CBM Oakland Health Plan Formulary

CBM ABW Formulary
www.communitybridgesihc.com
Brand Name (Reference only) Zyloprim Zyloprim Tylenol w/Codeine Tylenol w/Codeine Tylenol w/Codeine Tylenol w/Codeine Fiorinal Esgic Fioricet Norco Norco Norco Vicodin Vicodin ES Motrin Motrin Motrin Motrin Motrin Indocin Indocin Indocin Mobic Mobic Demerol Demerol Demerol Naprosyn Naprosyn Naprosyn Anaprox Anaprox DS Probenecid
Generic Name Allopurinol Allopurinol APAP/Codeine APAP/Codeine APAP/Codeine APAP/Codeine ASA/Caff/Butalbital Bulalb/APAP/Caff Bulalb/APAP/Caff Hydrocodone/APAP Hydrocodone/APAP Hydrocodone/APAP Hydrocodone/APAP Hydrocodone/APAP Ibuprofen Ibuprofen Ibuprofen Ibuprofen Ibuprofen Indomethacin Indomethacin Indomethacin Meloxicam Meloxicam Meperidine HCL Meperidine HCL Meperidine HCL Naproxen Naproxen Naproxen Naproxen Sod Naproxen Sod Probenecid
STRENGTH 300mg 100mg 120/12mg 120/12mg 300/30mg 300/60mg 325/40/50mg 50/325/40mg 50/325/40mg 7.5/325mg 10/325mg 5/325mg 5/500mg 7.5/750mg 400mg 600mg 800mg 50mg 100mg 25mg 50mg 75mg SR 7.5mg 15mg 50mg 100mg 50mg 250mg 375mg 500mg 275mg 550mg 500mg
Dosage Form tab tab elixir elixir tab tab tab tab tab tab tab tab tab tab tab tab tab tab chew tab chew cap cap cap tab tab soln tab tab tab tab tab tab tab tab
Drug Class Analgesic Analgesic Analgesic Analgesic Analgesic Analgesic Analgesic Analgesic Analgesic Analgesic Analgesic Analgesic Analgesic Analgesic Analgesic Analgesic Analgesic Analgesic Analgesic Analgesic Analgesic Analgesic Analgesic Analgesic Analgesic Analgesic Analgesic Analgesic Analgesic Analgesic Analgesic Analgesic Analgesic
Specific Therapeutic Description Antiarthritic Antiarthritic Narcotic Narcotic Narcotic Narcotic Narcotic Analgesic Analgesic Narcotic Narcotic Narcotic Narcotic Narcotic Non Steroidal Non Steroidal Non Steroidal Non Steroidal Non Steroidal NSAID NSAID NSAID NSAID NSAID Narcotic Narcotic Narcotic Non Steroidal Non Steroidal Non Steroidal Non Steroidal Non Steroidal Antiarthritic
Prescribing Edits
QL - 480 ml/month QL - 480 ml/month QL - 120 Tabs QL - 120 Tabs QL - 120 Tabs
QL - 120 Tabs QL - 120 Tabs QL - 120 Tabs QL - 120 Tabs QL - 120 Tabs
QL - 480 ml/month QL - 120 Tabs QL - 120 Tabs
12/23/2013
CBM ABW Formulary

Darvocet N Wygesic Disalcid Disalcid Ultram Fiorinal Lioresal Lioresal Flexeril Flexeril Robaxin Robaxin Zanaflex Zanaflex Zovirax Zovirax Zovirax Symmetrel Symmetrel Amoxil Amoxil Principen Principen Principen Zithromax Zithromax Zithromax Ceclor Ceclor Ceclor Ceclor Keflex Keflex Cipro Cipro Cipro Cleocin
Propoxyphene Naps/APAP Propoxyphene/APAP Salsalate Salsalate Tramadol ASA/Caff/Butalbital Baclofen Baclofen Cyclobenzaprine Cyclobenzaprine Methocarbamol Methocarbamol Tizanidine Tizanidine Acyclovir Acyclovir Acyclovir Amantadine Amantadine Amoxicillin Amoxicillin Ampicillin Ampicillin Ampicillin Azithromycin Azithromycin Azithromycin Cefaclor Cefaclor Cefaclor Cefaclor Cephalexin Cephalexin Ciprofloxacin Ciprofloxacin Ciprofloxacin Clindamycin
100/650mg 65/650mg 500mg 750mg 50mg 10mg 20mg 5mg 10mg 500mg 750mg 2mg 4mg 800mg 400mg 200mg 100mg 100mg 250mg 500mg 250mg 500mg 250/5 250mg 600mg 500mg 250mg 500mg 250/5mg 375/5mg 250mg 500mg 250mg 500mg 750mg 150mg
