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

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Medical (Miscellaneous) Supplies:Diabetic Supplies (continued)ACCU-CHEK COMPACT CARE KIT M B Q C D (1/365)ACCU-CHEK COMPACT DRUM M B Q C D (300/30)STRIPSACCU-CHEK COMPACT PLUS KIT M B Q C D (1/365)ACCU-CHEK COMPACT STRIPS M B Q C D (300/30)ACCU-CHEK COMPACT TEST DRUM M B Q C D (300/30)ACCU-CHEK CONTROL SOLUTION M BACCU-CHEK FASTCLIX LANCETS M BACCU-CHEK III DIABETES KIT M B Q C D (1/365)ACCU-CHEK MULTICLIX LANCET M BACCU-CHEK MULTICLIX LANCET KIT M BACCU-CHEK MULTICLIX LANCETS M BACCU-CHEK NANO SMARTVIEW M B Q C D (1/365)METERACCU-CHEK SAFE-T-PRO 23G M BLANCTACCU-CHEK SAFE-T-PRO LANCETS M BACCU-CHEK SAFE-T-PRO PLUS 23G M BACCU-CHEK SMARTVIEW CONTRL M BSOLACCU-CHEK SMARTVIEW STRIP M B Q C D (300/30)ACCU-CHEK SMARTVIEW TEST M B Q C D (300/30)STRIPACCU-CHEK SOFTCLIX LANCETS M BACCU-CHEK VOICEMATE SYSTEM M B Q C D (1/365)ACCUTREND GLUCOSE CONTROL M BMedical (Miscellaneous) Supplies:Diabetic Supplies (continued)ACTI-LANCE 23G LANCETS M BACTI-LANCE 28G LANCETS M BACTI-LANCE LITE 28G LANCETS M BACTI-LANCE SPECIAL 17G LANCETS M BACTI-LANCE UNIVERS 23G LANCETS M BACURA CONTROL SOLUTION HIGH M BACURA CONTROL SOLUTION LOW M BACURA CONTROL SOLUTION M BNORMALADVANCE MICRO-DRAW CNTRL M BSOLNADVANCE MICRO-DRAW CONTRL M BSOLNADVANCE NORMAL CONTROL SOLN M BADVANCED TRAVEL LANCETS 28G M BADVOCATE 26G LANCETS M BADVOCATE 30G LANCETS M BADVOCATE CONTROL SOLUTION M BHIGHADVOCATE CONTROL SOLUTION M BLOWADVOCATE INS 0.3 ML 30GX5/16 Tier 3ADVOCATE INS 0.3 ML 31GX5/16 Tier 3ADVOCATE INS 0.5 ML 30GX5/16 Tier 3ADVOCATE INS 0.5 ML 31GX5/16 Tier 3ADVOCATE INS 1 ML 31GX5/16 Tier 352Q 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.
Medical (Miscellaneous) Supplies:Diabetic Supplies (continued)ADVOCATE INS SYR 0.3ML 29GX1/2 Tier 3ADVOCATE INS SYR 0.5ML 29GX1/2 Tier 3ADVOCATE INS SYR 1 ML 29GX1/2 Tier 3ADVOCATE INS SYR 1 ML 30GX5/16 Tier 3ADVOCATE PEN NEEDLES 5MM 31G Tier 3ADVOCATE PEN NEEDLES 8MM 31G Tier 3ADVOCATE REDI-CODE+ CTRL M BSOLNAGAMATRIX HIGH CONTROL SOLN M BAGAMATRIX NORM-HI CONTROL M BSOLNAIMSCO INS PEN NDL 29GX1/2 Tier 3AIMSCO INS PEN NDL 31GX3/16 Tier 3AIMSCO INS PEN NDL 31GX5/16 Tier 3AIMSCO INS SYR 0.3 ML 29GX1/2 Tier 3AIMSCO INS SYR 0.3 ML 30GX5/16 Tier 3AIMSCO INS SYR 0.5 ML 28GX1/2 Tier 3AIMSCO INS SYR 0.5 ML 29GX1/2 Tier 3AIMSCO INS SYR 1 ML 28GX1/2 Tier 3AIMSCO INS SYR 1 ML 29GX1/2 Tier 3AIMSCO INS SYR 1 ML 30GX5/16 Tier 3AIMSCO SYRING 0.3 ML 31GX5/16 Tier 3AIMSCO SYRING 0.5 ML 30GX5/16 Tier 3AIMSCO SYRING 0.5 ML 31GX5/16 Tier 3AIMSCO ULTR-THIN II 28G LANCET M BMedical (Miscellaneous) Supplies:Diabetic Supplies (continued)ALCOHOL 70% PADS Tier 3ALCOHOL 70% PREP PADS Tier 3ALCOHOL 70% SWABS Tier 3ALCOHOL PREP PADS Tier 3ALCOHOL PREP PADS 70% Tier 3ALCOHOL PREP SWABS Tier 3ALCOHOL SWAB Tier 3ALCOHOL SWABS Tier 3ALCOHOL WIPES Tier 3ALTERNATE SITE 26G LANCETS M BALTERNATE SITE LANCETS M BANTI-STICK INSULIN 0.5 ML SYR Tier 3ANTI-STICK INSULIN 1 ML SYR Tier 3ASCENSIA AUTODISC CTRL SOLN M BASSURE 3 CONTROL SOLUTION M BASSURE 4 CONTROL SOLUTION M BASSURE DOSE CONTROLM BSOLUTIONASSURE HAEMOLANCE PLUS 18G M BASSURE HAEMOLANCE PLUS 21G M BASSURE HAEMOLANCE PLUS 25G M BASSURE HAEMOLANCE PLUS M BLANCETSASSURE ID SYR 0.5 ML 29GX1/2 Tier 3ASSURE ID SYR 1 ML 29GX1/2 Tier 3Q 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. 53
