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

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