peach state health plan preferred diabetic supplies ...€¦ · preferred diabetic supplies:...
TRANSCRIPT
Key: PDL=Preferred Drug List AL=Age Limit QL=Quantity Limit ST=Step Therapy POS=Point Of Sale message Based on Q1 2016 P&T Page 1 of 22
Peach State Health Plan
Preferred Diabetic Supplies: Alcohol Pads and
Lancets
each State Health Plan routinely reviews the products available on the Preferred Drug List (PDL). Items are added, removed or modified periodically due to industry standards, market availability, and/or assessment of use. Below is a list of PDL products and the Non-PDL products which are being removed as of 06/01/2016.
ALCOHOL PREP PADS
Labeler Name PDL Product (NDC) Non-PDL Product (NDC) ALLISON MEDICAL ALCOHOL PAD PREP:
86227000855 86227012205
ALCOHOL PREP PAD: 86227012305
AMERICAN SALES COMPANY ALCOHOL SWAB PAD: 41520080930
AMERISOURCE BERGEN DRUGS GNP ALCOHOL PAD SWABS: 46122004378
APPLIED DIABETES RESEARCH FIFTY50 PREP PAD PADS: 08521080100
BD DIABETES CARE BD SWAB BFLY PAD SNGL USE: 08290006893
BD SWAB REG PAD SNGL USE: 08290326895
BEIERSDORF-FUTURO CURITY SWABS PAD ALCOHOL: 08225233300
BERGEN BRUNSWIG GNP ALCOHOL PAD SWABS: 24385006578
BOCA MEDICAL PRODUCTS ALCOHOL SWAB PAD: 43820005020
CHAIN DRUG CONSORTIUM ALCOHOL PREP PAD: 40986001290
CHAIN DRUG MARKETING ASSOC QC ALCOHOL PAD SWABS: 63868098903
P
Effective date: June 1, 2016
Preferred Diabetic Supplies: Alcohol Pads and Lancets
Key: PDL=Preferred Drug List AL=Age Limit QL=Quantity Limit ST=Step Therapy POS=Point Of Sale message
Based on Q1 2016 P&T Page 2 of 22
Labeler Name PDL Product (NDC) Non-PDL Product (NDC) COVIDIEN MEDICAL SUPPLIES CURITY PREP PAD
ALCOHOL: 08080176818 08080503300
WEBCOL PREP PAD LARGE: 08080511000 08080515000
WEBCOL PREP PAD MEDIUM: 08080575000 08080681800
CVS PHARMACY HEALTHCARE SERV
ALCOHOL SWAB PAD: 50428047377 50428130344
PREP PADS PAD: 50428297584
GLOBAL MEDICAL PRODUCTS GLOBAL PREP PAD PADS: 90166011103 90166022203
GOOD NEIGHBOR PHARMACY GNP ALCOHOL PAD SWABS: 87701069817
ALCOHOL SWAB PAD: 30142001032 30142001033 30142001050
ALCOHOL PREP PAD: 00904624560
SM ALCOHOL PAD PREP: 49348007753 49348089610
ALCOHOL WIPE PAD: 49614062278
ALCOHOL SWAB PAD: 19283059475
ALCOHOL SWAB PAD EX-THICK: 41250004081 41250004082
REALITY SWAB PAD: 41250064279
HOME AIDE DIAGNOSTICS ALCOHOL PAD: 91237000128
SAPS CARE PAD ALCOHOL: 91237000176
MEDICORE ALCOHOL PREP PAD: 32671000701
MEDISCA ALCOH-GLOVE PAD CONTOURE: 38779754401
ALCOH-WIPE PAD 12"X12": 38779754501
Preferred Diabetic Supplies: Alcohol Pads and Lancets
Key: PDL=Preferred Drug List AL=Age Limit QL=Quantity Limit ST=Step Therapy POS=Point Of Sale message
Based on Q1 2016 P&T Page 3 of 22
Labeler Name PDL Product (NDC) Non-PDL Product (NDC) MHC MEDICAL PRODUCTS ALCOHOL PREP PAD MED
70%: 42423027001 42423027002 42423027101 42423027102 42423027103 42423027104
NEW HAVEN PHARMACEUTICALS SAV-ON ALCO MIS SWABS: 98302000105
ONE PHARMA & MEDICAL SUPPLY CO
ALCOHOL PREP PAD: 59707000120 59707000125 59707011101 59707022201
PERRIGO DIABETES CARE ALCOHOL SWAB PAD: 00113200078
PHOENIX HEALTHCARE SOLUTIONS ALCOHOL PREP PAD: 60913000601 60913000702 60913000801 60913000902 60913001702 60913001802
PRESCRIPTION SOLUTIONS, INC. ALCOHOL SWAB PAD: 62451999810
RELIAMED ALCOHOL PREP PAD: 42167000630
RITE AID CORPORATION RA ALCOHOL PAD: 11822033374
RA ALCOHOL PAD SWABS: 11822080004 11822253720 11822515660
RUGBY ALCOHOL PREP PAD: 00536750001
SELECT BRAND SB ALCOHOL PAD PREP: 15127000887
