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

Medical (Miscellaneous) Supplies:Diabetic Supplies (continued)ASSURE II CONTROL SOLUTION M BASSURE LANCE 25G LANCETS M BASSURE LANCE MICRO FLOW M BLANCETASSURE PRO CONTROL SOLUTION M BASSURE ULTRA THIN LANCETS M BAT-LAST LANCETS M BAURORA HEALTHCARE LANCETS M BAURORA PEN NEEDLE 6MM 31G Tier 3AURORA PEN NEEDLES 12MM 29G Tier 3AURORA PEN NEEDLES 8MM 31G Tier 3AURORA SUPER THIN LANCET M BAURORA THIN LANCETS M BAUTODISC NORMAL CONTROL M BSOLNAUTOJECT 2 INJECTION DEVICE Tier 3AUTOPEN 1 TO 16 UNITS Tier 3AUTOPEN 1 TO 21 UNITS Tier 3AUTOPEN 2 TO 32 UNITS Tier 3AUTOPEN 2 TO 42 UNITS Tier 3BD 10 ML SYRINGE WITH NEEDLE Tier 3BD AUTO INJECTOR Tier 3BD ECLIPSE 30GX1/2 SYRINGE Tier 3BD INSUL SYR 0.3 ML 31GX15/64 Tier 3BD INSUL SYR 0.5 ML 31GX15/64 Tier 3Medical (Miscellaneous) Supplies:Diabetic Supplies (continued)BD INSULIN SYR 0.3 ML 28GX1/2 Tier 3BD INSULIN SYR 0.3 ML 29GX1/2 Tier 3BD INSULIN SYR 0.3 ML 30GX1/2 Tier 3BD INSULIN SYR 0.3ML 31GX5/16 Tier 3BD INSULIN SYR 0.5 ML 28GX1/2 Tier 3BD INSULIN SYR 0.5 ML 29GX1/2 Tier 3BD INSULIN SYR 0.5 ML 30GX1/2 Tier 3BD INSULIN SYR 0.5ML 31GX5/16 Tier 3BD INSULIN SYR 1 ML 25GX1 Tier 3BD INSULIN SYR 1 ML 25GX5/8 Tier 3BD INSULIN SYR 1 ML 26GX1/2 Tier 3BD INSULIN SYR 1 ML 27GX5/8 Tier 3BD INSULIN SYR 1 ML 28GX1/2 Tier 3BD INSULIN SYR 1 ML 29GX1/2 Tier 3BD INSULIN SYR 1 ML 30GX1/2 Tier 3BD INSULIN SYR 1 ML 31GX15/64 Tier 3BD INSULIN SYR 1 ML 31GX5/16 Tier 3BD INSULIN SYRINGE 1 ML Tier 3B-D INSULIN U100 2 ML SYRNGE Tier 3BD INSULIN U100-1 ML SYRNGE Tier 3B-D INSULIN U100-2 ML SYRNGE Tier 3BD INSULIN U100-3/10 ML SYR Tier 3B-D INSULIN U100-3/10 ML SYR Tier 3BD INTEGRA SYR 1 ML 29GX1/2 Tier 3BD INTEGRA SYRINGE 1 ML 25GX1 Tier 354Q 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.