tab tab tab tab tab cap tab tab tab tab tab tab tab tab tab tab cap cap tab cap cap cap cap susp tab tab tab cap cap susp susp cap cap tab tab tab cap
Analgesic Analgesic Analgesic Analgesic Analgesic Analgesic Analgesics Analgesics Analgesics Analgesics Analgesics Analgesics Analgesics Analgesics Anti-Infective Anti-Infective Anti-Infective Anti-Infective Anti-Infective Anti-Infective Anti-Infective Anti-Infective Anti-Infective Anti-Infective Anti-Infective Anti-Infective Anti-Infective Anti-Infective Anti-Infective Anti-Infective Anti-Infective Anti-Infective Anti-Infective Anti-Infective Anti-Infective Anti-Infective Anti-Infective
Narcotic Narcotic Salicylate Salicylate Analgesic Narcotic Muscle Relaxants Muscle Relaxants Muscle Relaxants Muscle Relaxants Muscle Relaxants Muscle Relaxants Muscle Relaxants Muscle Relaxants Antiviral Antiviral Antiviral Miscellaneous Miscellaneous Penicillin Penicillin Penicillin Penicillin Penicillin Macrolide Macrolide Macrolide Cephalosporin Cephalosporin Cephalosporin Cephalosporin Cephalosporin Cephalosporin Quinolone Quinolone Quinolone Miscellaneous
QL - 120 Tabs QL - 120 Tabs
QL - 120 tabs
12/23/2013
CBM ABW Formulary

Vibramycin Vibramycin Vibramycin Vibra-Tab Eryc Ery-Tab Erythromycin Erythromycin EES Erythrocin Diflucan Grifulvin V Vermox Flagyl Flagyl Minocin Minocin Macrodantin Macrodantin Mycostatin Mycostatin Pen-VK Pen-VK Silvadene Bactrim Bactrim Bactrim DS Azulfadine Azulfadine Gantrisin Sumycin Sumycin Proloprim Proloprim Nolvadex Nolvadex Proventil
Doxycycline Doxycycline Doxycycline Doxycycline Erythromycin Base Erythromycin Base Erythromycin Base Erythromycin Base Erythromycin Ethylsuccinate Erythromycin Ster Fluconazole Griseofulvin Mebendazole Metronidazole Metronidazole Minocycline Minocycline Nitrofurantoin macro Nitrofurantoin macro Nystatin Nystatin Penicillin Penicillin Silver Sulfasalazine SMZ/TMP SMZ/TMP SMZ/TMP Sulfasalazine Sulfasalazine DR Sulfisoxazole Tetracycline Tetracycline Trimethoprim Trimethoprim Tamoxifen Tamoxifen Albuterol Sulfate
20mg 100mg 50mg 100mg 250mg 333mg 250mg 500mg 400mg 250mg 150mg 125/5 100mg 250mg 500mg 100mg 50mg 25mg 50mg 100mu/ml 500mu 250mg 500mg 1% 400/80mg 800/160mg 500mg 500mg 500/5 250mg 500mg 100mg 200mg 10mg 20mg 2mg
tab cap cap tab cap tab tab tab tab tab tab susp tab tab tab cap cap cap cap susp tab tab tab cream susp tab tab tab tab susp cap cap tab tab tab tab tab
Anti-Infective Anti-Infective Anti-Infective Anti-Infective Anti-Infective Anti-Infective Anti-Infective Anti-Infective Anti-Infective Anti-Infective Anti-Infective Anti-Infective Anti-Infective Anti-Infective Anti-Infective Anti-Infective Anti-Infective Anti-Infective Anti-Infective Anti-Infective Anti-Infective Anti-Infective Anti-Infective Anti-Infective Anti-Infective Anti-Infective Anti-Infective Anti-Infective Anti-Infective Anti-Infective Anti-Infective Anti-Infective Anti-Infective Anti-Infective Antineoplastic Antineoplastic Bronchial
