUTED 10000 UNIT (chorionic gonadotropin) PREGNYL (chorionic gonadotropin) PSP PA; SP Pharmacy GLUCOCORTICOIDS - DRUGS TO TREAT INFLAMMATORY RESPONSE ALKINDI SPRINKLE (hydrocortisone) NC budesonide er oral tablet extended release 24 hour PG QL (1 tablet per 1 day) CORTEF (hydrocortisone) NC cortisone acetate oral PG 2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 109 Drug Name Drug Status Drug Details prednisone (Deltasone) PG DEXAMETHASONE INTENSOL (dexamethasone) PB dexamethasone oral PG dexamethasone (Dexpak 10 Day Oral Tablet Therapy Pack) NC dexamethasone (Dexpak 13 Day Oral Tablet Therapy Pack) NC dexamethasone (Dexpak 6 Day Oral Tablet Therapy Pack) NC DXEVO 11-DAY (dexamethasone) NC EMFLAZA (deflazacort) NC fludrocortisone acetate oral PG HEMADY (dexamethasone) NC dexamethasone (Hidex 6-Day) PG hydrocortisone oral PG LOCORT 11-DAY (dexamethasone) NC LOCORT 7-DAY (dexamethasone) NC MEDROL ORAL TABLET 16 MG, 32 MG, 4 MG, 8 MG NC (methylprednisolone) MEDROL ORAL TABLET 2 MG (methylprednisolone) PB MEDROL ORAL TABLET THERAPY PACK NC (methylprednisolone) methylprednisolone oral PG MILLIPRED DP 12-DAY ORAL TABLET THERAPY NP PACK (prednisolone) MILLIPRED DP ORAL TABLET THERAPY PACK NP (prednisolone) MILLIPRED ORAL SOLUTION (prednisolone sodium NC phosphate) MILLIPRED ORAL TABLET (prednisolone) PB ORAPRED ODT (prednisolone sodium phosphate) NC PEDIAPRED (prednisolone sodium phosphate) NC prednisolone oral solution PG prednisolone oral syrup 15 mg/5ml PG prednisolone sodium phosphate oral solution 10 mg/5ml, 20 NP mg/5ml, 25 mg/5ml prednisolone sodium phosphate oral solution 15 mg/5ml, 6.7 (5 PG base) mg/5ml prednisolone sodium phosphate oral tablet dispersible NP

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 110 Drug Name Drug Status Drug Details PREDNISONE INTENSOL (prednisone) PB prednisone oral solution PG prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg PG LGC prednisone oral tablet 50 mg PG prednisone oral tablet therapy pack PG TAPERDEX 12-DAY (dexamethasone) NC dexamethasone (Taperdex 6-Day Oral Tablet Therapy Pack NC 1.5 Mg (21)) TAPERDEX 7-DAY ORAL TABLET THERAPY PACK NC 1.5 MG (27) (dexamethasone) VERIPRED 20 (prednisolone sodium phosphate) NC zcort 7-day NC ZODEX 12-DAY (dexamethasone) NC ZONACORT 11 DAY (dexamethasone) NC ZONACORT 7 DAY (dexamethasone) NC GLUCOSE ELEVATING AGENTS - DRUGS TO TREAT LOW BLOOD SUGAR BAQSIMI ONE PACK () NC BAQSIMI TWO PACK (glucagon) NC BD GLUCOSE (dextrose (diabetic use)) NP DEX4 GLUCOSE GO-POUCH (dextrose (diabetic use)) NP DEX4 GLUCOSE ORAL LIQUID (dextrose (diabetic use)) NP DEX4 QUICK DISSOLVE GLUCOSE (dextrose (diabetic NP use)) diazoxide oral PG GLUCAGEN HYPOKIT (glucagon hcl (rdna)) PB GLUCAGON EMERGENCY INJECTION KIT NC glucagon emergency injection solution reconstituted NP GLUCO BURST ORAL GEL (dextrose (diabetic use)) PG glucose oral gel 40 % PG glucose oral liquid 15 gm/59ml PG glucose oral tablet chewable NP GVOKE HYPOPEN 1-PACK (glucagon) NC GVOKE HYPOPEN 2-PACK (glucagon) NC GVOKE PFS (glucagon) NC

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 111 Drug Name Drug Status Drug Details INSTA-GLUCOSE ORAL GEL 77.4 % (dextrose (diabetic NP use)) leader quick dissolve glucose NP PROGLYCEM (diazoxide) NP RELION GLUCOSE DRINK (dextrose (diabetic use)) PG RELION GLUCOSE ORAL GEL (dextrose (diabetic use)) PG value plus glucose oral gel PG ZEGALOGUE (dasiglucagon hcl) NC HUMAN GROWTH HORMONES - DRUGS TO REGULATE PITUITARY HORMONES GENOTROPIN (somatropin) NC GENOTROPIN MINIQUICK (somatropin) NC HUMATROPE (somatropin) PSP PA; SP Pharmacy NORDITROPIN FLEXPRO (somatropin) NC NUTROPIN AQ NUSPIN 10 (somatropin) NC NUTROPIN AQ NUSPIN 20 (somatropin) NC NUTROPIN AQ NUSPIN 5 (somatropin) NC OMNITROPE (somatropin) NC SAIZEN (somatropin (non-refrigerated)) NC SAIZEN CLICK.EASY (somatropin (non-refrigerated)) NC SAIZENPREP (somatropin (non-refrigerated)) NC SEROSTIM SUBCUTANEOUS SOLUTION RECONSTITUTED 4 MG, 5 MG, 6 MG (somatropin (non- NPSP PA; ST; SP Pharmacy refrigerated)) ZOMACTON (somatropin) NC ZOMACTON (FOR ZOMA-JET 10) (somatropin) NC ZORBTIVE (somatropin (non-refrigerated)) NPSP PA; ST; SP Pharmacy MISCELLANEOUS ACTHAR (corticotropin) NC ANDROID (methyltestosterone) NC ANDROXY (fluoxymesterone) NP BYNFEZIA PEN (octreotide acetate) NC PG (salmon) nasal PG CERVIDIL (dinoprostone) NC D-CARE DM2 (metformin hcl-diagnostic test) NC 2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 112 Drug Name Drug Status Drug Details EVENITY (romosozumab-aqqg) NC EVISTA ( hcl) NC FORTEO SUBCUTANEOUS SOLUTION 600 NPSP PA; ST; #; SP Pharmacy MCG/2.4ML ( (recombinant)) FORTEO SUBCUTANEOUS SOLUTION PEN- NPSP # INJECTOR 600 MCG/2.4ML (teriparatide (recombinant)) FORTEO SUBCUTANEOUS SOLUTION PEN- NPSP INJECTOR 620 MCG/2.48ML (teriparatide (recombinant)) PA; SP Pharmacy; QL (14 GALAFOLD (migalastat hcl) NPSP capsules per 28 days) INCRELEX () PSP PA; SP Pharmacy ISTURISA (osilodrostat phosphate) NC JYNARQUE ORAL TABLET THERAPY PACK PSP PA; SP Pharmacy (tolvaptan) PA; #; SP Pharmacy; QL (4 KORLYM (mifepristone) NPSP tabs per 1 day) methylergonovine maleate (Methergine Oral) PG QL (28 tablets per 7 days) MIACALCIN NASAL (calcitonin (salmon)) NC MYCAPSSA (octreotide acetate) NC NATPARA ( (recomb)) NC octreotide acetate injection solution 100 mcg/ml, 50 mcg/ml, 500 PA; SP Pharmacy; QL (90 PSP mcg/ml ml per 30 days) PA; SP Pharmacy; QL (45 octreotide acetate injection solution 1000 mcg/ml PSP ml per 30 days) PA; SP Pharmacy; QL (225 octreotide acetate injection solution 200 mcg/ml PSP ml per 30 days) OSPHENA () PB OXANDRIN ORAL TABLET 2.5 MG (oxandrolone) NC PREPIDIL (dinoprostone) NP PROLIA SUBCUTANEOUS SOLUTION (denosumab) NPSP PA; ST; SP Pharmacy PROLIA SUBCUTANEOUS SOLUTION PREFILLED PSP SYRINGE (denosumab) PROSTIN E2 (dinoprostone) NP raloxifene hcl CE N2 (PG) SAMSCA ORAL TABLET 15 MG (tolvaptan) NC PA; SP Pharmacy; QL (2 SAMSCA ORAL TABLET 30 MG (tolvaptan) NPSP tabs per 1 day)

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 113 Drug Name Drug Status Drug Details SANDOSTATIN (octreotide acetate) NC SANDOSTATIN LAR DEPOT (octreotide acetate) NC # PA; SP Pharmacy; QL (2 SIGNIFOR (pasireotide diaspartate) NPSP amps per 1 day) SIGNIFOR LAR INTRAMUSCULAR SUSPENSION NC RECONSTITUTED ER (pasireotide pamoate) PA; #; SP Pharmacy; QL (1 SOMATULINE DEPOT (lanreotide acetate) PSP injection per 28 days) PA; #; SP Pharmacy; QL (1 SOMAVERT (pegvisomant) PSP vial per 1 day) teriparatide (recombinant) NC TESTRED (methyltestosterone) NC tolvaptan oral tablet 15 mg PSP PA; SP Pharmacy PA; SP Pharmacy; QL (2 tolvaptan oral tablet 30 mg PSP tablets per 1 day) PA; SP Pharmacy; QL (1 TYMLOS () PSP injection per 1 month) XGEVA (denosumab) NPSP PA; ST; SP Pharmacy PA; SP Pharmacy; QL (4 XURIDEN (uridine triacetate) NPSP packets per 1 day) ZOKINVY (lonafarnib) NC PHOSPHATE BINDER AGENTS - DRUGS TO REGULATE CALCIUM AND PHOSPHORUS LEVELS AURYXIA (ferric citrate) NC calcium acetate (phos binder) PG calcium acetate oral capsule PG CALPHRON (calcium acetate (phos binder)) PG FOSRENOL ORAL PACKET (lanthanum carbonate) NP FOSRENOL ORAL TABLET CHEWABLE 1000 MG, 500 NC MG, 750 MG (lanthanum carbonate) GEMTESA (vibegron) NC lanthanum carbonate PG MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 PB ST; #; QL (1 tab per 1 day) HOUR 50 MG (mirabegron) PHOSLYRA (calcium acetate (phos binder)) PB RENAGEL ORAL TABLET 400 MG (sevelamer hcl) NP # RENAGEL ORAL TABLET 800 MG (sevelamer hcl) NC

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 114 Drug Name Drug Status Drug Details RENVELA (sevelamer carbonate) NC sevelamer carbonate oral packet PG sevelamer carbonate oral tablet NP sevelamer hcl PG VELPHORO (sucroferric oxyhydroxide) NP # PROGESTINS - DRUGS TO REGULATE FEMALE HORMONES AYGESTIN (norethindrone acetate) NC CRINONE (progesterone) PB PA; SP Pharmacy; QL (5 hydroxyprogesterone caproate intramuscular oil PSP vials per 1 year) LUPANETA PACK (leuprolide & norethindrone) NPSP PA; SP Pharmacy MAKENA INTRAMUSCULAR (hydroxyprogesterone NC caproate) MAKENA SUBCUTANEOUS (hydroxyprogesterone PA; ST; QL (21 syringes per NPSP caproate) 365 Days) medroxyprogesterone acetate oral PG LGC MEGACE ES (megestrol acetate) CE N2 (Not Covered) norethindrone acetate oral PG progesterone intramuscular NC progesterone micronized oral PG progesterone oral NC PROMETRIUM (progesterone) NC PROVERA (medroxyprogesterone acetate) NC THYROID AGENTS - DRUGS TO REGULATE THYROID LEVELS ARMOUR THYROID (thyroid) NP CYTOMEL (liothyronine sodium) NC levothyroxine sodium (Euthyrox Oral Tablet 88 Mcg) PG HECTOROL ORAL (doxercalciferol) NC levothyroxine sodium (Levo-T) PG levothyroxine sodium oral capsule NC levothyroxine sodium oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, PG LGC 88 mcg levothyroxine sodium oral tablet 300 mcg PG

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 115 Drug Name Drug Status Drug Details levoxyl PG LGC liothyronine sodium oral PG methimazole oral PG NATURE-THROID (thyroid) NP np thyroid oral tablet 15 mg, 30 mg, 60 mg, 90 mg NP propylthiouracil oral PG SYNTHROID (levothyroxine sodium) PB TAPAZOLE (methimazole) NC THYQUIDITY (levothyroxine sodium) NC THYROLAR-1 ORAL TABLET 60 (12.5-50) MG (MCG) NP (liotrix (t3-t4)) THYROLAR-1/2 ORAL TABLET 30 (6.25-25) MG (MCG) NP (liotrix (t3-t4)) THYROLAR-1/4 ORAL TABLET 15 (3.1-12.5) MG (MCG) NP (liotrix (t3-t4)) THYROLAR-2 ORAL TABLET 120 (25-100) MG (MCG) NP (liotrix (t3-t4)) THYROLAR-3 ORAL TABLET 180 (37.5-150) MG (MCG) NP (liotrix (t3-t4)) TIROSINT (levothyroxine sodium) NP TIROSINT-SOL ORAL SOLUTION 100 MCG/ML, 112 MCG/ML, 125 MCG/ML, 13 MCG/ML, 137 MCG/ML, 150 MCG/ML, 175 MCG/ML, 200 MCG/ML, 25 MCG/ML, 50 NP # MCG/ML, 75 MCG/ML, 88 MCG/ML (levothyroxine sodium) TIROSINT-SOL ORAL SOLUTION 37.5 MCG/ML, 44 NC MCG/ML, 62.5 MCG/ML (levothyroxine sodium) levothyroxine sodium (Unithroid Direct) PG unithroid oral tablet 100 mcg, 112 mcg, 125 mcg, 150 mcg, 175 PG LGC mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg levothyroxine sodium (Unithroid Oral Tablet 137 Mcg) PG unithroid oral tablet 300 mcg PG WESTHROID ORAL TABLET 130 MG, 195 MG, 32.5 MG, NP 65 MG, 97.5 MG (thyroid) WP THYROID (thyroid) NP VASOPRESSINS - DRUGS TO REGULATE PITUITARY HORMONES DDAVP NASAL (desmopressin acetate spray) NC 2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 116 Drug Name Drug Status Drug Details DDAVP ORAL (desmopressin acetate) NC DDAVP RHINAL TUBE (desmopressin ace refrigerated) NC desmopressin ace spray refrig PG desmopressin acetate oral PG desmopressin acetate spray NP NOCDURNA (desmopressin acetate) NP PA; QL (1 tablet per 1 Day) PA; QL (1 bottle per 30 NOCTIVA (desmopressin acetate) NP Days); AL (Min 50 Years) STIMATE (desmopressin acetate) NP PA GASTROINTESTINAL - DRUGS TO TREAT STOMACH AND INTESTINAL DISORDERS ANTICHOLINERGICS belladonna alkaloids-opium rectal suppository 16.2-60 mg NP BENTYL ORAL CAPSULE (dicyclomine hcl) NC chlordiazepoxide-clidinium NC CUVPOSA (glycopyrrolate) PB # dicyclomine hcl oral capsule PG LGC dicyclomine hcl oral solution PG dicyclomine hcl oral tablet PG LGC ed-spaz PG glycopyrrolate oral tablet 1 mg, 2 mg NP hyoscyamine sulfate er oral tablet extended release 12 hour NC hyoscyamine sulfate oral tablet PG hyoscyamine sulfate oral tablet dispersible PG hyoscyamine sulfate sublingual PG LIBRAX (chlordiazepoxide-clidinium) NC methscopolamine bromide oral NP PA; AL (Max 70 Years) hyoscyamine sulfate (Nulev) PG oscimin PG oscimin sr NC PAMINE (methscopolamine bromide) NC PAMINE FORTE (methscopolamine bromide) NC propantheline bromide oral NP ROBINUL ORAL (glycopyrrolate) NC ROBINUL-FORTE (glycopyrrolate) NC

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 117 Drug Name Drug Status Drug Details hyoscyamine sulfate (Symax-Sl) PG hyoscyamine sulfate (Symax-Sr) NC ANTIEMETICS - DRUGS FOR NAUSEA AND VOMITING AKYNZEO ORAL (netupitant-palonosetron) NP QL (2 capsules per 1 month) ANZEMET ORAL (dolasetron mesylate) NP QL (6 tablets per 1 month) aprepitant oral capsule 125 mg, 40 mg, 80 mg PG QL (5 capsules per 30 days) aprepitant oral capsule 80 & 125 mg PG QL (9 capsules per 30 days) BONJESTA (doxylamine-pyridoxine) NC # CESAMET (nabilone) NP QL (2 caps per 1 day) compro PG DICLEGIS (doxylamine-pyridoxine) NC doxylamine-pyridoxine NC DRAMAMINE LESS DROWSY (meclizine hcl) PG OTC QL (4 CAPSULES per 1 dronabinol NP day) EMEND ORAL CAPSULE 125 MG, 40 MG, 80 MG NC (aprepitant) EMEND ORAL SUSPENSION RECONSTITUTED PB # (aprepitant) EMEND TRI-PACK (aprepitant) NC GIMOTI ( hcl) NC granisetron hcl oral NP QL (12 tablets per 21 days) MARINOL (dronabinol) NC meclizine hcl oral tablet 12.5 mg, 25 mg PG OTC meclizine hcl oral tablet 50 mg NC metoclopramide hcl oral solution 10 mg/10ml, 5 mg/5ml PG LGC metoclopramide hcl oral tablet 10 mg PG LGC metoclopramide hcl oral tablet 5 mg PG metoclopramide hcl oral tablet dispersible 10 mg NP metoclopramide hcl oral tablet dispersible 5 mg PG ondansetron PG QL (18 tablets per 21 days) ondansetron hcl oral solution PG QL (200 ml per 21 days) ondansetron hcl oral tablet 24 mg PG QL (2 tablets per 21 days) ondansetron hcl oral tablet 4 mg, 8 mg PG QL (18 tablets per 21 days) phenadoz NP 2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 118 Drug Name Drug Status Drug Details promethazine hcl (Phenergan Rectal Suppository 12.5 Mg, 25 NP Mg) promethazine hcl (Phenergan Rectal Suppository 50 Mg) PG prochlorperazine PG prochlorperazine maleate oral PG promethazine hcl oral PG PA; AL (Max 70 Years) promethazine hcl rectal NP promethegan rectal suppository 12.5 mg, 25 mg NP promethegan rectal suppository 50 mg PG REGLAN ORAL (metoclopramide hcl) NC SANCUSO (granisetron) PB QL (2 patches per 21 days) scopolamine PG SYNDROS (dronabinol) NC # TIGAN ORAL (trimethobenzamide hcl) NC TRANSDERM-SCOP (1.5 MG) (scopolamine base) NC trimethobenzamide hcl oral PG VARUBI (180 MG DOSE) (rolapitant hcl) PB VARUBI ORAL (rolapitant hcl) NC ZOFRAN ODT (ondansetron) NC ZOFRAN ORAL (ondansetron hcl) NC ZUPLENZ (ondansetron) NC H2-RECEPTOR ANTAGONISTS - DRUGS FOR ULCERS AND STOMACH ACID cimetidine hcl oral solution 300 mg/5ml PG cimetidine oral tablet 200 mg, 300 mg, 400 mg PG OTC cimetidine oral tablet 800 mg PG LGC; OTC eq famotidine max st PG famotidine oral suspension reconstituted PG famotidine oral tablet 20 mg PG LGC; OTC famotidine oral tablet 40 mg PG LGC nizatidine PG PEPCID ORAL SUSPENSION RECONSTITUTED NC (famotidine) PEPCID ORAL TABLET 40 MG (famotidine) NC ranitidine hcl oral capsule PG OTC

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 119 Drug Name Drug Status Drug Details ranitidine hcl oral syrup PG OTC ranitidine hcl oral tablet 150 mg PG ranitidine hcl oral tablet 300 mg PG LGC; OTC ZANTAC ORAL TABLET 300 MG (ranitidine hcl) NC INFLAMMATORY BOWEL DISEASE - BOWEL, INTESTINE, AND STOMACH CONDITION DRUGS APRISO (mesalamine) PB QL (4 caps per 1 day) ASACOL HD (mesalamine) NC AZULFIDINE (sulfasalazine) NC AZULFIDINE EN-TABS (sulfasalazine) NC balsalazide disodium PG budesonide oral NP ST; QL (1 suppository per 1 CANASA (mesalamine) NP day) COLAZAL (balsalazide disodium) NC colocort PG CORTENEMA (hydrocortisone) NC CORTIFOAM EXTERNAL (hydrocortisone acetate) NP CORTIFOAM RECTAL (hydrocortisone acetate) NP QL (30 grams per 30 days) DELZICOL (mesalamine) NC DIPENTUM (olsalazine sodium) NP PA ENTOCORT EC ORAL CAPSULE DELAYED RELEASE NC PARTICLES (budesonide) GIAZO (balsalazide disodium) NP ST; #; QL (6 tabs per 1 day) hydrocortisone rectal enema PG LIALDA (mesalamine) NC mesalamine er PG mesalamine oral capsule delayed release PG mesalamine oral tablet delayed release NP mesalamine rectal PG mesalamine-cleanser PG ORTIKOS (budesonide) NC PENTASA ORAL CAPSULE EXTENDED RELEASE 250 NP ST; QL (16 caps per 1 day) MG (mesalamine) PENTASA ORAL CAPSULE EXTENDED RELEASE 500 NP ST; QL (8 caps per 1 day) MG (mesalamine) 2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 120 Drug Name Drug Status Drug Details SFROWASA (mesalamine) NC sulfasalazine oral PG sulfazine PG QL (8 tabs per 1 day) UCERIS ORAL (budesonide) NC UCERIS RECTAL (budesonide) NC # IRRITABLE BOWEL SYNDROME WITH CONSTIPATION AMITIZA (lubiprostone) NC LINZESS (linaclotide) PB lubiprostone PG TRULANCE (plecanatide) NC ZELNORM (tegaserod maleate) NC IRRITABLE BOWEL SYNDROME WITH DIARRHEA alosetron hcl NP PA LOTRONEX (alosetron hcl) NC VIBERZI (eluxadoline) NC LAXATIVES - DRUGS FOR CONSTIPATION N2 (Not Covered); AL (Min bisacodyl NP 50 Years and Max 74 Years) N2 (Not Covered); AL (Min bisacodyl rectal CE 50 Years and Max 74 Years) N2 (Not Covered); AL (Min citrate of magnesia CE 50 Years and Max 74 Years) N2 (NP); AL (Min 45 Years CLENPIQ (sod picosulfate-mag ox-cit acd) CE and Max 74 Years) COLYTE WITH FLAVOR PACKS ORAL SOLUTION NP RECONSTITUTED 240 GM (peg 3350-kcl-nabcb-nacl-nasulf) constulose PG LGC N2 (Not Covered); AL (Min DULCOLAX BOWEL PREP KIT (bisacodyl) CE 50 Years and Max 74 Years) enulose PG LGC N2 (Not Covered); AL (Min FLEET LAXATIVE ORAL (bisacodyl) CE 50 Years and Max 74 Years) gavilyte-c PG gavilyte-g PG N2 (PG); AL (Min 45 Years bisacodyl-peg-kcl-nabicar-nacl (Gavilyte-H) CE and Max 74 Years) 2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 121 Drug Name Drug Status Drug Details gavilyte-n with flavor pack PG generlac PG LGC GOLYTELY ORAL SOLUTION RECONSTITUTED 227.1 PB GM (peg 3350-kcl-nabcb-nacl-nasulf) GOLYTELY ORAL SOLUTION RECONSTITUTED 236 NP GM (peg 3350-kcl-nabcb-nacl-nasulf) KRISTALOSE (lactulose) NP QL (60 packets per 30 days) lactulose encephalopathy PG LGC lactulose oral packet NP QL (2 packets per 1 day) lactulose oral solution PG LGC MOVIPREP (peg-kcl-nacl-nasulf-na asc-c) NC NULYTELY WITH FLAVOR PACKS (peg 3350-kcl-na NP bicarb-nacl) OSMOPREP (sod phos mono-sod phos dibasic) NP # peg 3350 oral powder PG peg 3350/electrolytes PG peg 3350-kcl-na bicarb-nacl PG peg-3350/electrolytes PG peg-3350/electrolytes/ascorbat PG N2 (Not Covered); AL (Min peg-kcl-nacl-nasulf-na asc-c CE 45 Years and Max 74 Years) N2 (PG); AL (Min 45 Years PEG-PREP (bisacodyl-peg-kcl-nabicar-nacl) CE and Max 74 Years) N2 (NP); AL (Min 45 Years PLENVU (peg-kcl-nacl-nasulf-na asc-c) CE and Max 74 Years) polyethylene glycol 3350 oral powder PG POLY-PREP (bisacodyl-peg 3350-lido-hc) NP #; N2 (NP); AL (Min 45 PREPOPIK (sod picosulfate-mag ox-cit acd) CE Years and Max 74 Years) N2 (Not Covered); AL (Min saline laxative oral solution 0.9-2.4 gm/5ml CE 50 Years and Max 74 Years) #; N2 (NP); AL (Min 45 SUPREP BOWEL PREP KIT (na sulfate-k sulfate-mg sulf) CE Years and Max 74 Years) N2 (NP); AL (Min 45 Years SUTAB (sodium sulfate-mag sulfate-kcl) CE and Max 74 Years) trilyte PG

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 122 Drug Name Drug Status Drug Details MISCELLANEOUS ACTIGALL (ursodiol) NC bethanechol chloride oral PG CARAFATE ORAL SUSPENSION (sucralfate) NP CARAFATE ORAL TABLET (sucralfate) NC CHENODAL (chenodiol) NPSP PA CHOLBAM (cholic acid) NC # cromolyn sodium oral NP CYTOTEC (misoprostol) NC diphenoxylate-atropine oral liquid PG diphenoxylate-atropine oral tablet 2.5-0.025 mg PG flavoxate hcl PG GASTROCROM (cromolyn sodium) NC PA; SP Pharmacy; QL (1 GATTEX ( (rdna)) NPSP box per 30 fillss) HELIDAC THERAPY (metronid-tetracyc-bis subsal) NC LOMOTIL ORAL TABLET (diphenoxylate-atropine) NC loperamide hcl oral capsule PG misoprostol oral PG MOTEGRITY (prucalopride succinate) NC MOTOFEN (difenoxin-atropine) NP MOVANTIK (naloxegol oxalate) PB PA; ST; QL (2 tablets per 1 MYTESI (crofelemer) NP Day) OCALIVA (obeticholic acid) NC paregoric NP PYLERA (bis subcit-metronid-tetracyc) NP # RELISTOR ORAL (methylnaltrexone bromide) NC # RELISTOR SUBCUTANEOUS SOLUTION 12 MG/0.6ML NP PA; QL (0.6 ml per 1 day) (methylnaltrexone bromide) RELISTOR SUBCUTANEOUS SOLUTION 8 MG/0.4ML NP PA; QL (0.4 ml per 1 day) (methylnaltrexone bromide) RELTONE (ursodiol) NC sucralfate oral PG SYMPROIC (naldemedine tosylate) NC URECHOLINE (bethanechol chloride) NC 2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 123 Drug Name Drug Status Drug Details URSO 250 (ursodiol) NC URSO FORTE (ursodiol) NC ursodiol oral capsule 200 mg, 400 mg NC ursodiol oral capsule 300 mg PG ursodiol oral tablet NP VSL#3 JUNIOR (probiotic product) NC VSL#3 ORAL PACKET (probiotic product) NC XERMELO (telotristat etiprate) NC PANCREATIC CREON (pancrelipase (lip-prot-amyl)) PB PA PANCREAZE ORAL CAPSULE DELAYED RELEASE PARTICLES 10500-35500 UNIT, 16800-56800 UNIT, 21000- NP ST 54700 UNIT, 4200-14200 UNIT (pancrelipase (lip-prot-amyl)) PANCREAZE ORAL CAPSULE DELAYED RELEASE NP PA; ST PARTICLES 2600-6200 UNIT (pancrelipase (lip-prot-amyl)) PANCREAZE ORAL CAPSULE DELAYED RELEASE PARTICLES 2600-8800 UNIT, 37000-97300 UNIT NC (pancrelipase (lip-prot-amyl)) PERTZYE (pancrelipase (lip-prot-amyl)) NP PA; ST PA; QL (354 ml per 1 SUCRAID (sacrosidase) NP month) VIOKACE (pancrelipase (lip-prot-amyl)) PB PA ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 10000 UNIT, 15000-51000 UNIT, 20000-68000 PB UNIT, 25000 UNIT, 3000-10000 UNIT, 40000-136000 UNIT, 5000 UNIT (pancrelipase (lip-prot-amyl)) ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 10000-32000 UNIT, 15000-47000 UNIT, 20000- 63000 UNIT, 25000-79000 UNIT, 3000-10000 UNIT, 40000- PB PA 126000 UNIT, 5000-24000 UNIT (pancrelipase (lip-prot- amyl)) PROTON PUMP INHIBITORS - DRUGS FOR ULCERS AND STOMACH ACID PA; QL (1 capsule per day acid reducer oral capsule delayed release PG and 90 capsules per 365 days) ACIPHEX (rabeprazole sodium) NC ACIPHEX SPRINKLE ORAL CAPSULE SPRINKLE 10 NC MG (rabeprazole sodium) 2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 124 Drug Name Drug Status Drug Details ACIPHEX SPRINKLE ORAL CAPSULE SPRINKLE 5 NC # MG (rabeprazole sodium) ST; #; QL (1 capsule per 1 DEXILANT (dexlansoprazole) NP day) esomeprazole magnesium oral capsule delayed release 20 mg PG esomeprazole magnesium oral capsule delayed release 40 mg NP QL (1 capsule per 1 day) PA; QL (1 packet per day, esomeprazole magnesium oral packet PG 90 day supply per 365 days) esomeprazole strontium oral capsule delayed release 24.65 mg NC esomeprazole strontium oral capsule delayed release 49.3 mg NP PA; QL (1 capsule per 1 lansoprazole oral capsule delayed release PG day) lansoprazole oral tablet dispersible NP QL (1 tablet per 1 Day) NEXIUM 24HR ORAL CAPSULE DELAYED RELEASE PA; OTC; QL (1 capsule per PG (esomeprazole magnesium) 1 day) NEXIUM ORAL PACKET 10 MG, 20 MG, 40 MG PA; ST; QL (1 packet per 1 NP (esomeprazole magnesium) day) NEXIUM ORAL PACKET 2.5 MG, 5 MG (esomeprazole PA; #; QL (1 packet per 1 NP magnesium) day) PA; LGC; OTC; QL (1 omeprazole magnesium oral capsule delayed release PG capsule per day, 90 day supply per 365 days) PA; OTC; QL (1 capsule per omeprazole oral capsule delayed release 10 mg, 40 mg PG day, 90 day supply per 365 days) QL (90 capsules per 365 omeprazole oral capsule delayed release 20 mg PG days) PA; OTC; QL (1 tablet per omeprazole oral tablet delayed release PG day, 90 day supply per 365 days) PA; QL (1 capsule per 1 omeprazole-sodium bicarbonate oral capsule PG day) omeprazole-sodium bicarbonate oral packet NC QL (1 packet per day, 90 pantoprazole sodium oral packet NP day supply per 365 days) pantoprazole sodium oral tablet delayed release NC PA; OTC; QL (2 caps per 1 PREVACID 24HR (lansoprazole) PG day)

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 125 Drug Name Drug Status Drug Details PREVACID ORAL CAPSULE DELAYED RELEASE 30 NC MG (lansoprazole) PREVACID SOLUTAB ORAL TABLET DISPERSIBLE NC (lansoprazole) PRILOSEC ORAL CAPSULE DELAYED RELEASE 10 NC MG, 40 MG (omeprazole) PRILOSEC ORAL PACKET (omeprazole magnesium) NC # PRILOSEC OTC (omeprazole magnesium) PG LGC; OTC PROTONIX ORAL (pantoprazole sodium) NC PA; QL (1 capsule per day, rabeprazole sodium oral capsule sprinkle NP 90 day supply per 365 days) PA; QL (1 tablet per day, 90 rabeprazole sodium oral tablet delayed release PG day supply per 365 days) ZEGERID ORAL CAPSULE 40-1100 MG (omeprazole- NC sodium bicarbonate) ZEGERID ORAL PACKET (omeprazole-sodium bicarbonate) NC PA; OTC; QL (1 cap per 1 ZEGERID OTC (omeprazole-sodium bicarbonate) PG day) RECTAL,CORTICOSTEROIDS ANALPRAM-HC EXTERNAL LOTION (hydrocortisone NC ace-pramoxine) ANALPRAM-HC RECTAL LOTION 2.5-1 % NC (hydrocortisone ace-pramoxine) ANUSOL-HC EXTERNAL (hydrocortisone) NC ANUSOL-HC RECTAL CREAM (hydrocortisone) NC hydrocortisone (perianal) PG hydrocortisone rectal cream PG PROCTOCORT EXTERNAL (hydrocortisone) NC PROCTOCORT RECTAL CREAM (hydrocortisone) NC PROCTOFOAM HC EXTERNAL (hydrocortisone ace- NP pramoxine) PROCTOFOAM HC RECTAL (hydrocortisone ace- NP QL (20 grams per 30 days) pramoxine) hydrocortisone (Procto-Med Hc) PG hydrocortisone (Procto-Pak External) PG procto-pak rectal PG hydrocortisone (Proctosol Hc External) PG

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 126 Drug Name Drug Status Drug Details proctosol hc rectal PG hydrocortisone (Proctozone-Hc External) PG proctozone-hc rectal PG RECTIV (nitroglycerin) NP ULCER THERAPY COMBINATIONS OMECLAMOX-PAK (amoxicill-clarithro-omeprazole) NC PREVPAC (amoxicill-clarithro-lansopraz) NC TALICIA (amoxicill-rifabutin-omeprazole) NP GENITOURINARY - DRUGS TO TREAT GENITAL AND URINARY TRACT CONDITIONS BENIGN PROSTATIC HYPERPLASIA - DRUGS TO TREAT ENLARGED PROSTATE alfuzosin hcl er PG AVODART (dutasteride) NC CARDURA XL (doxazosin mesylate) NP ST dutasteride oral PG dutasteride-tamsulosin hcl PG finasteride oral tablet 5 mg PG FLOMAX (tamsulosin hcl) NC JALYN (dutasteride-tamsulosin hcl) NC PROSCAR (finasteride) NC RAPAFLO (silodosin) NP silodosin PG tamsulosin hcl PG UROXATRAL (alfuzosin hcl) NC CONTRACEPTIVES - PRODUCTS FOR BIRTH CONTROL ENCARE VAGINAL SUPPOSITORY (nonoxynol-9) CE N2 (Not Covered) OPTIONS CONCEPTROL (nonoxynol-9) CE N2 (Not Covered) OPTIONS GYNOL II CONTRACEPTIVE (nonoxynol-9) CE N2 (Not Covered) PHEXXI (lactic ac-citric ac-pot bitart) NC SHUR-SEAL CONTRACEPTIVE (nonoxynol-9) CE N2 (Not Covered) TODAY SPONGE (nonoxynol-9) CE N2 (Not Covered) VCF VAGINAL CONTRACEPTIVE (nonoxynol-9) CE N2 (Not Covered)

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 127 Drug Name Drug Status Drug Details ERECTILE DYSFUNCTION tadalafil oral tablet 2.5 mg, 5 mg PG PA; QL (1 tablet per 1 day) MISCELLANEOUS acetic acid irrigation NP sodium chloride (gu irrigant) (Argyle Sterile Saline) PG azo tabs PG azo-standard PG sodium chloride (gu irrigant) (Curity Sterile Saline) PG cytra k crystals PG ELMIRON (pentosan polysulfate sodium) NP gnp urinary pain relief oral tablet 95 mg PG K-PHOS NO 2 (pot & sod ac phosphates) NP LITHOSTAT (acetohydroxamic acid) NP neomycin-polymyxin b gu NP ORACIT (sod citrate-citric acid) NP potassium citrate er PG potassium citrate-citric acid oral packet NP PROCYSBI (cysteamine bitartrate) NC qc azo PG qc urinary pain relief PG ra urinary pain relief PG RENACIDIN (citric ac-gluconolact-mg carb) NP sodium chloride irrigation solution 0.9 % PG sorbitol-mannitol NP taron-crystals NP THIOLA (tiopronin) NPSP PA THIOLA EC (tiopronin) NPSP PA; SP Pharmacy tiopronin oral NC tricitrates PG UROCIT-K 10 (potassium citrate) NC UROCIT-K 15 (potassium citrate) NC UROCIT-K 5 (potassium citrate) NC virtrate-3 PG

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 128 Drug Name Drug Status Drug Details PROGESTINS - DRUGS TO REGULATE FEMALE HORMONES ENDOMETRIN (progesterone) NP PA; # URINARY ANTISPASMODICS - DRUGS TO TREAT URINARY INCONTINENCE darifenacin hydrobromide er NP DETROL (tolterodine tartrate) NC DETROL LA (tolterodine tartrate) NC DITROPAN XL (oxybutynin chloride) NC ENABLEX (darifenacin hydrobromide) NC GELNIQUE PUMP (oxybutynin chloride) NP ST; # GELNIQUE TRANSDERMAL GEL 10 % (oxybutynin NP ST; # chloride) MYRBETRIQ ORAL SUSPENSION RECONSTITUTED NC ER (mirabegron) MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 PB ST; #; QL (1 tab per 1 day) HOUR 25 MG (mirabegron) oxybutynin chloride er PG oxybutynin chloride oral syrup PG oxybutynin chloride oral tablet PG LGC #; OTC; QL (8 patches per 1 OXYTROL FOR WOMEN (oxybutynin) PG month) solifenacin succinate PG tolterodine tartrate PG tolterodine tartrate er NP TOVIAZ (fesoterodine fumarate) NP ST; # trospium chloride PG trospium chloride er NP VESICARE (solifenacin succinate) NC VESICARE LS (solifenacin succinate) NC VAGINAL ANTI-INFECTIVES - DRUGS TO TREAT VAGINAL INFECTIONS AVC VAGINAL (sulfanilamide) NP CLEOCIN VAGINAL CREAM (clindamycin phosphate) NC CLEOCIN VAGINAL SUPPOSITORY (clindamycin PB phosphate)

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 129 Drug Name Drug Status Drug Details clindamycin phosphate vaginal NP CLINDESSE (clindamycin phosphate (1 dose)) NC GYNAZOLE-1 (butoconazole nitrate (1 dose)) NP METROGEL-VAGINAL (metronidazole) NC metronidazole vaginal PG miconazole 3 vaginal suppository PG NUVESSA (metronidazole) NC TERAZOL 7 (terconazole) NC terconazole vaginal cream PG terconazole vaginal suppository NP vandazole PG HEMATOLOGIC - DRUGS TO TREAT BLOOD DISORDERS ANTICOAGULANTS - BLOOD THINNERS ANTICOAGULANT COMPOUND (anticoag cit phos dex NP soln) ARIXTRA (fondaparinux sodium) NC BEVYXXA (betrixaban maleate) NC COUMADIN ORAL (warfarin sodium) NC ELIQUIS (apixaban) PB ELIQUIS DVT/PE STARTER PACK ORAL TABLET PB QL (1 pack per 365 Days) (apixaban) ELIQUIS DVT/PE STARTER PACK ORAL TABLET PB QL (1 pack per 365 days) THERAPY PACK (apixaban) enoxaparin sodium PG fondaparinux sodium NP FRAGMIN SUBCUTANEOUS SOLUTION 10000 UNIT/ML, 12500 UNIT/0.5ML, 15000 UNIT/0.6ML, 18000 NP UNT/0.72ML, 2500 UNIT/0.2ML, 5000 UNIT/0.2ML, 7500 UNIT/0.3ML, 95000 UNIT/3.8ML (dalteparin sodium) heparin sodium (porcine) injection solution 1000 unit/ml, 10000 PG unit/ml, 20000 unit/ml, 5000 unit/ml heparin sodium (porcine) pf injection solution 5000 unit/0.5ml PG heparin sodium (porcine) pf injection solution 5000 unit/ml NC IPRIVASK (desirudin) NC jantoven PG LGC

