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

Medical (Miscellaneous) Supplies:Diabetic Supplies (continued)CVS SYRINGE 3/10 ML Tier 3CVS THIN LANCETS M BCVS ULTRA THIN LANCETS M BDR LANCET M BDR SUPER THIN 30G LANCETS M BDR ULTRA THIN LANCET M BDR UNIFINE PENTIPS 12MM NDL Tier 3DR UNIFINE PENTIPS 6MM NDL Tier 3DR UNIFINE PENTIPS 8MM NDL Tier 3DROPLET 30G LANCETS M BDRUG MART THIN LANCETS M BDRUG MART ULTRA COMFORT SYR Tier 3DRUG MART ULTRA THIN LANCETS M BDUO-CARE CONTROL SOLUTION M BEASY CHECK CONTROL SOLN HIGH M BEASY CHECK CONTROL SOLN LOW M BEASY COMFORT 0.3 ML SYRINGE Tier 3EASY COMFORT 0.5 ML SYRINGE Tier 3EASY COMFORT 30G LANCETS M BEASY COMFORT INSULIN 1 ML SYR Tier 3EASY TALK CONTROL SOLN LOW M BEASY TALK HIGH CONTROL SOLN M BEASY TEST II LANCETS M BEASY TEST LANCETS M BEASY TOUCH 0.3 ML SYR 30GX1/2 Tier 3Medical (Miscellaneous) Supplies:Diabetic Supplies (continued)EASY TOUCH 0.5 ML SYR 27GX1/2 Tier 3EASY TOUCH 0.5 ML SYR 30GX1/2 Tier 3EASY TOUCH 1 ML SYR 27GX1/2 Tier 3EASY TOUCH 1 ML SYR 30GX1/2 Tier 3EASY TOUCH ALCOHOL 70% PADS Tier 3EASY TOUCH CONTROL SOLUTION M BEASY TOUCH INSULIN SYR 0.3 ML Tier 3EASY TOUCH INSULIN SYR 0.5 ML Tier 3EASY TOUCH INSULIN SYR 1 ML Tier 3EASY TOUCH LANCETS M BEASY TOUCH PEN NDL 32GX1/4 Tier 3EASY TOUCH PEN NDL 32GX3/16 Tier 3EASY TOUCH PEN NEEDLE 29G Tier 3EASY TOUCH PEN NEEDLE 31G Tier 3EASY TOUCH PEN NEEDLETier 331GX3/16EASY TRAK CONTROL SOLN HIGH M BEASY TRAK CONTROL SOLNM BNORMALEASYMAX HIGH CONTROL SOLN M BEASYMAX LOW CONTROL SOLN M BEASYMAX NORMAL CONTROL SOLN M BEASY-TOUCH INS 1 ML 31GX5/16 Tier 3ECLIPSE CONTROL SOLN NORMAL 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. 57