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

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