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 130 Drug Name Drug Status Drug Details LOVENOX (enoxaparin sodium) NC PRADAXA (dabigatran etexilate mesylate) NP # SAVAYSA (edoxaban tosylate) NC TRICITRASOL (anticoagulant sodium citrate) NP warfarin sodium oral PG LGC XARELTO (rivaroxaban) PB XARELTO STARTER PACK (rivaroxaban) PB ANTI-VON WILLEBRAND FACTOR AGENTS PA; SP Pharmacy; QL (1 CABLIVI (caplacizumab-yhdp) NPSP vial per day, 2 courses (58 day supply) per 1 lifetime) BLEEDING DISORDERS AGENTS SEVENFACT (coagulation factor viia-jncw) NC HEMATOPOIETIC GROWTH FACTORS ARANESP (ALBUMIN FREE) INJECTION SOLUTION 100 MCG/ML, 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, PSP PA; SP Pharmacy 40 MCG/ML, 60 MCG/ML (darbepoetin alfa) ARANESP (ALBUMIN FREE) INJECTION SOLUTION PSP PA PREFILLED SYRINGE 10 MCG/0.4ML (darbepoetin alfa) ARANESP (ALBUMIN FREE) INJECTION SOLUTION PREFILLED SYRINGE 100 MCG/0.5ML, 150 MCG/0.3ML, 200 MCG/0.4ML, 25 MCG/0.42ML, 300 PSP PA; SP Pharmacy MCG/0.6ML, 40 MCG/0.4ML, 500 MCG/ML, 60 MCG/0.3ML (darbepoetin alfa) DOPTELET ORAL TABLET 20 MG (avatrombopag PA; SP Pharmacy; QL (3 NPSP maleate) /day for 5 days per 30 days) EPOGEN INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 NPSP PA; SP Pharmacy UNIT/ML (epoetin alfa) FULPHILA (pegfilgrastim-jmdb) PSP PA; SP Pharmacy GRANIX (tbo-filgrastim) NC MIRCERA INJECTION SOLUTION PREFILLED SYRINGE 100 MCG/0.3ML, 200 MCG/0.3ML, 50 NPSP PA MCG/0.3ML, 75 MCG/0.3ML (methoxy peg-epoetin beta) MIRCERA INJECTION SOLUTION PREFILLED SYRINGE 150 MCG/0.3ML, 30 MCG/0.3ML (methoxy peg- NPSP PA; SP Pharmacy epoetin beta) PA; SP Pharmacy; QL (1 MULPLETA (lusutrombopag) NPSP /day for 7 days per 30 days) 2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 131 Drug Name Drug Status Drug Details PA; QL (2 injections per 1 NEULASTA ONPRO (pegfilgrastim) PSP month) NEULASTA SUBCUTANEOUS SOLUTION PREFILLED PA; QL (2 injections per 1 PSP SYRINGE (pegfilgrastim) month) NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 NPSP PA; ST; SP Pharmacy MCG/1.6ML (filgrastim) NEUPOGEN INJECTION SOLUTION PREFILLED NPSP PA; ST SYRINGE (filgrastim) NIVESTYM (filgrastim-aafi) PSP PA; SP Pharmacy NPLATE SUBCUTANEOUS SOLUTION NC RECONSTITUTED 125 MCG (romiplostim) NPLATE SUBCUTANEOUS SOLUTION NPSP PA; SP Pharmacy RECONSTITUTED 250 MCG, 500 MCG (romiplostim) NYVEPRIA (pegfilgrastim-apgf) NC PROCRIT (epoetin alfa) NPSP PA; SP Pharmacy PROMACTA ORAL PACKET 12.5 MG (eltrombopag PA; SP Pharmacy; QL (4 NPSP olamine) packets per 1 day) PROMACTA ORAL PACKET 25 MG (eltrombopag PA; SP Pharmacy; QL (180 NPSP olamine) packets per 30 days) PROMACTA ORAL TABLET 12.5 MG (eltrombopag PA; SP Pharmacy; QL (4 NPSP olamine) tablets per 1 day) PA; SP Pharmacy; QL (1 PROMACTA ORAL TABLET 25 MG (eltrombopag olamine) NPSP tab per 1 day) PA; SP Pharmacy; QL (2 PROMACTA ORAL TABLET 50 MG (eltrombopag olamine) NPSP tablets per 1 day) PROMACTA ORAL TABLET 75 MG (eltrombopag olamine) NPSP PA; QL (2 tablets per 1 day) RETACRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, 40000 PSP PA; SP Pharmacy UNIT/ML (epoetin alfa-epbx) PA; SP Pharmacy; QL (2 UDENYCA (pegfilgrastim-cbqv) PSP injections per 1 month) ZARXIO (filgrastim-sndz) PSP PA ZIEXTENZO (pegfilgrastim-bmez) NC HEMOPHILIA A AGENTS ESPEROCT (antihemoph fact rcmb gpeg-exei) NC MISCELLANEOUS AGRYLIN (anagrelide hcl) NC alaway PG LGC; OTC

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 132 Drug Name Drug Status Drug Details altafrin ophthalmic solution 10 %, 2.5 % NP AMICAR ORAL SOLUTION (aminocaproic acid) NC AMICAR ORAL TABLET 1000 MG (aminocaproic acid) PB AMICAR ORAL TABLET 500 MG (aminocaproic acid) NC aminocaproic acid oral solution NC aminocaproic acid oral tablet PG anagrelide hcl oral capsule 0.5 mg PG anagrelide hcl oral capsule 1 mg NP atropine sulfate ophthalmic solution 1 % NC BEOVU (brolucizumab-dbll) NC CEQUA (cyclosporine) NC cilostazol PG CLARITIN EYE (ketotifen fumarate) PG OTC CORVITE 150 ORAL TABLET (iron combinations) NC corvite fe NC CYCLOGYL (cyclopentolate hcl) NC CYCLOMYDRIL (cyclopentolate-phenylephrine) NP cyclopentolate hcl ophthalmic solution 0.5 % NP cyclopentolate hcl ophthalmic solution 1 %, 2 % PG CYSTADROPS (cysteamine hcl) NC PA; #; SP Pharmacy; QL (4 CYSTARAN (cysteamine hcl) NPSP bottles per 1 month) DURLAZA (aspirin) NC ELESTAT (epinastine hcl) NC EMADINE (emedastine difumarate) NP ENDARI (glutamine (sickle cell)) NC EVITHROM (thrombin (human)) NC FIRAZYR (icatibant acetate) NC FLURA-SAFE (fluorexon-benoxinate) NC FOLVITE-FE (iron-vit c-vit b12-folic acid) NC GELFILM OPHTHALMIC (gelatin adsorbable) NC PA; ST; SP Pharmacy; QL HAEGARDA (c1 esterase inhibitor (human)) PSP (20 vials per 1 month) HEMOCYTE-F ORAL ELIXIR (iron combinations) NC

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 133 Drug Name Drug Status Drug Details PA; SP Pharmacy; QL (15 icatibant acetate PSP syringes per 1 month) KALBITOR (ecallantide) NC ketotifen fumarate ophthalmic PG LGC LACRISERT (artificial tear insert) NP LYSTEDA (tranexamic acid) NC MOZOBIL (plerixafor) NPSP PA MYDRIACYL (tropicamide) NC NIFEREX ORAL TABLET (iron combinations) NC NUFERA (iron combinations) NC ORLADEYO (berotralstat hcl) NC OXBRYTA (voxelotor) NC PA; SP Pharmacy; QL (2 ml OXERVATE (cenegermin-bkbj) NPSP per 1 day and 112 ml per lifetime) PAREMYD (hydroxyamphetamine-tropicamide) NP PATADAY OPHTHALMIC SOLUTION 0.2 % (olopatadine NC hcl) PATANOL (olopatadine hcl) NC pentoxifylline er PG phenylephrine hcl ophthalmic solution 10 %, 2.5 % PG proparacaine hcl ophthalmic PG RADIOGARDASE (prussian blue insoluble) NC PA; #; QL (2 single use vials RESTASIS (cyclosporine) NP per 1 day) RESTASIS MULTIDOSE OPHTHALMIC EMULSION NP # 0.05 % (cyclosporine) RESTASIS MULTIDOSE OPHTHALMIC EMULSION PA; QL (1 bottle per 28 NP 0.05 % (cyclosporine) days) RUCONEST (c1 esterase inhibitor (recomb)) NPSP SP Pharmacy SIKLOS (hydroxyurea) NP PA TAKHZYRO (lanadelumab-flyo) NC TAVALISSE (fostamatinib disodium) NC tranexamic acid oral PG tropicamide ophthalmic PG UPNEEQ (oxymetazoline hcl) NC

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 134 Drug Name Drug Status Drug Details ZADITOR (ketotifen fumarate) PG LGC; OTC PLATELET AGGREGATION INHIBITORS - BLOOD THINNERS AGGRENOX (aspirin-dipyridamole) NC aspirin-dipyridamole er PG aspirin-omeprazole NC BRILINTA (ticagrelor) PB clopidogrel bisulfate oral PG dipyridamole oral PG PA; AL (Max 70 Years) EFFIENT (prasugrel hcl) NC PLAVIX (clopidogrel bisulfate) NC prasugrel hcl NP ticlopidine hcl PG YOSPRALA (aspirin-omeprazole) NP ZONTIVITY (vorapaxar sulfate) NP IMMUNOLOGIC AGENTS - DRUGS TO TREAT DISORDERS OF THE IMMUNE SYSTEM ALLERGENIC EXTRACTS GRASTEK (timothy grass pollen allergen) NP PA; ST ODACTRA (dust mite mixed allergen ext) NP ORALAIR (grass mix pollens allergen ext) NP PALFORZIA (12 MG DAILY DOSE) ( powder-dnfp) NC PALFORZIA (120 MG DAILY DOSE) (peanut powder-dnfp) NC PALFORZIA (160 MG DAILY DOSE) (peanut powder-dnfp) NC PALFORZIA (20 MG DAILY DOSE) (peanut powder-dnfp) NC PALFORZIA (200 MG DAILY DOSE) (peanut powder-dnfp) NC PALFORZIA (240 MG DAILY DOSE) (peanut powder-dnfp) NC PALFORZIA (3 MG DAILY DOSE) (peanut powder-dnfp) NC PALFORZIA (300 MG MAINTENANCE) (peanut powder- NC dnfp) PALFORZIA (300 MG TITRATION) (peanut powder-dnfp) NC PALFORZIA (40 MG DAILY DOSE) (peanut powder-dnfp) NC PALFORZIA (6 MG DAILY DOSE) (peanut powder-dnfp) NC PALFORZIA (80 MG DAILY DOSE) (peanut powder-dnfp) NC PALFORZIA INITIAL ESCALATION (peanut powder-dnfp) NC

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 135 Drug Name Drug Status Drug Details RAGWITEK (short ragweed pollen ext) NP BIOLOGIC DISEASE-MODIFYING AGENTS PA; ST; SP Pharmacy; QL ACTEMRA ACTPEN (tocilizumab) NPSP (4 pens per 1 month) PA; ST; SP Pharmacy; QL ACTEMRA SUBCUTANEOUS (tocilizumab) NPSP (1 syringe per 1 month) AVSOLA (infliximab-axxq) NC CIMZIA PREFILLED (certolizumab pegol) NC CIMZIA STARTER KIT (certolizumab pegol) NC CIMZIA SUBCUTANEOUS KIT 2 X 200 MG (certolizumab NC pegol) PA; SP Pharmacy; QL (4 ENBREL MINI (etanercept) PSP syringes per 28 days) ENBREL SUBCUTANEOUS SOLUTION 25 MG/0.5ML PA; SP Pharmacy; QL (4 PSP (etanercept) vials per 28 days) ENBREL SUBCUTANEOUS SOLUTION PREFILLED PA; SP Pharmacy; QL (4 PSP SYRINGE (etanercept) syringes per 28 days) ENBREL SUBCUTANEOUS SOLUTION PSP PA; QL (4 vials per 28 days) RECONSTITUTED (etanercept) ENBREL SURECLICK SUBCUTANEOUS SOLUTION PA; SP Pharmacy; QL (4 PSP AUTO-INJECTOR (etanercept) injections per 28 days) HUMIRA PEDIATRIC CROHNS START PA; ST; SP Pharmacy; QL SUBCUTANEOUS PREFILLED SYRINGE KIT 40 PSP (6 injections per 28 days) MG/0.8ML (adalimumab) HUMIRA PEDIATRIC CROHNS START PA; SP Pharmacy; QL (3 SUBCUTANEOUS PREFILLED SYRINGE KIT 80 PSP syringes per 1 month) MG/0.8ML (adalimumab) HUMIRA PEDIATRIC CROHNS START PA; SP Pharmacy; QL (2 SUBCUTANEOUS PREFILLED SYRINGE KIT 80 PSP syringes per 1 month) MG/0.8ML & 40MG/0.4ML (adalimumab) HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT PA; SP Pharmacy; QL (6 PSP 40 MG/0.4ML (adalimumab) syringes per 1 month) HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT PA; ST; SP Pharmacy; QL PSP 40 MG/0.8ML (adalimumab) (6 injections per 28 days) HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT PSP PA; QL (1 kit per 28 days) 80 MG/0.8ML (adalimumab) HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PA; SP Pharmacy; QL (6 PSP PEN-INJECTOR KIT 40 MG/0.8ML (adalimumab) injections per 28 days)

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 136 Drug Name Drug Status Drug Details HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PA; SP Pharmacy; QL (1 kit PSP PEN-INJECTOR KIT 80 MG/0.8ML (adalimumab) per 1 month) HUMIRA PEN-PS/UV/ADOL HS START PA; SP Pharmacy; QL (6 SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML PSP injections per 28 days) (adalimumab) HUMIRA PEN-PSOR/UVEIT STARTER (adalimumab) PSP PA; QL (1 kit per 1 month) HUMIRA SUBCUTANEOUS PREFILLED SYRINGE PA; SP Pharmacy; QL (2 PSP KIT 10 MG/0.1ML, 20 MG/0.2ML (adalimumab) syringes per 1 month) HUMIRA SUBCUTANEOUS PREFILLED SYRINGE PA; SP Pharmacy; QL (2 PSP KIT 10 MG/0.2ML, 20 MG/0.4ML (adalimumab) injections per 28 days) HUMIRA SUBCUTANEOUS PREFILLED SYRINGE PA; SP Pharmacy; QL (6 PSP KIT 40 MG/0.4ML (adalimumab) syringes per 1 month) HUMIRA SUBCUTANEOUS PREFILLED SYRINGE PA; SP Pharmacy; QL (6 PSP KIT 40 MG/0.8ML (adalimumab) injections per 28 days) ILARIS SUBCUTANEOUS SOLUTION (canakinumab) NPSP PA; SP Pharmacy KEVZARA SUBCUTANEOUS SOLUTION AUTO- PSP INJECTOR (sarilumab) KEVZARA SUBCUTANEOUS SOLUTION PREFILLED QL (2 injections per 1 PSP SYRINGE (sarilumab) month) KINERET SUBCUTANEOUS SOLUTION PREFILLED NC SYRINGE (anakinra) OLUMIANT (baricitinib) NC ORENCIA CLICKJECT (abatacept) NC ORENCIA SUBCUTANEOUS SOLUTION PREFILLED NC SYRINGE (abatacept) PA; SP Pharmacy; QL (1 RINVOQ (upadacitinib) PSP tablet per 1 day) SIMPONI SUBCUTANEOUS SOLUTION AUTO- NPSP PA; ST; QL (1 pen per 1 fill) INJECTOR (golimumab) SIMPONI SUBCUTANEOUS SOLUTION PREFILLED NPSP PA; ST; QL (1 pen per 1 fill) SYRINGE (golimumab) PA; SP Pharmacy; QL (1 SKYRIZI (risankizumab-rzaa) PSP syringe per 84 days) SKYRIZI (150 MG DOSE) (risankizumab-rzaa) PSP PA; SP Pharmacy; QL (1 SKYRIZI PEN (risankizumab-rzaa) PSP syringe per 84 days) STELARA SUBCUTANEOUS SOLUTION 45 MG/0.5ML PA; ST; SP Pharmacy; QL PSP (ustekinumab) (2 vials per 90 days)

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 137 Drug Name Drug Status Drug Details STELARA SUBCUTANEOUS SOLUTION PREFILLED PA; SP Pharmacy; QL (2 PSP SYRINGE 45 MG/0.5ML (ustekinumab) syringes per 90 days) STELARA SUBCUTANEOUS SOLUTION PREFILLED PA; SP Pharmacy; QL (2 PSP SYRINGE 90 MG/ML (ustekinumab) syringes per 60 days) TALTZ (ixekizumab) PSP TREMFYA (guselkumab) PSP PA; SP Pharmacy; QL (10 XELJANZ ORAL SOLUTION (tofacitinib citrate) PSP ML per 1 day) PA; SP Pharmacy; QL (2 XELJANZ ORAL TABLET 10 MG (tofacitinib citrate) PSP tablets per 1 Day) XELJANZ ORAL TABLET 5 MG (tofacitinib citrate) PSP PA; QL (2 tabs per 1 day) XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 PSP PA; QL (1 tablet per 1 day) HOUR 11 MG (tofacitinib citrate) XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 PA; SP Pharmacy; QL (1 PSP HOUR 22 MG (tofacitinib citrate) tablet per 1 day) DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS) - DRUGS TO TREAT RHEUMATOID ARTHRITIS ARAVA (leflunomide) NC hydroxychloroquine sulfate oral PG leflunomide oral PG PA; SP Pharmacy; QL (2 OTEZLA ORAL TABLET (apremilast) PSP tablets per 1 day) PA; SP Pharmacy; QL (1 OTEZLA ORAL TABLET THERAPY PACK (apremilast) PSP pack per 1 year) OTREXUP SUBCUTANEOUS SOLUTION AUTO- INJECTOR 10 MG/0.4ML, 12.5 MG/0.4ML, 15 MG/0.4ML, NC 17.5 MG/0.4ML, 20 MG/0.4ML, 22.5 MG/0.4ML, 25 MG/0.4ML (methotrexate (anti-rheumatic)) PLAQUENIL (hydroxychloroquine sulfate) NC RASUVO SUBCUTANEOUS SOLUTION AUTO- INJECTOR 10 MG/0.2ML, 12.5 MG/0.25ML, 15 MG/0.3ML, 17.5 MG/0.35ML, 20 MG/0.4ML, 22.5 NC MG/0.45ML, 25 MG/0.5ML, 30 MG/0.6ML, 7.5 MG/0.15ML (methotrexate (anti-rheumatic)) REDITREX (methotrexate (anti-rheumatic)) NC IMMUNOGLOBULIN ASCENIV (immune globulin (human)-slra) NC

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 138 Drug Name Drug Status Drug Details CARIMUNE NF INTRAVENOUS SOLUTION RECONSTITUTED 12 GM, 6 GM (immune globulin NC (human)) CUTAQUIG (immune globulin (human)-hipp) NC CUVITRU SUBCUTANEOUS SOLUTION 1 GM/5ML, 2 GM/10ML, 4 GM/20ML, 8 GM/40ML (immune globulin NPSP PA; ST; SP Pharmacy (human)) CUVITRU SUBCUTANEOUS SOLUTION 10 GM/50ML NC (immune globulin (human)) GAMASTAN (immune globulin (human)) NC GAMASTAN S/D INTRAMUSCULAR INJECTABLE NC (immune globulin (human)) GAMMAGARD (immune globulin (human)) NC GAMMAGARD S/D LESS IGA (immune globulin (human)) NC GAMMAKED (immune globulin (human)) NC GAMUNEX-C (immune globulin (human)) PSP PA; SP Pharmacy HIZENTRA SUBCUTANEOUS SOLUTION 1 GM/5ML, 10 GM/50ML, 2 GM/10ML, 4 GM/20ML (immune globulin PSP PA; SP Pharmacy (human)) HIZENTRA SUBCUTANEOUS SOLUTION PREFILLED NC SYRINGE (immune globulin (human)) HYPERRAB (rabies immune globulin) NC HYQVIA (immune globulin-hyaluronidase) PSP PA; SP Pharmacy OCTAGAM INTRAVENOUS SOLUTION 30 GM/300ML PSP PA (immune globulin (human)) PANZYGA (immune globulin (human)-ifas) NC XEMBIFY (immune globulin (human)-klhw) NC IMMUNOMODULATORS ACTIMMUNE (interferon gamma-1b) PSP PA; SP Pharmacy PA; SP Pharmacy; QL (8 ARCALYST (rilonacept) PSP vials per 28 days) INTRON A (interferon alfa-2b) PSP PA; SP Pharmacy PA; #; SP Pharmacy; N2 POMALYST (pomalidomide) CE (PSP); QL (21 capsules per 28 days) REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 5 PA; #; SP Pharmacy; N2 CE MG (lenalidomide) (PSP); QL (1 cap per 1 day)

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 139 Drug Name Drug Status Drug Details PA; #; SP Pharmacy; N2 REVLIMID ORAL CAPSULE 20 MG, 25 MG CE (PSP); QL (21 capsules per 1 (lenalidomide) month) THALOMID ORAL CAPSULE 100 MG, 50 MG PA; #; SP Pharmacy; QL (1 PSP (thalidomide) capsule per 1 day) THALOMID ORAL CAPSULE 150 MG, 200 MG PA; #; SP Pharmacy; QL (2 PSP (thalidomide) capsules per 1 day) IMMUNOSUPPRESSANTS ASTAGRAF XL (tacrolimus) NC # AZASAN (azathioprine) NP azathioprine oral PG PA; ST; SP Pharmacy; QL BENLYSTA SUBCUTANEOUS (belimumab) NPSP (4 injections per 1 month) CELLCEPT ORAL CAPSULE (mycophenolate mofetil) NC CELLCEPT ORAL TABLET (mycophenolate mofetil) NC cyclosporine modified oral capsule PG cyclosporine modified oral solution PG SP Pharmacy cyclosporine oral capsule PG ENSPRYNG (satralizumab-mwge) NC ENVARSUS XR (tacrolimus) NC everolimus oral tablet 0.25 mg, 0.5 mg, 0.75 mg PG gengraf oral capsule 100 mg, 25 mg PG SP Pharmacy cyclosporine modified (Gengraf Oral Capsule 50 Mg) PG SP Pharmacy gengraf oral solution PG SP Pharmacy IMURAN (azathioprine) NC LUPKYNIS (voclosporin) NC mycophenolate mofetil oral PG mycophenolate sodium PG MYFORTIC (mycophenolate sodium) NC NEORAL (cyclosporine modified) NC PROGRAF ORAL PACKET (tacrolimus) NP RAPAMUNE ORAL SOLUTION () NPSP SP Pharmacy SANDIMMUNE ORAL CAPSULE (cyclosporine) NC SANDIMMUNE ORAL SOLUTION (cyclosporine) NP sirolimus oral PG tacrolimus oral PG 2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 140 Drug Name Drug Status Drug Details ZORTRESS ORAL TABLET 0.25 MG, 0.5 MG, 0.75 MG NPSP (everolimus) ZORTRESS ORAL TABLET 1 MG (everolimus) PB MEDICAL DEVICES CONTRACEPTIVES - PRODUCTS FOR BIRTH CONTROL FC FEMALE CONDOM (condoms - female) CE N2 (Not Covered) FC2 FEMALE CONDOM (condoms - female) CE N2 (Not Covered) FEMCAP (cervical caps) CE N2 (NP) N2 (NP); QL (1 diaphragm WIDE-SEAL DIAPHRAGM 60 (diaphragm wide seal) CE per 1 year) N2 (NP); QL (1 diaphragm WIDE-SEAL DIAPHRAGM 65 (diaphragm wide seal) CE per 1 year) N2 (NP); QL (1 diaphragm WIDE-SEAL DIAPHRAGM 70 (diaphragm wide seal) CE per 1 year) N2 (NP); QL (1 diaphragm WIDE-SEAL DIAPHRAGM 75 (diaphragm wide seal) CE per 1 year) N2 (NP); QL (1 diaphragm WIDE-SEAL DIAPHRAGM 80 (diaphragm wide seal) CE per 1 year) N2 (NP); QL (1 diaphragm WIDE-SEAL DIAPHRAGM 85 (diaphragm wide seal) CE per 1 year) N2 (NP); QL (1 diaphragm WIDE-SEAL DIAPHRAGM 90 (diaphragm wide seal) CE per 1 year) N2 (NP); QL (1 diaphragm WIDE-SEAL DIAPHRAGM 95 (diaphragm wide seal) CE per 1 year) DIABETES THERAPY NOVOFINE AUTOCOVER PEN NEEDLE (insulin pen PB needle) NOVOFINE PEN NEEDLE (insulin pen needle) PB NOVOTWIST PEN NEEDLE (insulin pen needle) PB DIABETIC SUPPLIES 1st tier unifine pentips 29g x 12mm , 31g x 5 mm , 31g x 6 mm , PB 31g x 8 mm , 32g x 4 mm 1st tier unifine pentips plus 31g x 8 mm PB 1ST TIER UNILET COMFORTOUCH PB ACCU-CHEK AVIVA PLUS IN VITRO (glucose blood) PB QL (300 strips per 30 days) ACCU-CHEK COMPACT PLUS (glucose blood) PB QL (300 strips per 30 days)

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 141 Drug Name Drug Status Drug Details ACCU-CHEK FASTCLIX LANCETS (lancets) PB ACCU-CHEK GUIDE IN VITRO (glucose blood) PB QL (300 strips per 30 days) ACCU-CHEK MULTICLIX LANCETS (lancets) PB ACCU-CHEK SAFE-T PRO LANCETS (lancets) PB ACCU-CHEK SMARTVIEW (glucose blood) PB QL (300 strips per 30 days) ACCU-CHEK SOFT TOUCH LANCETS (lancets) PB ACCU-CHEK SOFTCLIX LANCET DEV KIT (lancets PB misc.) ACCU-CHEK SOFTCLIX LANCETS (lancets) PB PA; QL (300 strips per 30 ACCUTREND GLUCOSE (glucose blood) NP days) ACCUTREND GLUCOSE CONTROL (blood glucose NC calibration) ACTI-LANCE 28G PB ACTI-LANCE LITE LANCETS 28G PB ACTI-LANCE SPECIAL LANCETS 17G PB ACTI-LANCE UNIVERSAL 23G PB adjustable lancing device NP PA; QL (300 strips per 30 ADVANCE INTUITION TEST (glucose blood) NP days) ADVOCATE INSULIN PEN NEEDLES 31G X 5 MM , NP 31G X 8 MM (insulin pen needle) ADVOCATE INSULIN SYRINGE (insulin syringe-needle u- NP 100) ADVOCATE LANCETS (lancets) NP ADVOCATE RAPID-SAFE LANCING (lancet devices) PB PA; QL (300 strips per 30 ADVOCATE REDI-CODE IN VITRO (glucose blood) NP days) PA; QL (300 strips per 30 ADVOCATE REDI-CODE+ TEST (glucose blood) NP days) ADVOCATE SAFETY LANCETS (lancets) PB PA; QL (300 strips per 30 ADVOCATE TEST (glucose blood) NP days) PA; QL (300 strips per 30 AGAMATRIX AMP TEST (glucose blood) NP days) PA; QL (300 strips per 30 AGAMATRIX JAZZ TEST (glucose blood) NP days)

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 142 Drug Name Drug Status Drug Details PA; QL (300 strips per 30 AGAMATRIX KEYNOTE TEST (glucose blood) NP days) PA; QL (300 strips per 30 AGAMATRIX PRESTO TEST (glucose blood) NP days) AGAMATRIX ULTRA-THIN LANCETS (lancets) PB alcohol swabs pad NP alternate site lancing device NP anti-stick insulin syringe 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml PG PA; QL (300 strips per 30 ASSURE 3 TEST (glucose blood) NP days) PA; QL (300 strips per 30 ASSURE 4 TEST (glucose blood) NP days) ASSURE COMFORT LANCETS 28G PB ASSURE COMFORT LANCETS 30G NP ASSURE HAEMOLANCE PLUS HIGH (lancets) PB ASSURE HAEMOLANCE PLUS LOW (lancets) PB ASSURE HAEMOLANCE PLUS MICRO (lancets) PB ASSURE HAEMOLANCE PLUS NORMAL (lancets) PB ASSURE HAEMOLANCE PLUS PED (lancets) PB ASSURE ID INSULIN SAFETY SYR (insulin syringe-needle PB u-100) ASSURE LANCE LANCETS (lancets) PB ASSURE LANCETS (lancets) PB PA; QL (300 strips per 30 ASSURE PLATINUM (glucose blood) NP days) PA; QL (300 strips per 30 ASSURE PRO TEST (glucose blood) NP days) AURORA LANCET SUPER THIN 30G PB AURORA LANCET THIN 23G PB AURORA PEN NEEDLES NP aurora unifine pentips 31g x 5 mm PB AURORA UNIFINE PENTIPS 32G X 4 MM NP PA; QL (300 strips per 30 BAYER BREEZE 2 TEST (glucose blood) NP days) PA; QL (300 strips per 30 BAYER CONTOUR NEXT TEST (glucose blood) NP days)

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 143 Drug Name Drug Status Drug Details PA; QL (300 strips per 30 BAYER CONTOUR TEST (glucose blood) NP days) BAYER MICROLET LANCETS (lancets) PB BD AUTOSHIELD 29G X 5MM , 29G X 8MM (insulin pen PB needle) BD INSULIN SYR ULTRAFINE II 31G X 5/16" 0.5 ML PB (insulin syringe-needle u-100) BD INSULIN SYR ULTRAFINE II 31G X 5/16" 1 ML PB (insulin syringe-needle u-100) BD INSULIN SYRINGE 25G X 1" 1 ML, 25G X 5/8" 1 ML, 26G X 1/2" 1 ML, 27G X 1/2" 1 ML, 29G X 1/2" 1 ML (insulin PB syringe-needle u-100) BD INSULIN SYRINGE 30G X 1/2" 0.5 ML (insulin syringe- PB needle u-100) BD INSULIN SYRINGE HALF-UNIT (insulin syringe- PB needle u-100) BD INSULIN SYRINGE MICROFINE 27G X 5/8" 1 ML, 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML (insulin syringe-needle PB u-100) BD INSULIN SYRINGE U/F 30G X 1/2" 1 ML, 31G X PB 5/16" 0.3 ML (insulin syringe-needle u-100) BD INSULIN SYRINGE U-100 1 ML (insulin syringes PB (disposable)) BD INSULIN SYRINGE ULTRAFINE (insulin syringe- PB needle u-100) BD LANCET ULTRAFINE 30G (lancets) PB BD LANCET ULTRAFINE 33G (lancets) PB BD MICROTAINER LANCETS (lancets) PB BD PEN NEEDLE MINI U/F (insulin pen needle) PB BD PEN NEEDLE NANO U/F (insulin pen needle) PB BD PEN NEEDLE ORIGINAL U/F (insulin pen needle) PB BD PEN NEEDLE SHORT U/F (insulin pen needle) PB BD SAFETYGLIDE INSULIN SYRINGE 30G X 5/16" 0.5 PB ML, 31G X 5/16" 0.3 ML (insulin syringe-needle u-100) BD SAFETY-LOK INSULIN SYRINGE (insulin syringe- PB needle u-100) BD VEO INSULIN SYR U/F 1/2UNIT (insulin syringe-needle PB u-100)

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 144 Drug Name Drug Status Drug Details BD VEO INSULIN SYRINGE U/F (insulin syringe-needle u- PB 100) blood NC BULLSEYE MINI SAFETY LANCETS PB CAREFINE PEN NEEDLES 31G X 6 MM (insulin pen PB needle) CAREONE LANCET SUPER THIN 30G (lancets) PB CAREONE LANCET THIN 23G PB CAREONE LANCET ULTRA THIN 28G PB CAREONE UNIFINE PENTIPS NP PA; QL (300 strips per 30 CARESENS N GLUCOSE TEST (glucose blood) NP days) CHEK-STIX CONTROL ( (urine) test) NP CHEMSTRIP 10 MD (multiple urine tests) NP CHEMSTRIP 10/SG (multiple urine tests) NP CHEMSTRIP 2 GP (multiple urine tests) NP CHEMSTRIP 5 OB (multiple urine tests) NP CHEMSTRIP 7 (multiple urine tests) NP CHEMSTRIP 9 (multiple urine tests) NP CHEMSTRIP K (acetone (urine) test) NP CHEMSTRIP UGK (urine glucose-ketones test) NP PA; QL (300 strips per 30 CLEVER CHEK AUTO-CODE TEST (glucose blood) NP days) CLEVER CHEK AUTO-CODE VOICE IN VITRO (glucose PA; QL (300 strips per 30 NP blood) days) CLEVER CHEK LANCETS (lancets) PB PA; QL (300 strips per 30 CLEVER CHEK TEST (glucose blood) NP days) PA; QL (300 strips per 30 CLEVER CHOICE AUTO-CODE TEST (glucose blood) NP days) PA; QL (300 strips per 30 CLEVER CHOICE MICRO TEST (glucose blood) NP days) CLICKFINE PEN NEEDLES 31G X 6 MM NP clickfine pen needles 31g x 8 mm PB COMBISTIX (multiple urine tests) NP COMFORT ASSURED LANCETS 28G PB

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 145 Drug Name Drug Status Drug Details COMFORT ASSURED LANCETS 33G PB COMFORT EZ INSULIN SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, NP 30G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML (insulin syringe-needle u-100) COMFORT EZ INSULIN SYRINGE 31G X 5/16" 0.5 ML, PB 31G X 5/16" 1 ML (insulin syringe-needle u-100) COMFORT EZ PEN NEEDLES 31G X 5 MM , 31G X 6 PB MM (insulin pen needle) COMFORT EZ PEN NEEDLES 31G X 8 MM (insulin pen NP needle) COMFORT LANCETS PB DEXCOM G4 PLAT PED RCV/SHARE DEVICE PB (continuous blood gluc receiver) DEXCOM G4 PLAT PED RECEIVER DEVICE (continuous PB blood gluc receiver) DEXCOM G4 PLATINUM RCV/SHARE DEVICE PB (continuous blood gluc receiver) DEXCOM G4 PLATINUM RECEIVER DEVICE PB (continuous blood gluc receiver) DEXCOM G4 PLATINUM TRANSMITTER (continuous PB blood gluc transmit) DEXCOM G4 SENSOR (continuous blood gluc sensor) PB DEXCOM G5 MOB/G4 PLAT SENSOR (continuous blood PB gluc sensor) DEXCOM G5 MOBILE RECEIVER DEVICE (continuous PB blood gluc receiver) DEXCOM G5 MOBILE TRANSMITTER (continuous blood PB gluc transmit) DEXCOM G5 RECEIVER KIT (continuous blood gluc PB receiver) DEXCOM G6 RECEIVER (continuous blood gluc receiver) PB DEXCOM G6 SENSOR (continuous blood gluc sensor) PB DEXCOM G6 TRANSMITTER (continuous blood gluc PB transmit) DROPLET LANCETS ULTRA THIN 30G (lancets) PB

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 146 Drug Name Drug Status Drug Details EASY COMFORT INSULIN SYRINGE 30G X 5/16" 0.5 NP ML, 30G X 5/16" 1 ML EASY COMFORT LANCETS PB PA; QL (300 strips per 1 EASY PLUS II GLUCOSE TEST NP month) PA; QL (300 strips per 30 EASY STEP TEST (glucose blood) NP days) PA; QL (300 strips per 30 EASY TALK BLOOD GLUCOSE TEST NP days) EASY TOUCH INSULIN SAFETY SYR 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 1 ML (insulin syringe- NP needle u-100) EASY TOUCH INSULIN SYRINGE 27G X 1/2" 0.5 ML, PB 27G X 1/2" 1 ML (insulin syringe-needle u-100) EASY TOUCH INSULIN SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 30G X NP 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100) EASY TOUCH LANCETS 21G (lancets) PB EASY TOUCH LANCETS 23G (lancets) PB EASY TOUCH LANCETS 26G (lancets) PB EASY TOUCH LANCETS 28G (lancets) PB EASY TOUCH LANCETS 28G/TWIST (lancets) NP EASY TOUCH LANCETS 30G (lancets) PB EASY TOUCH LANCETS 30G/TWIST (lancets) NP EASY TOUCH LANCETS 32G (lancets) PB EASY TOUCH LANCETS 32G/TWIST (lancets) NP EASY TOUCH LANCETS 33G/TWIST (lancets) PB EASY TOUCH PEN NEEDLES 29G X 12MM , 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 5 MM , 32G X 6 PB MM (insulin pen needle) EASY TOUCH SAFETY LANCETS 21G (lancets) NP EASY TOUCH SAFETY LANCETS 23G (lancets) NP EASY TOUCH SAFETY LANCETS 26G (lancets) NP EASY TOUCH SAFETY LANCETS 28G (lancets) NP

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 147 Drug Name Drug Status Drug Details PA; QL (300 strips per 30 EASY TOUCH TEST (glucose blood) NP days) PA; QL (300 strips per 30 EASY TRAK BLOOD GLUCOSE TEST NP days) EASY TWIST & CAP LANCETS (lancets) NP PA; QL (300 strips per 30 EASYGLUCO IN VITRO (glucose blood) NP days) PA; QL (300 strips per 30 EASYMAX 15 TEST (glucose blood) NP days) PA; QL (300 strips per 30 EASYMAX TEST (glucose blood) NP days) PA; QL (300 strips per 30 EASYPLUS BLOOD GLUCOSE TEST NP days) PA; QL (300 strips per 30 EASYPRO PLUS IN VITRO (glucose blood) NP days) PA; QL (300 strips per 30 ELEMENT TEST (glucose blood) NP days) elite-thin insulin syringe 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 29g NP x 5/16" 1 ml elite-thin insulin syringe 29g x 5/16" 0.5 ml PB PA; QL (300 strips per 30 EMBRACE BLOOD GLUCOSE TEST (glucose blood) NP days) ENLITE GLUCOSE SENSOR (continuous blood gluc sensor) NC eq blood glucose test NC PA; QL (300 strips per 1 EVENCARE + BLOOD GLUCOSE TEST (glucose blood) NP month) PA; QL (300 strips per 30 EVENCARE BLOOD GLUCOSE TEST (glucose blood) NP days) PA; QL (300 strips per 30 EVENCARE G2 TEST (glucose blood) NP days) PA; QL (300 strips per 30 EVENCARE G3 TEST (glucose blood) NP days) EVERSENSE SENSOR (continuous blood gluc sensor) NC EVERSENSE SENSOR/HOLDER (continuous blood gluc NC sensor) EVERSENSE SMART TRANSMITTER (continuous blood NC gluc transmit) PA; QL (300 strips per 30 EVOLUTION AUTOCODE IN VITRO (glucose blood) NP days) 2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 148 Drug Name Drug Status Drug Details EXEL COMFORT POINT INSULIN SYR 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 30G X 5/16" 0.3 PB ML, 30G X 5/16" 1 ML (insulin syringe-needle u-100) EXEL COMFORT POINT INSULIN SYR 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.5 ML (insulin syringe- NP needle u-100) EXELDERM EXTERNAL SOLUTION (sulconazole nitrate) NC E-Z JECT LANCET MICRO-THIN 33G (lancets) PB E-Z JECT LANCET SUPER THIN 30G (lancets) PB E-Z JECT LANCETS (lancets) PB E-Z JECT LANCETS 21G (lancets) PB E-Z JECT LANCETS THIN 26G (lancets) PB EZ SMART BLOOD GLUCOSE LANCETS (lancets) PB PA; QL (300 strips per 30 EZ SMART BLOOD GLUCOSE TEST (glucose blood) NP days) PA; QL (300 strips per 30 EZ SMART PLUS GLUCOSE TEST (glucose blood) NP days) PA; QL (300 strips per 30 FIFTY50 GLUCOSE TEST 2.0 (glucose blood) NP days) FIFTY50 PEN NEEDLES 31G X 5 MM (insulin pen needle) PB FIFTY50 SAFETY SEAL LANCETS (lancets) PB FIFTY50 SUPERIOR COMFORT SYR (insulin syringe- NP needle u-100) FINE 30 (lancets) PB FINGERSTIX LANCETS (lancets) PB PA; QL (300 strips per 30 FORA D15G BLOOD GLUCOSE TEST (glucose blood) NP days) PA; QL (300 strips per 30 FORA D20 BLOOD GLUCOSE TEST (glucose blood) NP days) PA; QL (300 strips per 30 FORA G20 BLOOD GLUCOSE TEST (glucose blood) NP days) PA; QL (300 strips per 30 FORA G30/PREM V10 GLUCOSE TEST (glucose blood) NP days) PA; QL (300 strips per 30 FORA GD20 TEST (glucose blood) NP days) FORA LANCETS (lancets) PB PA; QL (300 strips per 30 FORA V10 BLOOD GLUCOSE TEST (glucose blood) NP days)