SHOPKO STORES OPERATING CO ALCOHOL SWAB PAD: 37012049930
SPECIALTY MEDICAL SUPPLIES ALCOHOL PREP PAD: 38415000011 68113011401 68113099601
TARGET ALCOHOL SWAB PAD: 11673060010
WALGREENS ALCOHOL PREP PAD: 11917003175
ALCOHOL SWAB PAD: 11917006104 11917007088 11917008216 11917012805 11917012807 11917014296 11917014455
Preferred Diabetic Supplies: Alcohol Pads and Lancets
Key: PDL=Preferred Drug List AL=Age Limit QL=Quantity Limit ST=Step Therapy POS=Point Of Sale message
Based on Q1 2016 P&T Page 4 of 22
Labeler Name PDL Product (NDC) Non-PDL Product (NDC) WAL-MART ALCOHOL SWAB PAD:
81131006044 81306041113
LANCETS
Labeler Name PDL Product (NDC) Non-PDL Product (NDC) ABBOTT DIABETES CARE THIN LANCETS MIS :
57599004305 57599868102 57599868205 57599868206
FREESTYLE MIS LANCETS : 99073013001 99073013022 99073070428 99073083003
FREESTYLE MIS UNISTICK : 57599874605
ACCESS DIABETIC SUPPLY LANCETS MIS 30G : 08540003001
ACON LABORATORIES ON CALL MIS LANCETS : 82607054105
ON CALL PLUS MIS LANCETS : 82607053551
AGAMATRIX AGAMATRIX MIS 33G : 08554197101
AIMSCO/DELTA HI-TECH AUTO LANCET MIS : 51709000729
ULTRA THIN MIS LANC 26G : 89134072902
ULTRA THIN MIS LANC 28G : 89134072602
ULTRA-THIN MIS 28G : 51709000726 51709000727 89134072702
ULTRA-THIN MIS 30G : 51709000728 89134072802
ALLISON MEDICAL LANCETS MIS 30G : 86227000955
SURE COMFORT MIS LANCETS : 86227028105 86227028205 86227030105 86227030205
AMBIMEDINC EZ-LETS 21G MIS LANCETS : 25294000810
EZ-LETS II MIS LANCETS : 25294094300
EZ-LETS 23G MIS LANCETS : 25294000806
EZ-LETS 26G MIS LANCETS : 25294000815
EZ-LETS 28G MIS LANCETS : 25294000820
Preferred Diabetic Supplies: Alcohol Pads and Lancets
Key: PDL=Preferred Drug List AL=Age Limit QL=Quantity Limit ST=Step Therapy POS=Point Of Sale message
Based on Q1 2016 P&T Page 5 of 22
Labeler Name PDL Product (NDC) Non-PDL Product (NDC) AMBIMEDINC (cont) EZ-LETS 30G MIS LANCETS
: 25294000825
AMIRA MEDICAL AT LAST MIS LANCETS : 08238053904
APPLIED DIABETES RESEARCH FIFTY50 SAFE MIS LANCETS : 08521081030 08521081032
ARKRAY USA TECHLITE MIS LANC 30G : 08317880130
ASSURE LANCE MIS 21G : 08317980121
TECHLITE MIS LANCETS : 08317880125 08317880128 08317880225 08317880228
ASSURE LANCE MIS LOW FLOW : 08317980125 08317980225
TECHLITE AST MIS LANCETS : 08317880300
ASSURE LANCE MIS MICRO : 08317980128 08317980228
ASSURE LANCE MIS SAFE 25G : 08317990125
ASSURE LANCE MIS SAFE 30G : 08317990130
ASSURE PLUS MIS HIGH 18G : 08317970118
ASSURE PLUS MIS LOW 25G : 08317970125
ASSURE PLUS MIS MCRO 28G : 08317970128
ASSURE PLUS MIS NORM 21G : 08317970121
ASSURE PLUS MIS PEDIATRI : 08317970112
HAEMOLANCE MIS HIGH FLO : 08317990800
HAEMOLANCE MIS LANCETS : 08317045050
HAEMOLANCE MIS LOW FLOW : 08317950000 08317955000 08317960000 08317965000
HAEMOLANCE MIS PLUS : 08317990200 08317990250 08317990700 08317990750
HAEMOLANCE MIS PLUS LOW : 08317990900 08317990950
HAEMOLANCE MIS PLUS MAX : 08317990600
HAEMOLANCE MIS PLUS PED : 08317990400
Preferred Diabetic Supplies: Alcohol Pads and Lancets
Key: PDL=Preferred Drug List AL=Age Limit QL=Quantity Limit ST=Step Therapy POS=Point Of Sale message
Based on Q1 2016 P&T Page 6 of 22
Labeler Name PDL Product (NDC) Non-PDL Product (NDC) ARKRAY USA (cont) HAEMOLANCE MIS RETRACT :
08317015001 08317035050
QUICKLANCE MIS SYSTEM : 08317915050
A-S MEDICATION SOLUTIONS ONE TOUCH MIS LANCETS : 54569519000
ASCENSIA DIABETES CARE AMES GLU SYS MIS : 00193550921
BAYER MICRLT MIS LANCETS : 00193654621
FINGERSTIX MIS LANCETS : 00193596531
