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

Medical (Miscellaneous) Supplies:Diabetic Supplies (continued)MONOJECT INSULIN SYR U-100 Tier 3MONOJECT INSULIN SYRN 3/10 ML Tier 3MONOJECT SAFETY SYRINGE Tier 3MONOJECT SYRINGE 0.3 ML Tier 3MONOJECT SYRINGE 0.5 ML Tier 3MONOJECT SYRINGE 1 ML Tier 3MONOLET LANCETS M BMS INS SYR 0.5 ML 29GX1/2 Tier 3MS INS SYR 1 ML 29GX1/2 Tier 3MS INS SYRINGE 1 ML 30GX1/2 Tier 3MS INSUL SYR 0.3 ML 31GX5/16 Tier 3MS INSUL SYR 0.5 ML 30GX1/2 Tier 3MS INSUL SYR 0.5 ML 31GX5/16 Tier 3MS INSULIN SYR 0.3 ML 29GX1/2 Tier 3MS INSULIN SYR 1 ML 31GX5/16 Tier 3MS INSULIN SYRINGE 0.3 ML Tier 3MS LANCETS M BMS PEN NEEDLE 6MM 31G Tier 3MS SUPER THIN LANCETS M BMS THIN LANCETS M BMYGLUCOHEALTH 30G LANCETS M BNEXGEN NORMAL CONTROL M BSOLUTIONNORDIPEN 15 DELIVERY SYSTEM Tier 3NORDIPEN 5 DELIVERY SYSTEM Tier 3Medical (Miscellaneous) Supplies:Diabetic Supplies (continued)NORM-JECT 1 ML SYRINGE Tier 3NOVA MAX GLUCOSE CONTROL M BSOLNNOVA SAFETY 23G LANCETS M BNOVA SAFETY LANCETS 28G M BNOVA SUREFLEX LANCETS M BNOVA SUREFLEX THIN LANCETS M BNOVAMAX PLUS GLU-KET CTRL M BSOLNNOVOFINE 30 NEEDLES Tier 3NOVOFINE 30G X 1/3 NEEDLES Tier 3NOVOFINE 32G NEEDLES Tier 3NOVOFINE AUTOCOVER 30G Tier 3NEEDLENOVOPEN 3 INSULIN DEVICE Tier 3NOVOPEN 3 PENMATE DEVICE Tier 3NOVOPEN JR INSULIN DEVICE Tier 3NOVOTWIST NEEDLE 30G 8MM Tier 3NOVOTWIST NEEDLE 32G 5MM Tier 3ON CALL 30G LANCET M BON CALL PLUS 30G LANCET M BON CALL PLUS CONTROLM BSOLUTIONON CALL VIVID CONTROL SOLUTION M BONE TOUCH BASIC SYSTEM KIT M B Q C D (1/365)Q 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. 65