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 149 Drug Name Drug Status Drug Details PA; QL (300 strips per 30 FORA V12 BLOOD GLUCOSE TEST (glucose blood) NP days) PA; QL (300 strips per 30 FORA V20 BLOOD GLUCOSE TEST (glucose blood) NP days) PA; QL (300 strips per 30 FORA V30A BLOOD GLUCOSE TEST (glucose blood) NP days) PA; QL (300 strips per 30 FORACARE GD40 TEST (glucose blood) NP days) PA; QL (300 strips per 30 FORACARE PREMIUM V10 TEST (glucose blood) NP days) PA; QL (300 strips per 30 FREESTYLE INSULINX TEST (glucose blood) NP days) FREESTYLE LANCETS (lancets) NP FREESTYLE LIBRE 14 DAY READER (continuous blood NC gluc receiver) FREESTYLE LIBRE 14 DAY SENSOR (continuous blood NC gluc sensor) FREESTYLE LIBRE 2 READER (continuous blood gluc NC receiver) FREESTYLE LIBRE 2 SENSOR (continuous blood gluc NC sensor) FREESTYLE LIBRE READER (continuous blood gluc NC receiver) FREESTYLE LIBRE SENSOR SYSTEM (continuous blood NC gluc sensor) PA; QL (300 strips per 30 FREESTYLE LITE TEST (glucose blood) NP days) FREESTYLE PRECISION INS SYR (insulin syringe-needle NP u-100) PA; QL (300 strips per 30 FREESTYLE PRECISION NEO TEST (glucose blood) NP days) PA; QL (300 strips per 30 FREESTYLE TEST (glucose blood) NP days) FREESTYLE UNISTICK II LANCETS (lancets) PB PA; QL (300 strips per 30 GE100 BLOOD GLUCOSE TEST NP days) GLOBAL EASE INJECT PEN NEEDLES 29G X 12MM , NP 31G X 5 MM , 31G X 8 MM GLOBAL INJECT EASE INSULIN SYR NP 2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 150 Drug Name Drug Status Drug Details GLOBAL INJECT EASE LANCETS 28G PB GLOBAL INJECT EASE LANCETS 30G PB GLUCAGEN DIAGNOSTIC (glucagon hcl rdna NP QL (1 kit per 1 fill) (diagnostic)) PA; QL (300 strips per 30 GLUCOCARD 01 SENSOR PLUS (glucose blood) NP days) PA; QL (300 strips per 30 GLUCOCARD EXPRESSION TEST (glucose blood) NP days) PA; QL (300 strips per 30 GLUCOCARD VITAL TEST (glucose blood) NP days) PA; QL (300 strips per 30 GLUCOCARD X-SENSOR (glucose blood) NP days) GLUCOCOM LANCETS 28G (lancets) PB GLUCOCOM LANCETS 30G (lancets) PB GLUCOCOM LANCETS 33G (lancets) PB PA; QL (300 strips per 30 GLUCOCOM TEST (glucose blood) NP days) GLUCOPRO INSULIN SYRINGE (insulin syringe-needle u- NP 100) GOJJI BLOOD GLUCOSE TEST (glucose blood) NC GUARDIAN CONNECT TRANSMITTER (continuous NC blood gluc transmit) GUARDIAN LINK 3 TRANSMITTER (continuous blood NC gluc transmit) GUARDIAN SENSOR (3) (continuous blood gluc sensor) NC HAEMOLANCE (lancets) PB HAEMOLANCE LOW FLOW LANCETS (lancets) PB HAEMOLANCE PLUS (lancets) PB HAEMOLANCE PLUS HIGH FLOW (lancets) PB HAEMOLANCE PLUS LOW FLOW (lancets) PB HAEMOLANCE PLUS MAX FLOW (lancets) PB HAEMOLANCE PLUS PEDIATRIC FLOW (lancets) PB HEALTHWISE MINI PEN NEEDLES NP HEALTHWISE PEN NEEDLES NP HEALTHWISE SHORT PEN NEEDLES 31G X 8 MM NP HEALTHWISE UNIFINE PENTIPS NP

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 151 Drug Name Drug Status Drug Details HEALTHY ACCENTS UNIFINE PENTIP 29G X 12MM , NP 31G X 5 MM , 31G X 6 MM , 31G X 8 MM HEALTHY ACCENTS UNILET LANCETS PB HEMA-COMBISTIX (multiple urine tests) NP HM ULTICARE INSULIN SYRINGE 31G X 5/16" 0.3 ML PB (insulin syringe-needle u-100) PA; QL (300 strips per 30 INFINITY BLOOD GLUCOSE TEST (glucose blood) NP days) PA; QL (300 strips per 30 INFINITY VOICE IN VITRO STRIP (glucose blood) NP days) insulin syringe NP insulin syringe/needle NP insulin syringe-needle u-100 31g x 1/4" 0.3 ml, 31g x 1/4" 0.5 ml, NP 31g x 1/4" 1 ml insupen pen needles 32g x 4 mm PB INSUPEN SENSITIVE (insulin pen needle) PB INSUPEN ULTRAFIN 30G X 8 MM , 31G X 6 MM , 31G PB X 8 MM (insulin pen needle) KETOCARE (acetone (urine) test) NP KETO-DIASTIX (urine glucose-ketones test) NP ketone test NP KETOSTIX (acetone (urine) test) NP KINNEY LANCETS PB KINNEY THIN LANCETS PB kinray insulin syringe NP kroger blood glucose test NC LABSTIX (multiple urine tests) NP lancet device NP lancet transporter case NP lancets NP lancets 28g PG lancets 30g NP lancets thin NP LANCETS ULTRA FINE (lancets) PB LANCETS ULTRA THIN (lancets) PB LANCETS ULTRA THIN 30G PB

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 152 Drug Name Drug Status Drug Details lancing device NP LEADER INSULIN SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X NP 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 1 ML leader insulin syringe 30g x 5/16" 0.5 ml, 31g x 5/16" 0.3 ml, 31g NP x 5/16" 0.5 ml, 31g x 5/16" 1 ml LEADER UNIFINE PENTIPS (insulin pen needle) NP PA; QL (300 strips per 30 LIBERTY NEXT GENERATION TEST (glucose blood) NP days) PA; QL (300 strips per 30 LIBERTY TEST NP days) LITE TOUCH LANCETS PB LITE TOUCH PEN NEEDLES (insulin pen needle) NP LITETOUCH INSULIN SYRINGE (insulin syringe-needle u- NP 100) LITETOUCH PEN NEEDLES 29G X 12.7MM , 31G X 8 PB MM (insulin pen needle) LIVE BETTER LANCET SUPER THIN NP LIVE BETTER LANCET ULTRA THIN PB longs insulin syringe 31g x 5/16" 0.5 ml NP LONGS LANCETS STANDARD PB LONGS LANCETS THIN PB LONGS LANCETS ULTRA THIN PB MAGELLAN INSULIN SAFETY SYR 29G X 1/2" 0.3 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML PB (insulin syringe-needle u-100) MAGELLAN INSULIN SAFETY SYR 29G X 1/2" 0.5 ML, NP 29G X 1/2" 1 ML (insulin syringe-needle u-100) MAXI-COMFORT INSULIN SYRINGE (insulin syringe- NP needle u-100) MEDISENSE THIN LANCETS (lancets) PB MEDLANCE EXTRA 21G (lancets) PB MEDLANCE LITE 25G (lancets) PB MEDLANCE PLUS EXTRA 21G (lancets) PB MEDLANCE PLUS LANCETS (lancets) PB MEDLANCE PLUS LITE 25G (lancets) PB MEDLANCE PLUS SUPERLITE 30G (lancets) PB

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 153 Drug Name Drug Status Drug Details MEDLANCE PLUS UNIVERSAL 21G (lancets) PB MEDLANCE UNIVERSAL 21G (lancets) PB PA; QL (300 strips per 30 MICRODOT TEST (glucose blood) NP days) MICROLET LANCETS (lancets) PB MONOJECT INSULIN SYRINGE 25G X 5/8" 1 ML, 27G X PB 1/2" 1 ML (insulin syringe-needle u-100) MONOJECT INSULIN SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X NP 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100) MONOJECT INSULIN SYRINGE U-100 1 ML (insulin PB syringes (disposable)) MONOJECT ULTRA COMFORT SYRINGE 28G X 1/2" PB 0.5 ML, 28G X 1/2" 1 ML (insulin syringe-needle u-100) MONOJECT ULTRA COMFORT SYRINGE 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" NP 0.3 ML, 30G X 5/16" 0.5 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML (insulin syringe-needle u-100) MONOLET LANCETS (lancets) PB ms insulin syringe 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x NP 5/16" 1 ml multi-lancet device NP MULTISTIX (multiple urine tests) NP MULTISTIX 10 SG (multiple urine tests) NP MULTISTIX 5 (multiple urine tests) NP MULTISTIX 7 (multiple urine tests) NP MULTISTIX 8 (multiple urine tests) NP MULTISTIX 9 (multiple urine tests) NP MULTISTIX 9 SG (multiple urine tests) NP MYGLUCOHEALTH LANCETS 30G (lancets) PB PA; QL (300 strips per 30 MYGLUCOHEALTH TEST (glucose blood) NP days) PA; QL (300 strips per 30 NEUTEK 2TEK TEST (glucose blood) NP days) PA; QL (300 strips per 30 NOVA MAX GLUCOSE TEST (glucose blood) NP days) NOVA SAFETY LANCETS 23G (lancets) PB

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 154 Drug Name Drug Status Drug Details NOVA SAFETY LANCETS 28G (lancets) PB NOVA SUREFLEX LANCETS (lancets) PB NOVOFINE 32G X 6 MM (insulin pen needle) PB NOVOFINE AUTOCOVER (insulin pen needle) PB NOVOTWIST 32G X 5 MM (insulin pen needle) PB OMNIPOD 10 PACK (insulin disposable pump) PB OMNIPOD DASH 5 PACK PODS (insulin disposable pump) PB OMNIPOD DASH SYSTEM (insulin disposable pump) PB OMNIPOD STARTER (insulin disposable pump) PB ON CALL LANCETS (lancets) PB PA; QL (300 strips per 30 ON CALL PLUS BLOOD GLUCOSE (glucose blood) NP days) ON CALL PLUS LANCETS (lancets) PB PA; QL (300 strips per 30 ON CALL VIVID BLOOD GLUCOSE (glucose blood) NP days) ONETOUCH CLUB LANCETS FINE PT (lancets) PB ONETOUCH DELICA LANCETS 30G (lancets) PB ONETOUCH DELICA LANCETS 33G (lancets) PB ONETOUCH DELICA LANCETS FINE (lancets) NP ONETOUCH DELICA LANCING DEV (lancet devices) PB ONETOUCH DELICA SAFETY LANCING (lancet devices) PB ONETOUCH FINEPOINT LANCETS (lancets) NP ONETOUCH LANCETS (lancets) NP ONETOUCH SURESOFT LANCING DEV (lancets misc.) PB PA; QL (300 strips per 30 ONETOUCH ULTRA (glucose blood) NP days) PA; QL (300 strips per 30 ONETOUCH ULTRA BLUE (glucose blood) NP days) ONETOUCH ULTRASOFT LANCETS (lancets) PB PA; QL (300 strips per 30 ONETOUCH VERIO IN VITRO STRIP (glucose blood) NP days) pen needles 1/2" NP pen needles 29g x 12mm , 30g x 5 mm , 30g x 8 mm , 31g x 5 mm , 31g x 6 mm , 31g x 8 mm , 32g x 4 mm , 32g x 5 mm , 32g NP x 6 mm pen needles 3/16" NP

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 155 Drug Name Drug Status Drug Details pen needles 5/16" NP PA; QL (300 strips per 1 PHARMACIST CHOICE AUTOCODE (glucose blood) NP month) PHARMACIST CHOICE LANCETS (lancets) PB PA; QL (300 strips per 30 POCKETCHEM EZ TEST (glucose blood) NP days) POGO AUTOMATIC TEST CARTRIDGES (glucose blood) NC PA; QL (300 strips per 30 PRECISION PCX (glucose blood) NP days) PA; QL (300 strips per 30 PRECISION PCX PLUS TEST (glucose blood) NP days) PA; QL (300 strips per 30 PRECISION POINT OF CARE TEST (glucose blood) NP days) PA; QL (300 strips per 30 PRECISION QID TEST (glucose blood) NP days) PA; QL (300 strips per 30 PRECISION SOF-TACT TEST (glucose blood) NP days) PRECISION SUREDOSE PLUS SYR (insulin syringe-needle NP u-100) PRECISION SURE-DOSE SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.5 ML, 30G X 5/16" 0.3 ML NP (insulin syringe-needle u-100) PRECISION SURE-DOSE SYRINGE 30G X 3/8" 0.5 ML PB (insulin syringe-needle u-100) PRECISION THIN LANCETS (lancets) PB PRECISION ULTRA LANCET (lancets) PB PA; QL (300 strips per 30 PRECISION XTRA BLOOD GLUCOSE (glucose blood) NP days) PREFERRED PLUS INSULIN SYRINGE NP PREFERRED PLUS LANCETS COLORED PB PREFERRED PLUS LANCETS THIN PB PREFERRED PLUS UNIFINE PENTIPS NP PRODIGY INSULIN SYRINGE (insulin syringe-needle u- NP 100) PRODIGY LANCETS 28G (lancets) PB PRODIGY NO CODING BLOOD GLUC IN VITRO PA; QL (300 strips per 30 NP (glucose blood) days) PRODIGY TWIST TOP LANCETS 28G (lancets) NP

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 156 Drug Name Drug Status Drug Details QUINZYME (coenzyme q10) NC reality insulin syringe 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml NP PA; QL (300 strips per 1 REFUAH PLUS BLOOD GLUCOSE TEST (glucose blood) NP month) PA; QL (300 strips per 30 RELION BLOOD GLUCOSE TEST (glucose blood) NP days) RELI-ON INSULIN SYRINGE 29G 0.3 ML, 29G 0.5 ML, 30G 0.3 ML, 30G 0.5 ML, 30G 1 ML (insulin syringe-needle u- PB 100) RELION INSULIN SYRINGE 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G NP X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe-needle u- 100) RELI-ON INSULIN SYRINGE 29G X 1/2" 1 ML (insulin NP syringe-needle u-100) RELION KETONE (acetone (urine) test) NP RELION LANCETS STANDARD 21G (lancets) PB RELION LANCETS THIN 26G (lancets) PB RELION LANCETS ULTRA-THIN 30G (lancets) NP RELION MINI PEN NEEDLES (insulin pen needle) NP RELION PEN NEEDLES 29G X 12MM , 31G X 8 MM , PB 32G X 4 MM (insulin pen needle) RELION SHORT PEN NEEDLES (insulin pen needle) NP RELION ULTRA THIN LANCETS 30G (lancets) PB RELION ULTRA THIN PLUS LANCETS (lancets) PB PA; QL (300 strips per 1 REVEAL BLOOD GLUCOSE TEST (glucose blood) NP month) RIGHTEST GL300 LANCETS (lancets) PB PA; QL (300 strips per 1 RIGHTEST GS100 BLOOD GLUCOSE (glucose blood) NP month) PA; QL (300 strips per 1 RIGHTEST GS300 BLOOD GLUCOSE (glucose blood) NP month) PA; QL (300 strips per 1 RIGHTEST GS550 BLOOD GLUCOSE (glucose blood) NP month) SAFESNAP INSULIN SYRINGE (insulin syringe-needle u- NP 100) safety lancet 21g/pressure act NP

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 157 Drug Name Drug Status Drug Details safety lancet 28g/pressure act NP SAFETY LANCETS (lancets) PB SAFETY LANCETS 21G (lancets) NP safety lancets 28g NP SAFETY LET LANCETS (lancets) PB SAFETY SEAL LANCETS (lancets) PB SAFETY-GLIDE SYRINGE (insulin syringe-needle u-100) PB SHOPKO UNIFINE PENTIPS (insulin pen needle) NP SHOPKO UNILET LANCETS 28G (lancets) NP SHOPKO UNILET LANCETS 30G (lancets) NP SINGLE-LET (lancets) PB SMART SENSE COLOR LANCETS 33G (lancets) PB SMART SENSE STANDARD LANCETS (lancets) PB SMART SENSE SUPER THIN LANCETS (lancets) PB SMART SENSE THIN LANCETS 26G (lancets) PB PA; QL (300 strips per 30 SMARTEST BLOOD GLUCOSE TEST (glucose blood) NP days) SMARTEST LANCETS 28G (lancets) PB SOLUS V2 LANCETS 28G (lancets) PB PA; QL (300 strips per 30 SOLUS V2 TEST (glucose blood) NP days) SOLUS V2 TWIST LANCETS 30G (lancets) PB STERILANCE PA (lancets misc.) PB STERILANCE TL (lancets) PB SUPER THIN LANCETS NP SURE COMFORT INSULIN SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 NP ML, 30G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML SURE COMFORT LANCETS 28G NP SURE COMFORT LANCETS 30G PB sure comfort pen needles 29g x 12.7mm , 31g x 5 mm , 31g x 8 PB mm PA; QL (300 strips per 30 SURE EDGE TEST (glucose blood) NP days) 2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 158 Drug Name Drug Status Drug Details PA; QL (300 strips per 30 SURECHEK BLOOD GLUCOSE TEST (glucose blood) NP days) SURE-FINE PEN NEEDLES (insulin pen needle) PB SURE-JECT INSULIN SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X NP 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML (insulin syringe-needle u-100) SURE-LANCE FLAT LANCETS (lancets) PB SURE-LANCE THIN LANCETS 28G (lancets) NP SURE-LANCE ULTRA THIN LANCETS (lancets) NP PA; QL (300 strips per 30 SURE-TEST EASYPLUS MINI TEST (glucose blood) NP days) SURE-TOUCH LANCETS UNIVERSAL (lancets) PB TECHLITE AST LANCETS (lancets) PB TECHLITE LANCETS (lancets) PB TECHLITE LANCETS 30G (lancets) PB PA; QL (300 strips per 30 TELCARE BLOOD GLUCOSE TEST (glucose blood) NP days) THINLETS LANCET (lancets) PB topcare clickfine pen needles PB TOPCARE ULTRA COMFORT INS SYR NP TRUEPLUS INSULIN SYRINGE 28G X 1/2" 0.5 ML, 28G PB X 1/2" 1 ML (insulin syringe-needle u-100) TRUEPLUS INSULIN SYRINGE 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, NP 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100) TRUEPLUS LANCETS 28G (lancets) PB TRUEPLUS LANCETS 30G (lancets) PB TRUEPLUS LANCETS 33G (lancets) PB TRUEPLUS SAFETY LANCETS 28G (lancets) PB PA; QL (300 strips per 30 TRUETEST TEST (glucose blood) NP days) PA; QL (300 strips per 30 TRUETRACK TEST (glucose blood) NP days) ULTICARE INSULIN SAFETY SYR (insulin syringe-needle NP u-100)

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 159 Drug Name Drug Status Drug Details ULTICARE INSULIN SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X NP 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100) ULTICARE MICRO PEN NEEDLES 32G X 4 MM (insulin PB pen needle) ULTICARE MINI PEN NEEDLES 31G X 6 MM (insulin PB pen needle) ULTICARE PEN NEEDLES 29G X 12.7MM (insulin pen PB needle) ULTICARE PEN NEEDLES 29G X 12MM (insulin pen NP needle) ULTICARE SHORT PEN NEEDLES 31G X 8 MM (insulin PB pen needle) ULTILET CLASSIC LANCETS (lancets) PB ULTILET LANCETS (lancets) PB ULTILET SAFETY LANCETS 23G (lancets) PB PA; QL (300 strips per 30 ULTIMA TEST (glucose blood) NP days) ULTRA COMFORT INSULIN SYRINGE 30G X 5/16" 0.3 NP ML ULTRA-COMFORT INSULIN SYRINGE NP ULTRALANCE (lancets misc.) PB ULTRA-THIN II AUTO LANCET (lancets) PB ULTRA-THIN II INS SYR SHORT (insulin syringe-needle u- NP 100) ULTRA-THIN II INSULIN SYRINGE (insulin syringe- NP needle u-100) ULTRA-THIN II LANCETS (lancets) PB ULTRA-THIN II MINI PEN NEEDLE (insulin pen needle) NP ULTRA-THIN II PEN NEEDLE SHORT (insulin pen needle) NP ULTRA-THIN II PEN NEEDLES (insulin pen needle) PB PA; QL (300 strips per 30 ULTRATRAK PRO TEST (glucose blood) NP days) PA; QL (300 strips per 30 ULTRATRAK ULTIMATE TEST (glucose blood) NP days)

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 160 Drug Name Drug Status Drug Details UNIFINE PENTIPS 29G X 12MM , 31G X 5 MM , 31G X 6 NP MM , 31G X 8 MM , 32G X 4 MM (insulin pen needle) UNILET COMFORTOUCH LANCET (lancets) PB UNILET EXCELITE (lancets) PB UNILET EXCELITE II (lancets) PB UNILET G.P. LANCET (lancets) PB UNILET G.P. SUPERLITE LANCET (lancets) PB UNILET GP 28 ULTRA THIN (lancets) PB UNILET LANCET (lancets) PB UNILET SUPERLITE LANCET (lancets) PB UNISTIK 3 COMFORT (lancets misc.) PB UNISTIK 3 EXTRA (lancets misc.) PB UNISTIK 3 NORMAL (lancets misc.) PB UNISTIK CZT COMFORT (lancets misc.) PB UNISTIK CZT NORMAL (lancets misc.) PB UNIVERSAL 1 LANCETS THIN 26G (lancets) PB UNIVERSAL 1 LANCETS ULTRA THIN (lancets) PB URISTIX (multiple urine tests) NP URISTIX 4 (multiple urine tests) NP VALUE HEALTH INSULIN SYRINGE NP VALUE PLUS LANCET STANDARD 21G PB VALUE PLUS LANCETS SUPER THIN NP VALUE PLUS LANCETS THIN 26G NP VALUMARK LANCET SUPER THIN 30G PB VALUMARK LANCET ULTRA THIN 28G PB VALUMARK PEN NEEDLES NP VANISHPOINT INSULIN SYRINGE 29G X 1/2" 1 ML, NP 30G X 1/2" 0.5 ML (insulin syringe-needle u-100) V-GO 20 (insulin disposable pump) PB V-GO 30 (insulin disposable pump) PB V-GO 40 (insulin disposable pump) PB PA; QL (300 strips per 30 VICTORY AGM-4000 TEST (glucose blood) NP days) VIDA MIA UNIFINE PENTIPS 29G X 12MM , 31G X 6 NP MM , 31G X 8 MM (insulin pen needle) VIDA MIA UNILET LANCETS 28G (lancets) NP 2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 161 Drug Name Drug Status Drug Details VIDA MIA UNILET LANCETS 30G (lancets) NP PA; QL (300 strips per 30 VOCAL POINT BLOOD GLUCOSE TEST (glucose blood) NP days) PA; QL (300 strips per 1 WAVESENSE PRESTO (glucose blood) NP month) MISCELLANEOUS AEROCHAMBER PLUS FLO-VU (spacer/aero-holding PB chambers) FLEXICHAMBER ADULT MASK/SMALL (spacer/aero- PB hold chamber mask) OPTICHAMBER FACE MASK-LARGE (spacer/aero- PB holding chambers) PEDIATRIC PANDA MASK (spacer/aero-hold chamber PB mask) NUTRITIONAL/SUPPLEMENTS - VITAMINS AND SUPPLEMENTS ELECTROLYTES av-phos 250 neutral PG EFFER-K ORAL TABLET EFFERVESCENT 10 MEQ, 20 NP MEQ (potassium bicarb-citric acid) effer-k oral tablet effervescent 25 meq PG effervescent pot chloride PG GALZIN (zinc acetate (oral)) NP iodine strong oral NC k-effervescent NP potassium chloride (Klor-Con 10) PG potassium chloride crys er (Klor-Con M10) PG potassium chloride crys er (Klor-Con M15) PG klor-con m20 PG potassium chloride (Klor-Con Oral Tablet Extended Release) PG potassium chloride (Klor-Con Sprinkle) PG potassium bicarbonate (Klor-Con/Ef) PG K-PHOS (potassium phosphate monobasic) NP K-PHOS-NEUTRAL (k phos mono-sod phos di & mono) NC k-prime PG K-TAB (potassium chloride) NC

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 162 Drug Name Drug Status Drug Details k-vescent oral tablet effervescent NP MAGNEBIND 400 ORAL TABLET 400-200-1 MG NC (magnesium-calcium-folic acid) MICRO-K (potassium chloride) NC phospha 250 neutral PG pot bicarb-pot chloride PG potassium bicarbonate oral NP potassium chloride crys er oral tablet extended release 10 meq, PG 20 meq potassium chloride er PG potassium chloride oral packet NP potassium chloride oral solution 20 meq/15ml (10%) NP potassium chloride oral solution 40 meq/15ml (20%) PG virt-phos 250 neutral PG VITAMINS - VITAMINS AND SUPPLEMENTS ACCRUFER (ferric maltol) NC APPTRIM (dietary manage prod - diet aid) NC APPTRIM-D (dietary manage prod - diet aid) NC AVAILNEX (carbocysteine) NC AXONA (dietary management product) NC azeschew prenatal/postnatal NC azesco NC b-6 oral tablet 50 mg PG BAL-CARE DHA (prenat-fepoly-fered-fa-omega 3) NP bp folinatal plus b PG bp multinatal plus oral tablet chewable PG CALCIFOL (ca carb-fa-d-b6-b12-boron-mg) NC calcium pnv NP calcium-folic acid plus d NC CARDIOTEK RX ORAL TABLET (fa-b6-b12-arginine- NC blackpepper) CARDIOVID PLUS (dha-epa-vit b6-b12-folic acid) NC CEREFOLIN (l-methylfolate-b12-b6-b2) NC CEREFOLIN NAC (methylfol-algae-b12-acetylcyst) NC CITRANATAL 90 DHA ORAL 90-1 & 300 MG (prenat w/o NP a-fecbgl-dss-fa-dha) 2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 163 Drug Name Drug Status Drug Details CITRANATAL ASSURE ORAL 35-1 & 300 MG (prenat w/o NP a-fecbgl-dss-fa-dha) CITRANATAL B-CALM (prenat w/o a fecbnfeglu-fa &b6) NP CITRANATAL ESSENCE (prenat w/o a-fecbgl-fa-dha) NC CITRANATAL MEDLEY (prenat-fecb-fefum-fa-dha w/o a) NP CITRANATAL RX (prenat w/o a-fecb-fegl-dss-fa) NP complete natal dha NP completenate NP co-natal fa NP CONCEPT DHA (prenat-fefum-fepo-fa-omega 3) NP CONCEPT OB (prenat w/o a vit-fefum-fepo-fa) NP cyanocobalamin injection solution 1000 mcg/ml PG DECARA K (vitamin d-vitamin k) NC DECARA ORAL CAPSULE 625 MCG (25000 UT) CE N2 (Not Covered) (cholecalciferol) DEPLIN 15 (l-methylfolate-algae) NC DEPLIN 7.5 (l-methylfolate-algae) NC DIALYVITE 3000 (b complex-c-biotin-e-min-fa) NC DIALYVITE 5000 (b complex-c-biotin-e-min-fa) NC DIALYVITE SUPREME D (multiple vitamins-minerals-fa) NC DIALYVITE/ZINC (b complex-c-zn-folic acid) NC DUET DHA BALANCED ORAL 25-1 & 267 MG (prenat- NP fepoly-fered-fa-omega 3) elite-ob PG ENLYTE (dietary management product) NC ENTERAGAM (sbi/protein isolate) NC ergocal NP oral capsule PG FLORIVA ORAL LIQUID (sodium fluoride-vitamin d) NP N2 (NP); AL (Min 6 Years FLUORABON (sodium fluoride) CE and Max 16 Years) FLUOR-A-DAY ORAL TABLET CHEWABLE (sodium NP fluoride-xylitol) N2 (PG); AL (Min 6 Years fluoritab oral solution CE and Max 16 Years)

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 164 Drug Name Drug Status Drug Details LGC; N2 (PG); AL (Min 6 fluoritab oral tablet chewable 0.55 (0.25 f) mg CE Years and Max 16 Years) N2 (PG); AL (Min 6 Years fluoritab oral tablet chewable 1.1 (0.5 f) mg CE and Max 16 Years) fluoritab oral tablet chewable 2.2 (1 f) mg PG FLURA-DROPS ORAL SOLUTION 0.55 (0.25 F) N2 (NP); AL (Min 6 Years CE MG/DROP (sodium fluoride) and Max 16 Years) folate CE N2 (Not Covered) FOLBEE PLUS CZ (b-complex-c-biotin-minerals-fa) PG FOLBIC RF (l-methylfolate-b6-b12) NC FOLCAL DHA ORAL CAPSULE 27-1.25-300 MG NP FOLCAPS OMEGA 3 ORAL CAPSULE 27-1 MG (prenatal- NP fecbn-feaspgl-fa-omeg) folic acid oral capsule 0.8 mg CE N2 (Not Covered) folic acid oral tablet 1 mg PG folic acid oral tablet 400 mcg, 800 mcg CE N2 (Not Covered) FOLIVANE-OB (prenat w/o a vit-fefum-fepo-fa) NP FOLTANX (l-methylfolate-b6-b12) NC FOLTANX RF (l-methylfolate-algae-b12-b6) NC FOLTX ORAL TABLET 1.13-25-2 MG (l-methylfolate-b6- NC b12) FOSTEUM (-zn chelate-vit d) NC FOSTEUM PLUS (dietary management product) NC FOVEX (dietary management product) NC GABADONE (dietary management product) NC GENICIN VITA-Q (multiple vitamins with fa) NC g-levocarnitine s/f NP hemenatal ob NP hemenatal ob + dha NP hm biotin oral tablet dispersible NC HYPERTENSA (dietary management product) NC inatal advance PG INATAL GT (prenatal vit-dss-fe cbn-fa) PG inatal ultra oral tablet PG infanate balance NP jenliva prenatal/postnatal NC 2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 165 Drug Name Drug Status Drug Details KIDS PROTEIN ORGANIC SHAKE (nutritional NC supplements) levocarnitine (dietary) NP levocarnitine l-tartrate oral tablet NP levocarnitine-b5-taurine NC LEVOMEFOLATE DHA NP LIMBREL (flavocoxid) NC LIMBREL250 (flavocoxid-cit zn bisglcinate) NC LIMBREL500 (flavocoxid-cit zn bisglcinate) NC LIPICHOL 540 (dietary management product) NC LISTER-V (dietary management product) NC l-methylfolate NC l-methylfolate ca me-cbl nac NC l-methylfolate calcium oral NC l-methylfolate formula 15 NC l-methylfolate formula 7.5 NC l-methylfolate forte NC l-methylfolate-algae-b12-b6 NC l-methylfolate-b6-b12 NC l-methyl-mc NC l-methyl-mc nac NC LOZI-FLUR (sodium fluoride) NP LGC; N2 (PG); AL (Min 6 ludent oral tablet chewable 0.55 (0.25 f) mg CE Years and Max 16 Years) N2 (PG); AL (Min 6 Years ludent oral tablet chewable 1.1 (0.5 f) mg CE and Max 16 Years) ludent oral tablet chewable 2.2 (1 f) mg PG LUKAID GLA (dietary management product) NC MACUTEK (dietary management product) NC MEPHYTON (phytonadione) NP QL (25 tablets per 30 days) METAFOLBIC (l-methylfolate-b12-b6-b2) NC METAFOLBIC PLUS (methylfol-methylcob-acetylcyst) NC METAFOLBIC PLUS RF (methylfol-algae-b12-acetylcyst) NC METANX ORAL CAPSULE (l-methylfolate-algae-b12-b6) NC multi-vit/fluoride oral solution PG

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 166 Drug Name Drug Status Drug Details multivitamin/fluoride oral solution PG multi-vitamin/fluoride oral solution 0.25 mg/ml PG multivitamin/fluoride oral tablet chewable 0.25 mg, 0.5 mg, 1 mg PG multivitamins/fluoride PG pediatric multivitamins-fl (Mvc-Fluoride) PG m-vit PG mynatal advance PG mynatal oral tablet PG mynatal plus NP mynatal-z NP sodium fluoride (Nafrinse) PG NASCOBAL (cyanocobalamin) NC # NATACHEW ORAL TABLET CHEWABLE 28-1 MG NP (prenatal vit-fe fum-fe bisg-fa) NATALVIT (prenatal vit-fe fumarate-fa) NP NATELLE ONE ORAL CAPSULE 28-1-250 MG (prenat w/o NP a-fe fum-fa-omega 3) NEEVO DHA ORAL CAPSULE 27-1.13 MG (prenat w/oa- NP fefum-methf-omegas) neonatal + dha NC neonatal 19 NC neonatal fe NC NEPHPLEX RX (b complex-c-zn-folic acid) NC NESTABS (prenat-fe bisgly-fa-w/o vit a) NP NESTABS DHA (prenat-w/oa-fe bisgly-fa-omega) NP NEWGEN (prenat-fe bisgly-fa-w/o vit a) NP NEXA PLUS (prenat-fefum-doc-fa-dha w/o a) NP OB COMPLETE ADVANCED (prenat w/o a-fe-methf-fa- NP omega) OB COMPLETE GOLD (prenat w/o a-fecbn-meth-fa-dha) NP OB COMPLETE ONE (prenat-fecbn-feaspgl-fa-fish) NP OB COMPLETE ORAL TABLET (prenatal vit-iron carbonyl- NP fa) OB COMPLETE PREMIER (prenatal-fe cbn-fe asp gly-fa) NP OB COMPLETE/DHA (prenat-fecbn-feaspgl-fa-omega) NP O-CAL FA (prenatal vit-fe fumarate-fa) NP 2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 167 Drug Name Drug Status Drug Details O-CAL PRENATAL (prenatal vit-fe fumarate-fa) NP OCUVEL ORAL CAPSULE 0.5 MG (multiple vitamins- NC minerals-fa) ORGANIC NUTRITION SHAKE (nutritional supplements) NC PERCURA (dietary management product) NC phytonadione oral PG PNV FOLIC ACID + IRON NP pnv prenatal plus multivitamin NP pnv-dha PG PNV-DHA+DOCUSATE NP PNV-OMEGA NP pnv-select PG PNV-TOTAL NP pnv-vp-u NP POLY-VI-FLOR (pediatric multivitamins-fl) NP pr natal 400 PG pr natal 430 PG pr natal 430 ec PG PREFERA OB ORAL TABLET 34-1 MG (prenatal vit- NP fepoly-fehempo-fa) PREFERAOB ONE (prenat fepoly-fehempo-fa-dha) NP pregen dha NC pregenna NC PRENAISSANCE NP PRENAISSANCE BALANCE NP PRENAISSANCE HARMONY DHA NP PRENAISSANCE NEXT NP prenaissance next-b NP PRENAISSANCE PLUS NP prenara NC PRENATA (prenatal w/o a vit-fe fum-fa) NP prenatabs rx PG prenatal 19 oral tablet NP prenatal 19 oral tablet chewable PG prenatal low iron oral tablet 27-1 mg PG

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 168 Drug Name Drug Status Drug Details PRENATAL PLUS IRON NP PRENATAL-U (prenatal w/o a vit-fe fum-fa) NP PRENATE (prenat mv-min-methylfolate-fa) NP PRENATE DHA ORAL CAPSULE 28-0.6-0.4-300 MG NP (prenat w/o a-fe-methfol-fa-dha) PRENATE ELITE ORAL TABLET 26-0.6-0.4 MG (prenatal NP vit w/fe-methylfol-fa) PRENATE ESSENTIAL ORAL CAPSULE 29-0.6-0.4-340 NP MG (pren-fe-meth-fa-omeg w/o a) PRENATE MINI ORAL CAPSULE 29-0.6-0.4-350 MG NP (prenat w/o a-fecbn-meth-fa-dha) prenatvite complete NC prenatvite plus NC prenatvite rx NC pretab NP PRIMACARE ORAL CAPSULE (pren-fe-meth-fa-omeg w/o NP a) PROTEOLIN DS (dietary management product) NC PROTEOLIN ORAL TABLET (dietary management product) NC PULMONA (dietary management product) NC pyridoxine hcl oral tablet 25 mg, 50 mg PG QUFLORA FE PEDIATRIC (ped multivitamins-fl-iron) NP RELNATE DHA NP SELECT-OB ORAL TABLET CHEWABLE 29-1 MG NP (prenatal vit-fe psac cmplx-fa) se-natal 19 NP SENTRA AM (dietary management product) NC SENTRA PM (dietary management product) NC N2 (PG); AL (Min 6 Years sodium fluoride oral solution 1.1 (0.5 f) mg/ml CE and Max 16 Years) N2 (PG); AL (Min 6 Years sodium fluoride oral tablet 1.1 (0.5 f) mg CE and Max 16 Years) sodium fluoride oral tablet 2.2 (1 f) mg PG LGC; N2 (PG); AL (Min 6 sodium fluoride oral tablet chewable 0.55 (0.25 f) mg CE Years and Max 16 Years) N2 (PG); AL (Min 6 Years sodium fluoride oral tablet chewable 1.1 (0.5 f) mg CE and Max 16 Years)

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 169 Drug Name Drug Status Drug Details sodium fluoride oral tablet chewable 2.2 (1 f) mg PG SYNAGEX (multiple vitamins-minerals-fa) NP TARON-BC (prenatal w/o vit a-fecbn-fa-b6) NP TARON-C DHA (prenat-fefum-fepo-fa-omega 3) NP TARON-PREX (prenat-fefum-dss-fa-dha w/o a) NP THERAMINE (dietary management product) NC THERAMINE PLUS (dietary management product) NC tl-care dha NP TL-SELECT NP TREPADONE (dietary management product) NC tricare NP TRICARE PRENATAL DHA ONE ORAL CAPSULE 27-1- NP 500 MG (prenatal-fefum-fa-dss-fish oil) trinatal rx 1 NP TRINATE (prenatal vit-fe fumarate-fa) PG trinaz NC tristart dha NP TRISTART FREE (prenat w/o a-fecbn-meth-fa-dha) NC TRISTART ONE (prenat w/o a-fecbn-meth-fa-dha) NP tri-tabs dha NP TRIVEEN-DUO DHA (prenat-febis-fepro-fa-ca-omega) NP TRI-VI-FLOR (ped vit a-c-d-methylfolate-fl) NP TRI-VI-FLORO NP ultimatecare one PG VASCAZEN (omega-3-acid eth est (dietary)) NC VASCULERA (dietary management product) NC VAYACOG (phosphatidylserine-dha-epa) NC VAYARIN (phosphatidylserine-dha-epa) NC VAYAROL (phytosterol esters-dha-epa) NC VEMAVITE-PRX 2 (prenat-fefum-dss-fa-dha w/o a) NP VENA-BAL DHA NP vinate ii NP vinate one NP virt nate NP virt-advance NP 2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 170 Drug Name Drug Status Drug Details VIRT-PN NP VIRT-PN DHA NP virt-pn plus NP virtprex NP VIRT-SELECT NP virt-vite forte PG virt-vite gt NP VITAFOL FE+ ORAL CAPSULE (prenat-fe poly-methfol-fa- NC dha) iron-vitamins (Vitafol Oral Tablet) NC VITAFOL STRIPS (prenatal-b6-b12-d3-folic acid) NC VITAFOL-OB (prenatal vit-fe fumarate-fa) NP VITAFOL-ONE (prenatal vit-fepoly-fa-dha) NP VITAL HP 1.0 CAL (nutritional supplements) NC VITAL-D RX (b complex-c-biotin-d-zinc-fa) NC VITAMEDMD ONE RX/QUATREFOLIC (prenat w/o a-fe- NP methfol-fa-dha) vitamin b-6 oral tablet 25 mg, 50 mg PG vitamin d2 NP N2 (Not Covered) vitamin d3 oral capsule 10 mcg (400 unit), 25 mcg (1000 ut) CE N2 (Not Covered) vitamin d3 oral liquid 400 unit/ml CE N2 (Not Covered) vitamin d3 oral tablet 10 mcg (400 unit), 25 mcg (1000 ut) CE N2 (Not Covered) vitamin d3 oral tablet chewable 10 mcg (400 unit) CE N2 (Not Covered) VITAPEARL (prenat-fefum-fered-fa-dha w/oa) NP VIVA DHA (prenatal vit-fe fum-fa-omega) NP VOL-NATE NP VOL-PLUS NP VOL-TAB RX NP VP-CH-PNV NP VP-GGR-B6 PRENATAL NP vp-gstn NC vp-heme ob NP vp-heme ob + dha NP vp-heme one NP VP-PNV-DHA NP

