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

Medical (Miscellaneous) Supplies:Diabetic Supplies (continued)ULTCARE INS SYR 1 ML 30GX5/16 Tier 3ULTCARE INS SYR 1 ML 31GX5/16 Tier 3ULTICARE 30GX0.3 ML SYRINGE Tier 3ULTICARE 30GX0.5 ML SYRINGE Tier 3ULTICARE 30GX1 ML SYRINGE Tier 3ULTICARE 31GX0.3 ML SYRINGE Tier 3ULTICARE 31GX0.5 ML SYRINGE Tier 3ULTICARE 31GX1 ML SYRINGE Tier 3ULTICARE INS 0.5 ML 29GX1/2 Tier 3ULTICARE INS SYR 1 ML 28GX1/2 Tier 3ULTICARE INS SYR 1 ML 29GX1/2 Tier 3ULTICARE INSUL SYR U100 0.3 ML Tier 3ULTICARE INSUL SYR U100 0.5 ML Tier 3ULTICARE INSULIN SYR U100 1 ML Tier 3ULTICARE PEN NEEDLES 12MM 29G Tier 3ULTICARE PEN NEEDLES 4MM 32G Tier 3ULTICARE PEN NEEDLES 6 MM 31 G Tier 3ULTICARE PEN NEEDLES 6MM 31G Tier 3ULTICARE PEN NEEDLES 8 MM 31 G Tier 3ULTICARE PEN NEEDLES 8MM 31G Tier 3ULTICARE SYR 0.3 ML 31GX5/16 Tier 3ULTICARE SYR 0.5 ML 30GX5/16 Tier 3ULTICARE SYR 0.5 ML 31GX5/16 Tier 3ULTICARE SYRIN 0.3 ML 29GX1/2 Tier 3ULTICARE SYRIN 0.5 ML 28GX1/2 Tier 3Medical (Miscellaneous) Supplies:Diabetic Supplies (continued)ULTICARE THIN 28G LANCETS M BULTICARE THIN 30G LANCETS M BULTICARE U100 0.3 ML 30GX5/16 Tier 3ULTICARE U100 0.5 ML 29GX1/2 Tier 3ULTI-LANCE AUTO-AD DEVICE M BULTILET 28G LANCETS M BULTILET 30G LANCETS M BULTILET ALCOHOL STERL SWAB Tier 3ULTILET ALCOHOL SWAB Tier 3ULTILET BASIC 30G LANCETS M BULTILET CLASSIC 26G LANCETS M BULTILET CLASSIC 28G LANCETS M BULTILET CLASSIC 30G LANCETS M BULTILET INSULIN SYRINGE 0.3 ML Tier 3ULTILET INSULIN SYRINGE 0.5 ML Tier 3ULTILET INSULIN SYRINGE 1 ML Tier 3ULTILET LANCETS M BULTILET SAFETY LANCETS M BULTRA COMFORT 0.3 ML 29GX1/2 Tier 3ULTRA COMFORT 0.3 ML SYRINGE Tier 3ULTRA COMFORT 0.5 ML 28GX1/2 Tier 3ULTRA COMFORT 0.5 ML 29GX1/2 Tier 3ULTRA COMFORT 0.5 ML 30GX5/16 Tier 3ULTRA COMFORT 0.5 ML 31GX5/16 Tier 3ULTRA COMFORT 0.5 ML SYRINGE 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. 73