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

Medical (Miscellaneous) Supplies:Diabetic Supplies (continued)KROGER SYRING 0.3 ML 31GX5/16 Tier 3KROGER SYRING 0.5 ML 31GX5/16 Tier 3KROGER THIN LANCETS M BLADY LITE LANCETS M BLANCETS M BLANCETS 26G X 1.8MM M BLANCETS 28G M BLANCETS 30G M BLANCETS THIN M BLANCETS ULTRA THIN M BLEADER COLORED LANCETS M BLEADER INS SYR 0.3 ML 29GX1/2 Tier 3LEADER INS SYR 0.5 ML 28GX1/2 Tier 3LEADER INS SYR 0.5 ML 29GX1/2 Tier 3LEADER INS SYR 0.5 ML 30GX1/2 Tier 3LEADER INS SYR 1 ML 28GX1/2 Tier 3LEADER INS SYR 1 ML 29GX1/2 Tier 3LEADER INS SYR 1 ML 30GX1/2 Tier 3LEADER INS SYR 1 ML 30GX5/16 Tier 3LEADER INS SYR 1 ML 31GX5/16 Tier 3LEADER INSULIN SYRINGE 0.3 ML Tier 3LEADER PEN NEEDLE 6MM 31G Tier 3LEADER PEN NEEDLES 12MM 29G Tier 3LEADER PEN NEEDLES 31G Tier 3LEADER SUPER THIN LANCETS M BMedical (Miscellaneous) Supplies:Diabetic Supplies (continued)LEADER SYRING 0.3 ML 31GX5/16 Tier 3LEADER SYRING 0.5 ML 31GX5/16 Tier 3LEADER THIN LANCETS M BLIBERTY CONTROL SOLN NORMAL M BLIBERTY CONTROL SOLUTION HIGH M BLIBERTY LEV 1 GLUCOSE CTRL SOL M BLIBERTY LEV 2 GLUCOSE CTRL SOL M BLIFESCAN FINE POINT LANCETS M BLIFESCAN UNISTIK 2 LANCETS M BLITE TOUCH 30G LANCETS M BLITE TOUCH INSULIN 0.3 ML SYR Tier 3LITE TOUCH INSULIN 0.5 ML SYR Tier 3LITE TOUCH INSULIN 1 ML SYR Tier 3LITE TOUCH INSULIN SYR 0.3 ML Tier 3LITE TOUCH INSULIN SYR 0.5 ML Tier 3LITE TOUCH INSULIN SYR 1 ML Tier 3LITE TOUCH PEN NEEDLE 29G Tier 3LITE TOUCH PEN NEEDLE 31G Tier 3LIVE BETTER PEN NEEDLE 6MM 31G Tier 3LIVE BETTER PEN NEEDLES 12MM Tier 3LIVE BETTER PEN NEEDLES 8MM Tier 3LIVE BETTER SUPER THIN LANCET M BLIVE BETTER ULTRA THIN LANCET M BLONGS LANCETS 21G M BLONGS THIN LANCETS 26G M BQ 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. 63