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 171 Drug Name Drug Status Drug Details westab max PG ZATEAN-PN DHA (prenat w/o a-fe-methfol-fa-dha) NP ZATEAN-PN PLUS (prenat w/o a-fe-methf-fa-omega) NP ZYTAZE (zinc citrate-phytase) NC OPHTHALMIC - DRUGS TO TREAT EYE CONDITIONS ANTIALLERGICS - DRUGS TO TREAT ALLERGIES ALOCRIL (nedocromil sodium) NP ALOMIDE (lodoxamide tromethamine) NP azelastine hcl ophthalmic PG bepotastine besilate PG BEPREVE (bepotastine besilate) NP # cromolyn sodium ophthalmic PG epinastine hcl PG LASTACAFT (alcaftadine) PB olopatadine hcl ophthalmic PG PAZEO (olopatadine hcl) PB ZERVIATE (cetirizine hcl) NC ANTIGLAUCOMA - DRUGS TO TREAT GLAUCOMA ALPHAGAN P OPHTHALMIC SOLUTION 0.1 % NP (brimonidine tartrate) apraclonidine hcl PG AZOPT (brinzolamide) NC BETAGAN (levobunolol hcl) NC betaxolol hcl ophthalmic PG BETIMOL (timolol hemihydrate) NP BETOPTIC-S (betaxolol hcl) PB bimatoprost ophthalmic NC brimonidine tartrate ophthalmic PG brinzolamide PG carteolol hcl PG COMBIGAN (brimonidine tartrate-timolol) PB # COSOPT (dorzolamide hcl-timolol mal) NC COSOPT PF OPHTHALMIC SOLUTION 22.3-6.8 MG/ML NP ST (dorzolamide hcl-timolol mal) dorzolamide hcl ophthalmic NP

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 172 Drug Name Drug Status Drug Details dorzolamide hcl-timolol mal PG dorzolamide hcl-timolol mal pf PG IOPIDINE OPHTHALMIC SOLUTION 0.5 % NC (apraclonidine hcl) IOPIDINE OPHTHALMIC SOLUTION 1 % (apraclonidine NP hcl) ISOPTO CARPINE (pilocarpine hcl) NC ISTALOL (timolol maleate) NC latanoprost ophthalmic PG levobunolol hcl ophthalmic solution 0.5 % PG LUMIGAN OPHTHALMIC SOLUTION 0.01 % PB ST (bimatoprost) metipranolol NP PHOSPHOLINE IODIDE (echothiophate iodide) NP pilocarpine hcl ophthalmic solution 1 % PG pilocarpine hcl ophthalmic solution 2 %, 4 % NP RESCULA (unoprostone isopropyl) NP ST; # SIMBRINZA (brinzolamide-brimonidine) PB timolol maleate ophthalmic gel forming solution NP timolol maleate ophthalmic solution 0.25 %, 0.5 % PG timolol maleate ophthalmic solution 0.5 % (daily) NP timolol maleate pf NC TIMOPTIC (timolol maleate) NC TIMOPTIC OCUDOSE (timolol maleate) NP TIMOPTIC-XE (timolol maleate) NC TRAVATAN Z (travoprost) PB travoprost (bak free) PG TRUSOPT (dorzolamide hcl) NC VEXOL (rimexolone) NP VYZULTA (latanoprostene bunod) NC XALATAN (latanoprost) NC XELPROS (latanoprost) NP PA; ST ZIOPTAN (tafluprost) NP ST; # ANTI-INFECTIVE/ANTI-INFLAMMATORY - DRUGS TO TREAT INFECTIONS AND INFLAMMATION bacitra-neomycin-polymyxin-hc PG 2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 173 Drug Name Drug Status Drug Details BLEPHAMIDE (sulfacetamide-prednisolone) PB BLEPHAMIDE S.O.P. (sulfacetamide-prednisolone) PB double pm NC MAXITROL (neomycin-polymyxin-dexameth) NC neomycin-polymyxin-dexameth ophthalmic ointment PG neomycin-polymyxin-dexameth ophthalmic suspension 3.5- PG 10000-0.1 neomycin-polymyxin-hc ophthalmic suspension 3.5-10000-1 NP neo-polycin hc NP PRED-G (gentamicin-prednisolone acet) NP PRED-G S.O.P. (gentamicin-prednisolone acet) NP sulfacetamide-prednisolone ophthalmic solution PG TOBRADEX OPHTHALMIC OINTMENT (tobramycin- PB dexamethasone) TOBRADEX OPHTHALMIC SUSPENSION (tobramycin- NC dexamethasone) TOBRADEX ST (tobramycin-dexamethasone) PB tobramycin-dexamethasone NP ZYLET (loteprednol-tobramycin) NP ANTI-INFECTIVES - DRUGS TO TREAT INFECTIONS AZASITE (azithromycin) PB # BACIGUENT OPHTHALMIC (bacitracin) NC bacitracin ophthalmic NP bacitracin-polymyxin b ophthalmic ointment 500-10000 unit/gm PG BESIVANCE (besifloxacin hcl) NP BETADINE OPHTHALMIC PREP (povidone-iodine) NP BLEPH-10 (sulfacetamide sodium) NC CILOXAN OPHTHALMIC OINTMENT (ciprofloxacin hcl) NP CILOXAN OPHTHALMIC SOLUTION (ciprofloxacin hcl) NC ciprofloxacin hcl ophthalmic PG erythromycin ophthalmic PG gatifloxacin ophthalmic NP gentak ophthalmic ointment PG gentamicin sulfate ophthalmic solution PG levofloxacin ophthalmic PG

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 174 Drug Name Drug Status Drug Details MOXEZA (moxifloxacin hcl) NP moxifloxacin hcl (2x day) PG moxifloxacin hcl ophthalmic solution NP NATACYN (natamycin) PB neomycin-bacitracin zn-polymyx ophthalmic ointment 5-400- NP 10000 neomycin-polymyxin-gramicidin ophthalmic solution 1.75- PG 10000-.025 neo-polycin NP NEOSPORIN OPHTHALMIC (neomycin-polymyxin- NC gramicidin) OCUFLOX (ofloxacin) NC ofloxacin ophthalmic PG polycin PG polymyxin b-trimethoprim PG POLYTRIM (polymyxin b-trimethoprim) NC sulfacetamide sodium ophthalmic PG tobramycin ophthalmic PG TOBREX OPHTHALMIC OINTMENT (tobramycin) NP TOBREX OPHTHALMIC SOLUTION (tobramycin) NC trifluridine ophthalmic NP VIGAMOX (moxifloxacin hcl) NC VIROPTIC (trifluridine) NC ZIRGAN (ganciclovir) NP # ZYMAXID (gatifloxacin) NC ANTI-INFLAMMATORIES - DRUGS TO TREAT INFLAMMATION ACULAR (ketorolac tromethamine) NC ACULAR LS (ketorolac tromethamine) NC ACUVAIL (ketorolac tromethamine) PB ALREX (loteprednol etabonate) NP bromfenac sodium (once-daily) NP BROMSITE (bromfenac sodium) NC dexamethasone sodium phosphate ophthalmic PG diclofenac sodium ophthalmic PG DUREZOL (difluprednate) NP # 2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 175 Drug Name Drug Status Drug Details EYSUVIS (loteprednol etabonate) NC FLAREX (fluorometholone acetate) NP fluorometholone ophthalmic NP flurbiprofen sodium PG FML (fluorometholone) PB FML FORTE (fluorometholone) PB ILEVRO (nepafenac) PB INVELTYS (loteprednol etabonate) NP ketorolac tromethamine ophthalmic PG LOTEMAX OPHTHALMIC GEL (loteprednol etabonate) NP LOTEMAX OPHTHALMIC OINTMENT (loteprednol NP etabonate) LOTEMAX OPHTHALMIC SUSPENSION (loteprednol NC etabonate) LOTEMAX SM (loteprednol etabonate) NP # loteprednol etabonate ophthalmic gel NC loteprednol etabonate ophthalmic suspension PG MAXIDEX (dexamethasone) PB NEVANAC (nepafenac) PB PRED MILD (prednisolone acetate) PB prednisolone acetate ophthalmic PG prednisolone sodium phosphate ophthalmic NP PROLENSA (bromfenac sodium) NC # DRY EYE DISEASE XIIDRA () NP MISCELLANEOUS naphazoline hcl ophthalmic NP RHOPRESSA (netarsudil dimesylate) NP ST ROCKLATAN (netarsudil-latanoprost) NP ST OTHER IRRIGATION SOLUTIONS physiolyte PG irrigation solns physiological (Physiosol Irrigation) PG ringers irrigation NP ringers irrigation (Tis-U-Sol) PG

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 176 Drug Name Drug Status Drug Details PHARMACEUTICAL ADJUVANTS ORAL VEHICLES mouth wash-gp NC mouthwash-af NC mouthwash-om NC RESPIRATORY - DRUGS TO TREAT BREATHING DISORDERS ANAPHYLAXIS TREATMENT AGENTS ADYPHREN (epinephrine) NC ADYPHREN AMP (epinephrine) NC ADYPHREN AMP II (epinephrine) NC ADYPHREN II (epinephrine) NC AUVI-Q INJECTION SOLUTION AUTO-INJECTOR NC (epinephrine) epinephrine injection solution auto-injector 0.15 mg/0.15ml PG QL (1 pack per 1 fill) epinephrine injection solution auto-injector 0.15 mg/0.3ml, 0.3 PG QL (8 pens per 1 month) mg/0.3ml EPISNAP (epinephrine) NC SYMJEPI (epinephrine) NP QL (4 syringes per 30 days) ANTIALLERGICS - DRUGS TO TREAT ALLERGIES acetylcysteine inhalation solution 10 % PG PATANASE (olopatadine hcl) NC ANTICHOLINERGIC/BETA AGONIST COMBINATIONS - DRUGS TO TREAT COPD AIRDUO RESPICLICK 113/14 (fluticasone-salmeterol) NC AIRDUO RESPICLICK 232/14 (fluticasone-salmeterol) NC AIRDUO RESPICLICK 55/14 (fluticasone-salmeterol) NC ANORO ELLIPTA (umeclidinium-vilanterol) NP QL (1 kit per 1 fill) BEVESPI AEROSPHERE (glycopyrrolate-formoterol) PB BREZTRI AEROSPHERE (budeson-glycopyrrol-formoterol) NC COMBIVENT RESPIMAT (ipratropium-albuterol) NP QL (2 inhalers per 1 month) DULERA INHALATION AEROSOL 100-5 MCG/ACT, PB #; QL (1 inhaler per 1 fill) 200-5 MCG/ACT (mometasone furo-formoterol fum) DULERA INHALATION AEROSOL 50-5 MCG/ACT #; QL (1 inhaler per 1 PB (mometasone furo-formoterol fum) month)

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 177 Drug Name Drug Status Drug Details fluticasone-salmeterol inhalation aerosol powder breath PG QL (1 inhaler per 30 days) activated 113-14 mcg/act, 232-14 mcg/act, 55-14 mcg/act ipratropium-albuterol PG QL (6 boxes per 30 days) STIOLTO RESPIMAT INHALATION AEROSOL ST; QL (1 inhaler per 1 SOLUTION 2.5-2.5 MCG/ACT (tiotropium bromide- NP month) olodaterol) TRELEGY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100-62.5-25 MCG/INH PB (fluticasone-umeclidin-vilant) TRELEGY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 200-62.5-25 MCG/INH PB QL (1 pack per 1 month) (fluticasone-umeclidin-vilant) UTIBRON NEOHALER (indacaterol-glycopyrrolate) NC ANTICHOLINERGICS - DRUGS TO TREAT COPD ATROVENT HFA (ipratropium bromide hfa) NP QL (2 inhalers per 1 month) INCRUSE ELLIPTA (umeclidinium bromide) PB QL (1 blister per 1 day) ipratropium bromide inhalation PG QL (5 boxes per 25 days) ipratropium bromide nasal PG LONHALA MAGNAIR REFILL KIT (glycopyrrolate) NC LONHALA MAGNAIR STARTER KIT (glycopyrrolate) NC SEEBRI NEOHALER (glycopyrrolate) NC SPIRIVA HANDIHALER (tiotropium bromide monohydrate) PB QL (1 capsule per 1 day) SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 1.25 MCG/ACT (tiotropium bromide PB QL (1 inhaler per 30 days) monohydrate) SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 2.5 MCG/ACT (tiotropium bromide PB QL (1 inhaler per 1 month) monohydrate) TUDORZA PRESSAIR INHALATION AEROSOL PA; ST; QL (1 inhaler per 1 POWDER BREATH ACTIVATED 400 MCG/ACT NP month) (aclidinium bromide) YUPELRI (revefenacin) NC ANTIHISTAMINE COMBINATIONS azelastine-fluticasone PG QL (1 package per 1 month) DYMISTA (azelastine-fluticasone) PB ANTIHISTAMINES - DRUGS TO TREAT ALLERGIES alavert oral tablet PG LGC; OTC ALAVERT ORAL TABLET DISPERSIBLE (loratadine) PG OTC 2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 178 Drug Name Drug Status Drug Details ALLEGRA ALLERGY (fexofenadine hcl) PG OTC ALLEGRA ALLERGY CHILDRENS ORAL PG OTC SUSPENSION (fexofenadine hcl) ALLEGRA ALLERGY CHILDRENS ORAL TABLET PG OTC DISPERSIBLE (fexofenadine hcl) azelastine hcl nasal solution 0.1 % PG azelastine hcl nasal solution 0.15 %, 137 mcg/spray PG QL (60 ml per 30 days) brompheniramine tannate oral tablet chewable PG carbinoxamine maleate oral solution PG carbinoxamine maleate oral tablet 4 mg PG carbinoxamine maleate oral tablet 6 mg NC cetirizine hcl oral syrup 1 mg/ml PG LGC; OTC cetirizine hcl oral tablet PG LGC; OTC cetirizine hcl oral tablet chewable PG OTC CLARINEX (desloratadine) NC CLARITIN CHILDRENS (loratadine) PG OTC CLARITIN ORAL SYRUP (loratadine) PG OTC CLARITIN ORAL TABLET (loratadine) PG OTC CLARITIN ORAL TABLET CHEWABLE (loratadine) PG OTC CLARITIN REDITABS (loratadine) PG OTC clemastine fumarate oral syrup NC PA; OTC; AL (Max 70 clemastine fumarate oral tablet 2.68 mg PG Years) cyproheptadine hcl oral PG desloratadine oral tablet PG desloratadine oral tablet dispersible NP diphenhydramine hcl oral elixir PG PA; AL (Max 70 Years) fexofenadine hcl childrens PG OTC fexofenadine hcl oral tablet 180 mg, 60 mg PG OTC PA; LGC; AL (Max 70 hydroxyzine hcl oral syrup PG Years) hydroxyzine hcl oral tablet PG PA; AL (Max 70 Years) hydroxyzine pamoate oral PG PA; AL (Max 70 Years) KARBINAL ER ORAL SUSPENSION EXTENDED NC RELEASE (carbinoxamine maleate) levocetirizine dihydrochloride oral PG 2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 179 Drug Name Drug Status Drug Details loratadine allergy relief oral tablet dispersible PG LGC; OTC loratadine childrens oral syrup PG LGC; OTC loratadine oral tablet PG LGC; OTC loratadine oral tablet chewable PG OTC MUCINEX ALLERGY (fexofenadine hcl) PG OTC olopatadine hcl nasal NP QL (1 container per 30 days) RYCLORA (dexchlorpheniramine maleate) NC RYVENT (carbinoxamine maleate) NC VISTARIL (hydroxyzine pamoate) NC XYZAL ALLERGY 24HR (levocetirizine dihydrochloride) PG OTC XYZAL ALLERGY 24HR CHILDRENS (levocetirizine PG OTC dihydrochloride) ZYRTEC ALLERGY ORAL CAPSULE (cetirizine hcl) PG OTC ZYRTEC ALLERGY ORAL TABLET (cetirizine hcl) PG OTC ZYRTEC CHILDRENS ALLERGY ORAL SYRUP 1 PG OTC MG/ML (cetirizine hcl) BETA AGONISTS - DRUGS TO TREAT ASTHMA AND COPD albuterol sulfate er PG albuterol sulfate hfa inhalation aerosol solution 108 (90 base) PG QL (2 inhalers per 30 days) mcg/act albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) PG QL (5 boxes per 1 month) 0.083%, 0.63 mg/3ml, 1.25 mg/3ml albuterol sulfate inhalation nebulization solution (5 mg/ml) NP 0.5% albuterol sulfate inhalation nebulization solution 2.5 mg/0.5ml PG QL (2 ml per 1 day) albuterol sulfate oral PG ARCAPTA NEOHALER (indacaterol maleate) NC arformoterol tartrate NC PA; ST; #; QL (60 vials per BROVANA (arformoterol tartrate) NP 1 fill) formoterol fumarate inhalation PG QL (30 vials per 1 month) levalbuterol hcl inhalation nebulization solution 0.31 mg/3ml, NP QL (10 ml per 1 day) 0.63 mg/3ml, 1.25 mg/3ml levalbuterol hcl inhalation nebulization solution 1.25 mg/0.5ml NP QL (45 ml per 1 month) levalbuterol tartrate NP QL (2 inhalers per 1 month)

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 180 Drug Name Drug Status Drug Details metaproterenol sulfate oral PG PERFOROMIST (formoterol fumarate) NP #; QL (30 vials per 1 month) PROAIR DIGIHALER (albuterol sulfate) NC PROAIR HFA (albuterol sulfate) NC PROAIR RESPICLICK (albuterol sulfate) NC PROVENTIL HFA (albuterol sulfate) NC SEREVENT DISKUS (salmeterol xinafoate) NC STRIVERDI RESPIMAT (olodaterol hcl) PB QL (1 inhaler per 30 days) terbutaline sulfate oral PG VENTOLIN HFA (albuterol sulfate) PB VOSPIRE ER (albuterol sulfate) NC XOPENEX (levalbuterol hcl) NC XOPENEX CONCENTRATE (levalbuterol hcl) NC XOPENEX HFA (levalbuterol tartrate) NC BIOLOGIC RESPONSE MODIFIERS PA; SP Pharmacy; QL (1 FASENRA PEN (benralizumab) PSP pen per 56 days) NUCALA SUBCUTANEOUS SOLUTION AUTO- PSP INJECTOR (mepolizumab) NUCALA SUBCUTANEOUS SOLUTION PREFILLED PSP SYRINGE (mepolizumab) XOLAIR SUBCUTANEOUS SOLUTION PREFILLED PA; QL (8 syringes per 28 PSP SYRINGE 150 MG/ML (omalizumab) days) XOLAIR SUBCUTANEOUS SOLUTION PREFILLED PA; QL (2 injections per 1 PSP SYRINGE 75 MG/0.5ML (omalizumab) month) XOLAIR SUBCUTANEOUS SOLUTION PSP PA; QL (8 vials per 28 days) RECONSTITUTED (omalizumab) COLD/COUGH alavert allergy/sinus PG OTC ALLEGRA-D ALLERGY & CONGESTION (fexofenadine- PG OTC pseudoephedrine) benzonatate oral capsule 100 mg, 200 mg PG benzonatate oral capsule 150 mg NC bromfed dm NP CARBAPHEN 12 ORAL LIQUID (phenyleph-chlorphen- NC carbetapen)

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 181 Drug Name Drug Status Drug Details CARBAPHEN 12 PED ORAL SUSPENSION 2.5-1.25-7.5 NC MG/ML (phenyleph-chlorphen-carbetapen) cetirizine-pseudoephedrine er PG OTC CLARINEX-D 12 HOUR (desloratadine-pseudoephedrine) NC CLARITIN-D 12 HOUR (loratadine-pseudoephedrine) PG OTC CLARITIN-D 24 HOUR (loratadine-pseudoephedrine) PG OTC CODAR AR (chlorpheniramine-codeine) NC DECON-A ORAL ELIXIR (brompheniramine-phenylephrine) NC fexofenadine-pseudoephed er PG OTC HYCOFENIX (pseudoeph-hydrocodone-gg) NC PA; QL (10 ML per day for hydrocod polst-cpm polst er oral suspension extended release PG 7 days per 30 days) PA; QL (60 ml per 1 day hydrocodone-guaifenesin NP over 5 days in a 30 day period) PA; QL (30 ML per day for hydrocodone-homatropine oral syrup PG 7 days per 30 days) PA; QL (6 tablets per day hydrocodone-homatropine oral tablet PG for 7 days per 30 days) PA; QL (30 ML per day for hydromet PG 7 days per 30 days) HYPERSAL INHALATION NEBULIZATION NC SOLUTION 7 % (sodium chloride) loratadine-d 12hr PG OTC loratadine-d 24hr PG OTC nebusal inhalation nebulization solution 3 % NP OTC NEBUSAL INHALATION NEBULIZATION SOLUTION NC 6 % (sodium chloride) NEOTUSS PLUS (phenylephrine-chlorphen-dm) NC NORTUSS-DE (phenylephrine-dm-gg) NC nortuss-ex NC promethazine vc NC PA; QL (30 ML per day for promethazine vc/codeine PG 7 days per 30 days) promethazine-dm oral syrup PG promethazine-phenylephrine PG pseudoeph-chlorphen-hydrocod NP

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 182 Drug Name Drug Status Drug Details sodium chloride (Pulmosal) NP RELHIST (bromphen tann-phenyleph tann) NC SEMPREX-D (acrivastine-pseudoephedrine) NP SSKI (potassium iodide (expectorant)) NP TESSALON PERLES (benzonatate) NC tgq 15dm/5peh/2cpm NC tgq 30pse/150gfn/15dm NC tgq 30pse/3brm/15dm NC PA; QL (2 capsules per day TUSSICAPS (hydrocod polst-chlorphen polst) NP for 7 days per 30 days) PA; QL (6 tablets per day tussigon PG for 7 days per 30 days) TUSSIONEX PENNKINETIC ER ORAL SUSPENSION NC EXTENDED RELEASE (hydrocod polst-chlorphen polst) PA; QL (2 tablets per day TUXARIN ER (chlorpheniramine-codeine) NP for 7 days per 30 days) TUZISTRA XR ORAL SUSPENSION EXTENDED PA; QL (20 ML per day for NP RELEASE (codeine polst-chlorphen polst) 7 days per 30 days) ZONATUSS (benzonatate) NC ZUTRIPRO (pseudoeph-chlorphen-hydrocod) NC ZYRTEC-D ALLERGY & CONGESTION (cetirizine- PG OTC pseudoephedrine) LEUKOTRIENE MODIFIERS zileuton er NP ZYFLO (zileuton) NP QL (4 tablets per 1 day) LEUKOTRIENE RECEPTOR ANTAGONISTS - DRUGS TO TREAT ASTHMA AND ALLERGIES ACCOLATE (zafirlukast) NC montelukast sodium oral PG SINGULAIR (montelukast sodium) NC zafirlukast PG ZYFLO CR (zileuton) NC MAST CELL STABILIZERS - DRUGS TO TREAT ALLERGIES cromolyn sodium inhalation PG QL (2 boxes per 1 month)

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 183 Drug Name Drug Status Drug Details MISCELLANEOUS acetylcysteine inhalation solution 20 % PG ADRENALIN NASAL (epinephrine hcl (nasal)) NP BRONCHITOL (mannitol (cystic fibrosis)) NC DALIRESP (roflumilast) NP PA; # dyphylline-guaifenesin (Difil-G Forte) NC PA; SP Pharmacy; QL (9 ESBRIET ORAL CAPSULE (pirfenidone) PSP capsules per 1 day) PA; SP Pharmacy; QL (9 ESBRIET ORAL TABLET 267 MG (pirfenidone) PSP tablets per 1 day) PA; SP Pharmacy; QL (3 ESBRIET ORAL TABLET 801 MG (pirfenidone) PSP tablets per 1 day) HYPERSAL INHALATION NEBULIZATION NC SOLUTION 3.5 % (sodium chloride) KALYDECO ORAL PACKET 25 MG, 50 MG, 75 MG PA; SP Pharmacy; QL (2 PSP (ivacaftor) packets per 1 day) PA; SP Pharmacy; QL (2 KALYDECO ORAL TABLET (ivacaftor) PSP tabs per 1 day) PA; SP Pharmacy; QL (2 ORKAMBI ORAL PACKET (lumacaftor-ivacaftor) NPSP packets per 1 day) ORKAMBI ORAL TABLET 100-125 MG (lumacaftor- PA; QL (4 tablets per 1 NPSP ivacaftor) Day) ORKAMBI ORAL TABLET 200-125 MG (lumacaftor- NPSP PA; QL (4 tablets per 1 day) ivacaftor) sodium chloride inhalation nebulization solution 0.9 %, 10 %, 7 PG % sodium chloride inhalation nebulization solution 3 % PG OTC SYMDEKO ORAL TABLET THERAPY PACK 100-150 & PA; SP Pharmacy; QL (2 NPSP 150 MG (tezacaftor-ivacaftor) tablets per 1 Day) SYMDEKO ORAL TABLET THERAPY PACK 50-75 & 75 PA; SP Pharmacy; QL (2 NPSP MG (tezacaftor-ivacaftor) tablets per 1 day) TRIKAFTA ORAL TABLET THERAPY PACK 100-50-75 PA; SP Pharmacy; QL (1 PSP & 150 MG (elexacaftor-tezacaftor-ivacaft) pack per 28 days) TRIKAFTA ORAL TABLET THERAPY PACK 50-25-37.5 PA; SP Pharmacy; QL (3 PSP & 75 MG (elexacaftor-tezacaftor-ivacaft) tablets per 1 day) NASAL - DRUGS TO TREAT ALLERGIES BECONASE AQ (beclomethasone diprop monohyd) NP ST FLONASE ALLERGY RELIEF (fluticasone propionate) PG OTC

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 184 Drug Name Drug Status Drug Details flunisolide nasal solution 25 mcg/act (0.025%) PG QL (75 ml per 30 days) OTC; QL (1 16 gram bottle fluticasone propionate nasal PG per 30 days) mometasone furoate nasal PG QL (34 grams per 30 days) OTC; QL (1 bottle per 1 NASACORT ALLERGY 24HR (triamcinolone acetonide) PG month) NASONEX (mometasone furoate) NC ST; #; QL (1 inhaler per 30 OMNARIS (ciclesonide) NP days) QNASL (beclomethasone diprop (nasal)) NP ST QNASL CHILDRENS (beclomethasone diprop (nasal)) NP ST RHINOCORT ALLERGY (budesonide) PG OTC; QL (1 bottle per 1 triamcinolone acetonide nasal aerosol PG month) XHANCE (fluticasone propionate) NC ZETONNA (ciclesonide) NP ST PULMONARY FIBROSIS AGENTS OFEV (nintedanib esylate) NC SEVERE ASTHMA AGENTS DUPIXENT SOLUTION PEN-INJECTOR 200 NC MG/1.14ML SUBCUTANEOUS (dupilumab) DUPIXENT SOLUTION PREFILLED SYRINGE 200 NC MG/1.14ML SUBCUTANEOUS (dupilumab) DUPIXENT SOLUTION PREFILLED SYRINGE 300 NC MG/2ML SUBCUTANEOUS (dupilumab) INHALANTS - DRUGS TO TREAT ASTHMA AEROSPAN (flunisolide hfa) NC ST; QL (1 inhaler per 1 ALVESCO (ciclesonide) NP month) ARMONAIR DIGIHALER (fluticasone propionate (inhal)) NC ARMONAIR RESPICLICK 113 (fluticasone propionate NC (inhal)) ARMONAIR RESPICLICK 232 (fluticasone propionate NC (inhal)) ARMONAIR RESPICLICK 55 (fluticasone propionate NC (inhal)) ARNUITY ELLIPTA (fluticasone furoate) PB

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 185 Drug Name Drug Status Drug Details ST; #; QL (1 inhaler per 1 ASMANEX (120 METERED DOSES) (mometasone furoate) NP month) ST; #; QL (1 inhaler per 1 ASMANEX (14 METERED DOSES) (mometasone furoate) NP month) ST; #; QL (1 inhaler per 1 ASMANEX (30 METERED DOSES) (mometasone furoate) NP month) ST; #; QL (1 inhaler per 1 ASMANEX (60 METERED DOSES) (mometasone furoate) NP month) ST; #; QL (1 inhaler per 1 ASMANEX (7 METERED DOSES) (mometasone furoate) NP month) ASMANEX HFA INHALATION AEROSOL 100 ST; QL (1 inhaler per 1 NP MCG/ACT, 200 MCG/ACT (mometasone furoate) month) ASMANEX HFA INHALATION AEROSOL 50 NC MCG/ACT (mometasone furoate) budesonide inhalation suspension 0.25 mg/2ml NP QL (4 vials per 1 day) budesonide inhalation suspension 0.5 mg/2ml NP QL (4 ml per 1 day) QL (1 vial per 1 day); AL budesonide inhalation suspension 1 mg/2ml NP (Min 8 Years) ST; #; QL (2 blisters per 1 FLOVENT DISKUS (fluticasone propionate (inhal)) NP day) ST; #; QL (1 inhaler per 1 FLOVENT HFA (fluticasone propionate hfa) NP month) PULMICORT (budesonide) NC PA; ST; QL (1 inhaler per 1 PULMICORT FLEXHALER (budesonide) NP month) PA; SP Pharmacy; QL (60 PULMOZYME (dornase alfa) PSP units per 1 fill) QVAR INHALATION AEROSOL SOLUTION PB QL (1 inhaler per 1 month) (beclomethasone dipropionate) QVAR REDIHALER (beclomethasone diprop hfa) PB QL (1 inhaler per 1 month) STEROID/BETA-AGONIST COMBINATIONS - DRUGS TO TREAT ASTHMA AND COPD ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100-50 MCG/DOSE (fluticasone- NC salmeterol) ADVAIR DISKUS INHALATION AEROSOL POWDER ST; QL (1 diskus per 1 BREATH ACTIVATED 250-50 MCG/DOSE (fluticasone- NP month) salmeterol)

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 186 Drug Name Drug Status Drug Details ADVAIR DISKUS INHALATION AEROSOL POWDER ST; QL (2 inhalers per 1 BREATH ACTIVATED 500-50 MCG/DOSE (fluticasone- NP month) salmeterol) ADVAIR HFA (fluticasone-salmeterol) PB QL (1 inhaler per 1 month) AIRDUO DIGIHALER (fluticasone-salmeterol) NC BREO ELLIPTA (fluticasone furoate-vilanterol) NP ST; QL (2 blisters per 1 day) budesonide-formoterol fumarate PG QL (1 inhaler per 1 month) DUAKLIR PRESSAIR (aclidinium br-formoterol fum) NC fluticasone-salmeterol inhalation aerosol powder breath PG QL (2 inhalations per 1 day) activated 100-50 mcg/dose, 250-50 mcg/dose, 500-50 mcg/dose SYMBICORT (budesonide-formoterol fumarate) NC fluticasone-salmeterol (Wixela Inhub) PG QL (2 inhalations per 1 day) XANTHINES - DRUGS TO TREAT COPD ELIXOPHYLLIN (theophylline) NP THEO-24 (theophylline) NC theochron oral tablet extended release 12 hour 100 mg, 200 mg, PG 300 mg theophylline PG theophylline er PG TOPICAL - DRUGS TO TREAT EAR AND SKIN CONDITIONS DERMATOLOGY, ACNE ABSORICA (isotretinoin) NC ABSORICA LD (isotretinoin micronized) NC ACANYA (clindamycin phos-benzoyl perox) NC ACZONE EXTERNAL GEL 7.5 % (dapsone) NP QL (60 grams per 30 days) adapalene external cream NP PA; AL (Max 35 Years) adapalene external gel 0.1 % PG PA; AL (Max 35 Years) adapalene external gel 0.3 % NP PA; AL (Max 35 Years) adapalene external lotion NP PA; ST; AL (Max 35 Years) adapalene external solution NP QL (2 ml per 1 day) adapalene-benzoyl peroxide external gel NP PA; AL (Max 35 Years) AKLIEF (trifarotene) NC AKTIPAK (benzoyl peroxide-erythromycin) NP QL (2 packets per 1 day) ALTRENO (tretinoin) NC # amnesteem NP PA; ST 2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 187 Drug Name Drug Status Drug Details AMZEEQ (minocycline hcl micronized) NC ARAZLO (tazarotene) NC ATRALIN (tretinoin) NC AVAR LS CLEANSER (sulfacetamide sodium-sulfur) NC AVAR-E LS (sulfacetamide sodium-sulfur) NC avita external cream PG PA; AL (Max 35 Years) tretinoin (Avita External Gel) NP PA AZELEX (azelaic acid) NP BENZAC AC WASH EXTERNAL LIQUID (benzoyl NC peroxide) BENZACLIN (clindamycin phos-benzoyl perox) NC BENZACLIN WITH PUMP (clindamycin phos-benzoyl NC perox) BENZAMYCIN (benzoyl peroxide-erythromycin) NC BENZIQ (benzoyl peroxide) PB BENZIQ LS (benzoyl peroxide) PB benzoyl peroxide-erythromycin NP bp wash external liquid 2.5 % PG claravis NP PA; ST CLEOCIN-T (clindamycin phosphate) NC clindacin etz external swab NP clindacin-p NP CLINDAGEL (clindamycin phosphate) NC clindamycin phos-benzoyl perox external gel 1-5 %, 1.2-2.5 %, NP 1.2-5 % clindamycin phosphate external foam NP clindamycin phosphate external gel NC clindamycin phosphate external lotion NP QL (60 ml per 1 month) clindamycin phosphate external solution NP QL (2 ML per 1 day) clindamycin phosphate external swab PG clindamycin-tretinoin PG PA; AL (Max 35 Years) dapsone external gel 5 % PG QL (60 grams per 30 Days) dapsone external gel 7.5 % PG QL (60 GM per 30 days) DIFFERIN EXTERNAL CREAM (adapalene) NC DIFFERIN EXTERNAL GEL 0.3 % (adapalene) NC

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 188 Drug Name Drug Status Drug Details DIFFERIN EXTERNAL LOTION (adapalene) NC DUAC (clindamycin-benzoyl per (refr)) NC EPIDUO (adapalene-benzoyl peroxide) NC EPIDUO FORTE (adapalene-benzoyl peroxide) NP # ery PG erythromycin external gel NP QL (60 grams per 1 month) erythromycin external pad PG erythromycin external solution PG QL (60 ml per 1 month) EVOCLIN (clindamycin phosphate) NC FABIOR (tazarotene) NC isotretinoin oral capsule 10 mg, 20 mg, 30 mg, 40 mg NP PA isotretinoin oral capsule 25 mg, 35 mg NC KLARON (sulfacetamide sodium (acne)) NC myorisan oral capsule 10 mg, 20 mg, 40 mg NP PA; ST isotretinoin (Myorisan Oral Capsule 30 Mg) NP PA; ST clindamycin-benzoyl per (refr) (Neuac External Gel) NP ONEXTON (clindamycin phos-benzoyl perox) NC # PLEXION (sulfacetamide sodium-sulfur) NC PLEXION CLEANSER EXTERNAL LIQUID NC (sulfacetamide sodium-sulfur) PLEXION CLEANSING CLOTH EXTERNAL PAD NC (sulfacetamide sodium-sulfur) PLIXDA (adapalene) NC RETIN-A (tretinoin) NC RETIN-A MICRO (tretinoin microsphere) NC RETIN-A MICRO PUMP (tretinoin microsphere) NC sss 10-5 external foam NC sulfacetamide sodium (acne) PG SUMAXIN (sulfacetamide sodium-sulfur) NC SUMAXIN TS (sulfacetamide sodium-sulfur) NC tazarotene external foam NC tretinoin external cream PG PA; AL (Max 35 Years) tretinoin external gel 0.01 %, 0.05 % NP PA; AL (Max 35 Years) tretinoin external gel 0.025 % NP PA tretinoin microsphere PG PA; AL (Max 35 Years)

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 189 Drug Name Drug Status Drug Details tretinoin microsphere pump PG PA; AL (Max 35 Years) TRETIN-X EXTERNAL CREAM 0.075 % (tretinoin) NC WINLEVI (clascoterone) NC isotretinoin (Zenatane) NP PA; ST DERMATOLOGY, ACTINIC KERATOSIS CARAC (fluorouracil) NC EFUDEX EXTERNAL CREAM (fluorouracil) NC FLUOROPLEX (fluorouracil) NP fluorouracil external PG imiquimod external cream 5 % NP imiquimod pump NP QL (1 pump per 1 month) KLISYRI (tirbanibulin) NC PICATO (ingenol mebutate) NP TOLAK (fluorouracil) PB # ZYCLARA (imiquimod) NC ZYCLARA PUMP EXTERNAL CREAM 2.5 % (imiquimod) NC DERMATOLOGY, ANTIBIOTICS ALTABAX (retapamulin) NP BACTROBAN EXTERNAL CREAM (mupirocin calcium) NC BACTROBAN NASAL (mupirocin calcium) NP CENTANY (mupirocin) NC CORTISPORIN EXTERNAL (neomycin-polymyxin-hc) NP gentamicin sulfate external PG LGC mupirocin calcium NP QL (60 grams per 30 days) mupirocin external PG QL (60 grams per 30 days) NEO-SYNALAR EXTERNAL CREAM (neomycin- NP fluocinolone) silver sulfadiazine external PG ssd PG SULFAMYLON EXTERNAL CREAM (mafenide acetate) NP XEPI (ozenoxacin) NC DERMATOLOGY, ANTIFUNGALS ciclodan external cream NP ciclodan external solution PG PA ciclopirox external gel NP QL (120 grams per 1 month) 2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 190 Drug Name Drug Status Drug Details ciclopirox external shampoo NP QL (120 grams per 1 month) ciclopirox external solution PG ciclopirox olamine external PG QL (120 grams per 1 month) clotrimazole external cream PG QL (120 grams per 1 month) clotrimazole external solution PG QL (120 ml per 1 month) clotrimazole-betamethasone external cream PG QL (45 grams per 1 month) clotrimazole-betamethasone external lotion PG QL (2 ml per 1 day) econazole nitrate external NP QL (85 grams per 30 days) ECOZA (econazole nitrate) NC ERTACZO (sertaconazole nitrate) NP QL (60 grams per 30 days) EXELDERM EXTERNAL CREAM (sulconazole nitrate) NP QL (60 grams per 30 days) EXTINA (ketoconazole) NP QL (50 grams per 30 days) GRIS-PEG (griseofulvin ultramicrosize) NC HALOTIN (haloprogin) NC PA; #; QL (4 ML per 1 JUBLIA (efinaconazole) NP month) ketoconazole external cream PG QL (2 grams per 1 day) ketoconazole external foam NP QL (50 grams per 30 days) LOPROX EXTERNAL CREAM (ciclopirox olamine) NC LOPROX EXTERNAL SHAMPOO (ciclopirox) NC LOPROX EXTERNAL SUSPENSION (ciclopirox olamine) NC LOTRISONE EXTERNAL CREAM (clotrimazole- NC betamethasone) luliconazole PG LUZU (luliconazole) NC MENTAX (butenafine hcl) NP QL (60 grams per 1 month) miconazole-zinc oxide-petrolat NC naftifine hcl external cream 1 % NP QL (60 grams per 1 month) naftifine hcl external cream 2 % NP QL (60 grams per 30 days) NAFTIN EXTERNAL CREAM 2 % (naftifine hcl) NC ST; QL (60 grams per 30 NAFTIN EXTERNAL GEL 1 % (naftifine hcl) NP days) ST; #; QL (60 grams per 30 NAFTIN EXTERNAL GEL 2 % (naftifine hcl) NP days) nystatin (Nyamyc) PG QL (120 grams per 1 month) nystatin (Nyata External Powder) PG QL (120 grams per 1 month) 2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 191 Drug Name Drug Status Drug Details nystatin external PG QL (120 grams per 1 month) nystatin-triamcinolone NP QL (2 grams per 1 day) nystatin (Nystop) PG QL (120 grams per 1 month) oxiconazole nitrate NC OXISTAT EXTERNAL CREAM (oxiconazole nitrate) NC OXISTAT EXTERNAL LOTION (oxiconazole nitrate) NP QL (60 ml per 30 days) PENLAC (ciclopirox) NC sulconazole nitrate external cream PG QL (60 GM per 1 month) sulconazole nitrate external solution PG QL (2 mls per 1 day) XOLEGEL (ketoconazole) NP QL (50 grams per 30 days) DERMATOLOGY, ANTIPRURITIC ST; QL (45 grams per 1 doxepin hcl external NP month) PRUDOXIN (doxepin hcl (antipruritic)) NC ZONALON (doxepin hcl (antipruritic)) NC DERMATOLOGY, ANTIPSORIATICS acitretin NP calcipotriene external cream NP ST; QL (4 grams per 1 day) calcipotriene external foam NC calcipotriene external ointment NP ST calcipotriene external solution NP calcitrene NP ST calcitriol external NP PA; QL (2 injections per 1 COSENTYX (300 MG DOSE) (secukinumab) PSP month) PA; QL (2 injections per 1 COSENTYX SENSOREADY (300 MG) (secukinumab) PSP month) COSENTYX SENSOREADY PEN SUBCUTANEOUS PA; QL (1 package per 28 PSP SOLUTION AUTO-INJECTOR 150 MG/ML (secukinumab) days) COSENTYX SUBCUTANEOUS SOLUTION PREFILLED PA; QL (1 package per 28 PSP SYRINGE 150 MG/ML (secukinumab) days) COSENTYX SUBCUTANEOUS SOLUTION PREFILLED PA; SP Pharmacy; QL (1 PSP SYRINGE 75 MG/0.5ML (secukinumab) box per 1 month) DOVONEX EXTERNAL CREAM (calcipotriene) NC ILUMYA (tildrakizumab-asmn) NC methoxsalen oral NP

