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

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Medical (Miscellaneous) Supplies:Diabetic Supplies (continued)ONE TOUCH CLUB LANCETS M BONE TOUCH COMBO PACK M BONE TOUCH DELICA 30G LANCETS M BONE TOUCH DELICA 33G LANCETS M BONE TOUCH PROFILE SYSTEM KT M B Q C D (1/365)ONE TOUCH SURESOFT LANCING M BDEVONE TOUCH TEST STRIPS M B Q C D (300/30)ONE TOUCH ULTRA 2 GLUCOSE M B Q C D (1/365)SYSTONE TOUCH ULTRA CONTROL M BSOLNONE TOUCH ULTRA SMART METER M B Q C D (1/365)ONE TOUCH ULTRA SYSTEM KIT M B Q C D (1/365)ONE TOUCH ULTRA TEST STRIPS M B Q C D (300/30)ONE TOUCH ULTRALINK SYSTEM M B Q C D (1/365)ONE TOUCH ULTRAMINI METER M B Q C D (1/365)ONE TOUCH ULTRASOFT LANCETS M BONE TOUCH VERIO HIGH CNTRL M BSOLONE TOUCH VERIO IQ METER M B Q C D (1/365)ONE TOUCH VERIO MID CNTRL M BSOLNONE TOUCH VERIO TEST STRIP M B Q C D (300/30)ORSINI INSUL SYR U100 0.5 ML Tier 3ORSINI INSUL SYR U100 1 ML Tier 3Medical (Miscellaneous) Supplies:Diabetic Supplies (continued)PC SUPER THIN 30G LANCETS M BPC UNIFINE PENTIPS 12MM NEEDLE Tier 3PC UNIFINE PENTIPS 31GX3/16 Tier 3PC UNIFINE PENTIPS 6MM NEEDLE Tier 3PC UNIFINE PENTIPS 8MM NEEDLE Tier 3PEN NEEDLE 30G X 5/16 Tier 3PEN NEEDLE 31G X 3/16 Tier 3PEN NEEDLE 31G X 5/16 Tier 3PEN NEEDLE 6MM 31G Tier 3PEN NEEDLES 12MM 29G Tier 3PEN NEEDLES 29G Tier 3PEN NEEDLES 31G Tier 3PEN NEEDLES 5MM 31G Tier 3PEN NEEDLES 6MM 31G Tier 3PEN NEEDLES 8MM 31G Tier 3PHARM CHOICE ALCOHOL PREP Tier 3PADSPHARMACIST CHOICE 28GM BLANCETSPHARMACIST CHOICE 30GM BLANCETSPLASTIC INSULIN CARTRIDGE Tier 3POCKETCHEM EZ CONTROL M BSOLUTIONPRECISION CONTROL SOLUTION M B66Q 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.
Medical (Miscellaneous) Supplies:Diabetic Supplies (continued)PRECISION SURE DOSE SYRINGE Tier 3PRECISION THINS 28G LANCETS M BPRECISION THINS GP LANCETS M BPRECISION ULTRA 28G LANCETS M BPREF PLUS SYR 0.5 ML 30GX5/16 Tier 3PREF PLUS SYRING 1 ML 29GX1/2 Tier 3PREFERRED PLUS 0.3 ML 30GX5/16 Tier 3PREFERRED PLUS 0.5 ML 29GX1/2 Tier 3PREFERRED PLUS COLORED M BLANCETSPREFERRED PLUS LANCETS M BPREFERRED PLUS SYRINGE 0.3 ML Tier 3PREFERRED PLUS SYRINGE 0.5 ML Tier 3PREFERRED PLUS SYRINGE 1 ML Tier 3PREFERRED PLUS THIN LANCETS M BPREFPLS INS SYR 1 ML 30GX5/16 Tier 3PREP EASE ALCOHOL PADS Tier 3PRESSURE ACTIVATED 21GM BLANCETSPRESSURE ACTIVATED 28GM BLANCETSPRESTIGE GLUCOSE CONTROL M BPRODIGY CONTROL SOLUTION M BPRODIGY CONTROL SOLUTION M BLOWMedical (Miscellaneous) Supplies:Diabetic Supplies (continued)PRODIGY INS SYR 1ML 28GX1/2 Tier 3PRODIGY MINI PEN NDL 31GX3/16 Tier 3PRODIGY PEN NEEDLE 29GX1/2 Tier 3PRODIGY PEN NEEDLE 31GX5/16 Tier 3PRODIGY PRESSURE ACTIVATED M B28GPRODIGY PRESSURE ACTIVE M BLANCETPRODIGY SAFETY LANCETS M BPRODIGY SYRNG 0.5 ML 31GX5/16 Tier 3PRODIGY SYRNG 1 ML 29GX1/2 Tier 3PRODIGY SYRNGE 0.3ML 31GX5/16 Tier 3PRODIGY TWIST TOP 28G LANCET M BPSS SELECT GP LANCETS M BPSS SELECT SAFETY LANCETS M BPUB INS SYRIN 0.3 ML 30GX1/2 Tier 3PUB INS SYRINGE 1 ML 30GX1/2 Tier 3PUB INSUL SYR 0.3 ML 31GX5/16 Tier 3PUB INSUL SYR 0.5 ML 30GX1/2 Tier 3PUB INSUL SYR 0.5 ML 31GX5/16 Tier 3PUB INSULIN SYR 1 ML 31GX5/16 Tier 3PUB LANCETS M BPUB PEN 12MM 29G NEEDLES Tier 3PUB PEN 8MM 31G NEEDLES Tier 3PUB PEN NEEDLE 6MM 31G 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. 67
