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

Medical (Miscellaneous) Supplies:Diabetic Supplies (continued)SB INSULIN SYR 1 ML 31GX5/16 Tier 3SB INSULN SYR 0.5 ML 30GX5/16 Tier 3SB LANCETS THIN M BSB LANCETS ULTRA THIN M BSCHNUCKS SYR 0.5 ML 29GX1/2 Tier 3SCHNUCKS SYR 0.5 ML 30GX5/16 Tier 3SINGLE-LET LANCETS M BSM ALCOHOL 70% PREP PADS Tier 3SM ALCOHOL PREP PADS Tier 3SM COLORED LANCETS M BSM INS SYR 0.5 ML 29GX1/2 Tier 3SM INS SYR 0.5 ML 30GX5/16 Tier 3SM INS SYR 1 ML 29GX1/2 Tier 3SM INS SYRING 0.3 ML 30GX5/16 Tier 3SM INS SYRINGE 1 ML 28GX1/2 Tier 3SM INS SYRINGE 1 ML 30GX5/16 Tier 3SM INSUL SYR 0.3 ML 31GX5/16 Tier 3SM INSUL SYR 0.5 ML 31GX5/16 Tier 3SM INSULIN SYR 0.3 ML 29GX1/2 Tier 3SM INSULIN SYR 0.5 ML 28GX1/2 Tier 3SM INSULIN SYR 1 ML 31GX5/16 Tier 3SM LANCETS M BSM MICRO THIN 33G LANCETS M BSM SUPER THIN LANCETS M BSM THIN LANCETS M BMedical (Miscellaneous) Supplies:Diabetic Supplies (continued)SMART SENSE COLOR 33GM BLANCETSSMART SENSE STANDARD 21G M BSMART SENSE SUPER THIN 30G M BSMART SENSE THIN 26G LANCETS M BSMARTDIABETES VANTAGE 30G M BSMARTEST CONTROL SOLUTION M BSMARTEST LANCET M BSMS GLUCOSE CONTROL SOL M BNORMALSOFT TOUCH LANCETS M BSOFT TOUCH SAFE-T-PRO M BSOFTCLIX LANCETS M BSOLO V2 30G LANCETS M BSOLO V2 CONTROL SOLUTION M BHIGHSOLO V2 CONTROL SOLUTION LOW M BSTERILANCE TL TWIST 30G LANCET M BSTERILANCE TL TWIST 32G LANCET M BSUPER THIN 28G LANCETS M BSUPER THIN 30G LANCETS M BSUPER THIN 33G LANCETS M BSUPER THIN LANCETS M BSUPREME II CONTROL SOLUTION M BSURE COMFORT 0.3 ML SYRINGE Tier 370Q 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.