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

Medical (Miscellaneous) Supplies:Diabetic Supplies (continued)PUBLIX 28G LANCET M BPV INS SYRIN 1 ML 29GX1/2 Tier 3PV INSUL SYR 0.3 ML 31GX5/16 Tier 3PV INSUL SYR 0.5 ML 31GX5/16 Tier 3PV INSULIN SYR 1 ML 31GX5/16 Tier 3PV INSULIN SYRINGE 0.5 ML Tier 3PV INSULIN SYRINGE 1 ML Tier 3PV ISOPROPYL ALCOHOL 70% Tier 3WIPESPV PEN NEEDLE 6MM 31G Tier 3PV PEN NEEDLES 12MM 29G Tier 3PV PEN NEEDLES 8MM 31G Tier 3PV ULTRA THIN 30G LANCETS M BPV UNIFINE PENTIPS 31GX3/16 Tier 3PX PEN 8MM 31G NEEDLES Tier 3QC ALCOHOL 70% SWABS Tier 3QC INSUL SYR 0.5 ML 31GX5/16 Tier 3QC INSULIN SYR 1 ML 31GX5/16 Tier 3QC INSULIN SYRINGE 0.3 ML Tier 3QC INSULIN SYRINGE 0.5 ML Tier 3QC INSULIN SYRINGE 1 ML Tier 3QC PEN NEEDLES 12MM 29G Tier 3QC PEN NEEDLES 6MM 31G Tier 3QC PEN NEEDLES 8MM 31G Tier 3QC SUPER THIN LANCET M BMedical (Miscellaneous) Supplies:Diabetic Supplies (continued)QC ULTRA THIN LANCET M BQC UNIFINE PENTIP 12MM 29G Tier 3QC UNIFINE PENTIP 6MM 31G Tier 3QC UNIFINE PENTIP 8MM 31G Tier 3QC UNILET SUPER THIN 30G LANCT M BQUICKTEK CONTROL SOLUTION M BRA ALCOHOL SWABS Tier 3RA E-ZJECT 28G LANCETS M BRA E-ZJECT COLOR 33G LANCETS M BRA E-ZJECT LANCETS M BRA INS SYR 0.5 ML 29GX1/2 Tier 3RA INS SYR 0.5 ML 30GX5/16 Tier 3RA INS SYR 1 ML 29GX1/2 Tier 3RA INS SYRINGE 1 ML 30GX5/16 Tier 3RA ISOPROPYL ALCOHOL 70% Tier 3WIPESRA PEN NEEDLE 31GX3/16 Tier 3RA PEN NEEDLE 31GX5/16 Tier 3REALITY 1 ML SYRINGE Tier 3REALITY 1/2 ML SYRINGE Tier 3REALITY ALCOHOL SWABS Tier 3REALITY LANCETS M BREALITY TRIGGER LANCETS M BREFUAH PLUS CONTROL SOLUTION M BRELI ON 31G X 1/4 NEEDLES Tier 368Q 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.