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

Medical (Miscellaneous) Supplies:Diabetic Supplies (continued)SURE COMFORT 0.5 ML SYRINGE Tier 3SURE COMFORT 1 ML SYRINGE Tier 3SURE COMFORT 28G LANCETS M BSURE COMFORT 3/10 ML SYRINGE Tier 3SURE COMFORT 30G LANCETS M BSURE COMFORT 31G PEN NEEDLE Tier 3SURE COMFORT ALCOHOL PREP Tier 3PADSSURE COMFORT PEN NDL 29GX1/2 Tier 3SURE COMFORT PEN NDLTier 331GX3/16SURE EDGE GLUCOSE CONTROL M BSOLNSURECHEK GLUCOSE CONTROL M BSOLNSURE-FINE PEN NEEDLES 12.7MM Tier 3SURE-FINE PEN NEEDLES 5MM Tier 3SURE-FINE PEN NEEDLES 8MM Tier 3SURE-JECT INSU SYR U100 0.3 ML Tier 3SURE-JECT INSU SYR U100 0.5 ML Tier 3SURE-JECT INSU SYR U100 1 ML Tier 3SURE-JECT INSUL SYR U100 1 ML Tier 3SURE-JECT INSULIN SYR 0.3 ML Tier 3SURE-JECT INSULIN SYR 0.5 ML Tier 3SURE-JECT INSULIN SYRINGE 1 ML Tier 3Medical (Miscellaneous) Supplies:Diabetic Supplies (continued)SURE-LANCE 26G LANCETS M BSURE-LANCE FLAT LANCETS M BSURE-LANCE THIN LANCET M BSURE-LANCE ULTRA THIN 30G M BSURELITE LANCET REG BODY M BSURE-PREP ALCOHOL PREP PADS Tier 3SURESTEP GLUC CONTROL SOLN M BSURESTEP PRO CONTROL SOLN M BSURESTEP PRO LINEARITY KIT M B Q C D (1/365)SURESTEP PRO TEST STRIPS M B Q C D (300/30)SURESTEP TEST STRIPS M B Q C D (300/30)SURE-TEST EASYPLUS MINI SOLN M BSURE-TOUCH LANCET M BTECHLITE AST LANCETS M BTECHLITE BLOOD LANCET M BTELCARE CONTROL SOLUTION M BTERUMO INS SYR 0.3 ML 29GX1/2 Tier 3TERUMO INS SYRINGE U100-1 ML Tier 3TERUMO INS SYRINGE U100-1/2 ML Tier 3TERUMO INS SYRINGE U100-1/3 ML Tier 3TERUMO INS SYRNG U100-1/2 ML Tier 3TERUMO SURGUARD SYR 28G-1 ML Tier 3TERUMO SURGUARD SYR 28G-1/2 Tier 3MLQ 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. 71