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

Medical (Miscellaneous) Supplies:Diabetic Supplies (continued)ECLIPSE CONTROL SOLUTION M BHIGHECLIPSE CONTROL SOLUTION LOW M BELEMENT CONTROL SOLN NORMAL M BELEMENT CONTROL SOLUTION M BHIGHELEMENT CONTROL SOLUTION M BLOWELEMENT PLUS CONTROLM BSOLUTIONELITE-THIN INS SYR 0.5CC Tier 3ELITE-THIN INSUL SYR 0.3CC Tier 3ELITE-THIN INSUL SYR 0.5CC Tier 3ELITE-THIN INSUL SYR 1/2CC Tier 3ELITE-THIN INSUL SYR 1CC Tier 3ELITE-THIN INSULIN SYR 1CC Tier 3EMBRACE GLUC CONTROL SOLN M BLOWENVISION CONTROL SOLN HIGH M BENVISION CONTROL SOLN LOW M BENVISION CONTROL SOLN NORMAL M BEQL COLOR LANCETS M BEQL INS SYR 0.3 ML 29GX1/2 Tier 3EQL INS SYR 0.3 ML 30GX5/16 Tier 3EQL INS SYR 0.5 ML 29GX1/2 Tier 3EQL INS SYR 0.5 ML 30GX5/16 Tier 3Medical (Miscellaneous) Supplies:Diabetic Supplies (continued)EQL INS SYR 1 ML 29GX1/2 Tier 3EQL INSUL SYR 0.3 ML 31GX5/16 Tier 3EQL INSUL SYR 0.5 ML 31GX5/16 Tier 3EQL INSULIN 0.3 ML SYRINGE Tier 3EQL INSULIN 0.5 ML SYRINGE Tier 3EQL INSULIN 1 ML SYRINGE Tier 3EQL INSULIN SYR 1 ML 29GX1/2 Tier 3EQL INSULIN SYR 1 ML 30GX5/16 Tier 3EQL INSULIN SYR 1 ML 31GX5/16 Tier 3EQL LANCETS THIN M BEQL PEN 8MM 31G X 5/16 NEEDLE Tier 3EQL PEN NEEDLE 6MM 31G Tier 3EQL SUPER THIN LANCETS M BEVENCARE CONTROL SOLUTION M BEVENCARE G2 CONTROLM BSOLUTIONEVENCARE G3 CONTROLM BSOLUTIONEVOLUTION CONTROL SOLN M BNORMALEXEL HYPO NEEDLE 26GX0.5 Tier 3EXEL HYPO NEEDLE 26GX1.5 Tier 3EXEL HYPO NEEDLE 27GX0.5 Tier 3EXEL INS SYR U100 1 ML 28GX1/2 Tier 3EXEL INSUL PEN NEEDLES 8MM Tier 358Q 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.