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

Medical (Miscellaneous) Supplies:Diabetic Supplies (continued)CLEVER CHEK 30G LANCETS M BCLEVER CHEK CONTROL SOLUTION M BCLEVER CHEK ULTRA THINM BLANCETSCLICKFINE 31G X 1/4 NEEDLES Tier 3CLICKFINE 31G X 5/16 NEEDLES Tier 3CLICKFINE UNIVERSAL 31G X 1/4 Tier 3CLICKFINE UNIVERSAL 31GX5/16 Tier 3CLOSERCARE LANCETS M BCOAGUCHEK LANCETS M BCOMFORT EZ INS 0.3ML 30GX1/2 Tier 3COMFORT EZ INS 0.3ML 30GX5/16 Tier 3COMFORT EZ INSULIN SYR 0.3 ML Tier 3COMFORT EZ INSULIN SYR 0.5 ML Tier 3COMFORT EZ PEN NEEDLES 5MM Tier 331GCOMFORT EZ PEN NEEDLES 6MM Tier 331GCOMFORT EZ PEN NEEDLES 8MM Tier 331GCOMFORT EZ SYR 0.3 ML 29GX1/2 Tier 3COMFORT EZ SYR 0.5 ML 28GX1/2 Tier 3COMFORT EZ SYR 0.5 ML 29GX1/2 Tier 3COMFORT EZ SYR 0.5 ML 30GX1/2 Tier 3COMFORT EZ SYR 1 ML 28GX1/2 Tier 3Medical (Miscellaneous) Supplies:Diabetic Supplies (continued)COMFORT EZ SYR 1 ML 29GX1/2 Tier 3COMFORT EZ SYR 1 ML 30GX1/2 Tier 3COMFORT EZ SYR 1 ML 30GX5/16 Tier 3COMFORT EZ SYR 1 ML 31GX5/16 Tier 3COMFORT LANCETS M BCONTOUR NEXT LEV 1 CONTROL M BSOLCONTOUR NEXT LEV 2 CONTROL M BSOLCONTOUR SOLUTION M BCONTROL SOLUTION NORMAL M BCORNWALL METAL PIPET HOLDER Tier 3CURITY ALCOHOL PREPS Tier 3CURITY ALCOHOL SWABS Tier 3CVS ALCOHOL 70% PREP SWABS Tier 3CVS ALCOHOL SWABS Tier 3CVS INSULIN SYR 1 ML 29GX1/2 Tier 3CVS ISOPROPYL ALCOHOL 70% Tier 3WIPECVS LANCETS M BCVS LANCETS-ORIGINAL M BCVS LANCETS-THIN M BCVS LANCING DEVICE M BCVS MICRO THIN 33G LANCETS M BCVS SYRINGE 1/2 ML Tier 356Q 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.