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

Medical (Miscellaneous) Supplies:Diabetic Supplies (continued)ULTRA COMFORT 1 ML 28GX1/2 Tier 3ULTRA COMFORT 1 ML 29GX1/2 Tier 3ULTRA COMFORT 1 ML 30GX5/16 Tier 3ULTRA COMFORT 1 ML 31GX5/16 Tier 3ULTRA COMFORT 1 ML SYRINGE Tier 3ULTRA COMFORT 3/10 ML SYR Tier 3ULTRA THIN 28 G LANCET M BULTRA THIN 28G LANCETS M BULTRA THIN 31G LANCETS M BULTRA THIN 33G LANCETS M BULTRA THIN LANCETS M BULTRACOMFORT 30GX0.5 ML SYR Tier 3ULTRACOMFORT 30GX1 ML Tier 3SYRINGEULTRACOMFORT 31GX0.5 ML SYR Tier 3ULTRACOMFORT 31GX1 ML Tier 3SYRINGEULTRACOMFORT INSUL SYR 0.5 ML Tier 3ULTRACOMFORT INSULIN SYR 1 ML Tier 3ULTRACOMFORT PEN NEEDLES Tier 36MMULTRACOMFORT PEN NEEDLES Tier 38MMULTRALANCE 26G LANCETS M BULTRALANCE 28G LANCETS M BMedical (Miscellaneous) Supplies:Diabetic Supplies (continued)ULTRA-THIN II 26G LANCET M BULTRA-THIN II 28G LANCETS M BULTRA-THIN II 30G LANCETS M BULTRA-THIN II 31G SHORT NEEDLE Tier 3ULTRA-THIN II INS 0.3 ML 29G Tier 3ULTRA-THIN II INS 0.3 ML 30G Tier 3ULTRA-THIN II INS 0.3 ML 31G Tier 3ULTRA-THIN II INS 0.5 ML 29G Tier 3ULTRA-THIN II INS 0.5 ML 30G Tier 3ULTRA-THIN II INS 0.5 ML 31G Tier 3ULTRA-THIN II INS SYR 1 ML 29G Tier 3ULTRA-THIN II INS SYR 1 ML 30G Tier 3ULTRA-THIN II PEN NDL 29GX1/2 Tier 3ULTRA-THIN II PEN NDL 31GX5/16 Tier 3ULTRATRAK CONTROL SOL NORMAL M BULTRATRAK CONTROL SOLUTION M BULTRATRAK PRO CNTRL SOLUTION M BULTRATRAK ULTIMATE CNTRL SOLN M BUNIFINE PENTIP 0.5CC NEEDLE Tier 3UNIFINE PENTIP NEEDLES Tier 3UNIFINE PENTIPS 12MM 29G Tier 3UNIFINE PENTIPS 12MM NEEDLE Tier 3UNIFINE PENTIPS 31GX3/16 Tier 3UNIFINE PENTIPS 32GX5/32 Tier 3UNIFINE PENTIPS 6MM 31G Tier 374Q 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.