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

Medical (Miscellaneous) Supplies:Diabetic Supplies (continued)GNP ULTRA COMFORT 3/10 ML SYR Tier 3H&H THINLET LANCETS M BHAEMOLANCE LANCET M BHAEMOLANCE PLUS LANCET M BHAEMOLANCE PLUS LANCETS M BHAEMOLANCE, RETRACTABLE M BHEALTHY ACCENTS PENTIP 5MM Tier 331GHEALTHY ACCENTS PENTIP 6MM Tier 331GHEALTHY ACCENTS PENTIP 8MM Tier 331GHEALTHY ACCENTS PENTP 12MM Tier 329GHEALTHY ACCENTS UNILET 30G M BHM MICRO THIN 33G LANCETS M BHM ULTRA THIN 30G LANCETS M BHUMAPEN LUXURA HD Tier 3HUMAPEN MEMOIR Tier 3HYPODERMIC NEEDLE,ALUM HUB Tier 3HY-VEE LANCETS M BHY-VEE THIN LANCET M BIN CONTROL PEN NEEDLE 12MM Tier 329GIN CONTROL PEN NEEDLE 6MM 31G Tier 3IN CONTROL PEN NEEDLE 8MM 31G Tier 3Medical (Miscellaneous) Supplies:Diabetic Supplies (continued)INCONTROL PEN NDL 31GX3/16 Tier 3INCONTROL PEN NEEDLES 4MM Tier 332GINCONTROL SUPER THIN LANCETS M BINCONTROL ULTRA THIN LANCETS M BINFINITY CONTROL SOLN HIGH M BINFINITY CONTROL SOLN LOW M BINFINITY CONTROL SOLN NORMAL M BINJECT EASE 28G LANCETS M BINJECT EASE 30G LANCETS M BINJECT-EASE SYR NDL INTRODUCER Tier 3INJEX 30 AMPULE Tier 3INSULIN 1 ML SYRINGE Tier 3INSULIN 1/2 ML SYRINGE Tier 3INSULIN 3/10 ML SYRINGE Tier 3INSULIN SYR 1/2 ML BULK PACK Tier 3INSULIN SYRIN 0.3 ML 29GX1/2 Tier 3INSULIN SYRIN 0.3 ML 30GX1/2 Tier 3INSULIN SYRIN 0.3 ML 30GX5/16 Tier 3INSULIN SYRIN 0.3 ML 31GX5/16 Tier 3INSULIN SYRIN 0.5 ML 28GX1/2 Tier 3INSULIN SYRIN 0.5 ML 29GX1/2 Tier 3INSULIN SYRIN 0.5 ML 30GX1/2 Tier 3INSULIN SYRIN 0.5 ML 30GX5/16 Tier 3INSULIN SYRIN 0.5 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. 61