MICROLET MIS LANCETS : 00193658621
SINGLE-LET MIS 23G : 00193656801 00193656831
BD DIABETES CARE BD LANCET UF MIS 30G : 08290325772 08290325773
BD GENIE MIS LANCETS : 08290366579
BD LANCET UF MIS 33G : 08290322057 08290322065
BD MICROTAIN MIS LANCETS : 08290366592 08290366593 08290366594
BD MEDICAL SURGICAL SYSTEMS BD GENIE MIS LANCET : 08290366583
MICROTAINER MIS LANCET : 08290365759 08290366356 08290366357 08290366359
BERGEN BRUNSWIG GNP LANCETS MIS : 87701057044 87701057046
GNP LANCETS MIS MICRO : 87701040655
GNP LANCETS MIS SUP THIN : 87701039908
GNP LANCETS MIS THIN : 87701044671
GNP LANCETS MIS THIN 26G : 87701095986
LANCETS THIN MIS : 24385065482
BIONIME USA CORPORATION RIGHTEST MIS GL300 : 08539060000
Preferred Diabetic Supplies: Alcohol Pads and Lancets
Key: PDL=Preferred Drug List AL=Age Limit QL=Quantity Limit ST=Step Therapy POS=Point Of Sale message
Based on Q1 2016 P&T Page 7 of 22
Labeler Name PDL Product (NDC) Non-PDL Product (NDC) BIOSENSE MEDICAL DEVICES SOLUS V2 MIS LANC 28G :
08611504100
SOLUS V2 MIS LANC 30G : 08611504000
BOCA MEDICAL PRODUCTS ULTILET MIS 26G : 08326261001
LANCET MIS 2MM : 08326200001
LANCETS MIS 30G : 08326003001
ULTILET MIS 28G : 08326281001 08326281002
ULTILET MIS 30G : 08326300001 08326301001
ULTILET MIS 33G : 08326330001 08326331001
ULTILET MIS LANCETS : 08326280001 08326280002
ULTILET MIS SAFETY : 08326231001
BOCA PHARMACAL DIASTAR MIS LANCETS : 08385103001
DIASTAR EASY MIS LANCETS : 08385003001
CARDIOCOM GLUCOCOM MIS 28G : 08525010300
GLUCOCOM MIS 33G : 08525011300
GLUCOCOM MIS 30G : 08525011200
CHAIN DRUG CONSORTIUM LANCETS ULTR MIS THIN 30G : 40986001668 40986001669
UNILET LANCT MIS 33G : 40986003283
CLOSER HEALTHCARE LANCETS MIS : 08464010001
COVIDIEN MEDICAL SUPPLIES MONOLET MIS LANCETS : 08881602018 08881602034 08881602075 08881602125
MONOLET MIS LANCETS : 08881602141 08881602190
MONOLET OPD MIS LANCETS : 08080602422
MONOLETTOR MIS LANCETS : 08080602091
Preferred Diabetic Supplies: Alcohol Pads and Lancets
Key: PDL=Preferred Drug List AL=Age Limit QL=Quantity Limit ST=Step Therapy POS=Point Of Sale message
Based on Q1 2016 P&T Page 8 of 22
Labeler Name PDL Product (NDC) Non-PDL Product (NDC) CVS PHARMACY HEALTHCARE SERV
CVS LANCETS MIS ORIGINAL : 50428001773 59779032304
CVS LANCETS MIS THIN 26G : 50428001771 50428001772
ULTRA THIN MIS LANCETS : 50428235155 50428235157
DIABETIC SUPPLY OF SUNCOAST ADVCATE SAFE MIS LANC 26G : 94046000192
ADVOCATE MIS LANC 30G : 94046000110
ADVOCATE MIS LANCETS : 94046000106 94046000109 94046000118
DISPENSEXPRESS LANCETS MIS : 68115073000
ENTRA HEALTH SYSTEMS MYGLUCOHEALT MIS LANC 30G : 50081000303
FACET TECHNOLOGIES CLEANLET 28G MIS LANCETS : 94542005830 94542005835
SURELITE MIS LANCETS : 94542005005 94542051150
FORA CARE FORA MIS LANCETS : 98939000261
FORA LANCETS MIS 30G : 16042001201
FUTURA MEDICAL CORPORATION GENTLE-LET MIS 26G : 55283030001 55283030003
SAFE-T-LANCE MIS 21G : 55283084901 55283085000
GENTLE-LET MIS 28G : 55283031003
SAFE-T-LANCE MIS 25G : 55283084903 55283085100
GENTLE-LET MIS LANCETS : 55283011800 55283012100 55283012200 55283012400 55283070900 55283079600 55283080000
SAFE-T-LANCE MIS HI FLOW : 55283084905
LANCETS MIS 28G : 55283086502
SAFE-T-LANCE MIS LOW FLOW : 55283084909
PSS SAFE LAN MIS : 55283020603
SAFE-T-LANCE MIS NOR FLOW : 55283084907
PSS SEL LANC MIS : 55283020503
SURGILANCE MIS LANCETS : 55283083401 55283083402 55283083403 55283083404
THINLETS GP MIS 26G : 55283086501
