Volusia Health Network PHARMACY SERVICES, LOCATIONS & HOURS The pharmacy locations listed on the following pages provide members of Volusia Health Network maximum savings on prescription drug purchases. Prescriptions may be filled with a 93-day supply, only at Halifax outpatient pharmacy and FHCP mail order pharmacy. FHCP outpatient, walk-in pharmacies can fill a 31-day supply only. Next day service available on nonemergency prescriptions. .

PRESCRIPTION BENEFIT CO-PAYMENT (Co-pays are subject to change): PHARMACY LOCATION Halifax Health Outpatient Pharmacy Co-pay is per 31-day supply Maximum 93-day supply available Tier 5 & 6 available at Halifax Health only FHCP Retail Pharmacies Co-pay is per 31-day supply Maximum 31-day supply available FHCP Mail Order Pharmacy Co-pay is per 31-day supply Maximum 93-day supply available Walgreens Pharmacies (in-network only) Co-pay is per 31-day supply Maximum 31-day supply may be obtained

TIER Tier 1 Tier 2 Tier 3 Tier 4 Tiers 5 & 6 Tier 1 Tier 2 Tier 3 Tier 4 Tier 1 Tier 2 Tier 3 Tier 4 Tier 1 Tier 2 Tier 3 Tier 4

UPDATED JULY 1, 2016

CO-PAY $3 $10 $30 $55 $125 $3 $10 $30 $55 $2 $9 $29 $54 N/A $15 $35 $60

Volusia Health Network VOLUSIA COUNTY (alphabetical by city) Halifax Health Medical Center 93-day supply available Florida Health Care Plan Mail Order 93-day supply available Florida Health Care Plans Daytona Beach Florida Health Care Plans Deland Florida Health Care Plans Edgewater Walgreens Edgewater Florida Health Care Plans Holly Hill Florida Health Care Plans Orange City Walgreens Ormond Beach Florida Health Care Plans Port Orange

303 N Clyde Morris Blvd Daytona Beach, FL 32114 386-254-4197 PO Box 11696 Daytona Beach, FL 32120 386-676-7126 350 N Clyde Morris Blvd Daytona Beach, FL 32114 386-248-0832 939 N Spring Garden Ave Deland, FL 32720 386-736-7318 239 N Ridgewood Ave Edgewater, FL 32132 386-423-4212 3010 S Ridgewood Ave Edgewater, FL 32141 386-427-5208 1340 N Ridgewood Ave Holly Hill, FL 32117 386-676-7120 2777 Enterprise Rd Orange City, FL 32763 386-774-5961 205 E Granada Blvd Ormond Beach, FL 32176 386-677-8849 740 Dunlawton Ave, Ste 150 Port Orange, FL 32127 386-767-0563

Mon-Fri 8:30am to 5:00pm

Mon-Fri 8:30am to 5:30pm

Mon-Fri 8:30am to 6:00pm

Mon-Fri 8:30am to 6:00pm Sat 9:00am to 1:00pm Mon-Fri 8:30am to 6:00pm Sat 9:00am to 1:00pm Mon-Fri 9:00am to 9:00pm Sat 9:00am to 6:00pm Sun 9:00am to 5:00pm Mon-Fri 8:30am to 6:00pm Sat 9:00am to 1:00pm Mon-Fri 8:30am to 6:00pm Sat 9:00am to 1:00pm Mon-Fri 9:00am to 9:00pm Sat 9:00am to 6:00pm Sun 9:00am to 5:00pm Mon-Fri 8:30am to 6:00pm Sat 9:00am to 1:00pm

FLAGLER COUNTY Florida Health Care Plans Palm Coast

309 Palm Coast Pkwy Palm Coast, FL 32137 386-446-9447

UPDATED JULY 1, 2016

Mon-Fri 8:30am to 6:00pm Sat 9:00am to 1:00pm

Volusia Health Network BREVARD COUNTY (alphabetical by city) Walgreens Cocoa Walgreens Cocoa Walgreens Melbourne Florida Health Care Plans Melbourne Walgreens Melbourne Walgreens Palm Bay Walgreens Palm Bay Walgreens Palm Bay Florida Health Care Plans Rockledge Florida Health Care Plans Titusville

7415 N Hwy 1 Port St John, FL 32927 321-213-6233 4150 N Atlantic Ave Cocoa Beach, FL 32931 321-799-9112 2200 N Hwy A1A Melbourne, FL 32903 321-773-2022 785 N Wickham Rd, Suite 104 Melbourne, FL 32935 321-567-7505 7780 N Wickham Rd Melbourne, FL 32940 321-254-1072 1160 Malabar Rd SE Palm Bay, FL 32907 321-956-9626 3495 Bayside Lakes Blvd SE Palm Bay, FL 321-409-2828 175 Malabar Rd NW Palm Bay, FL 32909 321-728-4055 1954 Rockledge Blvd, Suite 107 Rockledge, FL 32955 321-567-7503 1021 S Washington Ave Titusville, FL 32780 321-567-7500

