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

Medical (Miscellaneous) Supplies:Diabetic Supplies (continued)RELIAMED SAFETY SEAL LANCETS M BRELION INS SYR 0.3 ML 29GX1/2 Tier 3RELION INS SYR 0.3 ML 30GX5/16 Tier 3RELION INS SYR 0.5 ML 29GX1/2 Tier 3RELION INS SYR 1 ML 29GX1/2 Tier 3RELION INS SYR 1 ML 30GX5/16 Tier 3RELION INS SYR 1 ML 31GX5/16 Tier 3RELI-ON INSULIN 0.3 ML SYR Tier 3RELI-ON INSULIN 0.5 ML SYR Tier 3RELI-ON INSULIN 1 ML SYR Tier 3RELION INSULIN SYR 0.3 ML Tier 3RELION INSULIN SYR 0.5 ML Tier 3RELION INSULIN SYRINGE 1 ML Tier 3RELION LANCETS M BRELION MINI PEN 31G X 1/4 NDL Tier 3RELION PEN 29G NEEDLE Tier 3RELION PEN 29G X 1/2 NEEDLE Tier 3RELION PEN 31G NEEDLE Tier 3RELION PEN 31G X 5/16 NEEDLE Tier 3RELION SYR 0.5 ML 30GX5/16 Tier 3RELION SYRING 0.3 ML 31GX5/16 Tier 3RELION SYRING 0.5 ML 31GX5/16 Tier 3RELION THIN LANCETS M BRELION ULTRA THIN 30G LANCETS M BRELION ULTRA THIN PLUS 33G M BMedical (Miscellaneous) Supplies:Diabetic Supplies (continued)RELION ULTRA THIN PLUS LANCETS M BRENEW ADVANCED MICRO-M BLANCETSRIGHTEST CONTROL SOLNM BNORMALRIGHTEST CONTROL SOLUTION M BHIGHRIGHTEST GL300 LANCETS M BSAFESNAP INSUL SYRINGE 0.3 ML Tier 3SAFESNAP INSUL SYRINGE 0.5 ML Tier 3SAFESNAP INSULIN SYRINGE 1 ML Tier 3SAFE-T-LANCE 21G LANCETS M BSAFE-T-LANCE 25G LANCETS M BSAFE-T-LANCE PLUS LANCETS M BSAFETY 21G LANCETS M BSAFETY 28G LANCETS M BSAFETY LANCET 2MM M BSAFETY LANCETS M BSAFETY SEAL 30G LANCETS M BSAFETY SYRINGE W-SHIELD 3 ML Tier 3SAFETY-LET LANCETS M BSB INS SYR 0.5 ML 29GX1/2 Tier 3SB INS SYR 0.5 ML 30GX5/16 Tier 3SB INS SYR 1 ML 29GX1/2 Tier 3SB INS SYRINGE 1 ML 30GX5/16 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. 69