2013 Medicare HMO Blue ValueRx/PlusRx Formulary - Blue Cross ...

Immunologicals and Vaccines: Myeloid StimulantsLEUKINETier 5 H I TNEULASTA Tier 5 Q C D (1.2syringes/30)NEUPOGEN 300 MCG/0.5 ML SYR Tier 5 Q C D (15/30)NEUPOGEN 300 MCG/ML VIAL Tier 5NEUPOGEN 480 MCG/0.8 ML SYR Tier 5 Q C D (24/30)NEUPOGEN 480 MCG/1.6 ML VIAL Tier 5 Q C D (48/30)Medical (Miscellaneous) Supplies: Diabetic Supplies1ST CHOICE SUPER THIN LANCETS M B1ST CHOICE THIN LANCETS M B1ST CHOICE ULTRA THIN LANCETS M B1ST TIER COMFORTOUCH 28G M BLANCT1ST TIER COMFORTOUCH 30G M BLANCT1ST TIER UNIFINE PENTP 5MM 31G Tier 31ST TIER UNIFINE PNTIP 4MM 32G Tier 31ST TIER UNIFINE PNTIP 6MM 31G Tier 31ST TIER UNIFINE PNTIP 8MM 31G Tier 31ST TIER UNIFINE PNTP 12MM 29G Tier 32TEK CONTROL SOLUTION M BACCU-CHEK ACTIVE GLUCOSE SOL M BACCU-CHEK ACTIVE TEST STRIP M B Q C D (300/30)ACCU-CHEK ADVANTAGE KIT M B Q C D (1/365)ACCU-CHEK AVIVA PLUS METER M B Q C D (1/365)ACCU-CHEK AVIVA PLUS TEST STRP M B Q C D (300/30)ACCU-CHEK AVIVA SOLUTION M BACCU-CHEK AVIVA TEST STRIPS M B Q C D (300/30)ACCU-CHEK CMFRT CURVE SOLN M BACCU-CHEK CMFRT CURVE STRIP M B Q C D (300/30)ACCU-CHEK COMFORT CURVE M B Q C D (300/30)STRIPACCU-CHEK COMPACT BLUECONTROLM BQ C D (Limit/days): Quality Care Dosing limits apply \ P A: Prior Authorization required \ S T: Step Therapy required \L P A: Limited Pharmacy Availability \ H I T: Home Infusion Therapy \ N M O: Not available through Mail Order \M B: These drugs and supplies are covered under your plan’s medical benefit and are available through network retail pharmaciesor mail-order service. See page 5 for more information. 51