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 192 Drug Name Drug Status Drug Details methoxsalen rapid PG OXSORALEN ULTRA (methoxsalen rapid) NC SILIQ (brodalumab) NC SORIATANE ORAL CAPSULE 10 MG, 17.5 MG, 25 MG NC (acitretin) SORILUX (calcipotriene) NC tazarotene external cream NP PA; AL (Max 35 Years) TAZORAC EXTERNAL CREAM 0.05 % (tazarotene) PB PA; AL (Max 35 Years) TAZORAC EXTERNAL CREAM 0.1 % (tazarotene) NC TAZORAC EXTERNAL GEL (tazarotene) PB PA; AL (Max 35 Years) VECTICAL (calcitriol) NC WYNZORA (calcipotriene-betameth diprop) NC DERMATOLOGY, ANTISEBORRHEICS ketoconazole external shampoo 2 % PG NIZORAL (ketoconazole) NC selenium sulfide external lotion PG DERMATOLOGY, ATOPIC DERMATITIS DUPIXENT SUBCUTANEOUS SOLUTION PEN- NC INJECTOR 200 MG/1.14ML (dupilumab) DUPIXENT SUBCUTANEOUS SOLUTION PREFILLED NC SYRINGE (dupilumab) DERMATOLOGY, CORTICOSTEROIDS ALA SCALP (hydrocortisone) NC ala-cort external cream 1 % PG QL (120 grams per 1 month) ala-cort external cream 2.5 % NC alclometasone dipropionate PG QL (120 grams per 1 month) amcinonide external cream NP QL (120 grams per 1 month) amcinonide external lotion NP QL (120 ml per 1 month) amcinonide external ointment NP APEXICON E (diflorasone diacet emoll base) NP betamethasone dipropionate aug external cream PG QL (120 grams per 1 month) betamethasone dipropionate aug external gel PG QL (120 grams per 1 month) betamethasone dipropionate aug external lotion PG QL (120 grams per 30 days) betamethasone dipropionate aug external ointment NP QL (100 grams per 30 days) betamethasone dipropionate external cream PG QL (4 grams per 1 day)

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 193 Drug Name Drug Status Drug Details betamethasone dipropionate external lotion PG QL (120 ml per 1 month) betamethasone dipropionate external ointment PG QL (4 grams per 1 day) betamethasone valerate external cream NP QL (120 grams per 1 month) betamethasone valerate external foam NP QL (120 grams per 1 month) betamethasone valerate external lotion NP QL (120 ml per 1 month) betamethasone valerate external ointment NP QL (4 grams per 1 day) BRYHALI (halobetasol propionate) NC calcipotriene-betameth diprop NC CAPEX (fluocinolone acetonide) NP QL (120 ml per 30 days) ST; QL (120 grams per 30 clobetasol propionate e NP days) clobetasol propionate emulsion NP QL (100 grams per 30 days) clobetasol propionate external cream NP QL (120 grams per 30 days) clobetasol propionate external foam NP QL (100 grams per 30 days) clobetasol propionate external gel NP QL (120 grams per 30 days) clobetasol propionate external liquid NP QL (125 ml per 30 days) clobetasol propionate external lotion NP QL (120 ml per 1 month) clobetasol propionate external ointment NP QL (120 grams per 30 days) clobetasol propionate external shampoo NP QL (236 ml per 30 days) clobetasol propionate external solution NP QL (120 ml per 1 month) CLOBEX (clobetasol propionate) NC CLOBEX SPRAY (clobetasol propionate) NC clocortolone pivalate NP QL (120 grams per 1 month) clocortolone pivalate pump NP QL (120 grams per 1 month) clobetasol propionate (Clodan External Shampoo) NP QL (236 ml per 30 days) CLODERM (clocortolone pivalate) NC CLODERM PUMP (clocortolone pivalate) NC CORDRAN EXTERNAL CREAM 0.05 % (flurandrenolide) NC CORDRAN EXTERNAL LOTION (flurandrenolide) NC CORDRAN EXTERNAL OINTMENT (flurandrenolide) NC CORDRAN EXTERNAL TAPE (flurandrenolide) NP #; QL (1 roll per 1 fill) cormax scalp application NP ST; QL (100 ml per 30 days) CUTIVATE EXTERNAL CREAM (fluticasone propionate) NC CUTIVATE EXTERNAL LOTION (fluticasone propionate) NC DERMA-SMOOTHE/FS BODY (fluocinolone acetonide) NC 2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 194 Drug Name Drug Status Drug Details DERMA-SMOOTHE/FS SCALP (fluocinolone acetonide) NC DERMATOP (prednicarbate) NC DESONATE (desonide) NC desonide external cream NP QL (120 grams per 1 month) desonide external gel NC desonide external lotion NP QL (120 ml per 1 month) desonide external ointment NP QL (120 grams per 1 month) DESOWEN EXTERNAL CREAM (desonide) NC DESOWEN EXTERNAL LOTION (desonide) NC desoximetasone external cream NP QL (120 grams per 1 month) desoximetasone external gel NP QL (120 grams per 1 month) desoximetasone external liquid NC desoximetasone external ointment 0.05 % NC desoximetasone external ointment 0.25 % NP QL (4 grams per 1 day) diflorasone diacetate external NP QL (120 grams per 1 month) DIPROLENE (betamethasone dipropionate aug) NC DIPROLENE AF (betamethasone dipropionate aug) NC QL (1 100 gram tube per 1 DUOBRII (halobetasol prop-tazarotene) NP month) ELOCON EXTERNAL CREAM (mometasone furoate) NC ELOCON EXTERNAL OINTMENT (mometasone furoate) NC ENSTILAR (calcipotriene-betameth diprop) NC fluocinolone acetonide body NP QL (120 ml per 1 month) fluocinolone acetonide external cream NP QL (120 grams per 1 month) fluocinolone acetonide external ointment NP QL (120 grams per 1 month) fluocinolone acetonide external solution NP QL (120 ml per 1 month) fluocinolone acetonide scalp NP QL (120 ml per 1 month) fluocinonide emulsified base PG QL (4 grams per 1 day) LGC; QL (120 grams per 30 fluocinonide external cream 0.05 % NP days) ST; QL (120 grams per 30 fluocinonide external cream 0.1 % NP days) fluocinonide external gel NP QL (120 grams per 30 days) fluocinonide external ointment NP QL (120 grams per 30 days) fluocinonide external solution PG QL (120 grams per 30 days)

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 195 Drug Name Drug Status Drug Details flurandrenolide external cream NP flurandrenolide external lotion NP flurandrenolide external ointment NC fluticasone propionate external cream NP QL (120 grams per 1 month) fluticasone propionate external lotion NP QL (120 ml per 1 month) fluticasone propionate external ointment PG QL (120 grams per 1 month) halcinonide NC halobetasol propionate external cream NP QL (120 grams per 1 month) halobetasol propionate external foam NC halobetasol propionate external ointment NP QL (120 grams per 1 month) HALOG EXTERNAL CREAM (halcinonide) NP HALOG EXTERNAL OINTMENT (halcinonide) NP HALOG EXTERNAL SOLUTION (halcinonide) NC hydrocortisone butyr lipo base NP hydrocortisone butyrate external cream NP QL (120 grams per 1 month) hydrocortisone butyrate external lotion NC hydrocortisone butyrate external ointment NP QL (120 grams per 1 month) hydrocortisone butyrate external solution PG QL (120 ml per 1 month) hydrocortisone external cream 1 %, 2.5 % PG QL (120 grams per 1 month) hydrocortisone external lotion 2.5 % PG QL (120 ml per 1 month) hydrocortisone external ointment 2.5 % PG QL (120 grams per 1 month) hydrocortisone valerate NP QL (120 grams per 1 month) IMPEKLO (clobetasol propionate) NC IMPOYZ (clobetasol propionate) NC # KENALOG EXTERNAL (triamcinolone acetonide) NC LEXETTE (halobetasol propionate) NC LOCOID (hydrocortisone butyrate) NC LOCOID LIPOCREAM (hydrocortisone butyr lipo base) NC LUXIQ (betamethasone valerate) NC MICORT-HC (hydrocortisone acetate) NC mometasone furoate external cream NP QL (120 grams per 1 month) mometasone furoate external ointment NP QL (120 grams per 1 month) mometasone furoate external solution PG QL (120 ml per 1 month) OLUX (clobetasol propionate) NC OLUX-E (clobetasol propionate emulsion) NC 2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 196 Drug Name Drug Status Drug Details PANDEL (hydrocortisone probutate) NC prednicarbate NP QL (120 grams per 1 month) psorcon NC SERNIVO (betamethasone dipropionate) NC SYNALAR (fluocinolone acetonide) NC TACLONEX EXTERNAL OINTMENT (calcipotriene- NC betameth diprop) TACLONEX EXTERNAL SUSPENSION (calcipotriene- ST; QL (60 grams per 30 NP betameth diprop) days) TEMOVATE (clobetasol propionate) NC TEXACORT (hydrocortisone) NP TOPICORT EXTERNAL CREAM (desoximetasone) NC TOPICORT EXTERNAL GEL (desoximetasone) NC TOPICORT EXTERNAL OINTMENT (desoximetasone) NC TOPICORT SPRAY (desoximetasone) NC triamcinolone acetonide external aerosol solution NC LGC; QL (120 grams per 1 triamcinolone acetonide external cream 0.025 %, 0.5 % PG month) LGC; QL (2 grams per 1 triamcinolone acetonide external cream 0.1 % PG day) triamcinolone acetonide external lotion PG QL (120 ml per 1 month) LGC; QL (120 grams per 1 triamcinolone acetonide external ointment 0.025 %, 0.5 % PG month) LGC; QL (2 grams per 1 triamcinolone acetonide external ointment 0.1 % PG day) LGC; QL (2 grams per 1 triderm external cream 0.1 % PG day) triamcinolone acetonide (Triderm External Cream 0.5 %) PG TRIDESILON (desonide) NC ULTRAVATE EXTERNAL CREAM (halobetasol NC propionate) ULTRAVATE EXTERNAL LOTION (halobetasol NC # propionate) ULTRAVATE EXTERNAL OINTMENT (halobetasol NC propionate) VANOS (fluocinonide) NC VERDESO (desonide) NP QL (100 grams per 30 days)

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 197 Drug Name Drug Status Drug Details WESTCORT (hydrocortisone valerate) NC DERMATOLOGY, LOCAL ANESTHETICS asperflex max st PG QL (1 patch per 1 day) cvs pain relief external patch PG QL (1 patch per 1 day) DOLOTRANZ (lidocaine-prilocaine) NC EPIFOAM (pramoxine-hc) NP eq lidocaine pain relieving PG QL (1 patch per 1 day) gnp lidocaine pain relief PG QL (1 patch per 1 day) hm lidocaine patch PG QL (1 patch per 1 day) PA; QL (50 grams per 30 lidocaine external ointment 5 % NP days) lidocaine external patch 4 % PG QL (1 patch per 1 day) lidocaine external patch 5 % PG PA lidocaine hcl external solution PG lidocaine hcl urethral/mucosal PG QL (2 ml per 1 day) lidocaine pain relief PG QL (1 patch per 1 day) PA; QL (90 grams per 1 lidocaine pak NP month) PA; QL (30 grams per 30 lidocaine-prilocaine external cream PG days) lidocaine-tetracaine external cream 7-7 % NC LIDODERM (lidocaine) NC pain relief maximum strength external patch PG QL (1 patch per 1 day) pain relieving lidocaine PG QL (1 patch per 1 day) PRAMOSONE EXTERNAL CREAM 1-1 % (pramoxine-hc) NC PA; QL (90 grams per 1 premium lidocaine NP month) qc lidocaine pain relief PG QL (1 patch per 1 day) ra lidocaine pain relieving PG QL (1 patch per 1 day) ra pain relieving PG QL (1 patch per 1 day) SYNERA (lidocaine-tetracaine) NP QL (10 patches per 30 days) theracare pain relief PG QL (1 patch per 1 day) XYLOCAINE EXTERNAL (lidocaine hcl) NC DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE ABREVA (docosanol) PG OTC 2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 198 Drug Name Drug Status Drug Details acyclovir external NC ALDARA (imiquimod) NC AMELUZ (aminolevulinic acid hcl) NP # ammonium lactate external cream PG ammonium lactate external lotion PG OTC BUCALSEP EXTERNAL SOLUTION (antiseptic products, NC misc.) chlorhexidine gluconate solution 20 % NC CONDYLOX EXTERNAL GEL (podofilox) NP DENAVIR (penciclovir) NP # PA; QL (2 patches per 1 diclofenac epolamine external PG day) diclofenac epolamine transdermal PG QL (2 patches per 1 day) diclofenac sodium external gel 1 % PG QL (300 GM per 1 month) diclofenac sodium external solution NC diclofenac sodium transdermal gel 1 % PG QL (300 grams per 1 month) diclofenac sodium transdermal gel 3 % NC diclofenac sodium transdermal solution NC docosanol external PG OTC ELIDEL (pimecrolimus) NC EUCRISA (crisaborole) NP ST FLECTOR (diclofenac epolamine) NC hyalucil-4 NC hydrogen peroxide solution 30 % NC diclofenac sodium (Klofensaid Ii) NC LEVULAN KERASTICK (aminolevulinic acid hcl) NP QL (1 stick per 30 days) LICART (diclofenac epolamine) NC lugols external NC lugols strong iodine NC NUVAIL (dermatological products, misc.) NP PANRETIN (alitretinoin) NP PENNSAID EXTERNAL (diclofenac sodium) NC PENNSAID TRANSDERMAL SOLUTION 2 % (diclofenac NC sodium) pimecrolimus NP PA; ST

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 199 Drug Name Drug Status Drug Details podofilox external PG PROTOPIC (tacrolimus) NC PA; ST; QL (1 pad per 1 QBREXZA (glycopyrronium tosylate) NP Day) SANTYL (collagenase) NP QL (60 grams per 30 days) SILVADENE (silver sulfadiazine) NC SOLARAZE (diclofenac sodium) NC SULFAMYLON EXTERNAL PACKET (mafenide acetate) NP tacrolimus external ointment NP TARGRETIN EXTERNAL (bexarotene) PSP PA; SP Pharmacy VALCHLOR (mechlorethamine hcl (topical)) NC # VEREGEN (sinecatechins) NP VOLTAREN TRANSDERMAL (diclofenac sodium) PG QL (300 grams per 1 month) XERAC AC (aluminum chloride in alcohol) PB ZOVIRAX EXTERNAL (acyclovir) NC ZYCLARA PUMP EXTERNAL CREAM 3.75 % NC (imiquimod) DERMATOLOGY, ROSACEA azelaic acid external NP FINACEA EXTERNAL FOAM (azelaic acid) PB FINACEA EXTERNAL GEL (azelaic acid) NC ivermectin external cream NP METROCREAM (metronidazole) NC METROGEL EXTERNAL GEL (metronidazole) NC METROLOTION (metronidazole) NC metronidazole external cream NP metronidazole external gel NP metronidazole external lotion PG MIRVASO (brimonidine tartrate) NP PA NORITATE (metronidazole) NC ORACEA (doxycycline) NC RHOFADE (oxymetazoline hcl) NC rosadan external cream NP rosadan external gel NP SOOLANTRA (ivermectin) NC

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 200 Drug Name Drug Status Drug Details ZILXI (minocycline hcl micronized) NC DERMATOLOGY, SCABICIDES AND PEDICULIDES CROTAN (crotamiton) PG cvs lice treatment PG cvs permethrin PG ELIMITE (permethrin) NC EURAX (crotamiton) NP ivermectin external lotion PG ST lindane external shampoo PG malathion external NP NATROBA (spinosad) NC OVIDE (malathion) NC permethrin external cream NP ra lice treatment PG SKLICE (ivermectin) NC # sm lice treatment PG spinosad NP ULESFIA (benzyl alcohol) NP #; QL (3 bottles per 1 fill) DERMATOLOGY, WOUND CARE AGENTS LIDOTREX (lidocaine) NC LIDOTREX (ALOE VERA) (lidocaine--aloe vera) NC REGRANEX (becaplermin) NP PA MOUTH/THROAT/DENTAL AGENTS cevimeline hcl NP chlorhexidine gluconate mouth/throat PG clotrimazole mouth/throat PG EVOXAC (cevimeline hcl) NC FLUORIDEX SENSITIVITY RELIEF DENTAL GEL (sod NP fluoride-potassium nitrate) lidocaine hcl mouth/throat PG lidocaine viscous PG N2 (Not Covered); AL (Min neutragard advanced CE 6 Years and Max 16 Years) N2 (Not Covered); AL (Min neutral sodium fluoride CE 6 Years and Max 16 Years)

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 201 Drug Name Drug Status Drug Details nystatin mouth/throat PG oralone PG ORAVIG (miconazole) NP #; QL (14 tabs per 1 fill) paroex PG PERIDEX (chlorhexidine gluconate) NC periogard PG pilocarpine hcl oral PG SALAGEN (pilocarpine hcl) NC N2 (Not Covered); AL (Min sf CE 6 Years and Max 16 Years) triamcinolone acetonide mouth/throat PG OTIC - DRUGS TO TREAT CONDITIONS OF THE EAR acetasol hc PG acetic acid otic PG CETRAXAL (ciprofloxacin hcl) NC CIPRO HC (ciprofloxacin-hydrocortisone) NP # CIPRODEX (ciprofloxacin-dexamethasone) NC ciprofloxacin hcl otic PG ciprofloxacin-dexamethasone PG ciprofloxacin-fluocinolone pf NC COLY-MYCIN S (neomycin-colist-hc-thonzonium) NP DERMOTIC (fluocinolone acetonide) NC FLOXIN OTIC (ofloxacin) NC fluocinolone acetonide otic NP hydrocortisone-acetic acid PG neomycin-polymyxin-hc otic PG ofloxacin otic NP OTIPRIO (ciprofloxacin) NC OTOVEL (ciprofloxacin-fluocinolone) NP PRAMOTIC (pramoxine-chloroxylenol) NC