Page 1:
Medicare HMO Blue SM ValueRx (HMO)M
Page 4 and 5: How do I use the Formulary?There ar
Page 6 and 7: What do I do before I can talk to m
Page 8 and 9: Your Medicare Prescription Drug Cos
Page 10 and 11: Antiinfectives: Antiretrovirals and
Page 12 and 13: Antiinfectives: Oral Antifungal Dru
Page 14 and 15: Antiinfectives: Other Antiviral Dru
Page 16 and 17: Antiinfectives: Sulfonamideserythro
Page 18 and 19: Antineoplastic/Immunosuppressant Dr
Page 20 and 21: Antineoplastic/Immunosuppressant Dr
Page 22 and 23: Autonomic and CNS Medications: Anal
Page 24: Autonomic and CNS Medications:Antiv
Page 28 and 29: Autonomic and CNS Medications: CNSS
Page 30 and 31: Autonomic and CNS Medications:Other
Page 32 and 33: Autonomic and CNS Medications: Sele
Page 34 and 35: Cardiovascular Medications: Beta-Ad
Page 36 and 37: Cardiovascular Medications: Loop Di
Page 38 and 39: Cardiovascular Medications: OtherVa
Page 40 and 41: Dermatological Medications: OralDer
Page 42 and 43: Dermatological Medications: Topical
Page 44 and 45: Endocrine Medications: Glucocortico
Page 46 and 47: Endocrine Medications: Oral Hypogly
Page 48 and 49: Gastrointestinal Medications: Antis
Page 50 and 51: Immunologicals and VaccinesACTHIB T
Page 52 and 53: Immunologicals and Vaccines: Interf
Page 56 and 57: Medical (Miscellaneous) Supplies:Di
Page 80 and 81: Musculoskeletal Medications: Non-St
Page 82 and 83: Nutrition, Blood Modifiers, Electro
Page 84 and 85: Nutrition, Blood Modifiers, Electro
Page 86 and 87: Obstetrical and Gynecological Medic
Page 88 and 89: Obstetrical and GynecologicalMedica
Page 90 and 91: Obstetrical and Gynecological Medic
Page 92 and 93: Ophthalmic Medications: Antiglaucom
Page 94 and 95: Ophthalmic Medications: OtherOphtha
Page 96 and 97: Respiratory Medications: Other Drug
Page 98 and 99: IndexSymbols1ST CHOICE SUPER THINLA
Page 100 and 101: aminophylline 250 mg/10 mlvl ......
Page 102 and 103: BD PEN NEEDLE NANO32GX5/32 ........
Page 104 and 105:
CLINIMIX E 2.75%-10%SOLUTION, -2.75
Page 106 and 107:
disulfiram ................ 29dival
Page 108 and 109:
ESTRACE VAGINALPRODUCTS. ..........
Page 110 and 111:
GAMASTAN S-D. ......... 48GAMMAGARD
Page 112 and 113:
IN CONTROL PEN NEEDLE6MM 31G. .....
Page 114 and 115:
lactulose ................ 78LADY L
Page 116 and 117:
metaproterenol sulfate syrup,-table
Page 118 and 119:
NILANDRON ............ 18nimodipine
Page 120 and 121:
PEGASYS PROCLICK 180MCG/0.5 .......
Page 122 and 123:
PUB INSUL SYR 0.3 ML31GX5/16 ......
Page 124 and 125:
SAPHRIS ............... 21SAVELLA.
Page 126 and 127:
SUSTIVA ................. 8SUTENT .
Page 128 and 129:
ULT CFT 0.3 ML 29GX1/2(1/2) .......
Page 130 and 131:
venlafaxine hcl ............ 28venl
Page 133:
®, SM Registered and Service Marks
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2013 Medicare HMO Blue ValueRx/PlusRx Formulary - Blue Cross ...

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