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

Medical (Miscellaneous) Supplies:Diabetic Supplies (continued)EXEL INSUL SYR 0.5 ML 28GX1/2 Tier 3EXEL INSULIN PEN NEEDLE Tier 3EXEL INSULIN SYRINGE 27G-1 ML Tier 3EXEL INSULIN SYRN 27G-1/2 ML Tier 3EXEL U100 0.3 ML 29GX1/2 Tier 3EXEL U100 0.3 ML 30GX5/16 Tier 3EXEL U100 0.5 ML 28GX1/2 Tier 3EXEL U100 0.5 ML 29GX1/2 Tier 3EXEL U100 0.5 ML 30GX5/16 Tier 3EXEL U100 1 ML 30GX5/16 Tier 3EXEL U100 INS SYR 1 ML 29GX1/2 Tier 3E-Z JECT COLORED LANCETS M BE-Z JECT LANCETS M BE-Z JECT SUPER THIN LANCETS M BEZ SMART BLOOD GLUCOSE M BLANCETSEZ SMART HIGH CONTROLM BSOLUTIONEZ SMART LOW CONTROLM BSOLUTIONEZ SMART NORMAL CONTROL M BSOLNE-ZJECT COLOR 32G LANCETS M BE-ZJECT COLOR 33G LANCETS M BE-ZJECT THIN LANCETS M BMedical (Miscellaneous) Supplies:Diabetic Supplies (continued)EZ-LETS LANCETS 23G M BFAST TAKE MONITORING SYSTEM M B Q C D (1/365)FAST TAKE TEST STRIPS M B Q C D (300/30)FIFTY50 ALCOHOL PREP PADS Tier 3FIFTY50 GLUCOSE CONTROL SOLN M BFIFTY50 INS SYR 1 ML 31GX5/16 Tier 3FIFTY50 INSULIN SYRINGE 0.3 ML Tier 3FIFTY50 INSULIN SYRINGE 0.5 ML Tier 3FIFTY50 PEN 31G X 3/16 NEEDLE Tier 3FIFTY50 PEN 31G X 5/16 NEEDLE Tier 3FIFTY50 SAFETY SEAL 30G LANCET M BFIFTY50 SAFETY SEAL 32G LANCET M BFINE 30 UNIVERSAL 30G LANCETS M BFINGERSTIX LANCETS M BFORA HIGH CONTROL SOLUTION M BFORA LANCETS M BFORA LOW CONTROL SOLUTION M BFORA NORMAL CONTROLM BSOLUTIONFREESTYLE CONTROL SOLUTION M BFREESTYLE LANCETS M BFREESTYLE PREC 0.5 ML 30GX5/16 Tier 3FREESTYLE PREC 0.5 ML 31GX5/16 Tier 3FREESTYLE PREC 1 ML 30GX5/16 Tier 3FREESTYLE PREC 1 ML 31GX5/16 Tier 3Q 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. 59