2021 Small Group ACA FL Plan The formulary is updated the first week of each month. 10/01/2021 202 Index 1st tier unifine pentips...... 141 acetasol hc...... 202 ADMELOG SOLOSTAR...... 94 1st tier unifine pentips plus...... 141 acetazolamide...... 62 ADOXA...... 39 1ST TIER UNILET acetazolamide er...... 62 ADRENALIN...... 184 COMFORTOUCH...... 141 acetic acid...... 128, 202 ADVAIR DISKUS...... 186, 187 abacavir sulfate...... 29 acetylcysteine...... 177, 184 ADVAIR HFA...... 187 abacavir sulfate-lamivudine...... 32 acid reducer...... 124 ADVANCE INTUITION abacavir-lamivudine-zidovudine 32 ACIPHEX...... 124 TEST...... 142 ABILIFY...... 76 ACIPHEX SPRINKLE.124, 125 ADVOCATE INSULIN PEN ABILIFY MAINTENA...... 76 acitretin...... 192 NEEDLES...... 142 abiraterone acetate...... 42 ACTEMRA...... 136 ADVOCATE INSULIN ABREVA...... 198 ACTEMRA ACTPEN...... 136 SYRINGE...... 142 ABSORICA...... 187 ACTHAR...... 112 ADVOCATE LANCETS...... 142 ABSORICA LD...... 187 ACTICLATE...... 39 ADVOCATE RAPID-SAFE ABSTRAL...... 18 ACTIGALL...... 123 LANCING...... 142 acamprosate calcium...... 89 ACTI-LANCE 28G...... 142 ADVOCATE REDI-CODE..142 ACANYA...... 187 ACTI-LANCE LITE ADVOCATE REDI-CODE+ acarbose...... 92 LANCETS 28G...... 142 TEST...... 142 ACCOLATE...... 183 ACTI-LANCE SPECIAL ADVOCATE SAFETY ACCRUFER...... 163 LANCETS 17G...... 142 LANCETS...... 142 ACCU-CHEK AVIVA PLUS ACTI-LANCE UNIVERSAL ADVOCATE TEST...... 142 ...... 141 23G...... 142 ADYPHREN...... 177 ACCU-CHEK COMPACT ACTIMMUNE...... 139 ADYPHREN AMP...... 177 PLUS...... 141 ACTIQ...... 19 ADYPHREN AMP II...... 177 ACCU-CHEK FASTCLIX ACTIVELLA...... 108 ADYPHREN II...... 177 LANCETS...... 142 ACTONEL...... 98 ADZENYS ER...... 78 ACCU-CHEK GUIDE...... 142 ACTOPLUS MET...... 97 ADZENYS XR-ODT...... 78 ACCU-CHEK MULTICLIX ACTOPLUS MET XR...... 97 AEMCOLO...... 27 LANCETS...... 142 ACTOS...... 97 AEROCHAMBER PLUS ACCU-CHEK SAFE-T PRO ACULAR...... 175 FLO-VU...... 162 LANCETS...... 142 ACULAR LS...... 175 AEROSPAN...... 185 ACCU-CHEK ACUVAIL...... 175 afeditab cr...... 59 SMARTVIEW...... 142 acyclovir...... 34, 199 AFINITOR...... 44 ACCU-CHEK SOFT ACZONE...... 187 AFINITOR DISPERZ...... 44 TOUCH LANCETS...... 142 ADAGEN...... 107 Afirmelle...... 100 ACCU-CHEK SOFTCLIX ADALAT CC...... 59 AFREZZA...... 94 LANCET DEV...... 142 adapalene...... 187 AFTERA...... 100 ACCU-CHEK SOFTCLIX adapalene-benzoyl peroxide.... 187 AGAMATRIX AMP TEST..142 LANCETS...... 142 ADCIRCA...... 65 AGAMATRIX JAZZ TEST.142 ACCUPRIL...... 52 ADDERALL...... 78 AGAMATRIX KEYNOTE ACCURETIC...... 51 ADDERALL XR...... 78 TEST...... 143 ACCUTREND GLUCOSE..142 ADDYI...... 89 AGAMATRIX PRESTO ACCUTREND GLUCOSE adefovir dipivoxil...... 34 TEST...... 143 CONTROL...... 142 ADEMPAS...... 65 AGAMATRIX ULTRA- acebutolol hcl...... 58 ADHANSIA XR...... 78 THIN LANCETS...... 143 ACEON...... 52 adjustable lancing device...... 142 AGGRENOX...... 135 acetaminophen-codeine...... 19 ADLYXIN...... 93 AGRYLIN...... 132 acetaminophen-codeine #2...... 19 ADLYXIN STARTER AIMOVIG...... 83 acetaminophen-codeine #3...... 19 PACK...... 93 AIMOVIG (140 MG DOSE)...83 acetaminophen-codeine #4...... 19 ADMELOG...... 94 AIRDUO DIGIHALER...... 187 203 AIRDUO RESPICLICK alprazolam er...... 66 amphetamine-dextroamphet er. 78 113/14...... 177 ALPRAZOLAM INTENSOL 66 amphetamine- AIRDUO RESPICLICK alprazolam xr...... 66 dextroamphetamine...... 78 232/14...... 177 ALREX...... 175 ampicillin...... 39 AIRDUO RESPICLICK ALTABAX...... 190 AMPYRA...... 86 55/14...... 177 ALTACE...... 52 AMRIX...... 88 AJOVY...... 83 altafrin...... 133 AMZEEQ...... 188 AKLIEF...... 187 altavera...... 100 ANADROL-50...... 91 AKTIPAK...... 187 alternate site lancing device.... 143 ANAFRANIL...... 71 AKYNZEO...... 118 ALTOPREV...... 56 anagrelide hcl...... 133 ALA SCALP...... 193 ALTRENO...... 187 ANALPRAM-HC...... 126 ala-cort...... 193 ALUNBRIG...... 44 ANAPROX DS...... 16 alavert...... 178 ALVESCO...... 185 anastrozole...... 42 ALAVERT...... 178 alyacen 1/35...... 100 ANCOBON...... 26 alavert allergy/sinus...... 181 alyacen 7/7/7...... 100 ANDRODERM...... 91 alaway...... 132 Alyq...... 65 ANDROGEL...... 91 albendazole...... 27 Amabelz...... 108 ANDROGEL PUMP...... 91 albuterol sulfate...... 180 amantadine hcl...... 74 ANDROID...... 112 albuterol sulfate er...... 180 AMARYL...... 98 ANDROXY...... 112 albuterol sulfate hfa...... 180 AMBIEN...... 81 ANGELIQ...... 108 alclometasone dipropionate.....193 AMBIEN CR...... 81 ANNOVERA...... 100 alcohol swabs...... 143 ambrisentan...... 65 ANORO ELLIPTA...... 177 ALDACTAZIDE...... 62 amcinonide...... 193 ANTABUSE...... 89 ALDACTONE...... 62 AMELUZ...... 199 ANTARA...... 55 ALDARA...... 199 AMERGE...... 83 ANTICOAGULANT ALECENSA...... 44 amethia...... 100 COMPOUND...... 130 alendronate sodium...... 98 amethia lo...... 100 anti-stick insulin syringe...... 143 ALFERON N...... 49 AMICAR...... 133 ANUSOL-HC...... 126 alfuzosin hcl er...... 127 amiloride hcl...... 62 ANZEMET...... 118 ALINIA...... 27 amiloride-hydrochlorothiazide.. 62 APADAZ...... 19 aliskiren fumarate...... 61 aminocaproic acid...... 133 apap-caff-dihydrocodeine...... 19 ALKERAN...... 40 amiodarone hcl...... 54 APEXICON E...... 193 ALKINDI SPRINKLE...... 109 AMITIZA...... 121 APIDRA...... 94 ALLEGRA ALLERGY...... 179 amitriptyline hcl...... 71 APIDRA SOLOSTAR...... 94 ALLEGRA ALLERGY AMLODIPINE APLENZIN...... 71 CHILDRENS...... 179 BES+SYRSPEND SF...... 59 APOKYN...... 74 ALLEGRA-D ALLERGY & amlodipine besy-benazepril hcl..51 APPTRIM...... 163 CONGESTION...... 181 amlodipine besylate...... 59 APPTRIM-D...... 163 allopurinol...... 15 amlodipine besylate-valsartan...53 apraclonidine hcl...... 172 ALLZITAL...... 15 amlodipine-atorvastatin...... 59 aprepitant...... 118 almotriptan malate...... 83 amlodipine-olmesartan...... 53 apri...... 100 ALOCRIL...... 172 amlodipine-valsartan-hctz...... 53 APRISO...... 120 alogliptin benzoate...... 93 ammonium lactate...... 199 APTENSIO XR...... 78 alogliptin-metformin hcl...... 93 amnesteem...... 187 APTIOM...... 66 alogliptin-pioglitazone...... 93 amoxapine...... 71 APTIVUS...... 29 ALOMIDE...... 172 amoxicillin...... 39 ARAKODA...... 29 ALORA...... 108 amoxicillin-pot clavulanate...... 39 aranelle...... 100 alosetron hcl...... 121 amoxicillin-pot clavulanate er...39 ARANESP (ALBUMIN ALPHAGAN P...... 172 amphetamine er...... 78 FREE)...... 131 alprazolam...... 66 amphetamine sulfate...... 78 ARAVA...... 138 204 ARAZLO...... 188 ASSURE COMFORT AURORA UNIFINE ARCALYST...... 139 LANCETS 30G...... 143 PENTIPS...... 143 ARCAPTA NEOHALER.....180 ASSURE HAEMOLANCE Aurovela 1.5/30...... 100 arformoterol tartrate...... 180 PLUS HIGH...... 143 Aurovela 1/20...... 100 Argyle Sterile Saline...... 128 ASSURE HAEMOLANCE Aurovela 24 Fe...... 100 ARICEPT...... 70 PLUS LOW...... 143 Aurovela Fe 1/20...... 101 ARIKAYCE...... 26 ASSURE HAEMOLANCE AURYXIA...... 114 ARIMIDEX...... 43 PLUS MICRO...... 143 AUSTEDO...... 84 aripiprazole...... 76 ASSURE HAEMOLANCE AUVI-Q...... 177 ARISTADA...... 76 PLUS NORMAL...... 143 AVAILNEX...... 163 ARISTADA INITIO...... 76 ASSURE HAEMOLANCE AVALIDE...... 53 ARIXTRA...... 130 PLUS PED...... 143 AVANDIA...... 97 armodafinil...... 89 ASSURE ID INSULIN AVAPRO...... 54 ARMONAIR DIGIHALER.185 SAFETY SYR...... 143 AVAR LS CLEANSER...... 188 ARMONAIR RESPICLICK ASSURE LANCE AVAR-E LS...... 188 113...... 185 LANCETS...... 143 AVC VAGINAL...... 129 ARMONAIR RESPICLICK ASSURE LANCETS...... 143 AVELOX...... 37 232...... 185 ASSURE PLATINUM...... 143 aviane...... 101 ARMONAIR RESPICLICK ASSURE PRO TEST...... 143 avidoxy...... 39 55...... 185 ASTAGRAF XL...... 140 avita...... 188 ARMOUR THYROID...... 115 ATACAND...... 54 Avita...... 188 ARNUITY ELLIPTA...... 185 ATACAND HCT...... 53 AVODART...... 127 AROMASIN...... 43 atazanavir sulfate...... 29 AVONEX...... 86 ARTHROTEC...... 18 ATELVIA...... 98 AVONEX PEN...... 86 ARYMO ER...... 19 atenolol...... 58 AVONEX PREFILLED...... 86 ASACOL HD...... 120 ATENOLOL+SYRSPEND av-phos 250 neutral...... 162 ASCENIV...... 138 SF PH4...... 58 AVSOLA...... 136 ascomp-codeine...... 19 atenolol-chlorthalidone...... 58 AXERT...... 83 asenapine maleate...... 76 ATIVAN...... 66 AXONA...... 163 Ashlyna...... 100 atomoxetine hcl...... 78 AYGESTIN...... 115 ASMANEX (120 METERED atorvastatin calcium...... 56 Ayuna...... 101 DOSES)...... 186 atovaquone...... 27 AYVAKIT...... 49 ASMANEX (14 METERED atovaquone-proguanil hcl...... 29 AZASAN...... 140 DOSES)...... 186 ATRALIN...... 188 AZASITE...... 174 ASMANEX (30 METERED ATRIPLA...... 32 azathioprine...... 140 DOSES)...... 186 atropine sulfate...... 133 azelaic acid...... 200 ASMANEX (60 METERED ATROVENT HFA...... 178 azelastine hcl...... 172, 179 DOSES)...... 186 AUBAGIO...... 86 azelastine-fluticasone...... 178 ASMANEX (7 METERED Aubra...... 100 AZELEX...... 188 DOSES)...... 186 Aubra Eq...... 100 azeschew prenatal/postnatal....163 ASMANEX HFA...... 186 AUGMENTIN...... 39 azesco...... 163 asperflex max st...... 198 AUGMENTIN ES-600...... 39 AZILECT...... 74 aspirin...... 25 AUGMENTIN XR...... 39 azithromycin...... 36 aspirin low dose...... 25 AURORA LANCET SUPER azo tabs...... 128 aspirin-dipyridamole er...... 135 THIN 30G...... 143 AZOPT...... 172 aspirin-omeprazole...... 135 AURORA LANCET THIN AZOR...... 53 ASSURE 3 TEST...... 143 23G...... 143 azo-standard...... 128 ASSURE 4 TEST...... 143 AURORA PEN NEEDLES..143 AZSTARYS...... 78 ASSURE COMFORT aurora unifine pentips...... 143 AZULFIDINE...... 120 LANCETS 28G...... 143 AZULFIDINE EN-TABS.... 120 205 azurette...... 101 BD MICROTAINER betamethasone dipropionate b-6...... 163 LANCETS...... 144 ...... 193, 194 Bac...... 15 BD PEN NEEDLE MINI betamethasone dipropionate BACIGUENT...... 174 U/F...... 144 aug...... 193 bacitracin...... 174 BD PEN NEEDLE NANO betamethasone valerate...... 194 bacitracin-polymyxin b...... 174 U/F...... 144 BETAPACE...... 58 bacitra-neomycin-polymyxin- BD PEN NEEDLE BETAPACE AF...... 58 hc...... 173 ORIGINAL U/F...... 144 BETASERON...... 86 baclofen...... 88 BD PEN NEEDLE SHORT betaxolol hcl...... 58, 172 BACTRIM...... 27 U/F...... 144 bethanechol chloride...... 123 BACTRIM DS...... 27 BD SAFETYGLIDE BETHKIS...... 26 BACTROBAN...... 190 INSULIN SYRINGE...... 144 BETIMOL...... 172 BACTROBAN NASAL...... 190 BD SAFETY-LOK BETOPTIC-S...... 172 BAFIERTAM...... 86 INSULIN SYRINGE...... 144 BEVESPI AEROSPHERE....177 BAL-CARE DHA...... 163 BD VEO INSULIN SYR U/F BEVYXXA...... 130 BALCOLTRA...... 101 1/2UNIT...... 144 bexarotene...... 49 balsalazide disodium...... 120 BD VEO INSULIN BEYAZ...... 101 BALVERSA...... 45 SYRINGE U/F...... 145 BIAXIN...... 36 balziva...... 101 BECONASE AQ...... 184 bicalutamide...... 43 BANZEL...... 66 Bekyree...... 101 BIDIL...... 63 BAQSIMI ONE PACK...... 111 BELBUCA...... 25 BIEST/PROGESTERONE...108 BAQSIMI TWO PACK...... 111 belladonna alkaloids-opium.....117 BIJUVA...... 108 BARACLUDE...... 34 BELSOMRA...... 81 BIKTARVY...... 32 BASAGLAR KWIKPEN...... 94 BELVIQ...... 84 BILTRICIDE...... 27 BAXDELA...... 37 benazepril hcl...... 52 bimatoprost...... 172 BAYER BREEZE 2 TEST....143 benazepril-hydrochlorothiazide.51 BINOSTO...... 98 BAYER CONTOUR NEXT BENICAR...... 54 bio-statin...... 26 TEST...... 143 BENICAR HCT...... 53 bisacodyl...... 121 BAYER CONTOUR TEST..144 BENLYSTA...... 140 bisoprolol fumarate...... 58 bayer low dose...... 25 BENTYL...... 117 bisoprolol-hydrochlorothiazide..58 BAYER MICROLET BENZAC AC WASH...... 188 BLEPH-10...... 174 LANCETS...... 144 BENZACLIN...... 188 BLEPHAMIDE...... 174 BD AUTOSHIELD...... 144 BENZACLIN WITH PUMP 188 BLEPHAMIDE S.O.P...... 174 BD GLUCOSE...... 111 BENZAMYCIN...... 188 Blisovi 24 Fe...... 101 BD INSULIN SYR benzhydrocodone- Blisovi Fe 1.5/30...... 101 ULTRAFINE II...... 144 acetaminophen...... 19 Blisovi Fe 1/20...... 101 BD INSULIN SYRINGE.....144 BENZIQ...... 188 blood glucose test...... 145 BD INSULIN SYRINGE BENZIQ LS...... 188 BONIVA...... 98 HALF-UNIT...... 144 benznidazole...... 27 BONJESTA...... 118 BD INSULIN SYRINGE benzonatate...... 181 bosentan...... 65 MICROFINE...... 144 benzoyl peroxide-erythromycin BOSULIF...... 45 BD INSULIN SYRINGE ...... 188 bp folinatal plus b...... 163 U/F...... 144 benztropine mesylate...... 74 bp multinatal plus...... 163 BD INSULIN SYRINGE BEOVU...... 133 bp wash...... 188 ULTRAFINE...... 144 bepotastine besilate...... 172 BRAFTOVI...... 49 BD LANCET ULTRAFINE BEPREVE...... 172 BREO ELLIPTA...... 187 30G...... 144 BESIVANCE...... 174 BREXAFEMME...... 26 BD LANCET ULTRAFINE BETADINE OPHTHALMIC BREZTRI AEROSPHERE.. 177 33G...... 144 PREP...... 174 briellyn...... 101 BETAGAN...... 172 BRILINTA...... 135 206 brimonidine tartrate...... 172 cabergoline...... 112 CARDIZEM LA...... 60 brinzolamide...... 172 CABLIVI...... 131 CARDURA...... 53 BRISDELLE...... 71 CABOMETYX...... 45 CARDURA XL...... 127 BRIVIACT...... 66 CADUET...... 59 CAREFINE PEN NEEDLES bromfed dm...... 181 caffeine citrate...... 84 ...... 145 bromfenac sodium (once-daily) CALAN...... 59 CAREONE LANCET ...... 175 CALAN SR...... 59 SUPER THIN 30G...... 145 bromocriptine mesylate...... 74 CALCIFOL...... 163 CAREONE LANCET THIN brompheniramine tannate...... 179 calcipotriene...... 192 23G...... 145 BROMSITE...... 175 calcipotriene-betameth diprop.194 CAREONE LANCET BRONCHITOL...... 184 calcitonin (salmon)...... 112 ULTRA THIN 28G...... 145 BROVANA...... 180 calcitrene...... 192 CAREONE UNIFINE BRUKINSA...... 45 calcitriol...... 99, 192 PENTIPS...... 145 BRYHALI...... 194 calcium acetate...... 114 CARESENS N GLUCOSE BUCALSEP...... 199 calcium acetate (phos binder).114 TEST...... 145 budesonide...... 120, 186 calcium pnv...... 163 CARIMUNE NF...... 139 budesonide er...... 109 calcium-folic acid plus d...... 163 carisoprodol...... 88 budesonide-formoterol CALPHRON...... 114 carisoprodol-aspirin...... 88 fumarate...... 187 CALQUENCE...... 45 carisoprodol-aspirin-codeine..... 88 BULLSEYE MINI SAFETY CAMBIA...... 16 CARNITOR...... 99 LANCETS...... 145 camila...... 101 CARNITOR SF...... 99 bumetanide...... 62 camrese...... 101 CAROSPIR...... 62 BUMEX...... 62 camrese lo...... 101 carteolol hcl...... 172 BUNAVAIL...... 18 CANASA...... 120 cartia xt...... 60 Bupap...... 15 candesartan cilexetil...... 54 carvedilol...... 58 BUPHENYL...... 107 candesartan cilexetil-hctz...... 53 carvedilol phosphate er...... 58 buprenorphine...... 25 capacet...... 15 CASODEX...... 43 buprenorphine hcl...... 25 capecitabine...... 41 CATAPRES...... 63 buprenorphine hcl-naloxone hcl.18 CAPEX...... 194 CATAPRES-TTS-1...... 63 bupropion hcl...... 72 CAPLYTA...... 76 CATAPRES-TTS-2...... 63 bupropion hcl er (smoking det).90 CAPRELSA...... 45 CATAPRES-TTS-3...... 63 bupropion hcl er (sr)...... 71 captopril...... 52 CAYSTON...... 27 bupropion hcl er (xl)...... 71, 72 captopril-hydrochlorothiazide...51 caziant...... 101 buspirone hcl...... 84 CARAC...... 190 CEDAX...... 35 butalbital-acetaminophen...... 15 CARAFATE...... 123 cefaclor...... 35 butalbital-apap-caff-cod...... 19 CARBAGLU...... 107 cefaclor er...... 35 butalbital-apap-caffeine...... 15 carbamazepine...... 66 cefadroxil...... 35 butalbital-asa-caff-codeine...... 19 carbamazepine er...... 66 cefdinir...... 35 butalbital-asa-caffeine...... 15 CARBAPHEN 12...... 181 cefditoren pivoxil...... 35 butalbital-aspirin-caffeine...... 15 CARBAPHEN 12 PED...... 182 cefixime...... 35 BUTISOL SODIUM...... 81 CARBATROL...... 66 cefpodoxime proxetil...... 36 butorphanol tartrate...... 19 carbidopa...... 74 cefprozil...... 36 BUTRANS...... 25 carbidopa-levodopa...... 74 ceftibuten...... 36 BYDUREON...... 94 carbidopa-levodopa er...... 74 CEFTIN...... 36 BYDUREON BCISE...... 93 carbidopa-levodopa-entacapone 74 cefuroxime axetil...... 36 BYETTA 10 MCG PEN...... 94 carbinoxamine maleate...... 179 CELEBREX...... 14 BYETTA 5 MCG PEN...... 94 CARDIOTEK RX...... 163 celecoxib...... 14, 15 BYNFEZIA PEN...... 112 CARDIOVID PLUS...... 163 CELEXA...... 72 BYSTOLIC...... 58 CARDIZEM...... 60 CELLCEPT...... 140 BYVALSON...... 53 CARDIZEM CD...... 60 CELONTIN...... 67 207 CENTANY...... 190 cilostazol...... 133 CLEVER CHOICE MICRO cephalexin...... 36 CILOXAN...... 174 TEST...... 145 CEQUA...... 133 CIMDUO...... 32 CLICKFINE PEN CERDELGA...... 107 cimetidine...... 119 NEEDLES...... 145 CEREFOLIN...... 163 cimetidine hcl...... 119 clickfine pen needles...... 145 CEREFOLIN NAC...... 163 CIMZIA...... 136 CLIMARA...... 108 CERVIDIL...... 112 CIMZIA PREFILLED...... 136 CLIMARA PRO...... 108 CESAMET...... 118 CIMZIA STARTER KIT..... 136 clindacin etz...... 188 cesia...... 101 cinacalcet hcl...... 99 clindacin-p...... 188 cetirizine hcl...... 179 CIPRO...... 37 CLINDAGEL...... 188 cetirizine-pseudoephedrine er.. 182 CIPRO HC...... 202 clindamycin hcl...... 28 CETRAXAL...... 202 CIPRO XR...... 37 clindamycin palmitate hcl...... 28 cevimeline hcl...... 201 CIPRODEX...... 202 clindamycin phos-benzoyl CHANTIX...... 90 ciprofloxacin...... 37 perox...... 188 CHANTIX CONTINUING ciprofloxacin hcl...... 37, 174, 202 clindamycin phosphate.... 130, 188 MONTH PAK...... 90 ciprofloxacin-ciproflox hcl er....37 clindamycin-tretinoin...... 188 CHANTIX STARTING ciprofloxacin-dexamethasone..202 CLINDESSE...... 130 MONTH PAK...... 90 ciprofloxacin-fluocinolone pf.. 202 clobazam...... 67 chateal...... 101 citalopram hydrobromide...... 72 clobetasol propionate...... 194 Chateal Eq...... 101 CITRANATAL 90 DHA...... 163 clobetasol propionate e...... 194 CHEK-STIX CONTROL..... 145 CITRANATAL ASSURE.... 164 clobetasol propionate emulsion194 CHEMET...... 99 CITRANATAL B-CALM.... 164 CLOBEX...... 194 CHEMSTRIP 10 MD...... 145 CITRANATAL ESSENCE.. 164 CLOBEX SPRAY...... 194 CHEMSTRIP 10/SG...... 145 CITRANATAL MEDLEY...164 clocortolone pivalate...... 194 CHEMSTRIP 2 GP...... 145 CITRANATAL RX...... 164 clocortolone pivalate pump..... 194 CHEMSTRIP 5 OB...... 145 citrate of magnesia...... 121 Clodan...... 194 CHEMSTRIP 7...... 145 claravis...... 188 CLODERM...... 194 CHEMSTRIP 9...... 145 CLARINEX...... 179 CLODERM PUMP...... 194 CHEMSTRIP K...... 145 CLARINEX-D 12 HOUR.... 182 clomipramine hcl...... 84, 85 CHEMSTRIP UGK...... 145 clarithromycin...... 36 clonazepam...... 67 CHENODAL...... 123 clarithromycin er...... 36 clonidine hcl...... 63 childrens aspirin...... 26 CLARITIN...... 179 clonidine hcl er...... 79 chlordiazepoxide hcl...... 66 CLARITIN CHILDRENS... 179 clopidogrel bisulfate...... 135 chlordiazepoxide-amitriptyline. 90 CLARITIN EYE...... 133 clorazepate dipotassium...... 67 chlordiazepoxide-clidinium..... 117 CLARITIN REDITABS...... 179 CLORPRES...... 53 chlorhexidine gluconate...199, 201 CLARITIN-D 12 HOUR...... 182 clotrimazole...... 191, 201 chloroquine phosphate...... 29 CLARITIN-D 24 HOUR...... 182 clotrimazole-betamethasone....191 chlorothiazide...... 62 clemastine fumarate...... 179 clozapine...... 76 chlorpromazine hcl...... 76 CLENPIQ...... 121 CLOZARIL...... 76 chlorpropamide...... 98 CLEOCIN...... 28, 129 COARTEM...... 29 chlorthalidone...... 62 CLEOCIN-T...... 188 CODAR AR...... 182 chlorzoxazone...... 88 CLEVER CHEK AUTO- codeine sulfate...... 19 CHOLBAM...... 123 CODE TEST...... 145 COLAZAL...... 120 cholestyramine...... 55 CLEVER CHEK AUTO- colchicine...... 15 cholestyramine light...... 55 CODE VOICE...... 145 colchicine-probenecid...... 15 choline-mag trisalicylate...... 26 CLEVER CHEK LANCETS 145 COLCRYS...... 15 chorionic gonadotropin...... 109 CLEVER CHEK TEST...... 145 colesevelam hcl...... 55 ciclodan...... 190 CLEVER CHOICE AUTO- COLESTID...... 55 ciclopirox...... 190, 191 CODE TEST...... 145 COLESTID FLAVORED...... 55 ciclopirox olamine...... 191 colestipol hcl...... 55 208 colocort...... 120 CORTIFOAM...... 120 CYMBALTA...... 72 COLY-MYCIN S...... 202 cortisone acetate...... 109 cyproheptadine hcl...... 179 COLYTE WITH FLAVOR CORTISPORIN...... 190 Cyred...... 101 PACKS...... 121 CORVITE 150...... 133 CYSTADANE...... 107 COMBIGAN...... 172 corvite fe...... 133 CYSTADROPS...... 133 COMBIPATCH...... 108 CORZIDE...... 58 CYSTAGON...... 107 COMBISTIX...... 145 COSENTYX...... 192 CYSTARAN...... 133 COMBIVENT RESPIMAT..177 COSENTYX (300 MG CYTOMEL...... 115 COMBIVIR...... 32 DOSE)...... 192 CYTOTEC...... 123 COMETRIQ (100 MG COSENTYX cytra k crystals...... 128 DAILY DOSE)...... 45, 49 SENSOREADY (300 MG)... 192 D.H.E. 45...... 83 COMETRIQ (140 MG COSENTYX DAKLINZA...... 37 DAILY DOSE)...... 45, 49 SENSOREADY PEN...... 192 dalfampridine er...... 86 COMETRIQ (60 MG DAILY COSOPT...... 172 DALIRESP...... 184 DOSE)...... 45 COSOPT PF...... 172 danazol...... 106 COMFORT ASSURED COTELLIC...... 45 DANTRIUM...... 88 LANCETS 28G...... 145 COTEMPLA XR-ODT...... 79 dantrolene sodium...... 88 COMFORT ASSURED COUMADIN...... 130 dapsone...... 28, 188 LANCETS 33G...... 146 COZAAR...... 54 DARAPRIM...... 28 COMFORT EZ INSULIN CREON...... 124 darifenacin hydrobromide er... 129 SYRINGE...... 146 CRESEMBA...... 27 dasetta 1/35...... 101 COMFORT EZ PEN CRESTOR...... 56 dasetta 7/7/7...... 101 NEEDLES...... 146 CRINONE...... 115 DAURISMO...... 41 COMFORT LANCETS...... 146 CRIXIVAN...... 29 DAXBIA...... 36 COMPLERA...... 32 cromolyn sodium..... 123, 172, 183 DAYPRO...... 16 complete natal dha...... 164 CROTAN...... 201 daysee...... 101 completenate...... 164 cryselle-28...... 101 DAYTRANA...... 79 compro...... 118 CUPRIMINE...... 99 DAYVIGO...... 82 COMTAN...... 74 Curity Sterile Saline...... 128 D-CARE DM2...... 112 co-natal fa...... 164 CUTAQUIG...... 139 DDAVP...... 116, 117 CONCEPT DHA...... 164 CUTIVATE...... 194 DDAVP RHINAL TUBE.....117 CONCEPT OB...... 164 CUVITRU...... 139 deblitane...... 101 CONCERTA...... 79 CUVPOSA...... 117 DECARA...... 164 CONDYLOX...... 199 cvs lice treatment...... 201 DECARA K...... 164 CONJUPRI...... 60 cvs pain relief...... 198 DECON-A...... 182 CONSENSI...... 60 cvs permethrin...... 201 deferasirox...... 99 constulose...... 121 cvs ultra sleep...... 81 deferasirox granules...... 99 CONZIP...... 19 cyanocobalamin...... 164 deferiprone...... 99 COPAXONE...... 86 cyclafem 1/35...... 101 DELESTROGEN...... 108 COPEGUS...... 37 cyclafem 7/7/7...... 101 DELSTRIGO...... 32 COPIKTRA...... 45 cyclobenzaprine hcl...... 88 Deltasone...... 110 CORDRAN...... 194 cyclobenzaprine hcl er...... 88 Delyla...... 101 COREG...... 58 CYCLOGYL...... 133 DELZICOL...... 120 COREG CR...... 58 CYCLOMYDRIL...... 133 DEMADEX...... 62 Coremino...... 39 cyclopentolate hcl...... 133 demeclocycline hcl...... 39 CORGARD...... 58 cyclophosphamide...... 40 DEMEROL...... 19 CORLANOR...... 63 cycloserine...... 33 DEMSER...... 63 cormax scalp application...... 194 CYCLOSET...... 93 DENAVIR...... 199 CORTEF...... 109 cyclosporine...... 140 DEPAKENE...... 67 CORTENEMA...... 120 cyclosporine modified...... 140 DEPAKOTE...... 67 209 DEPAKOTE ER...... 67 DEXCOM G4 PLATINUM Difil-G Forte...... 184 DEPAKOTE SPRINKLES.... 67 RECEIVER...... 146 diflorasone diacetate...... 195 DEPEN TITRATABS...... 99 DEXCOM G4 PLATINUM DIFLUCAN...... 27 DEPLIN 15...... 164 TRANSMITTER...... 146 diflunisal...... 26 DEPLIN 7.5...... 164 DEXCOM G4 SENSOR...... 146 Digitek...... 61 DEPO-ESTRADIOL...... 108 DEXCOM G5 MOB/G4 Digox...... 61 DEPO-PROVERA...... 43 PLAT SENSOR...... 146 digoxin...... 61 DEPO-SUBQ PROVERA DEXCOM G5 MOBILE dihydroergotamine mesylate..... 83 104...... 101 RECEIVER...... 146 DILANTIN...... 67 DEPO-TESTOSTERONE...... 91 DEXCOM G5 MOBILE DILANTIN INFATABS...... 67 DERMA-SMOOTHE/FS TRANSMITTER...... 146 DILATRATE-SR...... 64 BODY...... 194 DEXCOM G5 RECEIVER DILAUDID...... 19 DERMA-SMOOTHE/FS KIT...... 146 diltiazem cd...... 60 SCALP...... 195 DEXCOM G6 RECEIVER.. 146 diltiazem hcl...... 60 DERMATOP...... 195 DEXCOM G6 SENSOR...... 146 diltiazem hcl er...... 60 DERMOTIC...... 202 DEXCOM G6 diltiazem hcl er beads...... 60 DESCOVY...... 33 TRANSMITTER...... 146 diltiazem hcl er coated beads.... 60 desipramine hcl...... 72 DEXEDRINE...... 79 dilt-xr...... 60 desloratadine...... 179 DEXILANT...... 125 dimethyl fumarate...... 86 desmopressin ace rhinal tube.....63 dexmethylphenidate hcl...... 79 DIOVAN...... 54 desmopressin ace spray refrig. 117 dexmethylphenidate hcl er...... 79 DIOVAN HCT...... 53 desmopressin acetate...... 117 Dexpak 10 Day...... 110 DIPENTUM...... 120 desmopressin acetate spray..... 117 Dexpak 13 Day...... 110 diphenhydramine hcl...... 179 desogestrel-ethinyl estradiol....101 Dexpak 6 Day...... 110 diphenoxylate-atropine...... 123 DESONATE...... 195 dextroamphetamine sulfate...... 79 DIPROLENE...... 195 desonide...... 195 dextroamphetamine sulfate er...79 DIPROLENE AF...... 195 DESOWEN...... 195 DIACOMIT...... 67 dipyridamole...... 135 desoximetasone...... 195 DIALYVITE 3000...... 164 disopyramide phosphate...... 54 DESOXYN...... 79 DIALYVITE 5000...... 164 disulfiram...... 90 desvenlafaxine er...... 72 DIALYVITE SUPREME D. 164 DITROPAN XL...... 129 desvenlafaxine succinate er...... 72 DIALYVITE/ZINC...... 164 DIURIL...... 62 DETROL...... 129 DIAMOX SEQUELS...... 62 divalproex sodium...... 67 DETROL LA...... 129 DIASTAT ACUDIAL...... 67 divalproex sodium er...... 67 DEX4 GLUCOSE...... 111 DIASTAT PEDIATRIC...... 67 DIVIGEL...... 108 DEX4 GLUCOSE GO- diazepam...... 67 docosanol...... 199 POUCH...... 111 diazepam intensol...... 67 dofetilide...... 54 DEX4 QUICK DISSOLVE diazoxide...... 111 DOLOPHINE...... 19 GLUCOSE...... 111 DIBENZYLINE...... 63 DOLOTRANZ...... 198 dexamethasone...... 110 DICLEGIS...... 118 donepezil hcl...... 70 DEXAMETHASONE diclofenac...... 16 DOPTELET...... 131 INTENSOL...... 110 diclofenac epolamine...... 199 DORAL...... 82 dexamethasone sodium diclofenac potassium...... 16 DORYX...... 39 phosphate...... 175 diclofenac sodium.16, 34, 175, 199 DORYX MPC...... 39 DEXCOM G4 PLAT PED diclofenac sodium er...... 16 dorzolamide hcl...... 172 RCV/SHARE...... 146 diclofenac-misoprostol...... 18 dorzolamide hcl-timolol mal....173 DEXCOM G4 PLAT PED dicloxacillin sodium...... 39 dorzolamide hcl-timolol mal pf173 RECEIVER...... 146 dicyclomine hcl...... 117 double pm...... 174 DEXCOM G4 PLATINUM didanosine...... 29 DOVATO...... 33 RCV/SHARE...... 146 DIFFERIN...... 188, 189 DOVONEX...... 192 DIFICID...... 36 doxazosin mesylate...... 53 210 doxepin hcl...... 72, 82, 192 EASY COMFORT EASYPLUS BLOOD doxercalciferol...... 99 LANCETS...... 147 GLUCOSE TEST...... 148 doxycycline hyclate...... 39 EASY PLUS II GLUCOSE EASYPRO PLUS...... 148 doxycycline monohydrate....39, 40 TEST...... 147 EC-NAPROSYN...... 16 doxylamine-pyridoxine...... 118 EASY STEP TEST...... 147 econazole nitrate...... 191 d-penamine...... 99 EASY TALK BLOOD ECONTRA EZ...... 101 DRAMAMINE LESS GLUCOSE TEST...... 147 ecotrin low strength...... 26 DROWSY...... 118 EASY TOUCH INSULIN ECOZA...... 191 DRIZALMA SPRINKLE...... 72 SAFETY SYR...... 147 EDARBI...... 54 dronabinol...... 118 EASY TOUCH INSULIN EDARBYCLOR...... 53 DROPLET LANCETS SYRINGE...... 147 EDECRIN...... 62 ULTRA THIN 30G...... 146 EASY TOUCH LANCETS EDLUAR...... 82 drospiren-eth estrad-levomefol 101 21G...... 147 ed-spaz...... 117 drospirenone-ethinyl estradiol. 101 EASY TOUCH LANCETS EDURANT...... 29 DROXIA...... 49 23G...... 147 efavirenz...... 30 droxidopa...... 63 EASY TOUCH LANCETS efavirenz-emtricitab-tenofovir...33 DUAC...... 189 26G...... 147 efavirenz-lamivudine-tenofovir..33 DUAKLIR PRESSAIR...... 187 EASY TOUCH LANCETS EFFER-K...... 162 DUAVEE...... 108 28G...... 147 effer-k...... 162 DUET DHA BALANCED...164 EASY TOUCH LANCETS effervescent pot chloride...... 162 DUETACT...... 98 28G/TWIST...... 147 EFFEXOR XR...... 72 DUEXIS...... 18 EASY TOUCH LANCETS EFFIENT...... 135 DULCOLAX BOWEL PREP 30G...... 147 EFUDEX...... 190 KIT...... 121 EASY TOUCH LANCETS ELAVIL...... 72 DULERA...... 177 30G/TWIST...... 147 ELDEPRYL...... 74 duloxetine hcl...... 72 EASY TOUCH LANCETS ELEMENT TEST...... 148 DUOBRII...... 195 32G...... 147 ELEPSIA XR...... 68 DUOPA...... 74 EASY TOUCH LANCETS ELESTAT...... 133 DUPIXENT...... 185, 193 32G/TWIST...... 147 ELESTRIN...... 108 DURAGESIC-100...... 19 EASY TOUCH LANCETS eletriptan hydrobromide...... 83 DURAGESIC-12...... 19 33G/TWIST...... 147 ELIDEL...... 199 DURAGESIC-25...... 19 EASY TOUCH PEN ELIGARD...... 43 DURAGESIC-50...... 20 NEEDLES...... 147 ELIMITE...... 201 DURAGESIC-75...... 20 EASY TOUCH SAFETY elinest...... 102 duraxin...... 15 LANCETS 21G...... 147 ELIQUIS...... 130 DUREZOL...... 175 EASY TOUCH SAFETY ELIQUIS DVT/PE DURLAZA...... 133 LANCETS 23G...... 147 STARTER PACK...... 130 dutasteride...... 127 EASY TOUCH SAFETY elite-ob...... 164 dutasteride-tamsulosin hcl...... 127 LANCETS 26G...... 147 elite-thin insulin syringe...... 148 DUZALLO...... 15 EASY TOUCH SAFETY ELIXOPHYLLIN...... 187 DXEVO 11-DAY...... 110 LANCETS 28G...... 147 ELLA...... 102 DYANAVEL XR...... 79 EASY TOUCH TEST...... 148 ELMIRON...... 128 DYAZIDE...... 62 EASY TRAK BLOOD ELOCON...... 195 DYMISTA...... 178 GLUCOSE TEST...... 148 Eluryng...... 102 DYRENIUM...... 62 EASY TWIST & CAP EMADINE...... 133 E.E.S. 400...... 26 LANCETS...... 148 EMBEDA...... 20 E.E.S. GRANULES...... 36 EASYGLUCO...... 148 EMBRACE BLOOD EASY COMFORT EASYMAX 15 TEST...... 148 GLUCOSE TEST...... 148 INSULIN SYRINGE...... 147 EASYMAX TEST...... 148 EMCYT...... 40 EMEND...... 118 211 EMEND TRI-PACK...... 118 EPOGEN...... 131 etidronate disodium...... 99 EMFLAZA...... 110 epoprostenol sodium...... 65 etodolac...... 16 EMGALITY...... 83 eprosartan mesylate...... 54 etodolac er...... 16 EMGALITY (300 MG EPZICOM...... 33 etoposide...... 51 DOSE)...... 83 eq blood glucose test...... 148 etravirine...... 30 emoquette...... 102 eq famotidine max st...... 119 EUCRISA...... 199 EMSAM...... 72 eq lidocaine pain relieving...... 198 EURAX...... 201 emtricitabine...... 30 eql sleep aid...... 82 Euthyrox...... 115 emtricitabine-tenofovir df...... 33 equapax/ibuprofen/minrex...... 16 EVAMIST...... 108 EMTRIVA...... 30 EQUETRO...... 76 EVEKEO...... 79 EMVERM...... 28 ergocal...... 164 EVEKEO ODT...... 79 ENABLEX...... 129 ergocalciferol...... 164 EVENCARE + BLOOD enalapril maleate...... 52 ergoloid mesylates...... 71 GLUCOSE TEST...... 148 enalapril-hydrochlorothiazide... 52 ERGOMAR...... 83 EVENCARE BLOOD ENBREL...... 136 ergotamine-caffeine...... 83 GLUCOSE TEST...... 148 ENBREL MINI...... 136 ERIVEDGE...... 41 EVENCARE G2 TEST...... 148 ENBREL SURECLICK...... 136 ERLEADA...... 43 EVENCARE G3 TEST...... 148 ENCARE...... 127 erlotinib hcl...... 45 EVENITY...... 113 ENDARI...... 133 errin...... 102 everolimus...... 45, 140 endocet...... 20 ERTACZO...... 191 EVERSENSE SENSOR...... 148 Endocet...... 20 ery...... 189 EVERSENSE ENDOMETRIN...... 129 ERYPED 200...... 36 SENSOR/HOLDER...... 148 ENLITE GLUCOSE ERYPED 400...... 36 EVERSENSE SMART SENSOR...... 148 ERY-TAB...... 36 TRANSMITTER...... 148 ENLYTE...... 164 ERYTHROCIN STEARATE 36 EVISTA...... 113 enoxaparin sodium...... 130 erythromycin...... 174, 189 EVITHROM...... 133 enpresse-28...... 102 erythromycin base...... 36 EVOCLIN...... 189 enskyce...... 102 erythromycin ethylsuccinate..... 36 EVOLUTION AUTOCODE 148 ENSPRYNG...... 140 erythromycin stearate...... 36 EVOTAZ...... 33 ENSTILAR...... 195 ESBRIET...... 184 EVOXAC...... 201 entacapone...... 74 escitalopram oxalate...... 72 EVRYSDI...... 85 entecavir...... 34 Esgic...... 15 EVZIO...... 90 ENTERAGAM...... 164 ESGIC...... 16 EXALGO...... 20 ENTOCORT EC...... 120 esomeprazole magnesium...... 125 EXEL COMFORT POINT ENTRESTO...... 63 esomeprazole strontium...... 125 INSULIN SYR...... 149 enulose...... 121 ESPEROCT...... 132 EXELDERM...... 149, 191 ENVARSUS XR...... 140 estarylla...... 102 EXELON...... 71 EPANED...... 52 estazolam...... 82 exemestane...... 43 EPCLUSA...... 37 ESTRACE...... 108 EXFORGE...... 53 EPIDIOLEX...... 68 estradiol...... 108 EXFORGE HCT...... 53 EPIDUO...... 189 estradiol valerate...... 108 EXJADE...... 99 EPIDUO FORTE...... 189 estradiol-norethindrone acet... 108 EXSERVAN...... 85 EPIFOAM...... 198 ESTRING...... 108 EXTAVIA...... 86 epinastine hcl...... 172 ESTROGEL...... 108 EXTINA...... 191 epinephrine...... 177 estropipate...... 108 EYSUVIS...... 176 EPISNAP...... 177 eszopiclone...... 82 E-Z JECT LANCET epitol...... 68 ethacrynic acid...... 62 MICRO-THIN 33G...... 149 EPIVIR...... 30 ethambutol hcl...... 33 E-Z JECT LANCET SUPER EPIVIR HBV...... 34 ethosuximide...... 68 THIN 30G...... 149 eplerenone...... 53 ethynodiol diac-eth estradiol... 102 E-Z JECT LANCETS...... 149 212 E-Z JECT LANCETS 21G....149 FERRIPROX TWICE-A- FLOXIN OTIC...... 202 E-Z JECT LANCETS THIN DAY...... 100 floxuridine...... 41 26G...... 149 FETZIMA...... 72 fluconazole...... 27 EZ SMART BLOOD FETZIMA TITRATION...... 72 flucytosine...... 27 GLUCOSE LANCETS...... 149 FEXMID...... 88 fludrocortisone acetate...... 110 EZ SMART BLOOD fexofenadine hcl...... 179 FLUMADINE...... 34 GLUCOSE TEST...... 149 fexofenadine hcl childrens...... 179 flunisolide...... 185 EZ SMART PLUS fexofenadine-pseudoephed er.. 182 fluocinolone acetonide..... 195, 202 GLUCOSE TEST...... 149 FIASP...... 94 fluocinolone acetonide body.... 195 EZALLOR SPRINKLE...... 56 FIASP FLEXTOUCH...... 94 fluocinolone acetonide scalp....195 ezetimibe...... 55 FIASP PENFILL...... 94 fluocinonide...... 195 ezetimibe-simvastatin...... 57 FIBRICOR...... 56 fluocinonide emulsified base....195 FABIOR...... 189 FIFTY50 GLUCOSE TEST FLUORABON...... 164 FACTIVE...... 37 2.0...... 149 FLUOR-A-DAY...... 164 FALESSA...... 102 FIFTY50 PEN NEEDLES... 149 FLUORIDEX falmina...... 102 FIFTY50 SAFETY SEAL SENSITIVITY RELIEF...... 201 famciclovir...... 34 LANCETS...... 149 fluoritab...... 164, 165 famotidine...... 119 FIFTY50 SUPERIOR fluorometholone...... 176 FANAPT...... 76 COMFORT SYR...... 149 FLUOROPLEX...... 190 FANAPT TITRATION FINACEA...... 200 fluorouracil...... 190 PACK...... 76 finasteride...... 127 fluoxetine hcl...... 72 FARESTON...... 43 FINE 30...... 149 fluoxetine hcl (pmdd)...... 72 FARXIGA...... 98 FINGERSTIX LANCETS... 149 fluphenazine decanoate...... 76 FARYDAK...... 41 FINTEPLA...... 68 fluphenazine hcl...... 76 FASENRA PEN...... 181 FIORICET...... 16 FLURA-DROPS...... 165 favipiravir...... 34 FIORICET/CODEINE...... 20 flurandrenolide...... 196 Fayosim...... 102 FIORINAL...... 