Brand/Generic Name

Dosage/Strength

Status

Restrictions

Notes

Relative Cost

Accusure Insulin Syringe insulin syringe-needle U-100 Syringe     $$ BD Allergy Syringe syringe with needle (disp) Syringe     $$ BD Autoshield Pen Needle insulin safety needles (disp) 29 x 1/2 Needle     $$ BD Autoshield Pen Needle insulin safety needles (disp) Needle     $$ BD Eclipse Syringe insulin syringe-needle U-100 1 mL 30 x 1/2 Syringe; 1 mL 27 x 1/2 Syringe; 3 mL 23 x 1 Syringe; 3 mL 25 x 5/8 Syringe     $$ BD Eclipse Syringe syringe with needle (disp) 1 mL 30 x 1/2 Syringe; 1 mL 27 x 1/2 Syringe; 3 mL 23 x 1 Syringe; 3 mL 25 x 5/8 Syringe     $$ BD Insulin Pen Needle UF Mini insulin needles (disposable) 31 x 3/16 Needle     $$ BD Insulin Pen Needle UF Orig insulin needles (disposable) 29 x 1/2 Needle     $$ BD Insulin Pen Needle UF Short insulin needles (disposable) 31 X 5/16 Needle     $$ BD Insulin Syringe insulin syringe-needle U-100 Syringe     $$ BD Insulin Syringe Half Unit insulin syr/ndl U100 half mark 0.3 mL 31 x 5/16 Syringe; 0.3 mL 31 x 15/64 Syringe     $$ BD Insulin Syringe Micro-Fine insulin syringe-needle U-100 1 mL 28 x 1/2 Syringe; 1/2 mL 28 x 1/2 Syringe; 0.3 mL 28 x 1/2 Syringe; 0.3 mL 28 Syringe     $$ BD Insulin Syringe Safety-Lok insulin syringe-needle U-100 1 mL 29 x 1/2 Syringe     $$ BD Insulin Syringe Slip Tip insulin syringe needleless 1 mL Syringe     $$ BD Insulin Syringe Ult-Fine II insulin syringe-needle U-100 1 mL 31 x 5/16 Syringe; 1/2 mL 31 x 5/16 Syringe; 0.3 mL 31 x 5/16 Syringe     $$ BD Insulin Syringe Ultra-Fine insulin syringe-needle U-100 0.3 mL 30 x 1/2 Syringe; 1 mL 29 x 1/2 Syringe     $$ BD Integra Insulin Syringe insulin syringe-needle U-100 Syringe     $$ BD Integra Syringe syringe with needle (disp) Syringe     $$ BD Integra Syringe syringe with needle, safety Syringe     $$ BD Luer-Lok Syringe syringe (disposable) 1 mL Syringe     $$ BD Luer-Lok Syringe syringe (disposable) Syringe     $$ BD Luer-Lok Syringe syringe with needle (disp) Syringe     $$ BD Pen Mini insulin admin supplies Insulin Pen     $$ BD Plastipak Syringes Allergy Tuberculin-Allergy Syringes Misc     $$ BD SafetyGlide Allergist Tray syringe with needle (disp) Syringe     $$ BD SafetyGlide Allergist Tray tuberculin-allergy syringes Syringe     $$ BD SafetyGlide Insulin Syringe insulin syringe-needle U-100 Syringe     $$ BD SafetyGlide Needle safety needles 25 x 5/8 Needle; 23 X 1 Needle; 21 x 1 1/2 Needle; 25 X 1 Needle; 22 x 1 1/2 Needle; 18 x 1 1/2 Needle; 27 x 5/8 Needle; 21 x 1 Needle     $$ BD SafetyGlide Shielding Reg syringe with needle (disp) Syringe     $$ BD SafetyGlide Shielding Reg syringe with needle, safety Syringe     $$ BD SafetyGlide Syringe insulin syringe-needle U-100 3 mL 22 x 1 1/2 Syringe; 10 mL 22 x 1 1/2 Syringe; 1 mL 27 x 5/8 Syringe     $$ BD SafetyGlide Syringe syringe with needle (disp) 3 mL 22 x 1 1/2 Syringe; 10 mL 22 x 1 1/2 Syringe; 1 mL 27 x 5/8 Syringe     $$ BD Slip Tip Syringe syringe (disposable) Syringe     $$ BD Slip Tip Syringe syringe with needle (disp) Syringe     $$ BD Syringe syringe (disposable) Syringe     $$ BD Syringe 50-60 ML Syringe (Disposable) Misc     $$ BD Syringe Cath Tip Syringe (Disposable) Misc     $$ BD Syringe Luer Slip Tip Syringe (Disposable) Misc     $$ BD Syringe-Dual Cannula syringe w-needle-cannula, disp 10 mL 20 & 17 Syringe     $$ Novofine insulin needles (disposable) Needle     $$ NovoPen 3 insulin admin supplies Insulin Pen     Not Applicable NovoPen Jr insulin admin supplies Insulin Pen     Not Applicable Prodigy Voice Glucose Meter blood-glucose meter Kit   Not Applicable

Key for Product(s) Listed Above

Formulary Prior Authorization (PA may not be required for some benefit plans) Non-Formulary (Third tier coverage applies for selected plans) Not Reimbursed Quantity Limit Not available through mail order as 90-day supply* Step Therapy Generic Available. Brand name medication may be covered at a higher member cost or may not be covered for certain plans. Notes $Relative cost compared to others in category Specialty distribution for selected plans (Fourth or fifth tier coverage applied for selected plans)

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