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

Medical (Miscellaneous) Supplies:Diabetic Supplies (continued)LONGS THIN LANCETS 30G M BMAGELLAN INSUL SYRINGE 0.5 ML Tier 3MAGELLAN INSULIN SYRINGE 1 ML Tier 3MAJOR COMFORT LANCETS M BMAXI-COMFORT INS 0.5 ML 28G Tier 3MAXI-COMFORT INS 1 ML 28GX1/2 Tier 3MAXIMA CONTROL SOLUTION M BMEDI-LANCE LANCETS M BMEDISENSE CONTROL SOLUTION M BMEDISENSE GLUC-KET CONT SOL M BMEDISENSE H-L CONTROLM BSOLUTIONMEDISENSE H-M-L CONTROL SOLN M BMEDISENSE MID CONTROLM BSOLUTIONMEDISENSE THIN LANCETS M BMEDLANCE PLUS 21G LANCETS M BMEDLANCE PLUS 30G LANCETS M BMEDLANCE PLUS EXTRA LANCETS M BMEDLANCE PLUS LITE 25GM BLANCETSMEDLANCE PLUS LITE LANCETS M BMEDLANCE PLUS UNIVERSAL M BLANCETMEDPOINT CONTROL SOLUTION M BMedical (Miscellaneous) Supplies:Diabetic Supplies (continued)MEIJER LANCETS M BMEIJER THIN GAUGE LANCETS M BMICRO THIN 33G LANCETS M BMICRODOT HIGH-LOW CONTROL M BSOLMICRODOT NORMAL CONTROL M BSOLUTMICROLET LANCETS M BMICROTAINER SAFETY LANCET M BMINI ULTRA-THIN II PEN NDL 31G Tier 3MONOJECT 0.3 ML INSULIN SYR Tier 3MONOJECT 0.5 ML INSULIN SYR Tier 3MONOJECT 0.5 ML SYRN 28GX1/2 Tier 3MONOJECT 0.5 ML SYRN 29GX1/2 Tier 3MONOJECT 1 ML INSULIN SYRINGE Tier 3MONOJECT 1 ML SYRN 25X5/8 Tier 3MONOJECT 1 ML SYRN 27X1/2 Tier 3MONOJECT 1 ML SYRN 28GX1/2 Tier 3MONOJECT BLOOD LANCET STERL M BMONOJECT INSUL SYR U100 Tier 3MONOJECT INSUL SYR U100 0.5 ML Tier 3MONOJECT INSUL SYR U100 1 ML Tier 3MONOJECT INSULIN SYR 0.3 ML Tier 3MONOJECT INSULIN SYR 0.5 ML Tier 3MONOJECT INSULIN SYR 1 ML Tier 364Q 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.