Mon-Fri 9:00am to 9:00pm Sat 9:00am to 5:00pm Sun 10:00am to 6:00pm Open 24 hours 7 days a week Mon-Fri 9:00am to 9:00pm Sat-Sun 10:00am-6:00pm Mon-Fri 8:30am to 6:00pm Sat 9:00-1:00pm Mon-Fri 7:00am to midnight Sat-Sun 7:00am to midnight Mon-Fri 6:00am to midnight Sat-Sun 6:00am to midnight Mon-Fri 9:00am to 9:00pm Sat-Sun 10:00am to 6:00pm Mon-Fri 9:00am to 9:00pm Sat-Sun 10:00am to 6:00pm Mon-Fri 8:30am to 6:00pm Sat 9:00am-5:00pm Mon-Fri 8:30am to 6:00pm Sat 9:00am to 1:00pm

SEMINOLE COUNTY (alphabetical by city) Walgreens Altamonte Springs Walgreens Fern Park Walgreens Oviedo Florida Health Care Plans Sanford Walgreens Winter Springs

113 Maitland Ave Altamonte Springs, FL 32701 407-331-4698 7815 Hwy. 17-92 Fern Park, FL 32730 407.331.0968 785 Lockwood Blvd Oviedo, FL 32765 407-359-2453 4932 W SR-46, Suite 1000 Sanford, FL 32771 407-732-7950 5205 Red Bug Lake Rd Winter Springs, FL 32708 407-696-2242

UPDATED JULY 1, 2016

Mon-Fri 7:00am to midnight Sat-Sun 7:00am to midnight Mon-Fri 9:00am to 9:00pm Sat-Sun 9:00am to 5:00pm Mon-Fri 9:00am to 9:00pm Sat-Sun 9:00am to 5:00pm Mon-Fri 8:30am to 6:00pm Sat 9:00am to 1:00pm Mon-Fri 7:00am to midnight Sat-Sun 7:00am to midnight

Volusia Health Network WEEKEND, AFTER HOURS AND EMERGENCY PRESCRIPTIONS ONLY The following Florida Health Care Plans Contract Pharmacies can fill Volusia Health Network prescriptions after hours, on weekends, and for emergency prescriptions only: After hours is defined as: Monday through Friday, 6:00 pm to 8:00 am and all day Saturday and Sunday. A maximum 31-day supply may be obtained from these pharmacies:

VOLUSIA COUNTY (alphabetical by city) Walgreens Daytona Beach

1420 Beville Rd Daytona Beach, FL 32114 386-257-5773

Walgreens Deland

100 E International Speedway Blvd Deland, FL 32724 386-738-4371 897 Saxon Blvd Orange City, FL 32763 386-775-5336 790 W Granada Blvd Ormond Beach, FL 32174 386-672-7107 1650 Dunlawton Ave Port Orange, FL 32127 386-322-3267

Walgreens Orange City Walgreens Ormond Beach Walgreens Port Orange

After Hours & Weekends Only Sun-Thurs 8:00am to 10:00pm Fri 9:00am to 6:00pm Sat 9:00am to 5:00pm After Hours & Weekends Only 7:00am to midnight 7 days a week After Hours & Weekends Only 7:00am to 11:00pm 7 days a week After Hours & Weekends Only 7am to midnight 7 days a week After Hours & Weekends Only 7:00am to midnight 7 days per week

FLAGLER COUNTY Walgreens Palm Coast

1109 Palm Coast Pkwy Palm Coast, FL 386-445-7041

After Hours & Weekends Only Open 24 hours 7 days a week

BREVARD COUNTY (alphabetical by city) Walgreens Cocoa

1106 Clearlake Rd Cocoa, FL 32922 321-632-3150

Walgreens Melbourne

1350 N Wickham Rd Melbourne, FL 32935 321-254-5507 2475 US Hwy 1 Mims, FL 32754 321-267-1788 4600 S Washington Ave Titusville, FL 32780 321-269-7573

Walgreens Mims Walgreens Titusville

UPDATED JULY 1, 2016

After Hours & Weekends Only Mon-Fri 8:00am to 10:00pm Sat 9:00am to 6:00pm Sun 9:00am to 5:00pm After Hours & Weekends Only Open 24 hours After Hours & Weekends Only Mon-Fri 9:00am to 9:00pm Sat-Sun 10:00am to 6:00pm After Hours & Weekends Only Mon-Fri 8:00am to 10:00pm Sat-Sun 8:00am to 10:00pm

Volusia Health Network SEMINOLE COUNTY (alphabetical by city) Walgreens Lake Mary Walgreens Lake Mary Walgreens Sanford

4024 W Lake Mary Blvd Lake Mary, FL 32746 407-549-3115 7085 CR-46A Lake Mary, FL 32746 407-833-0276 2501 French Ave Sanford, FL 32773 407-321-0518