16 FLURA-SAFE...... 133 FAZACLO...... 76 FIORINAL/CODEINE #3.....20 flurazepam hcl...... 82 FC FEMALE CONDOM..... 141 FIRAZYR...... 133 flurbiprofen...... 16 FC2 FEMALE CONDOM... 141 FIRDAPSE...... 85 flurbiprofen sodium...... 176 febuxostat...... 15 FIRMAGON...... 43 flutamide...... 43 felbamate...... 68 FIRMAGON (240 MG fluticasone propionate..... 185, 196 FELBATOL...... 68 DOSE)...... 43 fluticasone-salmeterol..... 178, 187 FELDENE...... 16 FIRVANQ...... 28 fluvastatin sodium...... 56 felodipine er...... 60 FLAGYL...... 28 fluvastatin sodium er...... 56 FEMARA...... 43 FLAREX...... 176 fluvoxamine maleate...... 85 FEMCAP...... 141 flavoxate hcl...... 123 fluvoxamine maleate er...... 85 FEMRING...... 108 flecainide acetate...... 54 FML...... 176 Femynor...... 102 FLECTOR...... 199 FML FORTE...... 176 fenofibrate...... 56 FLEET LAXATIVE...... 121 FOCALIN...... 79 fenofibrate micronized...... 55 FLEXICHAMBER ADULT FOCALIN XR...... 79 fenofibric acid...... 56 MASK/SMALL...... 162 folate...... 165 FENOGLIDE...... 56 FLOLAN...... 65 FOLBEE PLUS CZ...... 165 fenoprofen calcium...... 16 flolipid...... 56 FOLBIC RF...... 165 FENORTHO...... 16 FLOMAX...... 127 FOLCAL DHA...... 165 FENSOLVI...... 43 FLONASE ALLERGY FOLCAPS OMEGA 3...... 165 fentanyl...... 20 RELIEF...... 184 folic acid...... 165 fentanyl citrate...... 20 FLORIVA...... 164 FOLIVANE-OB...... 165 FENTORA...... 20 FLOVENT DISKUS...... 186 FOLTANX...... 165 FERRIPROX...... 99, 100 FLOVENT HFA...... 186 FOLTANX RF...... 165 213 FOLTX...... 165 FREESTYLE LIBRE 2 gemfibrozil...... 56 FOLVITE-FE...... 133 SENSOR...... 150 Gemmily...... 102 fondaparinux sodium...... 130 FREESTYLE LIBRE GEMTESA...... 114 FORA D15G BLOOD READER...... 150 generlac...... 122 GLUCOSE TEST...... 149 FREESTYLE LIBRE gengraf...... 140 FORA D20 BLOOD SENSOR SYSTEM...... 150 Gengraf...... 140 GLUCOSE TEST...... 149 FREESTYLE LITE TEST....150 GENICIN VITA-Q...... 165 FORA G20 BLOOD FREESTYLE PRECISION GENOTROPIN...... 112 GLUCOSE TEST...... 149 INS SYR...... 150 GENOTROPIN FORA G30/PREM V10 FREESTYLE PRECISION MINIQUICK...... 112 GLUCOSE TEST...... 149 NEO TEST...... 150 gentak...... 174 FORA GD20 TEST...... 149 FREESTYLE TEST...... 150 gentamicin sulfate...... 174, 190 FORA LANCETS...... 149 FREESTYLE UNISTICK II GENVOYA...... 33 FORA V10 BLOOD LANCETS...... 150 GEODON...... 76 GLUCOSE TEST...... 149 FROVA...... 83 gianvi...... 102 FORA V12 BLOOD frovatriptan succinate...... 83 GIAZO...... 120 GLUCOSE TEST...... 150 FULPHILA...... 131 gildagia...... 102 FORA V20 BLOOD fulvestrant...... 43 gildess fe 1.5/30...... 102 GLUCOSE TEST...... 150 FURADANTIN...... 28 gildess fe 1/20...... 102 FORA V30A BLOOD furosemide...... 62 GILENYA...... 86 GLUCOSE TEST...... 150 FUZEON...... 30 GILOTRIF...... 49 FORACARE GD40 TEST....150 Fyavolv...... 108 GIMOTI...... 118 FORACARE PREMIUM FYCOMPA...... 68 glatiramer acetate...... 86 V10 TEST...... 150 GABADONE...... 165 Glatopa...... 86 FORFIVO XL...... 72 gabapentin...... 68 GLEEVEC...... 45 formoterol fumarate...... 180 GABITRIL...... 68 GLEOSTINE...... 40, 41 FORTAMET...... 92 GALAFOLD...... 113 g-levocarnitine s/f...... 165 FORTEO...... 113 galantamine hydrobromide...... 71 glimepiride...... 98 FORTESTA...... 91 galantamine hydrobromide er... 71 glipizide...... 98 FOSAMAX...... 99 GALZIN...... 162 glipizide er...... 98 FOSAMAX PLUS D...... 99 GAMASTAN...... 139 glipizide xl...... 98 fosamprenavir calcium...... 30 GAMASTAN S/D...... 139 glipizide-metformin hcl...... 93 fosinopril sodium...... 52 GAMMAGARD...... 139 GLOBAL EASE INJECT fosinopril sodium-hctz...... 52 GAMMAGARD S/D LESS PEN NEEDLES...... 150 FOSRENOL...... 114 IGA...... 139 GLOBAL INJECT EASE FOSTEUM...... 165 GAMMAKED...... 139 INSULIN SYR...... 150 FOSTEUM PLUS...... 165 GAMUNEX-C...... 139 GLOBAL INJECT EASE FOTIVDA...... 45 GASTROCROM...... 123 LANCETS 28G...... 151 FOVEX...... 165 gatifloxacin...... 174 GLOBAL INJECT EASE FRAGMIN...... 130 GATTEX...... 123 LANCETS 30G...... 151 FREESTYLE INSULINX gavilyte-c...... 121 GLOPERBA...... 15 TEST...... 150 gavilyte-g...... 121 GLUCAGEN FREESTYLE LANCETS..... 150 Gavilyte-H...... 121 DIAGNOSTIC...... 151 FREESTYLE LIBRE 14 gavilyte-n with flavor pack...... 122 GLUCAGEN HYPOKIT..... 111 DAY READER...... 150 GAVRETO...... 49 GLUCAGON FREESTYLE LIBRE 14 GE100 BLOOD GLUCOSE EMERGENCY...... 111 DAY SENSOR...... 150 TEST...... 150 glucagon emergency...... 111 FREESTYLE LIBRE 2 GELFILM...... 133 GLUCO BURST...... 111 READER...... 150 GELNIQUE...... 129 GLUCOCARD 01 SENSOR GELNIQUE PUMP...... 129 PLUS...... 151 214 GLUCOCARD GUARDIAN CONNECT HEALTHWISE UNIFINE EXPRESSION TEST...... 151 TRANSMITTER...... 151 PENTIPS...... 151 GLUCOCARD VITAL GUARDIAN LINK 3 HEALTHY ACCENTS TEST...... 151 TRANSMITTER...... 151 UNIFINE PENTIP...... 152 GLUCOCARD X-SENSOR.151 GUARDIAN REAL-TIME HEALTHY ACCENTS GLUCOCOM LANCETS REPLACE PED...... 14 UNILET LANCETS...... 152 28G...... 151 GUARDIAN REAL-TIME heather...... 102 GLUCOCOM LANCETS REPLACEMENT...... 14 HECTOROL...... 115 30G...... 151 GUARDIAN SENSOR (3)...151 HELIDAC THERAPY...... 123 GLUCOCOM LANCETS guardian sensor 3...... 14 HEMA-COMBISTIX...... 152 33G...... 151 GUARDIAN HEMADY...... 110 GLUCOCOM TEST...... 151 TRANSMITTER...... 14 HEMANGEOL...... 58 GLUCOPHAGE...... 92 GVOKE HYPOPEN 1- hemenatal ob...... 165 GLUCOPHAGE XR...... 92 PACK...... 111 hemenatal ob + dha...... 165 GLUCOPRO INSULIN GVOKE HYPOPEN 2- HEMOCYTE-F...... 133 SYRINGE...... 151 PACK...... 111 heparin sodium (porcine)...... 130 glucose...... 111 GVOKE PFS...... 111 heparin sodium (porcine) pf... 130 GLUCOTROL...... 98 GYNAZOLE-1...... 130 HEPSERA...... 34 GLUCOTROL XL...... 98 HAEGARDA...... 133 HETLIOZ...... 82 GLUCOVANCE...... 93 HAEMOLANCE...... 151 HETLIOZ LQ...... 82 GLUMETZA...... 92 HAEMOLANCE LOW HEXALEN...... 41 glyburide...... 98 FLOW LANCETS...... 151 Hidex 6-Day...... 110 glyburide micronized...... 98 HAEMOLANCE PLUS...... 151 HIPREX...... 28 glyburide-metformin...... 93 HAEMOLANCE PLUS HIZENTRA...... 139 glycopyrrolate...... 117 HIGH FLOW...... 151 hm biotin...... 165 GLYNASE...... 98 HAEMOLANCE PLUS hm lidocaine patch...... 198 GLYSET...... 92 LOW FLOW...... 151 hm sleep aid...... 82 GLYXAMBI...... 97 HAEMOLANCE PLUS HM ULTICARE INSULIN gnp lidocaine pain relief...... 198 MAX FLOW...... 151 SYRINGE...... 152 gnp urinary pain relief...... 128 HAEMOLANCE PLUS HORIZANT...... 89 GOCOVRI...... 74 PEDIATRIC FLOW...... 151 HUMALOG...... 94 GOJJI BLOOD GLUCOSE Hailey 24 Fe...... 102 HUMALOG JUNIOR TEST...... 151 halcinonide...... 196 KWIKPEN...... 94 GOLYTELY...... 122 HALCION...... 82 HUMALOG KWIKPEN...... 95 GONAL-F...... 109 HALDOL...... 76 HUMALOG MIX 50/50...... 95 GONAL-F RFF...... 109 HALDOL DECANOATE...... 76 HUMALOG MIX 50/50 GONAL-F RFF REDIJECT 109 halobetasol propionate...... 196 KWIKPEN...... 95 GONITRO...... 64 HALOG...... 196 HUMALOG MIX 75/25...... 95 goodsense nicotine...... 90 haloperidol...... 76 HUMALOG MIX 75/25 GRALISE...... 89 haloperidol decanoate...... 76 KWIKPEN...... 95 GRALISE STARTER...... 89 haloperidol lactate...... 76 HUMATIN...... 26 granisetron hcl...... 118 HALOTIN...... 191 HUMATROPE...... 112 GRANIX...... 131 HARVONI...... 37 HUMIRA...... 137 GRASTEK...... 135 HEALTHWISE MINI PEN HUMIRA PEDIATRIC griseofulvin microsize...... 27 NEEDLES...... 151 CROHNS START...... 136 griseofulvin ultramicrosize...... 27 HEALTHWISE PEN HUMIRA PEN...... 136 GRIS-PEG...... 191 NEEDLES...... 151 HUMIRA PEN-CD/UC/HS guanfacine hcl...... 63 HEALTHWISE SHORT STARTER...... 136, 137 guanfacine hcl er...... 79 PEN NEEDLES...... 151 HUMIRA PEN- guanidine hcl...... 85 PS/UV/ADOL HS START....137 215 HUMIRA PEN- IBRANCE...... 41, 42 INFINITY BLOOD PSOR/UVEIT STARTER.... 137 Ibu...... 16 GLUCOSE TEST...... 152 HUMULIN 70/30...... 95 IBUDONE...... 21 INFINITY VOICE...... 152 HUMULIN 70/30 ibudone...... 21 INGREZZA...... 85 KWIKPEN...... 95 ibuprofen...... 16 INLYTA...... 46 HUMULIN N...... 95 ibuprofen-famotidine...... 18 INNOPRAN XL...... 59 HUMULIN N KWIKPEN.....95 icatibant acetate...... 134 INQOVI...... 49 HUMULIN R...... 95 ICLUSIG...... 46 INREBIC...... 46 HUMULIN R U-500 icosapent ethyl...... 57 INSPRA...... 53 (CONCENTRATED)...... 95 IDHIFA...... 46 INSTA-GLUCOSE...... 112 HUMULIN R U-500 ILARIS...... 137 insulin asp prot & asp flexpen... 95 KWIKPEN...... 95 ILARIS (150MG insulin aspart...... 95 hyalucil-4...... 199 DELIVERED)...... 16 insulin aspart flexpen...... 95 HYCAMTIN...... 51 ILEVRO...... 176 insulin aspart penfill...... 95 HYCET...... 20 ILUMYA...... 192 insulin aspart prot & aspart...... 95 HYCOFENIX...... 182 imatinib mesylate...... 46 insulin lispro...... 95 hydralazine hcl...... 63 IMBRUVICA...... 46 insulin lispro (1 unit dial)...... 95 HYDREA...... 49 IMCIVREE...... 85 insulin lispro junior kwikpen..... 95 hydrochlorothiazide...... 62 imipramine hcl...... 72 insulin lispro prot & lispro...... 95 hydrocod polst-cpm polst er.... 182 imipramine pamoate...... 73 insulin syringe...... 152 hydrocodone bitartrate er...... 20 imiquimod...... 190 insulin syringe/needle...... 152 hydrocodone-acetaminophen imiquimod pump...... 190 insulin syringe-needle u-100.... 152 ...... 20, 21 IMITREX...... 83 insupen pen needles...... 152 hydrocodone-guaifenesin...... 182 IMITREX STATDOSE INSUPEN SENSITIVE...... 152 hydrocodone-homatropine...... 182 REFILL...... 83 INSUPEN ULTRAFIN...... 152 hydrocodone-ibuprofen...... 21 IMITREX STATDOSE INTELENCE...... 30 hydrocortisone. 110, 120, 126, 196 SYSTEM...... 83 INTERMEZZO...... 82 hydrocortisone (perianal)...... 126 IMPAVIDO...... 28 INTRAROSA...... 91 hydrocortisone butyr lipo base 196 IMPEKLO...... 196 INTRON A...... 139 hydrocortisone butyrate...... 196 IMPOYZ...... 196 introvale...... 102 hydrocortisone valerate...... 196 IMURAN...... 140 INTUNIV...... 79 hydrocortisone-acetic acid...... 202 IMVEXXY...... 108 INVEGA...... 76 hydrogen peroxide...... 199 IMVEXXY INVEGA SUSTENNA...... 76 hydromet...... 182 MAINTENANCE PACK.....108 INVEGA TRINZA...... 77 hydromorphone hcl...... 21 IMVEXXY STARTER INVELTYS...... 176 hydromorphone hcl er...... 21 PACK...... 109 INVIRASE...... 30 hydroxychloroquine sulfate.....138 inatal advance...... 165 INVOKAMET...... 97 hydroxyprogesterone caproate 115 INATAL GT...... 165 INVOKAMET XR...... 97 hydroxyurea...... 49 inatal ultra...... 165 INVOKANA...... 98 hydroxyzine hcl...... 179 INBRIJA...... 75 iodine strong...... 162 hydroxyzine pamoate...... 179 INCRELEX...... 113 IOPIDINE...... 173 hyoscyamine sulfate...... 117 INCRUSE ELLIPTA...... 178 ipratropium bromide...... 178 hyoscyamine sulfate er...... 117 indapamide...... 62 ipratropium-albuterol...... 178 HYPERRAB...... 139 INDERAL LA...... 58 IPRIVASK...... 130 HYPERSAL...... 182, 184 INDERAL XL...... 59 irbesartan...... 54 HYPERTENSA...... 165 INDOCIN...... 16 irbesartan-hydrochlorothiazide. 53 HYQVIA...... 139 indomethacin...... 16, 17 IRESSA...... 46 HYSINGLA ER...... 21 indomethacin er...... 16 ISENTRESS...... 30 HYZAAR...... 53 infanate balance...... 165 ISENTRESS HD...... 30 ibandronate sodium...... 99 Isibloom...... 102 216 isoniazid...... 33 KARBINAL ER...... 179 Klor-Con 10...... 162 ISOPTO CARPINE...... 173 kariva...... 102 Klor-Con M10...... 162 ISORDIL TITRADOSE...... 64 KATERZIA...... 60 Klor-Con M15...... 162 isosorbide dinitrate...... 64 KAZANO...... 93 klor-con m20...... 162 isosorbide dinitrate er...... 64 k-effervescent...... 162 Klor-Con Sprinkle...... 162 isosorbide mononitrate...... 64 KEFLEX...... 36 Klor-Con/Ef...... 162 isosorbide mononitrate er...... 64 kelnor 1/35...... 103 KLOXXADO...... 90 isotretinoin...... 189 KENALOG...... 196 kls sleep aid...... 82 isradipine...... 60 KEPPRA...... 68 KOMBIGLYZE XR...... 93 ISTALOL...... 173 KEPPRA XR...... 68 KORLYM...... 113 ISTURISA...... 113 KERYDIN...... 27 KOSELUGO...... 46 itraconazole...... 27 KETEK...... 28 K-PHOS...... 162 ivermectin...... 28, 200, 201 KETOCARE...... 152 K-PHOS NO 2...... 128 JADENU...... 100 ketoconazole...... 27, 191, 193 K-PHOS-NEUTRAL...... 162 JADENU SPRINKLE...... 100 KETO-DIASTIX...... 152 k-prime...... 162 JAKAFI...... 46 ketone test...... 152 KRINTAFEL...... 29 JALYN...... 127 ketoprofen...... 17 KRISTALOSE...... 122 jantoven...... 130 ketoprofen er...... 17 kroger blood glucose test...... 152 JANUMET...... 93 ketorolac tromethamine.... 17, 176 K-TAB...... 162 JANUMET XR...... 93 KETOSTIX...... 152 kurvelo...... 103 JANUVIA...... 93 ketotifen fumarate...... 134 KUVAN...... 107 JARDIANCE...... 98 KEVEYIS...... 62 k-vescent...... 163 Jasmiel...... 102 KEVZARA...... 137 KYLEENA...... 103 JATENZO...... 91 KHEDEZLA...... 73 KYNAMRO...... 57 jencycla...... 102 KIDS PROTEIN ORGANIC KYNMOBI...... 75 jenliva prenatal/postnatal...... 165 SHAKE...... 166 labetalol hcl...... 59 JENTADUETO...... 93 Kimidess...... 103 LABSTIX...... 152 JENTADUETO XR...... 93 KINERET...... 137 LACRISERT...... 134 jevantique lo...... 109 KINNEY LANCETS...... 152 lactulose...... 122 jinteli...... 109 KINNEY THIN LANCETS.152 lactulose encephalopathy...... 122 jolessa...... 102 kinray insulin syringe...... 152 LAMICTAL...... 68 jolivette...... 102 kionex...... 100 LAMICTAL ODT...... 68 JORNAY PM...... 79 KISQALI (200 MG DOSE).... 42 LAMICTAL XR...... 68 JUBLIA...... 191 KISQALI (400 MG DOSE).... 42 LAMISIL...... 27 Juleber...... 102 KISQALI (600 MG DOSE).... 42 lamivudine...... 30, 34 JULUCA...... 33 KISQALI 200 DOSE...... 42 lamivudine-zidovudine...... 33 junel 1.5/30...... 102 KISQALI 400 DOSE...... 42 lamotrigine...... 68 junel 1/20...... 102 KISQALI 600 DOSE...... 42 lamotrigine er...... 68 junel fe 1.5/30...... 102 KISQALI FEMARA (400 lamotrigine starter kit-blue...... 68 junel fe 1/20...... 102 MG DOSE)...... 42 lamotrigine starter kit-green.....68 Junel Fe 24...... 102 KISQALI FEMARA (600 lamotrigine starter kit-orange...68 JUXTAPID...... 57 MG DOSE)...... 42 LAMPIT...... 28 JYNARQUE...... 113 KISQALI FEMARA(200 lancet device...... 152 KADIAN...... 21 MG DOSE)...... 42 lancet transporter case...... 152 Kaitlib Fe...... 102 KITABIS PAK...... 26 lancets...... 152 KALBITOR...... 134 KLARON...... 189 lancets 28g...... 152 KALETRA...... 33 KLISYRI...... 190 lancets 30g...... 152 KALYDECO...... 184 Klofensaid Ii...... 199 lancets thin...... 152 KAPSPARGO SPRINKLE....59 KLONOPIN...... 68 LANCETS ULTRA FINE....152 KAPVAY...... 80 Klor-Con...... 162 LANCETS ULTRA THIN...152 217 LANCETS ULTRA THIN LEUKERAN...... 41 LIMBREL...... 166 30G...... 152 leuprolide acetate...... 43 LIMBREL250...... 166 lancing device...... 153 levalbuterol hcl...... 180 LIMBREL500...... 166 LANOXIN...... 61 levalbuterol tartrate...... 180 lindane...... 201 lansoprazole...... 125 LEVAQUIN...... 37 linezolid...... 28 lanthanum carbonate...... 114 LEVATOL...... 59 LINZESS...... 121 LANTUS...... 95 LEVEMIR...... 95 liothyronine sodium...... 116 LANTUS SOLOSTAR...... 95 LEVEMIR FLEXTOUCH..... 95 LIPICHOL 540...... 166 Larin 1.5/30...... 103 levetiracetam...... 68 LIPITOR...... 56 Larin 1/20...... 103 levetiracetam er...... 68 LIPOFEN...... 56 Larin 24 Fe...... 103 levobunolol hcl...... 173 lisinopril...... 52 larin fe 1.5/30...... 103 levocarnitine...... 99 lisinopril-hydrochlorothiazide... 52 larin fe 1/20...... 103 levocarnitine (dietary)...... 166 LISTER-V...... 166 Larissia...... 103 levocarnitine l-tartrate...... 166 LITE TOUCH LANCETS....153 LASIX...... 62 levocarnitine-b5-taurine...... 166 LITE TOUCH PEN LASTACAFT...... 172 levocetirizine dihydrochloride..179 NEEDLES...... 153 latanoprost...... 173 levofloxacin...... 37, 174 LITETOUCH INSULIN LATUDA...... 77 LEVOMEFOLATE DHA.... 166 SYRINGE...... 153 Layolis Fe...... 103 levonest...... 103 LITETOUCH PEN LAZANDA...... 21 levonorgest-eth estrad 91-day. 103 NEEDLES...... 153 LEADER INSULIN levonorgestrel...... 103 lithium...... 85 SYRINGE...... 153 levonorgestrel-ethinyl estrad... 103 lithium carbonate...... 85 leader insulin syringe...... 153 levonorg-eth estrad triphasic...103 lithium carbonate er...... 85 leader quick dissolve glucose... 112 levora 0.15/30 (28)...... 103 LITHOBID...... 77 LEADER UNIFINE levorphanol tartrate...... 21 LITHOSTAT...... 128 PENTIPS...... 153 Levo-T...... 115 LIVALO...... 56 ledipasvir-sofosbuvir...... 37 levothyroxine sodium...... 115 LIVE BETTER LANCET leena...... 103 levoxyl...... 116 SUPER THIN...... 153 leflunomide...... 138 LEVULAN KERASTICK....199 LIVE BETTER LANCET LENVIMA (10 MG DAILY LEXAPRO...... 73 ULTRA THIN...... 153 DOSE)...... 47 LEXETTE...... 196 l-methylfolate...... 166 LENVIMA (12 MG DAILY LEXIVA...... 30 l-methylfolate ca me-cbl nac... 166 DOSE)...... 47 LIALDA...... 120 l-methylfolate calcium...... 166 LENVIMA (14 MG DAILY LIBERTY NEXT l-methylfolate formula 15...... 166 DOSE)...... 47 GENERATION TEST...... 153 l-methylfolate formula 7.5...... 166 LENVIMA (18 MG DAILY LIBERTY TEST...... 153 l-methylfolate forte...... 166 DOSE)...... 47 LIBRAX...... 117 l-methylfolate-algae-b12-b6....166 LENVIMA (20 MG DAILY LICART...... 199 l-methylfolate-b6-b12...... 166 DOSE)...... 47 lidocaine...... 198 l-methyl-mc...... 166 LENVIMA (24 MG DAILY lidocaine hcl...... 198, 201 l-methyl-mc nac...... 166 DOSE)...... 47 lidocaine hcl urethral/mucosal.198 LO LOESTRIN FE...... 103 LENVIMA (4 MG DAILY lidocaine pain relief...... 198 LOCOID...... 196 DOSE)...... 47 lidocaine pak...... 198 LOCOID LIPOCREAM...... 196 LENVIMA (8 MG DAILY lidocaine viscous...... 201 LOCORT 11-DAY...... 110 DOSE)...... 47 lidocaine-prilocaine...... 198 LOCORT 7-DAY...... 110 LESCOL XL...... 56 lidocaine-tetracaine...... 198 LODINE...... 17 lessina...... 103 LIDODERM...... 198 LODOSYN...... 75 LETAIRIS...... 65 LIDOTREX...... 201 Loestrin 1.5/30 (21)...... 103 letrozole...... 43 LIDOTREX (ALOE VERA) 201 Loestrin 1/20 (21)...... 103 leucovorin calcium...... 51 LILETTA (52 MG)...... 103 LOFIBRA...... 56 218 LOKELMA...... 100 LOZI-FLUR...... 166 marten-tab...... 16 lomedia 24 fe...... 103 Lo-Zumandimine...... 103 MATULANE...... 50 LOMOTIL...... 123 lubiprostone...... 121 matzim la...... 60 longs insulin syringe...... 153 LUCEMYRA...... 90 MAVENCLAD (10 TABS).....87 LONGS LANCETS ludent...... 166 MAVENCLAD (4 TABS)...... 87 STANDARD...... 153 lugols...... 199 MAVENCLAD (5 TABS)...... 87 LONGS LANCETS THIN... 153 lugols strong iodine...... 199 MAVENCLAD (6 TABS)...... 87 LONGS LANCETS ULTRA LUKAID GLA...... 166 MAVENCLAD (7 TABS)...... 87 THIN...... 153 luliconazole...... 191 MAVENCLAD (8 TABS)...... 87 LONHALA MAGNAIR LUMAKRAS...... 47 MAVENCLAD (9 TABS)...... 87 REFILL KIT...... 178 LUMIGAN...... 173 MAVYRET...... 37 LONHALA MAGNAIR LUNESTA...... 82 MAXALT...... 83 STARTER KIT...... 178 LUPANETA PACK...... 115 MAXALT-MLT...... 83 LONSURF...... 50 LUPKYNIS...... 140 MAXI-COMFORT loperamide hcl...... 123 LUPRON DEPOT (1- INSULIN SYRINGE...... 153 LOPID...... 56 MONTH)...... 43 MAXIDEX...... 176 lopinavir-ritonavir...... 33 LUPRON DEPOT (3- MAXITROL...... 174 Lopreeza...... 109 MONTH)...... 43 MAXZIDE...... 62 LOPRESSOR...... 59 LUPRON DEPOT (4- MAXZIDE-25...... 62 LOPRESSOR HCT...... 58 MONTH)...... 43 MAYZENT...... 87 LOPROX...... 191 LUPRON DEPOT (6- MAYZENT STARTER loratadine...... 180 MONTH)...... 43 PACK...... 87 loratadine allergy relief...... 180 LUPRON DEPOT-PED (1- meclizine hcl...... 118 loratadine childrens...... 180 MONTH)...... 43 meclofenamate sodium...... 17 loratadine-d 12hr...... 182 LUPRON DEPOT-PED (3- MEDISENSE THIN loratadine-d 24hr...... 182 MONTH)...... 44 LANCETS...... 153 lorazepam...... 66 lutera...... 103 MEDLANCE EXTRA 21G..153 Lorazepam Intensol...... 66 LUXIQ...... 196 MEDLANCE LITE 25G...... 153 LORBRENA...... 47 LUZU...... 191 MEDLANCE PLUS EXTRA lorcet...... 21 LYNPARZA...... 42, 50 21G...... 153 lorcet hd...... 21 LYRICA...... 68 MEDLANCE PLUS Lorcet Plus...... 21 LYRICA CR...... 89 LANCETS...... 153 LORTAB...... 21 LYSODREN...... 44 MEDLANCE PLUS LITE loryna...... 103 LYSTEDA...... 134 25G...... 153 Lorzone...... 88 LYUMJEV...... 95 MEDLANCE PLUS losartan potassium...... 54 LYUMJEV KWIKPEN...... 96 SUPERLITE 30G...... 153 losartan potassium-hctz...... 53 lyza...... 103 MEDLANCE PLUS LOTEMAX...... 176 MACROBID...... 28 UNIVERSAL 21G...... 154 LOTEMAX SM...... 176 MACRODANTIN...... 28 MEDLANCE UNIVERSAL LOTENSIN...... 52 MACUTEK...... 166 21G...... 154 LOTENSIN HCT...... 52 MAGELLAN INSULIN MEDROL...... 110 loteprednol etabonate...... 176 SAFETY SYR...... 153 medroxyprogesterone acetate LOTREL...... 52 MAGNEBIND 400...... 163 ...... 103, 115 LOTRISONE...... 191 MAKENA...... 115 mefenamic acid...... 17 LOTRONEX...... 121 MALARONE...... 29 mefloquine hcl...... 29 lovastatin...... 56 malathion...... 201 MEGACE ES...... 115 LOVAZA...... 57 maprotiline hcl...... 73 megestrol acetate...... 44 LOVENOX...... 131 MARINOL...... 118 MEKINIST...... 47 low-ogestrel...... 103 marlissa...... 103 MEKTOVI...... 50 loxapine succinate...... 77 MARPLAN...... 73 meloxicam...... 17 219 melphalan...... 41 methyldopa- MILLIPRED...... 110 memantine hcl...... 71 hydrochlorothiazide...... 63 MILLIPRED DP...... 110 memantine hcl er...... 71 METHYLIN...... 80 MILLIPRED DP 12-DAY....110 MENEST...... 109 methylphenidate hcl...... 80 mimvey...... 109 MENOSTAR...... 109 methylphenidate hcl er...... 80 Mimvey Lo...... 109 MENTAX...... 191 methylphenidate hcl er (cd)...... 80 MINASTRIN 24 FE...... 104 meperidine hcl...... 21, 22 methylphenidate hcl er (la)...... 80 MINIPRESS...... 53 MEPHYTON...... 166 methylphenidate hcl er (xr)...... 80 Minitran...... 64 meprobamate...... 66 methylprednisolone...... 110 MINIVELLE...... 109 mercaptopurine...... 41 methyltestosterone...... 91 MINOCIN...... 40 mesalamine...... 120 metipranolol...... 173 minocycline hcl...... 40 mesalamine er...... 120 metoclopramide hcl...... 118 minocycline hcl er...... 40 mesalamine-cleanser...... 120 metolazone...... 63 MINOLIRA...... 40 MESNEX...... 51 metoprolol succinate er...... 59 minoxidil...... 63 MESTINON...... 85 metoprolol tartrate...... 59 MIRAPEX...... 75 metadate er...... 80 metoprolol-hctz er...... 58 MIRAPEX ER...... 75 METAFOLBIC...... 166 metoprolol-hydrochlorothiazide 58 MIRCERA...... 131 METAFOLBIC PLUS...... 166 METROCREAM...... 200 MIRENA (52 MG)...... 104 METAFOLBIC PLUS RF....166 METROGEL...... 200 mirtazapine...... 73 METANX...... 166 METROGEL-VAGINAL.....130 MIRVASO...... 200 metaproterenol sulfate...... 181 METROLOTION...... 200 misoprostol...... 123 Metaxall...... 88 metronidazole...... 28, 130, 200 MITIGARE...... 15 metaxalone...... 88 METRONIDAZOLE MOBIC...... 17 metformin hcl...... 92 BENZO+SYRSPEND...... 28 modafinil...... 89 metformin hcl er...... 92 metyrosine...... 63 moderiba...... 38 metformin hcl er (mod)...... 92 MEVACOR...... 56 MODERIBA 1200 DOSE metformin hcl er (osm)...... 92 mexiletine hcl...... 54 PACK...... 38 methadone hcl...... 22 MIACALCIN...... 113 MODERIBA 800 DOSE methadone hcl intensol...... 22 Mibelas 24 Fe...... 103 PACK...... 38 METHADOSE...... 22 MICARDIS...... 54 moexipril hcl...... 52 Methadose...... 22 MICARDIS HCT...... 53 moexipril-hydrochlorothiazide.. 52 METHADOSE SUGAR- miconazole 3...... 130 mometasone furoate...... 185, 196 FREE...... 22 miconazole-zinc oxide-petrolat191 Mondoxyne Nl...... 40 methamphetamine hcl...... 80 MICORT-HC...... 196 MONODOX...... 40 methazolamide...... 62 MICRODOT TEST...... 154 MONOJECT INSULIN methenamine hippurate...... 28 microgestin 1.5/30...... 104 SYRINGE...... 154 methenamine mandelate...... 28 microgestin 1/20...... 104 MONOJECT ULTRA Methergine...... 113 microgestin fe 1.5/30...... 104 COMFORT SYRINGE...... 154 methimazole...... 116 microgestin fe 1/20...... 104 MONOLET LANCETS...... 154 METHITEST...... 91 MICRO-K...... 163 mono-linyah...... 104 methocarbamol...... 88 MICROLET LANCETS...... 154 mononessa...... 104 methotrexate...... 41 MICROZIDE...... 63 montelukast sodium...... 183 methotrexate sodium...... 41 midazolam hcl...... 82 MONUROL...... 26 methotrexate sodium (pf)...... 41 MIDAZOLAM+SYRSPEN Morgidox...... 40 methoxsalen...... 192 D SF PH4...... 82 MORPHABOND ER...... 22 methoxsalen rapid...... 193 midodrine hcl...... 63 morphine sulfate...... 22, 23 methscopolamine bromide...... 117 MIGERGOT...... 83 morphine sulfate (concentrate).22 methyclothiazide...... 62 miglitol...... 92 morphine sulfate er...... 22 methyldopa...... 63 miglustat...... 107 morphine sulfate er beads...... 22 MIGRANAL...... 83 MOTEGRITY...... 123 220 MOTOFEN...... 123 mynatal-z...... 167 NEBUPENT...... 28 mouth wash-gp...... 177 myorisan...... 189 nebusal...... 182 mouthwash-af...... 177 Myorisan...... 189 NEBUSAL...... 182 mouthwash-om...... 177 MYRBETRIQ...... 114, 129 necon 0.5/35 (28)...... 104 MOVANTIK...... 123 MYSOLINE...... 68 necon 1/35 (28)...... 104 MOVIPREP...... 122 MYTESI...... 123 necon 1/50 (28)...... 104 MOXATAG...... 39 myzilra...... 104 necon 7/7/7...... 104 MOXEZA...... 175 nabumetone...... 17 NEEVO DHA...... 167 moxifloxacin hcl...... 37, 175 nadolol...... 59 nefazodone hcl...... 73 moxifloxacin hcl (2x day)...... 175 nadolol-bendroflumethiazide.....58 neomycin sulfate...... 26 MOZOBIL...... 134 Nafrinse...... 167 neomycin-bacitracin zn- MS CONTIN...... 23 naftifine hcl...... 191 polymyx...... 175 ms insulin syringe...... 154 NAFTIN...... 191 neomycin-polymyxin b gu...... 128 MUCINEX ALLERGY...... 180 NALFON...... 17 neomycin-polymyxin-dexameth MULPLETA...... 131 nalocet...... 23 ...... 174 MULTAQ...... 54 naloxone hcl...... 90 neomycin-polymyxin- multi-lancet device...... 154 naltrexone hcl...... 90 gramicidin...... 175 MULTISTIX...... 154 NAMENDA...... 71 neomycin-polymyxin-hc.. 174, 202 MULTISTIX 10 SG...... 154 NAMENDA TITRATION neonatal + dha...... 167 MULTISTIX 5...... 154 PAK...... 71 neonatal 19...... 167 MULTISTIX 7...... 154 NAMENDA XR...... 71 neonatal fe...... 167 MULTISTIX 8...... 154 NAMENDA XR neo-polycin...... 175 MULTISTIX 9...... 154 TITRATION PACK...... 71 neo-polycin hc...... 174 MULTISTIX 9 SG...... 154 NAMZARIC...... 71 NEORAL...... 140 multi-vit/fluoride...... 166 naphazoline hcl...... 176 NEOSPORIN...... 175 multivitamin/fluoride...... 167 NAPRELAN...... 17 NEO-SYNALAR...... 190 multi-vitamin/fluoride...... 167 NAPROSYN...... 17 NEOTUSS PLUS...... 182 multivitamins/fluoride...... 167 naproxen...... 17 NEPHPLEX RX...... 167 mupirocin...... 190 naproxen dr...... 17 NEPTAZANE...... 63 mupirocin calcium...... 190 naproxen sodium...... 17 NERLYNX...... 47 Mvc-Fluoride...... 167 naproxen sodium er...... 17 NESINA...... 93 m-vit...... 167 naproxen-esomeprazole...... 18 NESTABS...... 167 my way...... 104 naratriptan hcl...... 83 NESTABS DHA...... 167 MYALEPT...... 107 NARCAN...... 90 Neuac...... 189 MYAMBUTOL...... 33 NARDIL...... 73 NEULASTA...... 132 MYCAPSSA...... 113 NASACORT ALLERGY NEULASTA ONPRO...... 132 MYCOBUTIN...... 33 24HR...... 185 NEUPOGEN...... 132 mycophenolate mofetil...... 140 NASCOBAL...... 167 NEUPRO...... 75 mycophenolate sodium...... 140 NASONEX...... 185 NEURONTIN...... 69 MYDAYIS...... 80 NATACHEW...... 167 NEUTEK 2TEK TEST...... 154 MYDRIACYL...... 134 NATACYN...... 175 neutragard advanced...... 201 MYFORTIC...... 140 NATALVIT...... 167 neutral sodium fluoride...... 201 MYGLUCOHEALTH NATAZIA...... 104 NEVANAC...... 176 LANCETS 30G...... 154 nateglinide...... 97 nevirapine...... 30 MYGLUCOHEALTH TEST NATELLE ONE...... 167 nevirapine er...... 30 ...... 154 NATESTO...... 91 NEWGEN...... 167 MYLERAN...... 41 NATPARA...... 113 NEXA PLUS...... 167 mynatal...... 167 NATROBA...... 201 NEXAVAR...... 47 mynatal advance...... 167 NATURE-THROID...... 116 NEXIUM...... 125 mynatal plus...... 167 NAYZILAM...... 69 NEXIUM 24HR...... 125 221 NEXLETOL...... 55 norethindrone-eth estradiol..... 109 NOVOLOG 70/30 FLEXPEN NEXLIZET...... 55 norethin-eth estradiol-fe...... 104 RELION...... 96 NEXPLANON...... 104 norgesic forte...... 88 NOVOLOG FLEXPEN...... 96 next choice one dose...... 104 norgestimate-eth estradiol...... 104 NOVOLOG FLEXPEN NEXTSTELLIS...... 104 norgestim-eth estrad triphasic.104 RELION...... 96 niacin (antihyperlipidemic)...... 57 NORITATE...... 200 NOVOLOG MIX 70/30...... 96 niacin er (antihyperlipidemic).. 57 norlyroc...... 104 NOVOLOG MIX 70/30 NIACOR...... 57 NORPACE...... 54 FLEXPEN...... 96 NIASPAN...... 57 NORPACE CR...... 54 NOVOLOG MIX 70/30 nicardipine hcl...... 60 NORPRAMIN...... 73 RELION...... 96 nicotine...... 90 NORTHERA...... 64 NOVOLOG PENFILL...... 96 nicotine polacrilex...... 90 nortrel 0.5/35 (28)...... 104 NOVOLOG RELION...... 96 NICOTROL...... 90 nortrel 1/35 (21)...... 104 NOVOTWIST...... 155 NICOTROL NS...... 90 nortrel 1/35 (28)...... 104 NOVOTWIST PEN nifediac cc...... 61 nortrel 7/7/7...... 104 NEEDLE...... 141 nifedical xl...... 61 nortriptyline hcl...... 73 NOXAFIL...... 27 nifedipine...... 61 NORTUSS-DE...... 182 np thyroid...... 116 nifedipine er...... 61 nortuss-ex...... 182 NPLATE...... 132 nifedipine er osmotic release..... 61 NORVASC...... 61 NUBEQA...... 44 NIFEREX...... 134 NORVIR...... 30, 31 NUCALA...... 181 nikki...... 104 NOURIANZ...... 75 NUCYNTA...... 23 NILANDRON...... 44 NOVA MAX GLUCOSE NUCYNTA ER...... 23 nilutamide...... 44 TEST...... 154 NUEDEXTA...... 85 nimodipine...... 61 NOVA SAFETY LANCETS NUFERA...... 134 NINLARO...... 51 23G...... 154 Nulev...... 117 nisoldipine er...... 61 NOVA SAFETY LANCETS NULYTELY WITH nitazoxanide...... 28 28G...... 155 FLAVOR PACKS...... 122 nitisinone...... 107 NOVA SUREFLEX NUPLAZID...... 77 NITRO-BID...... 64 LANCETS...... 155 NURTEC...... 83 NITRO-DUR...... 64 NOVAREL...... 109 NUTROPIN AQ NUSPIN 10 nitrofurantoin...... 28 NOVOFINE...... 155 ...... 112 nitrofurantoin macrocrystal...... 28 NOVOFINE AUTOCOVER 155 NUTROPIN AQ NUSPIN 20 nitrofurantoin monohyd macro. 28 NOVOFINE AUTOCOVER ...... 112 nitroglycerin...... 64 PEN NEEDLE...... 141 NUTROPIN AQ NUSPIN 5 112 NITROLINGUAL...... 64 NOVOFINE PEN NEEDLE 141 NUVAIL...... 199 NITROMIST...... 64 NOVOLIN 70/30...... 96 NUVARING...... 104 NITROSTAT...... 64 NOVOLIN 70/30 FLEXPEN NUVESSA...... 130 NITYR...... 107 RELION...... 96 NUVIGIL...... 89 NIVESTYM...... 132 NOVOLIN 70/30 RELION.....96 NUZYRA...... 40 nizatidine...... 119 NOVOLIN N...... 96 Nyamyc...... 191 NIZORAL...... 193 NOVOLIN N FLEXPEN...... 96 Nyata...... 191 NOCDURNA...... 117 NOVOLIN N FLEXPEN NYMALIZE...... 61 NOCTIVA...... 117 RELION...... 96 nystatin...... 27, 192, 202 nora-be...... 104 NOVOLIN N RELION...... 96 nystatin-triamcinolone...... 192 NORCO...... 23 NOVOLIN R...... 96 Nystop...... 192 NORDITROPIN FLEXPRO112 NOVOLIN R FLEXPEN...... 96 NYVEPRIA...... 132 norethin ace-eth estrad-fe...... 104 NOVOLIN R FLEXPEN OB COMPLETE...... 167 norethindrone...... 104 RELION...... 96 OB COMPLETE norethindrone acetate...... 115 NOVOLIN R RELION...... 96 ADVANCED...... 167 norethindrone acet-ethinyl est. 104 NOVOLOG...... 96 OB COMPLETE GOLD...... 167 222 OB COMPLETE ONE...... 167 ONETOUCH CLUB ORFADIN...... 107 OB COMPLETE PREMIER 167 LANCETS FINE PT...... 155 ORGANIC NUTRITION OB COMPLETE/DHA...... 167 ONETOUCH DELICA SHAKE...... 168 O-CAL FA...... 167 LANCETS 30G...... 155 ORGOVYX...... 44 O-CAL PRENATAL...... 168 ONETOUCH DELICA ORIAHNN...... 109 OCALIVA...... 123 LANCETS 33G...... 155 ORILISSA...... 106 ocella...... 105 ONETOUCH DELICA ORKAMBI...... 184 OCTAGAM...... 139 LANCETS FINE...... 155 ORLADEYO...... 134 octreotide acetate...... 113 ONETOUCH DELICA orphenadrine citrate er...... 88 OCUFLOX...... 175 LANCING DEV...... 155 orphenadrine-asa-caffeine...... 88 OCUVEL...... 168 ONETOUCH DELICA Orphengesic Forte...... 88 ODACTRA...... 135 SAFETY LANCING...... 155 orsythia...... 105 ODEFSEY...... 33 ONETOUCH FINEPOINT ORTHO TRI-CYCLEN LO. 105 ODOMZO...... 50 LANCETS...... 155 ORTHO-NOVUM 7/7/7 (28) 105 OFEV...... 185 ONETOUCH LANCETS..... 155 ORTIKOS...... 120 ofloxacin...... 37, 175, 202 ONETOUCH SURESOFT oscimin...... 117 ogestrel...... 105 LANCING DEV...... 155 oscimin sr...... 117 olanzapine...... 77 ONETOUCH ULTRA...... 155 oseltamivir phosphate...... 34 olanzapine-fluoxetine hcl.... 90, 91 ONETOUCH ULTRA OSENI...... 93 olmesartan medoxomil...... 54 BLUE...... 155 OSMOLEX ER...... 75 olmesartan medoxomil-hctz...... 53 ONETOUCH ULTRASOFT OSMOPREP...... 122 olmesartan-amlodipine-hctz...... 54 LANCETS...... 155 OSPHENA...... 113 olopatadine hcl...... 172, 180 ONETOUCH VERIO...... 155 OTEZLA...... 138 OLUMIANT...... 137 ONEXTON...... 189 OTIPRIO...... 202 OLUX...... 196 ONFI...... 69 OTOVEL...... 202 OLUX-E...... 196 ONGENTYS...... 75 OTREXUP...... 138 OLYSIO...... 38 ONGLYZA...... 93 OVIDE...... 201 OMECLAMOX-PAK...... 127 ONMEL...... 27 OXANDRIN...... 91, 113 omega-3-acid ethyl esters...... 57 ONUREG...... 41 oxandrolone...... 91 omeprazole...... 125 ONZETRA XSAIL...... 84 oxaprozin...... 17 omeprazole magnesium...... 125 OPANA...... 23 OXAYDO...... 23 omeprazole-sodium OPANA ER...... 23 oxazepam...... 66 bicarbonate...... 125 OPCICON ONE-STEP...... 105 OXBRYTA...... 134 OMNARIS...... 185 OPSUMIT...... 65 oxcarbazepine...... 69 OMNIPOD 10 PACK...... 155 OPTICHAMBER FACE OXERVATE...... 134 OMNIPOD DASH 5 PACK MASK-LARGE...... 162 oxiconazole nitrate...... 192 PODS...... 155 OPTION 2...... 105 OXISTAT...... 192 OMNIPOD DASH SYSTEM OPTIONS CONCEPTROL.. 127 OXSORALEN ULTRA...... 193 ...... 155 OPTIONS GYNOL II OXTELLAR XR...... 69 OMNIPOD STARTER...... 155 CONTRACEPTIVE...... 127 oxybutynin chloride...... 129 OMNITROPE...... 112 ORACEA...... 200 oxybutynin chloride er...... 129 ON CALL LANCETS...... 155 ORACIT...... 128 oxycodone hcl...... 23 ON CALL PLUS BLOOD ORALAIR...... 135 oxycodone hcl er...... 23 GLUCOSE...... 155 oralone...... 202 oxycodone-acetaminophen...... 24 ON CALL PLUS LANCETS155 ORAP...... 85 oxycodone-aspirin...... 24 ON CALL VIVID BLOOD ORAPRED ODT...... 110 oxycodone-ibuprofen...... 24 GLUCOSE...... 155 ORAVIG...... 202 OXYCONTIN...... 24 ONCASPAR...... 50 ORENCIA...... 137 oxymorphone hcl...... 24 ondansetron...... 118 ORENCIA CLICKJECT...... 137 oxymorphone hcl er...... 24 ondansetron hcl...... 118 ORENITRAM...... 65 OXYTROL FOR WOMEN..129 223 OZEMPIC (0.25 OR 0.5 PARLODEL...... 75 perphenazine...... 77 MG/DOSE)...... 94 PARNATE...... 73 perphenazine-amitriptyline...... 91 OZEMPIC (1 MG/DOSE)...... 