Preferred Diabetic Supplies: Alcohol Pads and Lancets
Key: PDL=Preferred Drug List AL=Age Limit QL=Quantity Limit ST=Step Therapy POS=Point Of Sale message
Based on Q1 2016 P&T Page 9 of 22
Labeler Name PDL Product (NDC) Non-PDL Product (NDC) GLOBAL MEDICAL PRODUCTS GLOBAL 28G MIS LANCETS :
90166012804
GLOBAL 30G MIS LANCETS : 90166013004
LANCETS MIS 33G : 90166001334
GLUCO PERFECT PERFECT 30G MIS LANCETS : 08531010030
PERFECT 28G MIS LANCETS : 08531010028
H&H WHOLESALE INC EASYTEST MIS LANCETS : 08385022650
EASYTEST II MIS LANCETS : 08385110579
PRECISION MIS 28G : 08385086701
PRECISION MIS 28G(T) : 08385086601
THINLETS MIS 28G(T) : 08385086501
W&F LANCETS MIS 21G : 08385610001
W&F LANCETS MIS 26G : 08385850501
HEALTH ALLIANCE LANCETS MIS : 08347100010
HOME AIDE DIAGNOSTICS ACTIVE 1ST MIS LANC 30G : 91237000187
EASY COMFORT MIS 30G : 91237000104 91237000116
EASY COMFORT MIS LANC/30G : 91237000115 91237000129
SAPSCARE MIS TWIST : 91237000175
HTL-STREFA DROPLET LANC MIS 30G : 08489716130
ACTI-LANCE MIS LITE 28G : 08489715510 08638714120 08638715510 08638731125 08638732150
ACTI-LANCE MIS SPEC 17G : 08489715710 08638714320 08638715710 08638731325 08638732350
Preferred Diabetic Supplies: Alcohol Pads and Lancets
Key: PDL=Preferred Drug List AL=Age Limit QL=Quantity Limit ST=Step Therapy POS=Point Of Sale message
Based on Q1 2016 P&T Page 10 of 22
Labeler Name PDL Product (NDC) Non-PDL Product (NDC) HTL-STREFA (cont) ACTI-LANCE MIS UNIV 23G :
08489715610 08638714220 08638715610 08638731225 08638732250
MEDLANCE MIS PLUS 30G : 08489724120 08489724210 08489727625 08489728650
MEDLANCE PLS MIS 0.8MM : 08489704620 08489724610 08489728025 08489729050
MEDLANCE PLS MIS EXTR 21G : 08489704520 08489724510 08489727925 08489728950
MEDLANCE PLS MIS LITE 25G : 08489704320 08489724310 08489727725 08489728750
MEDLANCE PLS MIS UNIV 21G : 08489704420 08489724410 08489727825 08489728850
HY-VEE LANCETS MIS ORIGINAL : 75450031195
LANCETS MIS THIN : 75450031095
INFOPIA USA LANCETS MIS 30G : 08522000082
VANTAGE LANC MIS UNIV 30G : 08522000052
INVACARE SUPPLY GROUP LANCETS MIS 30G : 08618003001
INVERNESS MEDICAL KROGER LANCE MIS : 36652030418
KROGER LANCE MIS THIN : 36652030118 36652030218
KROGER LANCE MIS THIN 30G : 36652030318
LEADER BRAND PRODUCTS LANCETS MIS : 37205011882
LIFESCAN INC ONETOUCH MIS LANCETS : 53885010207
LIFESCAN MIS UNISTIK2 : 53885040410
ONETOUCH MIS 30G : 53885059501
ONETOUCH MIS COMBO : 53885073102
Preferred Diabetic Supplies: Alcohol Pads and Lancets
Key: PDL=Preferred Drug List AL=Age Limit QL=Quantity Limit ST=Step Therapy POS=Point Of Sale message
Based on Q1 2016 P&T Page 11 of 22
Labeler Name PDL Product (NDC) Non-PDL Product (NDC) LIFESCAN INC (cont) ONETOUCH MIS LANCETS :
53885004610 53885013610 53885014301
ONETOUCH FP MIS LANCETS : 53885071202
ONETOUCH US MIS LANCETS : 53885039310
UNISTIK 2 MIS NEONATAL : 53885019610
UNISTIK II MIS LANCETS : 53885063610
LINKS MEDICAL PRODUCTS ACTI-LANCE MIS 28G : 51028000128
MEDLANCE MIS 30G PLUS : 51028000133
MEDLANCE PLS MIS LITE 25G : 51028000103 51028000125
MEDLANCE PLS MIS UNIV 21G : 51028000102 51028000121
LIVONGO HEALTH IN TOUCH LAN MIS 30G : 53553000506
LOGIMEDIX LANCETS MIS : 08429111101
LONGS DRUG THIN LANCETS MIS ULTRA : 12333097541
MAJOR PHARMACEUTICALS MAJOR COMFOR MIS LANCETS : 00904437560
MALGAM ENTERPRISES INC. GLUCOSOURCE MIS LANCETS : 08278220011
MEDICAL PLASTIC DEVICES LANCETS THIN MIS : 08271033100 08271035100
FINE 30 MIS : 08271087100
LANCETS THIN MIS 23G : 28465000351
