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

Medical (Miscellaneous) Supplies:Diabetic Supplies (continued)INSULIN SYRIN 1 ML 29GX1/2 Tier 3INSULIN SYRINGE 0.3 ML Tier 3INSULIN SYRINGE 0.5 ML Tier 3INSULIN SYRINGE 1 ML Tier 3INSULIN SYRINGE 1 ML 28GX1/2 Tier 3INSULIN SYRINGE 1 ML 29GX1/2 Tier 3INSULIN SYRINGE 1 ML 30GX1/2 Tier 3INSULIN SYRINGE 1 ML 30GX5/16 Tier 3INSULIN SYRINGE 1 ML 31GX5/16 Tier 3INSULIN SYRINGE 1 ML-HARD PK Tier 3INSULIN SYRINGE 30GX1 ML SYR Tier 3INSULIN SYRINGE U100 0.5 ML Tier 3INSULIN SYRINGE U100 1 ML Tier 3INSULIN SYRINGE U100 1ML Tier 3INSULIN U100-1 ML SYRINGE Tier 3INSUMED SYR 0.3 ML 31GX5/16 Tier 3INSUPEN 29G ULTRAFIN NEEDLE Tier 3INSUPEN 30G ULTRAFIN NEEDLE Tier 3INSUPEN 31G ULTRAFIN NEEDLE Tier 3INSUPEN 32G 4MM PEN NEEDLE Tier 3INSUPEN 32G 6MM PEN NEEDLE Tier 3INSUPEN 32G 8MM PEN NEEDLE Tier 3INVACARE 30G LANCETS M BKEEP FIT SAFETY 21G LANCETS M BKEEP FIT SAFETY 23G LANCETS M BMedical (Miscellaneous) Supplies:Diabetic Supplies (continued)KEEP FIT SAFETY 26G LANCETS M BKEEP FIT SAFETY LANCETS 28G M BKEEP FIT TWIST 30G LANCETS M BKEEP FIT TWIST 32G LANCETS M BKEEP FIT TWIST 33G LANCETS M BKEEP FIT TWIST LANCETS 28G M BKINNEY BRAND 23G LANCETS M BKINRAY INS SYR 1 ML 31GX5/16 Tier 3KINRAY SYRING 0.3 ML 31GX5/16 Tier 3KINRAY SYRING 0.5 ML 31GX5/16 Tier 3KMART VALU PLUS SYR 1/2 ML Tier 3KMART VALU PLUS SYR 3/10 ML Tier 3KMART VALU PLUS SYRINGE 1 ML Tier 3KN THIN LANCETS M BKROGER INS SYR 0.3 ML 30GX5/16 Tier 3KROGER INS SYR 0.5 ML 29GX1/2 Tier 3KROGER INS SYR 1 ML 29GX1/2 Tier 3KROGER INS SYR 1 ML 31GX5/16 Tier 3KROGER INS SYRINGE 3/10 ML Tier 3KROGER INSULIN SYRINGE 1 ML Tier 3KROGER LANCETS M BKROGER PEN NEEDLES 29G Tier 3KROGER PEN NEEDLES 31G X 5/16 Tier 3KROGER SUPER THIN LANCETS M BKROGER SYR 0.5 ML 30GX5/16 Tier 362Q 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.