94 paroex...... 202 PERSERIS...... 77 OZOBAX...... 88 paromomycin sulfate...... 26 PERTZYE...... 124 pacerone...... 54 paroxetine hcl...... 73 PEXEVA...... 73 pain relief maximum strength. 198 paroxetine hcl er...... 73 PHARMACIST CHOICE pain relieving lidocaine...... 198 paroxetine mesylate...... 73 AUTOCODE...... 156 PALFORZIA (12 MG PASER...... 34 PHARMACIST CHOICE DAILY DOSE)...... 135 PATADAY...... 134 LANCETS...... 156 PALFORZIA (120 MG PATANASE...... 177 phenadoz...... 118 DAILY DOSE)...... 135 PATANOL...... 134 phendimetrazine tartrate...... 85 PALFORZIA (160 MG PAXIL...... 73 phendimetrazine tartrate er...... 85 DAILY DOSE)...... 135 PAXIL CR...... 73 phenelzine sulfate...... 73 PALFORZIA (20 MG PAZEO...... 172 Phenergan...... 119 DAILY DOSE)...... 135 PCE...... 36 phenobarbital...... 69 PALFORZIA (200 MG PEDIAPRED...... 110 phenoxybenzamine hcl...... 64 DAILY DOSE)...... 135 PEDIATRIC PANDA phentermine hcl...... 85 PALFORZIA (240 MG MASK...... 162 phenylephrine hcl...... 134 DAILY DOSE)...... 135 peg 3350...... 122 PHENYTEK...... 69 PALFORZIA (3 MG DAILY peg 3350/electrolytes...... 122 phenytoin...... 69 DOSE)...... 135 peg 3350-kcl-na bicarb-nacl.... 122 phenytoin infatabs...... 69 PALFORZIA (300 MG peg-3350/electrolytes...... 122 phenytoin sodium extended...... 69 MAINTENANCE)...... 135 peg-3350/electrolytes/ascorbat 122 PHEXXI...... 127 PALFORZIA (300 MG PEGANONE...... 69 philith...... 105 TITRATION)...... 135 PEGASYS...... 38 PHOSLYRA...... 114 PALFORZIA (40 MG PEGASYS PROCLICK...... 38 phospha 250 neutral...... 163 DAILY DOSE)...... 135 PEGINTRON...... 38 PHOSPHOLINE IODIDE....173 PALFORZIA (6 MG DAILY peg-kcl-nacl-nasulf-na asc-c....122 physiolyte...... 176 DOSE)...... 135 PEG-PREP...... 122 Physiosol Irrigation...... 176 PALFORZIA (80 MG PEMAZYRE...... 50 phytonadione...... 168 DAILY DOSE)...... 135 pen needles...... 155 PICATO...... 190 PALFORZIA INITIAL pen needles 1/2"...... 155 PIFELTRO...... 31 ESCALATION...... 135 pen needles 3/16"...... 155 pilocarpine hcl...... 173, 202 paliperidone er...... 77 pen needles 5/16"...... 156 pimecrolimus...... 199 PALYNZIQ...... 107 penicillamine...... 100 pimozide...... 85 PAMELOR...... 73 penicillin v potassium...... 39 pimtrea...... 105 PAMINE...... 117 PENLAC...... 192 pindolol...... 59 PAMINE FORTE...... 117 PENNSAID...... 199 pioglitazone hcl...... 97 PANCREAZE...... 124 pentamidine isethionate...... 28 pioglitazone hcl-glimepiride...... 97 PANDEL...... 197 PENTASA...... 120 pioglitazone hcl-metformin hcl..97 panlor...... 24 pentazocine-naloxone hcl...... 18 PIQRAY (200 MG DAILY PANRETIN...... 199 pentoxifylline er...... 134 DOSE)...... 47 pantoprazole sodium...... 125 PEPCID...... 119 PIQRAY (250 MG DAILY PANZYGA...... 139 PERCOCET...... 24 DOSE)...... 47 PARAFON FORTE DSC...... 88 PERCURA...... 168 PIQRAY (300 MG DAILY PARAGARD PERFOROMIST...... 181 DOSE)...... 47 INTRAUTERINE COPPER 105 PERIDEX...... 202 pirmella 1/35...... 105 paregoric...... 123 perindopril erbumine...... 52 pirmella 7/7/7...... 105 PAREMYD...... 134 periogard...... 202 piroxicam...... 17 paricalcitol...... 99 permethrin...... 201 PLAQUENIL...... 138 224 PLAVIX...... 135 PRAMOSONE...... 198 pregen dha...... 168 PLEGRIDY...... 87 PRAMOTIC...... 202 pregenna...... 168 PLEGRIDY STARTER PRANDIN...... 97 PREGNYL...... 109 PACK...... 87 prasugrel hcl...... 135 PREMARIN...... 109 PLENVU...... 122 PRAVACHOL...... 56 premium lidocaine...... 198 PLEXION...... 189 pravastatin sodium...... 57 PREMPHASE...... 109 PLEXION CLEANSER...... 189 praziquantel...... 28 PREMPRO...... 109 PLEXION CLEANSING prazosin hcl...... 53 PRENAISSANCE...... 168 CLOTH...... 189 PRECISION PCX...... 156 PRENAISSANCE PLIXDA...... 189 PRECISION PCX PLUS BALANCE...... 168 PNV FOLIC ACID + IRON 168 TEST...... 156 PRENAISSANCE pnv prenatal plus multivitamin 168 PRECISION POINT OF HARMONY DHA...... 168 pnv-dha...... 168 CARE TEST...... 156 PRENAISSANCE NEXT.....168 PNV-DHA+DOCUSATE.... 168 PRECISION QID TEST...... 156 prenaissance next-b...... 168 PNV-OMEGA...... 168 PRECISION SOF-TACT PRENAISSANCE PLUS...... 168 pnv-select...... 168 TEST...... 156 prenara...... 168 PNV-TOTAL...... 168 PRECISION SUREDOSE PRENATA...... 168 pnv-vp-u...... 168 PLUS SYR...... 156 prenatabs rx...... 168 POCKETCHEM EZ TEST...156 PRECISION SURE-DOSE prenatal 19...... 168 podofilox...... 200 SYRINGE...... 156 prenatal low iron...... 168 POGO AUTOMATIC TEST PRECISION THIN PRENATAL PLUS IRON... 169 CARTRIDGES...... 156 LANCETS...... 156 PRENATAL-U...... 169 polycin...... 175 PRECISION ULTRA PRENATE...... 169 polyethylene glycol 3350...... 122 LANCET...... 156 PRENATE DHA...... 169 polymyxin b-trimethoprim...... 175 PRECISION XTRA BLOOD PRENATE ELITE...... 169 POLY-PREP...... 122 GLUCOSE...... 156 PRENATE ESSENTIAL...... 169 POLYTRIM...... 175 PRECOSE...... 92 PRENATE MINI...... 169 POLY-VI-FLOR...... 168 PRED MILD...... 176 prenatvite complete...... 169 POMALYST...... 139 PRED-G...... 174 prenatvite plus...... 169 PONSTEL...... 17 PRED-G S.O.P...... 174 prenatvite rx...... 169 PONVORY...... 87 prednicarbate...... 197 PREPIDIL...... 113 PONVORY STARTER prednisolone...... 110 PREPOPIK...... 122 PACK...... 87 prednisolone acetate...... 176 PRESTALIA...... 52 portia-28...... 105 prednisolone sodium phosphate pretab...... 169 posaconazole...... 27 ...... 110, 176 pretomanid...... 34 pot bicarb-pot chloride...... 163 prednisone...... 111 PREVACID...... 126 potassium bicarbonate...... 163 PREDNISONE INTENSOL 111 PREVACID 24HR...... 125 potassium chloride...... 163 PREFERA OB...... 168 PREVACID SOLUTAB...... 126 potassium chloride crys er...... 163 PREFERAOB ONE...... 168 prevalite...... 55 potassium chloride er...... 163 PREFERRED PLUS previfem...... 105 potassium citrate er...... 128 INSULIN SYRINGE...... 156 PREVPAC...... 127 potassium citrate-citric acid....128 PREFERRED PLUS PREVYMIS...... 34 POTIGA...... 69 LANCETS COLORED...... 156 PREZCOBIX...... 33 pr natal 400...... 168 PREFERRED PLUS PREZISTA...... 31 pr natal 430...... 168 LANCETS THIN...... 156 PRIFTIN...... 34 pr natal 430 ec...... 168 PREFERRED PLUS PRILOSEC...... 126 PRADAXA...... 131 UNIFINE PENTIPS...... 156 PRILOSEC OTC...... 126 PRALUENT...... 57 PREFEST...... 109 PRIMACARE...... 169 pramipexole dihydrochloride.....75 pregabalin...... 69 primaquine phosphate...... 29 pramipexole dihydrochloride er.75 pregabalin er...... 69 primidone...... 69 225 PRIMLEV...... 24 proparacaine hcl...... 134 QUESTRAN LIGHT...... 55 PRIMSOL...... 28 propranolol hcl...... 59 quetiapine fumarate...... 77 PRINIVIL...... 52 propranolol hcl er...... 59 quetiapine fumarate er...... 77 PRISTIQ...... 73 propranolol-hctz...... 58 QUFLORA FE PEDIATRIC PROAIR DIGIHALER...... 181 propylthiouracil...... 116 ...... 169 PROAIR HFA...... 181 PROSCAR...... 127 QUILLICHEW ER...... 80, 81 PROAIR RESPICLICK...... 181 PROSTIN E2...... 113 QUILLIVANT XR...... 81 probenecid...... 15 PROTEOLIN...... 169 quinapril hcl...... 52 PROCARDIA...... 61 PROTEOLIN DS...... 169 quinapril-hydrochlorothiazide...52 PROCARDIA XL...... 61 PROTONIX...... 126 quinidine gluconate er...... 55 Procentra...... 80 PROTOPIC...... 200 quinidine sulfate...... 55 prochlorperazine...... 119 protriptyline hcl...... 73 quinine sulfate...... 29 prochlorperazine edisylate...... 77 PROVENTIL HFA...... 181 QUINZYME...... 157 prochlorperazine maleate...... 119 PROVERA...... 115 QVAR...... 186 PROCRIT...... 132 PROVIGIL...... 89 QVAR REDIHALER...... 186 PROCTOCORT...... 126 PROZAC...... 73 ra lice treatment...... 201 PROCTOFOAM HC...... 126 PRUDOXIN...... 192 ra lidocaine pain relieving...... 198 Procto-Med Hc...... 126 pseudoeph-chlorphen-hydrocod182 ra pain relieving...... 198 Procto-Pak...... 126 psorcon...... 197 ra sleep aid...... 82 procto-pak...... 126 PULMICORT...... 186 ra urinary pain relief...... 128 Proctosol Hc...... 126 PULMICORT rabeprazole sodium...... 126 proctosol hc...... 127 FLEXHALER...... 186 RADIOGARDASE...... 134 Proctozone-Hc...... 127 PULMONA...... 169 RAGWITEK...... 136 proctozone-hc...... 127 Pulmosal...... 183 Rajani...... 105 PROCYSBI...... 128 PULMOZYME...... 186 raloxifene hcl...... 113 PRODIGY INSULIN PURIXAN...... 41 ramelteon...... 82 SYRINGE...... 156 PYLERA...... 123 ramipril...... 52 PRODIGY LANCETS 28G..156 pyrazinamide...... 34 RANEXA...... 64, 65 PRODIGY NO CODING pyridostigmine bromide...... 85 ranitidine hcl...... 119, 120 BLOOD GLUC...... 156 pyridostigmine bromide er...... 85 ranolazine er...... 64 PRODIGY TWIST TOP pyridoxine hcl...... 169 RAPAFLO...... 127 LANCETS 28G...... 156 pyrimethamine...... 28 RAPAMUNE...... 140 progesterone...... 115 QBRELIS...... 52 rasagiline mesylate...... 75 progesterone micronized...... 115 QBREXZA...... 200 RASUVO...... 138 PROGLYCEM...... 112 qc azo...... 128 RAVICTI...... 107 PROGRAF...... 140 qc lidocaine pain relief...... 198 RAYALDEE...... 99 PROLATE...... 24 qc urinary pain relief...... 128 RAZADYNE...... 71 PROLENSA...... 176 QDOLO...... 24 RAZADYNE ER...... 71 PROLIA...... 113 QELBREE...... 80 REACT...... 105 PROMACTA...... 132 QINLOCK...... 50 reality insulin syringe...... 157 promethazine hcl...... 119 QMIIZ ODT...... 17 REBETOL...... 38 promethazine vc...... 182 QNASL...... 185 REBIF...... 87 promethazine vc/codeine...... 182 QNASL CHILDRENS...... 185 REBIF REBIDOSE...... 87 promethazine-dm...... 182 QTERN...... 97 REBIF REBIDOSE promethazine-phenylephrine... 182 QUALAQUIN...... 29 TITRATION PACK...... 87 promethegan...... 119 QUARTETTE...... 105 REBIF TITRATION PACK.. 87 PROMETRIUM...... 115 quasense...... 105 reclipsen...... 105 propafenone hcl...... 54 quazepam...... 82 RECTIV...... 127 propafenone hcl er...... 54 QUDEXY XR...... 69 REDITREX...... 138 propantheline bromide...... 117 QUESTRAN...... 55 226 REFUAH PLUS BLOOD REQUIP...... 75 risedronate sodium...... 99 GLUCOSE TEST...... 157 REQUIP XL...... 75 RISPERDAL...... 77 REGLAN...... 119 RESCRIPTOR...... 31 RISPERDAL CONSTA...... 77 REGRANEX...... 201 RESCULA...... 173 RISPERDAL M-TAB...... 77 Relafen...... 17 reserpine...... 64 risperidone...... 77 RELAFEN DS...... 17 RESTASIS...... 134 risperidone m-tab...... 77 RELENZA DISKHALER...... 34 RESTASIS MULTIDOSE....134 RITALIN...... 81 RELEXXII...... 81 RESTORIL...... 82 RITALIN LA...... 81 RELHIST...... 183 RETACRIT...... 132 ritonavir...... 31 RELION BLOOD RETEVMO...... 47 rivastigmine...... 71 GLUCOSE TEST...... 157 RETIN-A...... 189 rivastigmine tartrate...... 71 RELION GLUCOSE...... 112 RETIN-A MICRO...... 189 Rivelsa...... 105 RELION GLUCOSE RETIN-A MICRO PUMP....189 rizatriptan benzoate...... 84 DRINK...... 112 RETROVIR...... 31 ROBAXIN...... 88 RELION INSULIN REVATIO...... 65 ROBAXIN-750...... 88 SYRINGE...... 157 REVEAL BLOOD ROBINUL...... 117 RELI-ON INSULIN GLUCOSE TEST...... 157 ROBINUL-FORTE...... 117 SYRINGE...... 157 REVLIMID...... 139, 140 ROCALTROL...... 99 RELION KETONE...... 157 REXULTI...... 77 ROCKLATAN...... 176 RELION LANCETS REYATAZ...... 31 ropinirole hcl...... 75 STANDARD 21G...... 157 REYVOW...... 84 ropinirole hcl er...... 75 RELION LANCETS THIN RHINOCORT ALLERGY.. 185 rosadan...... 200 26G...... 157 RHOFADE...... 200 rosuvastatin calcium...... 57 RELION LANCETS RHOPRESSA...... 176 ROSZET...... 57 ULTRA-THIN 30G...... 157 ribasphere...... 38 Roweepra...... 69 RELION MINI PEN RIBASPHERE RIBAPAK.....38 ROXICODONE...... 24 NEEDLES...... 157 ribavirin...... 35, 38 ROZEREM...... 82 RELION PEN NEEDLES....157 RIDAURA...... 15 ROZLYTREK...... 47 RELION SHORT PEN rifabutin...... 34 RUBRACA...... 42 NEEDLES...... 157 RIFADIN...... 34 RUCONEST...... 134 RELION ULTRA THIN RIFAMATE...... 34 rufinamide...... 69 LANCETS 30G...... 157 rifampin...... 34 RUKOBIA...... 31 RELION ULTRA THIN RIFAMPIN+SYRSPEND RUZURGI...... 85 PLUS LANCETS...... 157 SF PH4...... 34 RYBELSUS...... 94 RELISTOR...... 123 RIFATER...... 34 RYCLORA...... 180 RELNATE DHA...... 169 RIGHTEST GL300 RYDAPT...... 42 RELPAX...... 84 LANCETS...... 157 RYTARY...... 75 RELTONE...... 123 RIGHTEST GS100 BLOOD RYTHMOL SR...... 55 REMERON...... 73 GLUCOSE...... 157 RYVENT...... 180 REMERON SOLTAB...... 73 RIGHTEST GS300 BLOOD SABRIL...... 69 REMODULIN...... 65 GLUCOSE...... 157 SAFESNAP INSULIN RENACIDIN...... 128 RIGHTEST GS550 BLOOD SYRINGE...... 157 RENAGEL...... 114 GLUCOSE...... 157 safety lancet 21g/pressure act. 157 RENVELA...... 115 RILUTEK...... 85 safety lancet 28g/pressure act. 158 repaglinide...... 97 riluzole...... 85 SAFETY LANCETS...... 158 repaglinide-metformin hcl...... 92 rimantadine hcl...... 35 SAFETY LANCETS 21G.....158 REPATHA...... 58 ringers irrigation...... 176 safety lancets 28g...... 158 REPATHA PUSHTRONEX RINVOQ...... 137 SAFETY LET LANCETS.... 158 SYSTEM...... 58 RIOMET...... 92 SAFETY SEAL LANCETS..158 REPATHA SURECLICK...... 58 RIOMET ER...... 92 227 SAFETY-GLIDE SYRINGE SFROWASA...... 121 SMARTEST BLOOD ...... 158 sharobel...... 105 GLUCOSE TEST...... 158 SAFYRAL...... 105 SHOPKO UNIFINE SMARTEST LANCETS 28G SAIZEN...... 112 PENTIPS...... 158 ...... 158 SAIZEN CLICK.EASY...... 112 SHOPKO UNILET sodium chloride...... 128, 184 SAIZENPREP...... 112 LANCETS 28G...... 158 sodium fluoride...... 169, 170 Sajazir...... 25 SHOPKO UNILET sodium phenylbutyrate...... 107 SALAGEN...... 202 LANCETS 30G...... 158 sodium polystyrene sulfonate.. 100 saline laxative...... 122 SHUR-SEAL sofosbuvir-velpatasvir...... 38 SAMSCA...... 113 CONTRACEPTIVE...... 127 SOLARAZE...... 200 SANCUSO...... 119 SIGNIFOR...... 114 solia...... 105 SANDIMMUNE...... 140 SIGNIFOR LAR...... 114 solifenacin succinate...... 129 SANDOSTATIN...... 114 SIKLOS...... 134 SOLIQUA...... 94 SANDOSTATIN LAR sildenafil citrate...... 65 SOLODYN...... 40 DEPOT...... 114 SILENOR...... 82 SOLOSEC...... 28 SANTYL...... 200 SILIQ...... 193 SOLTAMOX...... 44 SAPHRIS...... 77 silodosin...... 127 SOLUS V2 LANCETS 28G.. 158 sapropterin dihydrochloride.... 107 SILVADENE...... 200 SOLUS V2 TEST...... 158 SARAFEM...... 73 silver sulfadiazine...... 190 SOLUS V2 TWIST SAVAYSA...... 131 SIMBRINZA...... 173 LANCETS 30G...... 158 SAVELLA...... 85 Simliya...... 105 SOMA...... 88 SAVELLA TITRATION Simpesse...... 105 SOMATULINE DEPOT...... 114 PACK...... 85 SIMPONI...... 137 SOMAVERT...... 114 scopolamine...... 119 simvastatin...... 57 SONATA...... 82 SECONAL...... 69 SINEMET...... 75 SOOLANTRA...... 200 SECUADO...... 77 SINEMET CR...... 75 sorbitol-mannitol...... 128 SEEBRI NEOHALER...... 178 SINGLE-LET...... 158 SORIATANE...... 193 SEGLUROMET...... 97 SINGULAIR...... 183 SORILUX...... 193 SELECT-OB...... 169 sirolimus...... 140 sorine...... 55 selegiline hcl...... 75 SIRTURO...... 34 sotalol hcl...... 55 selenium sulfide...... 193 SITAVIG...... 35 sotalol hcl (af)...... 55 SELZENTRY...... 31 SIVEXTRO...... 28 SOTYLIZE...... 59 SEMGLEE...... 96 SKELAXIN...... 88 SOVALDI...... 38 SEMPREX-D...... 183 SKLICE...... 201 SPECTRACEF...... 36 se-natal 19...... 169 SKYLA...... 105 spinosad...... 201 SENSIPAR...... 99 SKYRIZI...... 137 SPIRIVA HANDIHALER...178 SENTRA AM...... 169 SKYRIZI (150 MG DOSE).. 137 SPIRIVA RESPIMAT...... 178 SENTRA PM...... 169 SKYRIZI PEN...... 137 spironolactone...... 63 SEREVENT DISKUS...... 181 sleep-aid...... 82 spironolactone-hctz...... 63 SERNIVO...... 197 SLYND...... 105 SPORANOX...... 27 SEROQUEL...... 77 sm lice treatment...... 201 SPORANOX PULSEPAK..... 27 SEROQUEL XR...... 77 sm sleep aid...... 82 sprintec 28...... 105 SEROSTIM...... 112 SMART SENSE COLOR SPRITAM...... 69 sertraline hcl...... 73, 74 LANCETS 33G...... 158 SPRIX...... 17 Setlakin...... 105 SMART SENSE SPRYCEL...... 47 sevelamer carbonate...... 115 STANDARD LANCETS..... 158 SPS...... 100 sevelamer hcl...... 115 SMART SENSE SUPER sronyx...... 105 SEVENFACT...... 131 THIN LANCETS...... 158 ssd...... 190 SEYSARA...... 40 SMART SENSE THIN SSKI...... 183 sf...... 202 LANCETS 26G...... 158 sss 10-5...... 189 228 st joseph aspirin...... 26 SUPREP BOWEL PREP KIT SYNDROS...... 119 STALEVO 100...... 75 ...... 122 SYNERA...... 198 STALEVO 125...... 75 SURE COMFORT SYNJARDY...... 97 STALEVO 150...... 75 INSULIN SYRINGE...... 158 SYNJARDY XR...... 97 STALEVO 200...... 75 SURE COMFORT SYNTHROID...... 116 STALEVO 50...... 75 LANCETS 28G...... 158 SYPRINE...... 100 STALEVO 75...... 81 SURE COMFORT TABLOID...... 41 STARLIX...... 97 LANCETS 30G...... 158 TABRECTA...... 50 stavudine...... 31 sure comfort pen needles...... 158 TACLONEX...... 197 STEGLATRO...... 98 SURE EDGE TEST...... 158 tacrolimus...... 140, 200 STEGLUJAN...... 97 SURECHEK BLOOD tadalafil...... 128 STELARA...... 137, 138 GLUCOSE TEST...... 159 tadalafil (pah)...... 65 STERILANCE PA...... 158 SURE-FINE PEN TAFINLAR...... 48 STERILANCE TL...... 158 NEEDLES...... 159 TAGRISSO...... 48 STIMATE...... 117 SURE-JECT INSULIN take action...... 105 STIOLTO RESPIMAT...... 178 SYRINGE...... 159 TAKHZYRO...... 134 STIVARGA...... 48 SURE-LANCE FLAT TALICIA...... 127 STRATTERA...... 81 LANCETS...... 159 TALTZ...... 138 STRENSIQ...... 99 SURE-LANCE THIN TALZENNA...... 42 STRIBILD...... 33 LANCETS 28G...... 159 TAMIFLU...... 35 STRIVERDI RESPIMAT.... 181 SURE-LANCE ULTRA tamoxifen citrate...... 44 SUBLOCADE...... 25 THIN LANCETS...... 159 tamsulosin hcl...... 127 SUBOXONE...... 18 SURE-TEST EASYPLUS TANZEUM...... 96 SUBSYS...... 24 MINI TEST...... 159 TAPAZOLE...... 116 SUCRAID...... 124 SURE-TOUCH LANCETS TAPERDEX 12-DAY...... 111 sucralfate...... 123 UNIVERSAL...... 159 Taperdex 6-Day...... 111 SULAR...... 61 SURMONTIL...... 74 TAPERDEX 7-DAY...... 111 sulconazole nitrate...... 192 SUSTIVA...... 31 TARCEVA...... 48 sulfacetamide sodium...... 175 SUTAB...... 122 Targadox...... 40 sulfacetamide sodium (acne).. 189 SUTENT...... 48 TARGRETIN...... 50, 200 sulfacetamide-prednisolone..... 174 syeda...... 105 Tarina 24 Fe...... 105 sulfadiazine...... 26 SYLATRON...... 50 Tarina Fe 1/20...... 105 sulfamethoxazole-trimethoprim Symax-Sl...... 118 TARKA...... 52 ...... 28, 29 Symax-Sr...... 118 TARON-BC...... 170 SULFAMYLON...... 190, 200 SYMBICORT...... 187 TARON-C DHA...... 170 sulfasalazine...... 121 SYMBYAX...... 91 taron-crystals...... 128 sulfatrim pediatric...... 29 SYMDEKO...... 184 TARON-PREX...... 170 sulfazine...... 121 SYMFI...... 33 TASIGNA...... 48 sulindac...... 17 SYMFI LO...... 33 TASMAR...... 75 sumatriptan...... 84 SYMJEPI...... 177 TAVALISSE...... 134 sumatriptan succinate...... 84 SYMLINPEN 120...... 92 TAYTULLA...... 105 sumatriptan succinate refill...... 84 SYMLINPEN 60...... 92 tazarotene...... 189, 193 sumatriptan-naproxen sodium...84 SYMPAZAN...... 69 TAZORAC...... 193 SUMAVEL DOSEPRO...... 84 SYMPROIC...... 123 taztia xt...... 61 SUMAXIN...... 189 SYMTUZA...... 33 TAZVERIK...... 50 SUMAXIN TS...... 189 SYNAGEX...... 170 TECFIDERA...... 87 sunitinib malate...... 48 SYNAGIS...... 35 TECHLITE AST LANCETS 159 SUNOSI...... 89 SYNALAR...... 197 TECHLITE LANCETS...... 159 SUPER THIN LANCETS.... 158 SYNALGOS-DC...... 24 TECHLITE LANCETS 30G 159 SUPRAX...... 36 SYNAREL...... 107 TECHNIVIE...... 38 229 TEGRETOL...... 69 thioridazine hcl...... 77 tolsura...... 27 TEGRETOL-XR...... 69 thiothixene...... 77 tolterodine tartrate...... 129 TEGSEDI...... 89 THRIVE...... 91 tolterodine tartrate er...... 129 TEKTURNA...... 61 THYQUIDITY...... 116 tolvaptan...... 114 TEKTURNA HCT...... 62 THYROLAR-1...... 116 TOPAMAX...... 70 TELCARE BLOOD THYROLAR-1/2...... 116 TOPAMAX SPRINKLE...... 70 GLUCOSE TEST...... 159 THYROLAR-1/4...... 116 topcare clickfine pen needles... 159 telmisartan...... 54 THYROLAR-2...... 116 TOPCARE ULTRA telmisartan-amlodipine...... 54 THYROLAR-3...... 116 COMFORT INS SYR...... 159 telmisartan-hctz...... 54 Tiadylt Er...... 61 TOPICORT...... 197 temazepam...... 82 tiagabine hcl...... 69, 70 TOPICORT SPRAY...... 197 TEMIXYS...... 33 TIAZAC...... 61 topiramate...... 70 TEMODAR...... 41 TIBSOVO...... 50 topiramate er...... 70 TEMOVATE...... 197 TICE BCG...... 50 TOPROL XL...... 59 temozolomide...... 41 ticlopidine hcl...... 135 toremifene citrate...... 44 tencon...... 16 TIGAN...... 119 torsemide...... 63 tenofovir disoproxil fumarate....31 TIGLUTIK...... 86 TOSYMRA...... 84 TENORETIC 100...... 58 TIKOSYN...... 55 TOUJEO MAX SOLOSTAR. 96 TENORETIC 50...... 58 tilia fe...... 106 TOUJEO SOLOSTAR...... 96 TENORMIN...... 59 timolol maleate...... 59, 173 TOVIAZ...... 129 TEPMETKO...... 48 timolol maleate pf...... 173 TRACLEER...... 65 TERAZOL 7...... 130 TIMOPTIC...... 173 TRADJENTA...... 93 terazosin hcl...... 53 TIMOPTIC OCUDOSE...... 173 tramadol hcl...... 24 terbinafine hcl...... 27 TIMOPTIC-XE...... 173 tramadol hcl er...... 24 terbutaline sulfate...... 181 TINDAMAX...... 26 tramadol hcl er (biphasic)...... 24 terconazole...... 130 tinidazole...... 26 tramadol-acetaminophen...... 24 teriparatide (recombinant).....114 tiopronin...... 128 trandolapril...... 52 TESSALON PERLES...... 183 TIROSINT...... 116 trandolapril-verapamil hcl er.... 52 TESTIM...... 91 TIROSINT-SOL...... 116 tranexamic acid...... 134 testosterone...... 91, 92 Tis-U-Sol...... 176 TRANSDERM-SCOP (1.5 testosterone cypionate...... 91 TIVICAY...... 31 MG)...... 119 testosterone enanthate...... 91 TIVICAY PD...... 31 TRANXENE-T...... 70 TESTRED...... 114 TIVORBEX...... 17 tranylcypromine sulfate...... 74 tetrabenazine...... 86 tizanidine hcl...... 89 TRAVATAN Z...... 173 tetracycline hcl...... 40 tl-care dha...... 170 travoprost (bak free)...... 173 TEXACORT...... 197 TL-SELECT...... 170 trazodone hcl...... 74 tgq 15dm/5peh/2cpm...... 183 TOBI...... 26 TRECATOR...... 34 tgq 30pse/150gfn/15dm...... 183 TOBI PODHALER...... 26 TRELEGY ELLIPTA...... 178 tgq 30pse/3brm/15dm...... 183 TOBRADEX...... 174 TRELSTAR MIXJECT...... 44 THALOMID...... 140 TOBRADEX ST...... 174 TREMFYA...... 138 THEO-24...... 187 tobramycin...... 26, 175 TREPADONE...... 170 theochron...... 187 tobramycin-dexamethasone.... 174 treprostinil...... 65 theophylline...... 187 TOBREX...... 175 TRESIBA...... 96 theophylline er...... 187 TODAY SPONGE...... 127 TRESIBA FLEXTOUCH...... 96 theracare pain relief...... 198 TOFRANIL...... 74 tretinoin...... 50, 189 THERAMINE...... 170 TOLAK...... 190 tretinoin microsphere...... 189 THERAMINE PLUS...... 170 tolazamide...... 98 tretinoin microsphere pump.....190 THINLETS LANCET...... 159 tolbutamide...... 98 TRETIN-X...... 190 THIOLA...... 128 tolcapone...... 75 TREXALL...... 41 THIOLA EC...... 128 tolmetin sodium...... 17, 18 TREXIMET...... 84 230 TREZIX...... 24 TRISTART ONE...... 170 TYLENOL WITH Tri Femynor...... 106 tri-tabs dha...... 170 CODEINE #3...... 25 triamcinolone acetonide TRIUMEQ...... 33 TYLENOL WITH ...... 185, 197, 202 TRIVEEN-DUO DHA...... 170 CODEINE #4...... 25 triamterene...... 63 TRI-VI-FLOR...... 170 TYMLOS...... 114 triamterene-hctz...... 63 TRI-VI-FLORO...... 170 TYVASO...... 65 triazolam...... 82 trivora (28)...... 106 TYVASO REFILL...... 65 TRIBENZOR...... 54 Tri-Vylibra Lo...... 106 TYVASO STARTER...... 65 tricare...... 170 TRIZIVIR...... 33 UBRELVY...... 84 TRICARE PRENATAL TROKENDI XR...... 70 UCERIS...... 121 DHA ONE...... 170 tropicamide...... 134 UDENYCA...... 132 TRICITRASOL...... 131 trospium chloride...... 129 UKONIQ...... 49 tricitrates...... 128 trospium chloride er...... 129 ULESFIA...... 201 TRICOR...... 56 TRUEPLUS INSULIN ULORIC...... 15 triderm...... 197 SYRINGE...... 159 ULTICARE INSULIN Triderm...... 197 TRUEPLUS LANCETS 28G159 SAFETY SYR...... 159 TRIDESILON...... 197 TRUEPLUS LANCETS 30G159 ULTICARE INSULIN trientine hcl...... 100 TRUEPLUS LANCETS 33G159 SYRINGE...... 160 tri-estarylla...... 106 TRUEPLUS SAFETY ULTICARE MICRO PEN trifluoperazine hcl...... 77 LANCETS 28G...... 159 NEEDLES...... 160 trifluridine...... 175 TRUETEST TEST...... 159 ULTICARE MINI PEN TRIGLIDE...... 56 TRUETRACK TEST...... 159 NEEDLES...... 160 trihexyphenidyl hcl...... 75 TRULANCE...... 121 ULTICARE PEN NEEDLES TRIJARDY XR...... 93 TRULICITY...... 94 ...... 160 TRIKAFTA...... 184 TRUSELTIQ (100MG ULTICARE SHORT PEN tri-legest fe...... 106 DAILY DOSE)...... 48 NEEDLES...... 160 TRILEPTAL...... 70 TRUSELTIQ (125MG ULTILET CLASSIC tri-linyah...... 106 DAILY DOSE)...... 48 LANCETS...... 160 TRILIPIX...... 56 TRUSELTIQ (50MG DAILY ULTILET LANCETS...... 160 Tri-Lo-Estarylla...... 106 DOSE)...... 48 ULTILET SAFETY Tri-Lo-Marzia...... 106 TRUSELTIQ (75MG DAILY LANCETS 23G...... 160 Tri-Lo-Sprintec...... 106 DOSE)...... 48 ULTIMA TEST...... 160 trilyte...... 122 TRUSOPT...... 173 ultimatecare one...... 170 trimethobenzamide hcl...... 119 TRUVADA...... 33 ULTRA COMFORT trimethoprim...... 29 TUDORZA PRESSAIR...... 178 INSULIN SYRINGE...... 160 Tri-Mili...... 106 TUKYSA...... 48 ULTRACET...... 25 trimipramine maleate...... 74 Tulana...... 106 ULTRA-COMFORT trimpex...... 29 TURALIO...... 48 INSULIN SYRINGE...... 160 trinatal rx 1...... 170 TUSSICAPS...... 183 ULTRALANCE...... 160 TRINATE...... 170 tussigon...... 183 ULTRAM...... 25 trinaz...... 170 TUSSIONEX ULTRA-THIN II AUTO trinessa (28)...... 106 PENNKINETIC ER...... 183 LANCET...... 160 Trinessa Lo...... 106 TUXARIN ER...... 183 ULTRA-THIN II INS SYR TRI-NORINYL (28)...... 106 TUZISTRA XR...... 183 SHORT...... 160 TRINTELLIX...... 74 TWIRLA...... 106 ULTRA-THIN II INSULIN tri-previfem...... 106 TWYNSTA...... 54 SYRINGE...... 160 TRIPTODUR...... 107 TYBOST...... 31 ULTRA-THIN II LANCETS tri-sprintec...... 106 Tydemy...... 106 ...... 160 tristart dha...... 170 TYKERB...... 48 ULTRA-THIN II MINI PEN TRISTART FREE...... 170 NEEDLE...... 160 231 ULTRA-THIN II PEN valganciclovir hcl...... 35 velivet...... 106 NEEDLE SHORT...... 160 VALIUM...... 70 VELPHORO...... 115 ULTRA-THIN II PEN valproate sodium...... 70 VELTASSA...... 100 NEEDLES...... 160 valproic acid...... 70 VEMAVITE-PRX 2...... 170 ULTRATRAK PRO TEST.. 160 valsartan...... 54 VEMLIDY...... 35 ULTRATRAK ULTIMATE valsartan-hydrochlorothiazide...54 VENA-BAL DHA...... 170 TEST...... 160 VALTOCO 10 MG DOSE...... 70 VENCLEXTA...... 51 ULTRAVATE...... 197 VALTOCO 15 MG DOSE...... 70 VENCLEXTA STARTING UNIFINE PENTIPS...... 161 VALTOCO 20 MG DOSE...... 70 PACK...... 51 UNILET COMFORTOUCH VALTOCO 5 MG DOSE...... 70 venlafaxine hcl...... 74 LANCET...... 161 VALTREX...... 35 venlafaxine hcl er...... 74 UNILET EXCELITE...... 161 VALUE HEALTH INSULIN VENTAVIS...... 66 UNILET EXCELITE II...... 161 SYRINGE...... 161 VENTOLIN HFA...... 181 UNILET G.P. LANCET...... 161 value plus glucose...... 112 verapamil hcl...... 61 UNILET G.P. SUPERLITE VALUE PLUS LANCET verapamil hcl er...... 61 LANCET...... 161 STANDARD 21G...... 161 VERDESO...... 197 UNILET GP 28 ULTRA VALUE PLUS LANCETS VERDROCET...... 25 THIN...... 161 SUPER THIN...... 161 VEREGEN...... 200 UNILET LANCET...... 161 VALUE PLUS LANCETS VERELAN...... 61 UNILET SUPERLITE THIN 26G...... 161 VERELAN PM...... 61 LANCET...... 161 VALUMARK LANCET VERIPRED 20...... 111 UNISTIK 3 COMFORT...... 161 SUPER THIN 30G...... 161 VERQUVO...... 63 UNISTIK 3 EXTRA...... 161 VALUMARK LANCET VERSACLOZ...... 77 UNISTIK 3 NORMAL...... 161 ULTRA THIN 28G...... 161 VERZENIO...... 42 UNISTIK CZT COMFORT.161 VALUMARK PEN VESICARE...... 129 UNISTIK CZT NORMAL...161 NEEDLES...... 161 VESICARE LS...... 129 unithroid...... 116 Vanadom...... 89 vestura...... 106 Unithroid...... 116 Vanatol Lq...... 16 VEXOL...... 173 Unithroid Direct...... 116 Vanatol S...... 16 VFEND...... 27 UNIVERSAL 1 LANCETS VANCOCIN HCL...... 29 V-GO 20...... 161 THIN 26G...... 161 vancomycin hcl...... 29 V-GO 30...... 161 UNIVERSAL 1 LANCETS vandazole...... 130 V-GO 40...... 161 ULTRA THIN...... 161 VANISHPOINT INSULIN VIBERZI...... 121 UPNEEQ...... 134 SYRINGE...... 161 VIBRAMYCIN...... 40 UPTRAVI...... 65, 66 VANOS...... 197 vicodin...... 25 URECHOLINE...... 123 VARUBI...... 119 vicodin es...... 25 URISTIX...... 161 VARUBI (180 MG DOSE)... 119 vicodin hp...... 25 URISTIX 4...... 161 VASCAZEN...... 170 VICTORY AGM-4000 TEST161 UROCIT-K 10...... 128 VASCEPA...... 57 VICTOZA...... 94 UROCIT-K 15...... 128 VASCULERA...... 170 VIDA MIA UNIFINE UROCIT-K 5...... 128 VASERETIC...... 52 PENTIPS...... 161 UROXATRAL...... 127 VASOTEC...... 53 VIDA MIA UNILET URSO 250...... 124 VAYACOG...... 170 LANCETS 28G...... 161 URSO FORTE...... 124 VAYARIN...... 170 VIDA MIA UNILET ursodiol...... 124 VAYAROL...... 170 LANCETS 30G...... 162 UTIBRON NEOHALER..... 178 VCF VAGINAL VIDEX...... 32 VAGIFEM...... 109 CONTRACEPTIVE...... 127 VIDEX EC...... 31, 32 valacyclovir hcl...... 35 VECAMYL...... 64 VIEKIRA PAK...... 38 VALCHLOR...... 200 VECTICAL...... 193 VIEKIRA XR...... 38 VALCYTE...... 35 VELETRI...... 66 Vienva...... 106 232 vigabatrin...... 70 VOGELXO...... 92 WIDE-SEAL DIAPHRAGM Vigadrone...... 70 VOGELXO PUMP...... 92 80...... 141 VIGAMOX...... 175 VOL-NATE...... 171 WIDE-SEAL DIAPHRAGM VIIBRYD...... 74 VOL-PLUS...... 171 85...... 141 VIIBRYD STARTER PACK.74 VOL-TAB RX...... 171 WIDE-SEAL DIAPHRAGM VIMOVO...... 18 VOLTAREN...... 200 90...... 141 VIMPAT...... 70 voriconazole...... 27 WIDE-SEAL DIAPHRAGM vinate ii...... 170 VOSEVI...... 38 95...... 141 vinate one...... 170 VOSPIRE ER...... 181 WINLEVI...... 190 VIOKACE...... 124 VOTRIENT...... 49 Wixela Inhub...... 187 viorele...... 106 VP-CH-PNV...... 171 WP THYROID...... 116 VIRACEPT...... 32 VP-GGR-B6 PRENATAL....171 wymzya fe...... 106 VIRAMUNE...... 32 vp-gstn...... 171 WYNZORA...... 193 VIRAMUNE XR...... 32 vp-heme ob...... 171 XADAGO...... 75 VIREAD...... 32 vp-heme ob + dha...... 171 XALATAN...... 173 VIROPTIC...... 175 vp-heme one...... 171 XALKORI...... 49 virt nate...... 170 VP-PNV-DHA...... 171 XANAX...... 66 virt-advance...... 170 VRAYLAR...... 78 XANAX XR...... 66 virt-phos 250 neutral...... 163 VSL#3...... 124 XARELTO...... 131 VIRT-PN...... 171 VSL#3 JUNIOR...... 124 XARELTO STARTER VIRT-PN DHA...... 171 VTOL LQ...... 16 PACK...... 131 virt-pn plus...... 171 VUMERITY...... 87 XATMEP...... 41 virtprex...... 171 VUMERITY (STARTER)..... 87 XCOPRI...... 70 virtrate-3...... 128 vyfemla...... 106 XCOPRI (250 MG DAILY VIRT-SELECT...... 171 VYLEESI...... 91 DOSE)...... 70 virt-vite forte...... 171 VYNDAMAX...... 64 XCOPRI (350 MG DAILY virt-vite gt...... 171 VYNDAQEL...... 64 DOSE)...... 70 VISTARIL...... 180 VYTORIN...... 57 XELJANZ...... 138 VISTOGARD...... 50 VYVANSE...... 81 XELJANZ XR...... 138 Vitafol...... 171 VYZULTA...... 173 XELODA...... 41 VITAFOL FE+...... 171 WAKIX...... 89 XELPROS...... 173 VITAFOL STRIPS...... 171 wal-som...... 82 XEMBIFY...... 139 VITAFOL-OB...... 171 warfarin sodium...... 131 XENAZINE...... 86 VITAFOL-ONE...... 171 WAVESENSE PRESTO...... 162 XENLETA...... 29 VITAL HP 1.0 CAL...... 171 WELCHOL...... 55 XEPI...... 190 VITAL-D RX...... 171 WELLBUTRIN SR...... 74 XERAC AC...... 200 VITAMEDMD ONE WELLBUTRIN XL...... 74 XERESE...... 35 RX/QUATREFOLIC...... 171 wera...... 106 XERMELO...... 124 vitamin b-6...... 171 westab max...... 172 XGEVA...... 114 vitamin d2...... 171 WESTCORT...... 198 XHANCE...... 185 vitamin d3...... 171 WESTHROID...... 116 XIFAXAN...... 29 VITAPEARL...... 171 WIDE-SEAL DIAPHRAGM XIGDUO XR...... 97 VITRAKVI...... 49 60...... 141 XIIDRA...... 176 VIVA DHA...... 171 WIDE-SEAL DIAPHRAGM XIMINO...... 40 VIVELLE-DOT...... 109 65...... 141 XODOL...... 25 VIVITROL...... 91 WIDE-SEAL DIAPHRAGM XOFLUZA (40 MG DOSE)... 35 VIVLODEX...... 18 70...... 141 XOFLUZA (80 MG DOSE)... 35 VIZIMPRO...... 49 WIDE-SEAL DIAPHRAGM XOLAIR...... 181 VOCAL POINT BLOOD 75...... 141 XOLEGEL...... 192 GLUCOSE TEST...... 162 XOPENEX...... 181 233 XOPENEX ZEGERID...... 126 ZOLPIMIST...... 83 CONCENTRATE...... 181 ZEGERID OTC...... 126 ZOMACTON...... 112 XOPENEX HFA...... 181 ZEJULA...... 42 ZOMACTON (FOR ZOMA- XOSPATA...... 49 ZELAPAR...... 76 JET 10)...... 112 XPOVIO (100 MG ONCE ZELBORAF...... 49 ZOMIG...... 84 WEEKLY)...... 50 ZELNORM...... 121 ZOMIG ZMT...... 84 XPOVIO (40 MG ONCE ZEMBRACE SYMTOUCH...84 ZONACORT 11 DAY...... 111 WEEKLY)...... 50 ZEMPLAR...... 99 ZONACORT 7 DAY...... 111 XPOVIO (40 MG TWICE Zenatane...... 190 ZONALON...... 192 WEEKLY)...... 50 zenchent...... 106 ZONATUSS...... 183 XPOVIO (60 MG ONCE ZENPEP...... 124 ZONEGRAN...... 70 WEEKLY)...... 50 Zenzedi...... 81 zonisamide...... 70 XPOVIO (60 MG TWICE ZENZEDI...... 81 ZONTIVITY...... 135 WEEKLY)...... 51 ZEPATIER...... 38 ZORBTIVE...... 112 XPOVIO (80 MG ONCE ZEPOSIA...... 87 ZORTRESS...... 141 WEEKLY)...... 51 ZEPOSIA 7-DAY STARTER ZORVOLEX...... 18 XPOVIO (80 MG TWICE PACK...... 87 zovia 1/35e (28)...... 106 WEEKLY)...... 51 ZEPOSIA STARTER KIT..... 87 zovia 1/50e (28)...... 106 XTAMPZA ER...... 25 ZERIT...... 32 ZOVIRAX...... 35, 200 XTANDI...... 44 ZERVIATE...... 172 ZUBSOLV...... 18 xulane...... 106 ZESTORETIC...... 52 Zumandimine...... 106 XULTOPHY...... 94 ZESTRIL...... 53 ZUPLENZ...... 119 XURIDEN...... 114 ZETIA...... 55 ZURAMPIC...... 15 XYLOCAINE...... 198 ZETONNA...... 185 ZUTRIPRO...... 183 Xylon...... 25 ZIAC...... 58 ZYCLARA...... 190 XYOSTED...... 92 ZIAGEN...... 32 ZYCLARA PUMP...... 190, 200 XYREM...... 89 zidovudine...... 32 ZYDELIG...... 49 XYWAV...... 89 ZIEXTENZO...... 132 ZYFLO...... 183 XYZAL ALLERGY 24HR...180 zileuton er...... 183 ZYFLO CR...... 183 XYZAL ALLERGY 24HR ZILXI...... 201 ZYKADIA...... 49, 51 CHILDRENS...... 180 ZIOPTAN...... 173 ZYLET...... 174 YONSA...... 44 ziprasidone hcl...... 78 ZYLOPRIM...... 15 YOSPRALA...... 135 ziprasidone mesylate...... 78 ZYMAXID...... 175 YUPELRI...... 178 ZIPSOR...... 18 ZYPITAMAG...... 57 Yuvafem...... 109 ZIRGAN...... 175 ZYPREXA...... 78 ZADITOR...... 135 ZITHROMAX...... 37 ZYPREXA RELPREVV...... 78 zafirlukast...... 183 ZITHROMAX TRI-PAK...... 37 ZYPREXA ZYDIS...... 78 zaleplon...... 82 ZITHROMAX Z-PAK...... 37 ZYRTEC ALLERGY...... 180 ZAMICET...... 25 ZMAX...... 37 ZYRTEC CHILDRENS ZANAFLEX...... 89 ZOCOR...... 57 ALLERGY...... 180 ZANTAC...... 120 ZODEX 12-DAY...... 111 ZYRTEC-D ALLERGY & zarah...... 106 ZOFRAN...... 119 CONGESTION...... 183 ZARONTIN...... 70 ZOFRAN ODT...... 119 ZYTAZE...... 172 ZARXIO...... 132 ZOHYDRO ER...... 25 ZYTIGA...... 44 ZATEAN-PN DHA...... 172 ZOKINVY...... 114 ZYVOX...... 29 ZATEAN-PN PLUS...... 172 ZOLINZA...... 42 ZAVESCA...... 107 zolmitriptan...... 84 zcort 7-day...... 111 ZOLOFT...... 74 zebutal...... 16 zolpidem tartrate...... 83 ZEGALOGUE...... 112 zolpidem tartrate er...... 82 234