MEDLANCE MIS EXTR 21G : 08271138300
LANCETS ULTR MIS THIN : 08271036100 08271036200
MEDLANCE MIS LITE 25G : 08271138100
VITALET LANCETS : 28465000331
MEDLANCE MIS PLUS : 08271138400
MEDLANCE MIS UNV 21G : 08271138200
VITALET PRO MIS : 28465001212 28465001222
VITALET PRO MIS PLUS : 28465001340 28465001350
Preferred Diabetic Supplies: Alcohol Pads and Lancets
Key: PDL=Preferred Drug List AL=Age Limit QL=Quantity Limit ST=Step Therapy POS=Point Of Sale message
Based on Q1 2016 P&T Page 12 of 22
Labeler Name PDL Product (NDC) Non-PDL Product (NDC) MEDICINE SHOPPE LANCETS MIS :
49614062178 49614062181
LANCETS THIN MIS : 49614063078 49614063081
MEDICORE LITE TOUCH MIS LANCETS : 32671020133 32671020233
LITETOUCH MIS LANCETS : 32671020333
MEDLINE INDUS SAFETY 21G MIS LANCETS : 08327006729 08327006929
SAFETY 28G MIS LANCETS : 08327006829 08327007029
MEDTRONIC MINIMED MINILET LANC MIS THIN : 63706001110
MEIJER LANCETS MIS 21G : 41250088304
LANCETS MIS 26G : 41250088305 41250088306
MEIJER MIS LANCETS : 38396030320
MEIJER LANCE MIS COLOR : 13733021547
MEIJER LANCE MIS UNIV 21G : 41250088303
MEIJER LANCE MIS UNIV 30G : 41250003693
REALITY MIS LANCETS : 41250084211
REALITY TRIG MIS LANCETS : 41250066828
MHC MEDICAL PRODUCTS EASY TOUCH MIS LANC/26G : 08496261001 08496261201
EASY TOUCH MIS LANC/21G : 08496212201 08496212401
EASY TOUCH MIS LANC/28G : 08496281001 08496281201
EASY TOUCH MIS LANC/23G : 08496231801 08496232201
EASY TOUCH MIS LANC/30G : 08496301001 08496301201
EASY TOUCH MIS LANC/26G : 08496260801 08496261801 08496265801
EASY TOUCH MIS LANC/32G : 08496321001 08496321201
EASY TOUCH MIS LANC/28G : 08496280801 08496281801 08496285801
Preferred Diabetic Supplies: Alcohol Pads and Lancets
Key: PDL=Preferred Drug List AL=Age Limit QL=Quantity Limit ST=Step Therapy POS=Point Of Sale message
Based on Q1 2016 P&T Page 13 of 22
Labeler Name PDL Product (NDC) Non-PDL Product (NDC) MHC MEDICAL PRODUCTS (cont) EASY TOUCH MIS
LANC/33G : 08496331001 EASY TOUCH MIS LANC/30G : 08496300601 08496305801
EASY TOUCH MIS LANC/32G : 08496320601
NEW HAVEN PHARMACEUTICALS OSCO LANCETS MIS STANDARD : 41280021546
NOVA BIOMEDICAL SUREFLEX MIS LANCETS : 08548048738
NOVA SAFETY MIS LANC 23G : 08548050939
NOVA SAFETY MIS LANC 28G : 08548050938
NOVA SURE MIS LANCETS : 08548043421
OMNIS HEALTH EMBRACE LANC MIS THIN 30G : 94030000204
ONE PHARMA & MEDICAL SUPPLY CO
SURE-LANCE MIS LANCETS : 59707028101 59707030101
SURE-LANCE MIS 26G : 59707000108
SURE-LANCE MIS LANCETS : 59707000110 59707000112 59707000166
SURE-TOUCH MIS UNV LANC : 59707000165
OWEN MUMFORD 1ST CHOICE MIS LANCETS : 08517015722 08517030722 08517035722 08517065722
ADV TRAVEL MIS LANC 28G : 08214048715
AURORA LANCE MIS 30G : 08214065724
MEDICHOICE MIS LANCET : 08214500712 08214501712 08214502712 08214503712 08214504712 08214506712
AURORA LANCE MIS THIN 23G : 08214015724
ON-THE-GO MIS LANC 30G : 08214028739 08214028755
CAREONE LANC MIS 28G : 08214035721
SAFETY 21G MIS LANCETS : 08470101501
CAREONE LANC MIS THIN 23G : 08214015721
TRAVEL LANCE MIS 30G : 08214028715
COMFORT MIS LANCETS : 08214065711
UNISTIK 3 MIS GENT 30G : 08470102201 08470102401 08470102701 08470102801
Preferred Diabetic Supplies: Alcohol Pads and Lancets
Key: PDL=Preferred Drug List AL=Age Limit QL=Quantity Limit ST=Step Therapy POS=Point Of Sale message
Based on Q1 2016 P&T Page 14 of 22
Labeler Name PDL Product (NDC) Non-PDL Product (NDC) OWEN MUMFORD (cont) COMFORTOUCH MIS
