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

Medical (Miscellaneous) Supplies:Diabetic Supplies (continued)BD LANCETS 30G M BBD LANCETS 33G M BBD LANCETS MICROTAINER M BBD LANCETS MICROTAINER 21G M BBD LANCETS MICROTAINER 30G M BBD LUER-LOK SYRINGE 1 ML Tier 3BD LUER-LOK SYRINGE 1ML 20GX1 Tier 3BD NEEDLES 26GX0.5 Tier 3BD NEEDLES 27GX0.5 Tier 3BD PEN INSULIN DEVICE Tier 3BD PEN MINI INSULIN DEVICE Tier 3BD PEN NEEDLE 29GX1/2 Tier 3BD PEN NEEDLE 29GX3/16 Tier 3BD PEN NEEDLE 29GX5/16 Tier 3BD PEN NEEDLE 30GX3/16 Tier 3BD PEN NEEDLE MINI 31GX3/16 Tier 3BD PEN NEEDLE NANO 32GX5/32 Tier 3BD PEN NEEDLE ORIG 29GX1/2 Tier 3BD PEN NEEDLE SHORT 31GX5/16 Tier 3BD SAFETYGLIDE SYRINGE 27GX5/8 Tier 3BD SAFTGLD INS 0.3 ML 31GX5/16 Tier 3BD SAFTGLD INS SYR 0.3 ML 29G Tier 3BD SAFTGLD INS SYR 0.5 ML 30G Tier 3BD SINGLE USE ALCOHOL SWAB Tier 3BD SINGLE USE SWAB Tier 3Medical (Miscellaneous) Supplies:Diabetic Supplies (continued)BD SYR 0.3 ML 31GX15/64 (1/2) Tier 3BD SYR 0.3 ML 31GX5/16 (1/2) Tier 3BD ULTRA FINE LANCETS M BBL ALCOHOL PREP SWABS Tier 3BL INSULIN 0.3 ML SYRINGE Tier 3BL INSULIN 0.5 ML SYRINGE Tier 3BL INSULIN 1 ML SYRINGE Tier 3BL LANCETS M BBLOOD GLUCOSE CONTROL M BSOLUTIONBREEZE 2 SOLUTION M BBULLSEYE MINI SAFETY 21G M BBULLSEYE MINI SAFETY 28G LANCT M BBULLSEYE MINI SAFETY LANCETS M BCAREONE INS SYR 1 ML 30GX5/16 Tier 3CAREONE THIN LANCET M BCAREONE ULTRA THIN LANCET M BCAREONE UNIFINE PENTIP 5MM Tier 331GCAREONE UNIFINE PENTIP 6MM Tier 331GCAREONE UNIFINE PENTIP 8MM Tier 331GCAREONE UNIFINE PNTP 12MM 29G Tier 3CARESENS CONTROL SOLUTION M 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. 55