Tetracycline Tetracycline Tetracycline Tetracycline Macrolide Macrolide Macrolide Macrolide Macrolide Macrolide Antifungal Antifungal Miscellaneous Antibacterial Antibacterial Tetracycline Tetracycline Miscellaneous Miscellaneous Miscellaneous Miscellaneous Penicillin Penicillin Sulfonamide Sulfonamide Sulfonamide Sulfonamide Sulfonamide Sulfonamide Sulfonamide Tetracycline Tetracycline Miscellaneous Miscellaneous SERM SERM Asthma/COPD
QL - 2
12/23/2013
CBM ABW Formulary

Proventil Proventil Proventil Proventil Ventolin HFA Tessalon Chlor-Trimeton Chlor-Trimeton Tavist Tavist Intal Neb Periactin Periactin Benadryl Benadryl Atrovent Atrovent Atrovent Claritin Claritin Claritin Reditab Phenergan Phenergan Phenergan Promethazine DM Serevent Diamox Norvasc Norvasc Norvasc Tenormin Tenormin Tenormin Tenoretic Tenoretic Lotensin Lotensin
Albuterol Sulfate Albuterol Sulfate Albuterol Sulfate Albuterol Sulfate Albuterol Sulfate Benzonatate Chlorpheniramine Mal Chlorpheniramine Mal Clemastine Clemastine Cromolyn Sodium Cyproheptadine Cyproheptadine Diphenhydramine Diphenhydramine Ipratropium Br Ipratropium Br Ipratropium Br Loratadine Loratadine Loratadine Promethazine Promethazine Promethazine Promethazine DM Salmeterol Xinafoate Acetazolamide Amlodipine Besylate Amlodipine Besylate Amlodipine Besylate Atenolol Atenolol Atenolol Atenolol/Chorthalidone Atenolol/Chorthalidone Benazepril Benazepril
4mg 2/5 5mg 0.83mg 90mcg 100mg 8mg 4mg 1.34mg 2.68mg 20mg/2ml 2/5 4mg 25mg 50mg 0.02% 42mcg 21mcg 10mg 5/5 10mg 12.5mg 25mg 50mg 50 mcg 250mg 2.5mg 10mg 5mg 100mg 50mg 25mg 50/25 100/25 5mg 10mg
tab syrup soln soln inh cap tab tab tab tab vial syrup tab cap cap neb soln soln tab syrup tab tab tab tab syrup Disk tab tab tab tab tab tab tab tab tab tab tab
Bronchial Bronchial Bronchial Bronchial Bronchial Bronchial Bronchial Bronchial Bronchial Bronchial Bronchial Bronchial Bronchial Bronchial Bronchial Bronchial Bronchial Bronchial Bronchial Bronchial Bronchial Bronchial Bronchial Bronchial Bronchial Bronchial Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular
Asthma/COPD Asthma/COPD Asthma/COPD Asthma/COPD Asthma/COPD Cough/Cold Antihistamine Antihistamine Antihistamine Antihistamine Mast Cell Stabilizer Antihistamine Antihistamine Antihistamine Antihistamine Asthma/COPD Asthma/COPD Asthma/COPD Antihistamine Antihistamine Antihistamine Antihistamine Antihistamine Antihistamine Antihistamine/Decong LABA Diuretic, Carbonic Anhydrase Calcium Channel Blocker Calcium Channel Blocker Calcium Channel Blocker Beta Blocker Beta Blocker Beta Blocker Beta Blocker + Diuretic Beta Blocker + Diuretic ACE Inhibitor ACE Inhibitor
QL - 2
QL - 1/Day QL - 1/Day QL - 1/Day
12/23/2013
CBM ABW Formulary

Lotensin Lotensin Lotensin HCT Lotensin HCT Lotensin HCT Lotensin HCT Ziac Ziac Ziac Bumex Bumex Bumex Capoten Capoten Capoten Capoten Capozide Capozide Capozide Coreg Coreg Coreg Coreg Hygroton Hygroton Hygroton Catapres Catapres Catapres Plavix Lanoxin Lanoxin Lanoxin Cardizem Cardizem Cardizem Cardizem