LANCET : 08214046001 08214046002 08214046501 08470043001 08470043501 08470046001 08470046501
UNISTIK SAFE MIS LANC 28G : 08470144201
HLTHY ACCNTS MIS LANC 30G : 08214065750
UNISTIK SAFE MIS LANC 30G : 08470142201
INCONTROL MIS LANC 28G : 08214025727
INCONTROL MIS LANC 30G : 08214065727
INCONTROL MIS LANC 33G : 08214085727
KINNEY MIS LANCETS : 08214018718
KINNEY THIN MIS LANCETS : 08214020718
LANCET ALTER MIS SITE 26G : 08214043514
LANCET SUPER MIS THIN 30G : 08214065714 08214065726 08214065735 08214465714
LANCET ULTRA MIS 28G : 08214025735
LANCET ULTRA MIS THIN 28G : 08214025714
LANCETS MIS 23G : 08214515714
LANCETS ULTR MIS THIN 28G : 08214535714
LB LANCET MIS 28G : 08214035726
PC LANCETS MIS 30G : 08214535716
PX LANCETS MIS ULT THIN : 08214035729
QC LANCETS MIS 28G : 08214053533
QC LANCETS MIS 30G : 08214046533
SUPER THIN MIS LANCETS : 08214065740
Preferred Diabetic Supplies: Alcohol Pads and Lancets
Key: PDL=Preferred Drug List AL=Age Limit QL=Quantity Limit ST=Step Therapy POS=Point Of Sale message
Based on Q1 2016 P&T Page 15 of 22
Labeler Name PDL Product (NDC) Non-PDL Product (NDC) OWEN MUMFORD (cont) TARGET LANCE MIS THIN
28G : 08214037020
TGT LANCET MIS 23G : 08214015720
TGT LANCET MIS 28G : 08214025720 08214030720 08214035720
TGT LANCET MIS 30G : 08214046520 08214065720
TGT LANCET MIS ALTERNAT : 08214043520
ULTRA THIN MIS LANCETS : 08214020740 08214025740
UNILET MIS 21G : 08470040001
UNILET CMFR MIS TCH 28G : 08517025736
UNILET CMFR MIS TCH 30G : 08517065736
UNILET EX II MIS 28G : 08214053001 08214053501 08470053001 08470053501
UNILET EXCEL MIS 23G : 08214051001 08214051501 08470051001 08470051501
UNILET G.P MIS SUPR 23G : 08214045001 08214045501
UNILET G.P. MIS 21G : 08214041401 08214041801 08470041401 08470041801
UNILET GP 28 MIS ULT THIN : 08214092001 08214092501 08470092001 08470092501
UNILET LANCE MIS 21G : 08214040001
UNILET LANCE MIS 33G : 08214058733
UNILET LANCT MIS 28G : 08214025739 08214025748 08214025755 08214025757 08214056761 08470056501
Preferred Diabetic Supplies: Alcohol Pads and Lancets
Key: PDL=Preferred Drug List AL=Age Limit QL=Quantity Limit ST=Step Therapy POS=Point Of Sale message
Based on Q1 2016 P&T Page 16 of 22
Labeler Name PDL Product (NDC) Non-PDL Product (NDC) OWEN MUMFORD (cont) UNILET LANCT MIS 30G :
08214057761 08214065739 08214065748 08214065755 08214065757 08470057501
UNILET LANCT MIS 33G : 08470058501
UNILET SUPER MIS 23G : 08214044001 08214044501 08470044001 08470044501
UNILET SUPER MIS G.P. 23G : 08470045001 08470045501
PERRIGO DIABETES CARE CVS LANCETS MIS 21G : 38396050275
FP LANCETS MIS THIN : 38396033477
CVS LANCETS MIS THIN 26G : 38396030175 38396050175 38396050375
LONGS LANCET MIS ULTRA TH : 38396033070
CVS LANCETS MIS THIN 30G : 38396030575 38396030775 38396052175 38396052275
RENEW ADV MIS REFILLS : 38396044455
CVS LANCETS MIS THIN 33G : 38396031775
EQL LANCETS MIS 21G COLR : 38396030740
EQL LANCETS MIS 33G COLR : 38396031640
EQL LANCETS MIS THIN 26G : 38396030140 38396030240
EQL LANCETS MIS THIN 30G : 38396030540 38396030640
E-Z JECT MIS 21G : 38396030400
E-Z JECT MIS 21G COLR : 38396030500 38396030600
E-Z JECT MIS 30G : 38396030800
E-Z JECT MIS 32G COLR : 38396030900
E-Z JECT MIS LANC 21G : 38396030300
E-Z JECT MIS THIN 26G : 38396030100 38396030200
Preferred Diabetic Supplies: Alcohol Pads and Lancets
Key: PDL=Preferred Drug List AL=Age Limit QL=Quantity Limit ST=Step Therapy POS=Point Of Sale message
Based on Q1 2016 P&T Page 17 of 22
Labeler Name PDL Product (NDC) Non-PDL Product (NDC) PERRIGO DIABETES CARE (cont) E-ZJECT LANC MIS 33G :
38396031600 38396031614
GNP LANCETS MIS 21G : 38396034264 38396034364
GNP LANCETS MIS THIN 26G : 38396034464 38396034564
LANCET MICRO MIS THIN 33G : 38396031618 38396031664
LANCET STAND MIS 21G : 38396091825 38396091925
LANCET SUPER MIS THIN 30G : 38396032325 38396054764
LANCET ULTRA MIS THIN 30G : 38396030318
LANCETS MIS 21G : 38396030418 38396050132
LANCETS MIS 21G COLR : 38396035506 38396036606
LANCETS MIS 30G : 38396030522
LANCETS MIS THIN 26G : 38396031506
LANCETS MIS THIN 30G : 38396031156
LANCETS THIN MIS 26G : 38396030118 38396030157 38396030218 38396031225 38396032225
LONGS LANCET MIS STANDARD : 38396032870
LONGS LANCET MIS THIN : 38396032970
MEIJER MIS LANCETS : 38396030120 38396030220 38396030420
MEIJER LANCE MIS UNIVERSA : 38396031620
MICRO THIN MIS LANC 33G : 38396031632
PHARMACY COU MIS LANCETS : 38396030505
Preferred Diabetic Supplies: Alcohol Pads and Lancets
Key: PDL=Preferred Drug List AL=Age Limit QL=Quantity Limit ST=Step Therapy POS=Point Of Sale message
Based on Q1 2016 P&T Page 18 of 22
Labeler Name PDL Product (NDC) Non-PDL Product (NDC) PERRIGO DIABETES CARE (cont) RA E-ZJECT MIS 28G :
38396031114
RA E-ZJECT MIS THIN 26G : 38396030114
RA E-ZJECT MIS THIN 28G : 38396031214
RA E-ZJECT MIS ULT THIN : 38396030514
RELION LANCE MIS THIN 26G : 38396030102 38396044902
RELION LANCE MIS THIN 30G : 38396045102 38396045202 38396045302 38396045402
RELION ULTRA MIS THIN PLS : 38396031402 38396031702
SM LANCETS MIS 33G : 38396031739
SMART SENSE MIS LANC 21G : 38396030325
SMART SENSE MIS LANC 26G : 38396030125 38396030225
SMART SENSE MIS LANC 30G : 38396030525
SMART SENSE MIS LANC 33G : 38396031625
SUPER THIN MIS LANC 28G : 38396031132 38396045532
SUPER THIN MIS LANCETS : 38396030520
TGT LANCET MIS 26G : 38396030191
TGT LANCET MIS 30G : 38396030591
TGT LANCET MIS 33G : 38396031691
THIN LANCETS MIS 26G : 38396050232 38396050332
THIN LANCETS MIS 30G : 38396050432
UNIVERSAL 1 MIS LANC 26G : 38396030137
Preferred Diabetic Supplies: Alcohol Pads and Lancets
Key: PDL=Preferred Drug List AL=Age Limit QL=Quantity Limit ST=Step Therapy POS=Point Of Sale message
Based on Q1 2016 P&T Page 19 of 22
Labeler Name PDL Product (NDC) Non-PDL Product (NDC) PERRIGO DIABETES CARE (cont) UNIVERSAL 1 MIS LANC
30G : 38396030537
PHILOSYS GMATE LANCET MIS 30G : 89157052101
PHOENIX HEALTHCARE SOLUTIONS ASSURE CMFRT MIS 28G : 60913000201
ASSURE CMFRT MIS 30G : 60913000101
PHYSICIANS TOTAL CARE BD ULT FINE MIS LANCETS : 54868580700
ONETOUCH US MIS LANCETS : 54868579800
SOFTCLIX MIS LANCETS : 54868493100
POLYMER TECHNOLOGY SYSTEMS LANCETS MIS ORANGE : 08193008912
PRODIGY DIABETES CARE PRODIGY MIS 28G : 08484990328
LANCETS MIS 28G : 08321081028 08321240128 08321240228
LANCETS MIS 30G : 08321081030 08321240110
PRODIGY MIS 21G : 08484082321 08484082341
PRODIGY MIS 26G : 08321000170 08484082026 08484082316
PRODIGY MIS 28G : 08484081028 08484990338
SAFE LANCETS MIS 21G : 08321240130
SAFE LANCETS MIS 26G : 08321240160
PROGRESSIVE HEALTH SUPPLY SMARTEST MIS LANCETS : 08524000403
RELIAMED LANCETS MIS 28G : 42167000552 42167000640
LANCET ULTRA MIS FINE : 42167003329
LANCETS MIS 30G : 42167000548
LANCET ULTRA MIS THIN 30G : 42167000554
RITE AID CORPORATION RA E-ZJECT MIS 33G : 11822350540
RA LANCETS MIS : 11822039928 11822098941
Preferred Diabetic Supplies: Alcohol Pads and Lancets
Key: PDL=Preferred Drug List AL=Age Limit QL=Quantity Limit ST=Step Therapy POS=Point Of Sale message
Based on Q1 2016 P&T Page 20 of 22
Labeler Name PDL Product (NDC) Non-PDL Product (NDC) RITE AID CORPORATION (cont) RA LANCETS MIS
COLORED : 11822087186
RA LANCETS MIS THIN : 11822098940
ROCHE DIAGNOSTICS ACCU-CHEK MIS MLTICLIX : 50924045001 50924098101
COAGUCHEK MIS LANCETS : 50924004301
FASTCLIX MIS LANCETS : 65702028810
SAFE-T-PRO MIS LANCETS : 50924095120
SAFE-T-PRO MIS PLUS : 50924007920
SOFT TOUCH MIS LANCETS : 50924058510
SOFTCLIX MIS LANCETS : 50924012410 50924013024 50924097110 50924098820 65702012410 65702015610
SELECT BRAND SB LANCETS MIS THIN : 15127099010 15127099020
SB LANCETS MIS ULTR THN : 15127099110 15127099120
SIMPLE DIAGNOSTICS CLEVER CHECK MIS : 98302000115
CLEVER CHECK MIS 30G : 98302000127
LANCETS ULTR MIS THIN : 98302000104
ULTRA THIN MIS 28G : 98302000126
ULTRA THIN MIS 30G : 98302000125
ULTRA THIN MIS 31G : 98302000160
ULTRA THIN MIS 33G : 98302001407
ULTRA THIN MIS LANCETS : 98302000106
Preferred Diabetic Supplies: Alcohol Pads and Lancets
Key: PDL=Preferred Drug List AL=Age Limit QL=Quantity Limit ST=Step Therapy POS=Point Of Sale message
Based on Q1 2016 P&T Page 21 of 22
Labeler Name PDL Product (NDC) Non-PDL Product (NDC) SPECIALTY MEDICAL SUPPLIES LANCETS MIS 21G :
38415010021 38415030021 ASSURE MIS LANCETS : 38415010029
LANCETS MIS 26G : 38415010026 38415030026
BULLSEYE MIS LANCETS : 38415000013 38415000015
LANCETS MIS 28G : 38415020028 38415030028
BULLSEYE MIS MINI LNC : 38415000021 38415000025 38415000028 38415002101 38415002501 38415002801
LANCETS MIS 30G : 38415030030
LANCETS MIS : 38415010028 38415060001
LANCETS MIS 28G : 38415040028
LANCETS MIS 30G : 38415010030
LANCETS MIS 31G : 38415010031
SAFETY LET MIS LANCETS : 38415010001
STERILANCE MEDICAL STERILANCE MIS TL 28G : 08565015915
STERILANCE MIS TL 30G : 08565016915
STERILANCE MIS TL 32G : 08565017915
TELCARE LANCET ULTRA MIS THIN 30G : 59519000202
TRIVIDIA HEALTH LANCETS MIS 28G : 56151024221
TRUPLUS LANC MIS 28G : 56151034001 56151034002 56151034025
TRUPLUS LANC MIS 26G : 56151014101
TRUPLUS LANC MIS 28G : 56151014260
TRUPLUS LANC MIS 30G : 56151014401 56151014801
TRUPLUS LANC MIS 33G : 56151014701
ULTIMED LANCETS THIN MIS 28G : 08222072085 57515007208
LANCETS THIN MIS 30G : 08222073015 57515007301
Preferred Diabetic Supplies: Alcohol Pads and Lancets
Key: PDL=Preferred Drug List AL=Age Limit QL=Quantity Limit ST=Step Therapy POS=Point Of Sale message
Based on Q1 2016 P&T Page 22 of 22
Labeler Name PDL Product (NDC) Non-PDL Product (NDC) US DIAGNOSTICS LANCETS MIS 28G :
08463701228 SAFETY MIS LANCETS : 08463803028
LANCETS MIS 30G : 08463702930
VIP INTERNATIONAL EZ SMART MIS LANCETS : 53459000073
WALGREENS COMFORT ASSU MIS LANC 28G : 11917011815 11917011816
LANCET ULTRA MIS THIN 30G : 11917015018
COMFORT ASSU MIS LANC 33G : 11917011817
LANCETS MIS 28G : 11917013416
LANCETS MIS 28G : 11917013415
LANCETS MIS 30G : 11917013417
SUPER THIN MIS LANCETS : 11917001648
LANCETS MIS 33G : 11917013418
LANCETS MICR MIS THIN 33G : 11917015019
LANCETS SUPR MIS THIN 28G : 11917015021
WAL-MART RELION LANCE MIS STND 21G : 81306022114
RELION LANCE MIS THIN 26G : 81306021214
RELION LANCE MIS THIN 30G : 78742002644 78742002646 81131009885 81306021314 81306022314
RELION MICRO MIS THIN 33G : 78742002648
RELION ULTRA MIS THIN 32G : 81131025695
For the most current program description you may call Member Services at 1-800-704-1484 (TTY/TTD 1-800-255-0056) or visit the Peach State Health Plan website at www.pshp.com