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

Medical (Miscellaneous) Supplies:Diabetic Supplies (continued)TERUMO SURGUARD SYR 29G-0.3 Tier 3MLTERUMO SURGUARD SYR 29G-1/2 Tier 3MLTERUMO SURGUARD SYRN 29G-1 Tier 3MLTHIN LANCET M BTHINLETS 28G(T) LANCETS M BTHINLETS GP LANCETS M BTHINPRO INS SYRIN U100-0.3 ML Tier 3THINPRO INS SYRIN U100-0.5 ML Tier 3THINPRO INS SYRIN U100-1 ML Tier 3TODAY’S HEALTH SUPER THIN 30G M BTODAY’S HLT PN NEEDLE 12MM 29G Tier 3TODAY’S HLTH PN NEEDLE 6MM 31G Tier 3TODAY’S HLTH PN NEEDLE 8MM 31G Tier 3TODAY’S HLTH ULTRA THIN LANCET M BTOPCARE CLICKFINE 31G X 1/4 Tier 3TOPCARE CLICKFINE 31G X 5/16 Tier 3TOPCARE ULTRA COMFORT Tier 3SYRINGETOPCARE UNIVERSAL1 THIN M BLANCETTRUECONTROL GLUCOSEM BSOLUTIONTRUEPLUS 33G LANCETS M BMedical (Miscellaneous) Supplies:Diabetic Supplies (continued)TRUEPLUS LANCETS 28G M BTRUEPLUS SUPER THIN 28G M BLANCETTRUEPLUS SYR 0.3ML 29GX1/2 Tier 3TRUEPLUS SYR 0.3ML 30GX5/16 Tier 3TRUEPLUS SYR 0.3ML 31GX5/16 Tier 3TRUEPLUS SYR 0.5ML 28GX1/2 Tier 3TRUEPLUS SYR 0.5ML 29GX1/2 Tier 3TRUEPLUS SYR 0.5ML 30GX5/16 Tier 3TRUEPLUS SYR 0.5ML 31GX5/16 Tier 3TRUEPLUS SYR 1ML 28GX1/2 Tier 3TRUEPLUS SYR 1ML 29GX1/2 Tier 3TRUEPLUS SYR 1ML 30GX5/16 Tier 3TRUEPLUS SYR 1ML 31GX5/16 Tier 3TRUEPLUS ULTRA THIN 30G LANCET M BTRUETEST CONTROL SOLN HIGH M BTRUETEST CONTROL SOLNM BNORMALTRUETEST CONTROL SOLUTION M BLOWTRUETRACK GLUCOSE CONTROL M BTWIST LANCETS M BULT CFT 0.3 ML 29GX1/2 (1/2) Tier 3ULT CFT 0.3 ML 30GX5/16 (1/2) Tier 3ULT CFT 0.3 ML 31GX5/16 (1/2) Tier 372Q 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.