Benazepril Benazepril Benazepril/HCTZ Benazepril/HCTZ Benazepril/HCTZ Benazepril/HCTZ Bisoprol/HCTZ Bisoprol/HCTZ Bisoprol/HCTZ Bumetanide Bumetanide Bumetanide Captopril Captopril Captopril Captopril Captopril/HCTZ Captopril/HCTZ Captopril/HCTZ Carvedilol Carvedilol Carvedilol Carvedilol Chlorthalidone Chlorthalidone Chlorthalidone Clonidine Clonidine Clonidine Clopidogrel Digoxin Digoxin Digoxin Diltiazem Diltiazem Diltiazem Diltiazem
20mg 40mg 5/6.25 10/12.5 20/12.5 20/25 2.5/6.25 5/6.25 10/6.25 0.5mg 1mg 2mg 100mg 25mg 50mg 12.5mg 25/15 25/25 50/25 25mg 12.5mg 3.125mg 6.25mg 100mg 25mg 50mg 0.1mg 0.2mg 0.3mg 75mg SR 50mcg 125mcg 25mcg 30mg 60mg 90mg 120mg
tab tab tab tab tab tab tab tab tab tab tab tab tab tab tab tab tab tab tab tab tab tab tab tab tab tab tab tab tab tab soln tab tab tab tab tab tab
Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular
ACE Inhibitor ACE Inhibitor ACE Inhibitor/Diuretic ACE Inhibitor/Diuretic ACE Inhibitor/Diuretic ACE Inhibitor/Diuretic Beta Blocker + Diuretic Beta Blocker + Diuretic Beta Blocker + Diuretic Diuretics, Loop Diuretics, Loop Diuretics, Loop ACE Inhibitor ACE Inhibitor ACE Inhibitor ACE Inhibitor ACE Inhibitor/Diuretic ACE Inhibitor/Diuretic ACE Inhibitor/Diuretic Alpha/Beta Blocker Alpha/Beta Blocker Alpha/Beta Blocker Alpha/Beta Blocker Diuretic, Thiazide Diuretic, Thiazide Diuretic, Thiazide Antihypertensives, Misc Antihypertensives, Misc Antihypertensives, Misc Anticoagulant Digitalis Glycoside Digitalis Glycoside Digitalis Glycoside Calcium Channel Blocker Calcium Channel Blocker Calcium Channel Blocker Calcium Channel Blocker
12/23/2013
CBM ABW Formulary

Persantine Persantine Persantine Norpace Norpace Cardura Cardura Cardura Cardura Vasotec Vasotec Vasotec Vasotec Vaseretic Vaseretic Lasix Lasix Lasix Lasix Lopid Wytensin Wytensin Tenex Tenex Hydrodiuril Hydrodiuril Hydrodiuril Moduretic Dyazide Maxzide Maxzide Apresoline Apresoline Apresoline Lozol Lozol Isordil
Dipyridamole Dipyridamole Dipyridamole Disopyramide Phos Disopyramide Phos Doxazosin Doxazosin Doxazosin Doxazosin Enalapril Enalapril Enalapril Enalapril Enalapril/HCTZ Enalapril/HCTZ Furosemide Furosemide Furosemide Furosemide Gemfibrozil Guanabenz acet Guanabenz acet Guanfacine Guanfacine HCTZ HCTZ HCTZ HCTZ/Amiloride HCTZ/Triamterene HCTZ/Triamterene HCTZ/Triamterene Hydralazine Hydralazine Hydralazine Indapamide Indapamide Isosorbide dinitrare
25mg 50mg 75mg 100mg 150mg 1mg 2mg 4mg 8mg 5mg 10mg 20mg 2.5mg 10/25 5/12.5 10mg/ml 20mg 40mg 80mg 600mg 4mg 8mg 1mg 2mg 12.5mg 25mg 50mg 50/5 37.5/25 50/75 25/37.5 10mg 25mg 50mg 2.5mg 1.25mg 20mg
tab tab tab cap cap tab tab tab tab tab tab tab tab tab tab soln tab tab tab tab tab tab tab tab tab tab tab tab cap tab tab tab tab tab tab tab tab
Coronary Vasodilator Coronary Vasodilator Coronary Vasodilator Antiarrhythmic Antiarrhythmic Alpha Blocker Alpha Blocker Alpha Blocker Alpha Blocker ACE Inhibitor ACE Inhibitor ACE Inhibitor ACE Inhibitor ACE Inhibitor/Diuretic ACE Inhibitor/Diuretic Diuretic, Thiazide Diuretic, Thiazide Diuretic, Thiazide Diuretic, Thiazide Lipotropic Antihypertensives, Misc Antihypertensives, Misc Antihypertensives, Misc Antihypertensives, Misc Diuretic, Thiazide Diuretic, