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

Medical (Miscellaneous) Supplies:Diabetic Supplies (continued)FREESTYLE UNISTIK 2 LANCETS M BGE100 CONTROL SOLUTION M BNORMALGENTLE-LET G.P. LANCETS M BGENTLE-LET GP 26G LANCETS M BGENTLE-LET GP 28G LANCETS M BGENTLE-LET SAFETY LANCETS M BGLUCOCARD 01 CONTROLM BSOLUTIONGLUCOCARD EXPRESSION CNTRL M BSLNGLUCOCARD X-METER CONTROL M BSOLNGLUCOCOM 30G LANCETS M BGLUCOCOM 33G LANCETS M BGLUCOCOM CONTROL SOLUTION M BGLUCOCOM LANCETS 28G M BGLUCOLAB CONTROL SOLN M BNORMALGLUCOLAB CONTROL SOLUTION M BHIGHGLUCOLAB CONTROL SOLUTION M BLOWGLUCOPRO INSUL SYR U100 0.3 ML Tier 3GLUCOPRO INSUL SYR U100 0.5 ML Tier 3GLUCOPRO INSULIN SYR 0.5 ML Tier 3Medical (Miscellaneous) Supplies:Diabetic Supplies (continued)GLUCOPRO INSULIN SYR 1 ML Tier 3GLUCOPRO INSULIN SYR U100 1 Tier 3MLGLUCOPRO SYRINGE U100 1 ML Tier 3GLUCOPRO U100 INSUL SYR 0.3 ML Tier 3GLUCOSE CONTROL SOLNM BNORMALGLUCOSE CONTROL SOLUTION M BGLUCOSOURCE LANCETS M BGNP ALCOHOL PREP SWABS Tier 3GNP ALCOHOL SWAB Tier 3GNP CLICKFINE 31G X 1/4 NDL Tier 3GNP CLICKFINE 31G X 5/16 NDL Tier 3GNP CLICKFINE PEN NDL 31GX1/4 Tier 3GNP CLICKFINE PEN NDL 31GX5/16 Tier 3GNP INSUL SYR 0.3 ML 31GX5/16 Tier 3GNP INSUL SYR 0.5 ML 31GX5/16 Tier 3GNP INSULIN SYR 1 ML 31GX5/16 Tier 3GNP LANCETS M BGNP MICRO THIN 33G LANCETS M BGNP SUPER THIN LANCETS M BGNP THIN LANCETS M BGNP ULTRA COMFORT 0.5 ML SYR Tier 3GNP ULTRA COMFORT 1 ML Tier 3SYRINGE60Q 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.