After Hours & Weekends Only Mon-Fri 9:00am to 9:00pm Sat-Sun 9:00am to 5:00pm After Hours & Weekends Only Mon-Fri 9:00am to 9:00pm Sat-Sun 9:00am to 5:00pm After Hours & Weekends Only Mon-Fri 8:00am to 10:00pm Sat-Sun 8:00 to 10:00pm

REIMBURSEMENT FOR OUT OF AREA EMERGENCY PRESCRIPTIONS ONLY You may be eligible for reimbursement of prescription costs incurred outside of the Central Florida area provided the following requirements are met: • •

•

The prescription must be for an emergency situation (not for maintenance drugs, forgotten prescriptions, etc) You are required to pay out-of-pocket initially; then submit the entire prescription receipt (including prescribing doctor, name of medication, dosage, quantity, etc.) to Volusia Health Network Prescriptions will be reimbursed at the price you paid minus the appropriate Walgreens copay amount

Purchases that do not meet the above criteria will not be eligible for reimbursement. No purchases at local, out-of-network pharmacies will be eligible for reimbursement.

NON-FORMULARY MEDICATIONS A member may choose to purchase a non-formulary medication (if it is available) at Halifax Health’s Outpatient Pharmacy at cost plus a $5 dispensing fee. The cost is the member’s responsibility; there is no reimbursement under the Plan. However, not all non-formulary medications are available at Halifax Health’s outpatient pharmacy. If the cost of the medication exceeds the Tier 4 or Tier 5 co-pay amount, AND the prescribing physician believes an exception should be made, a request for a non-formulary exception may be submitted for Medical Director Review.

UPDATED JULY 1, 2016

Volusia Health Network DIABETIC SUPPLIES - HOW TO OBTAIN THEM 1. Blood Glucose Monitors - The Plan provides the Ascensia Breeze, Contour and Contour Next at no cost to the member. Please call the Outpatient Diabetes Education Department at 386.258.4829 for information on how to obtain one. 2. Testing Strips - are covered for copay at Florida Health Care Plans Pharmacies and Halifax Health Medical Center outpatient pharmacy. You must have a prescription from your Provider indicating how many times a day you are to test. Supplies are filled for one month’s supply or three months if done by mail order. Refer to Pharmacy Formulary on the Volusia Health Network website for copay. 3. Syringes - are covered for copay at Florida Health Care Plans Pharmacies and Halifax Health Medical Center outpatient pharmacy. You must have a prescription from your Provider indicating how many times a day you are to administer the medication. Supplies are filled for one month’s supply or three months if done by mail order. 4. Lancets - are not covered by the Plan.

UPDATED JULY 1, 2016

Volusia Health Network PHARMACY EXCLUSIONS AND LIMITATIONS • • •

• • • • • •

• •

• • •

• • • • • • • •

Over the counter drugs; Brand name medications when a generic equivalent is available; Prescriptions filled at a non-participating pharmacy, except for prescriptions required during emergency care; Any drug, medicine or medication that is consumed at the place where the prescription is given or that is dispensed by a physician; Any portion of a prescription or refill that exceeds a 31-days supply; Prescription refills in excess of the number specified by the physician; The administration of covered prescription medication; Prescriptions that may be paid without charge under local, state, or federal programs, including worker’s compensation; Prescriptions that are to be taken by or administered to the member in whole or in part, while he or she is a patient in a hospital, skilled nursing facility, convalescent hospital, inpatient hospice facility or other facility where drugs are ordinarily provided by the facility on an inpatient basis; Prescriptions ordered or received in excess of any maximums covered under this benefit, and not covered under any other provision in this group plan; Any drug, medicine or medication labeled “caution-limited by federal law to investigation use.” Any experimental drug or drug used for non-FDA approved indication or prescribed for use by a route of administration that is not approved by the FDA even though a charge is made to the member; a drug that is prescribed for the treatment of cancer is covered as long as that drug is recognized for treatment of that indication in a standard reference compendium or recommended in the medical literature and included in Florida Health Care Plan’s formulary; Immunizing agents, biological serums or allergy serums; Any drug or medicine that is lawfully obtainable without a prescription, with the exception of insulin; Therapeutic devices or appliances, including hypodermic needles/syringes (exception: insulin needles/syringes with insulin), support garments, and other non-medical substances, regardless of intended use; Nutritional supplements given as a medicine between meals to boost protein-caloric intake or the mainstay of a daily nutritional plan; Prescriptions and non prescription appetite suppressants and products for the purpose of weight loss; Nicotine suppressants and smoking cessations products and services; Any drug for cosmetic use or alteration of one’s appearance (i.e. Rogaine, bleaching agents, acne medications, nail fungus treatment); Infertility agents; Transdermal scopolamine patches; Abortifacients; Erectile Dysfunction drugs.

UPDATED JULY 1, 2016