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

Medical (Miscellaneous) Supplies:Diabetic Supplies (continued)UNIFINE PENTIPS 6MM NEEDLE Tier 3UNIFINE PENTIPS 6MM NEEDLES Tier 3UNIFINE PENTIPS 8MM 31G Tier 3UNIFINE PENTIPS 8MM NEEDLE Tier 3UNIFINE PENTIPS 8MM NEEDLES Tier 3UNIFINE PENTIPS NEEDLES 29G Tier 3UNIFINE PENTIPS NEEDLES 31G Tier 3UNILET COMFORTOUCH 26G M BLANCETSUNILET COMFORTOUCH LANCET M BUNILET EXCELITE II LANCET M BUNILET EXCELITE LANCET M BUNILET GP LANCET M BUNILET GP LANCET SUPERLITE M BUNILET LANCET M BUNILET LANCET 28G M BUNILET LANCET SUPERLITE M BUNILET SUPER THIN 30G LANCETS M BUNILET ULTRA THIN 28G LANCETS M BUNISTIK 3 COMFORT LANCET M BUNISTIK 3 EXTRA 21G LANCETS M BUNISTIK 3 NORMAL 23G LANCETS M BUNISTIK 3 SAFETY 21G LANCETS M BUNISTIK CZT COMFORT LANCET M BMedical (Miscellaneous) Supplies:Diabetic Supplies (continued)UNISTIK CZT NORMAL 23GM BLANCETSUNIVERSAL 1 33G LANCETS M BVALUE PLUS STANDARD LANCETS M BVALUE PLUS SUPER THIN LANCETS M BVALUE PLUS THIN LANCETS M BVALUEPLUS SYR 0.3 ML 29GX1/2 Tier 3VANISHPOINT 0.5 ML 30GX1/2 SY Tier 3VANISHPOINT U-100 29X1/2 SYR Tier 3VH INS SYR 0.5 ML 29GX1/2 Tier 3VH INS SYR 1 ML 29GX1/2 Tier 3VICTORY HIGH-LOW CONTROL M BSOLNVITALET 23 GAUGE LANCET M BVITALET PRO LANCETS M BVITALET PRO PLUS LANCETS M BVITALET THIN 26GAUGE LANCET M BW & F 26G LANCETS M BW & F COLORED 21G LANCETS M BW&F COLORED LANCETS M BW&F THIN LANCETS M BWALGREENS LANCETS M BWALGREENS THIN LANCETS M BWALGREENS ULTRA THIN LANCETS M BQ 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. 75