Page 1:
Medicare HMO Blue SM ValueRx (HMO)M
Page 4 and 5:
How do I use the Formulary?There ar
Page 6 and 7:
What do I do before I can talk to m
Page 8 and 9:
Your Medicare Prescription Drug Cos
Page 10 and 11:
Antiinfectives: Antiretrovirals and
Page 12 and 13:
Antiinfectives: Oral Antifungal Dru
Page 14 and 15:
Antiinfectives: Other Antiviral Dru
Page 16 and 17:
Antiinfectives: Sulfonamideserythro
Page 18 and 19: Antineoplastic/Immunosuppressant Dr
Page 20 and 21: Antineoplastic/Immunosuppressant Dr
Page 22 and 23: Autonomic and CNS Medications: Anal
Page 24: Autonomic and CNS Medications:Antiv
Page 28 and 29: Autonomic and CNS Medications: CNSS
Page 30 and 31: Autonomic and CNS Medications:Other
Page 32 and 33: Autonomic and CNS Medications: Sele
Page 34 and 35: Cardiovascular Medications: Beta-Ad
Page 36 and 37: Cardiovascular Medications: Loop Di
Page 38 and 39: Cardiovascular Medications: OtherVa
Page 40 and 41: Dermatological Medications: OralDer
Page 42 and 43: Dermatological Medications: Topical
Page 44 and 45: Endocrine Medications: Glucocortico
Page 46 and 47: Endocrine Medications: Oral Hypogly
Page 48 and 49: Gastrointestinal Medications: Antis
Page 50 and 51: Immunologicals and VaccinesACTHIB T
Page 52 and 53: Immunologicals and Vaccines: Interf
Page 54 and 55: Medical (Miscellaneous) Supplies:Di
Page 80 and 81: Musculoskeletal Medications: Non-St
Page 82 and 83: Nutrition, Blood Modifiers, Electro
Page 84 and 85: Nutrition, Blood Modifiers, Electro
Page 86 and 87: Obstetrical and Gynecological Medic
Page 88 and 89: Obstetrical and GynecologicalMedica
Page 90 and 91: Obstetrical and Gynecological Medic
Page 92 and 93: Ophthalmic Medications: Antiglaucom
Page 94 and 95: Ophthalmic Medications: OtherOphtha
Page 96 and 97: Respiratory Medications: Other Drug
Page 98 and 99: IndexSymbols1ST CHOICE SUPER THINLA
Page 100 and 101: aminophylline 250 mg/10 mlvl ......
Page 102 and 103: BD PEN NEEDLE NANO32GX5/32 ........
Page 104 and 105: CLINIMIX E 2.75%-10%SOLUTION, -2.75
Page 106 and 107: disulfiram ................ 29dival
Page 108 and 109: ESTRACE VAGINALPRODUCTS. ..........
Page 110 and 111: GAMASTAN S-D. ......... 48GAMMAGARD
Page 112 and 113: IN CONTROL PEN NEEDLE6MM 31G. .....
Page 114 and 115: lactulose ................ 78LADY L
Page 116 and 117: metaproterenol sulfate syrup,-table
Page 118 and 119:
NILANDRON ............ 18nimodipine
Page 120 and 121:
PEGASYS PROCLICK 180MCG/0.5 .......
Page 122 and 123:
PUB INSUL SYR 0.3 ML31GX5/16 ......
Page 124 and 125:
SAPHRIS ............... 21SAVELLA.
Page 126 and 127:
SUSTIVA ................. 8SUTENT .
Page 128 and 129:
ULT CFT 0.3 ML 29GX1/2(1/2) .......
Page 130 and 131:
venlafaxine hcl ............ 28venl
Page 133:
®, SM Registered and Service Marks
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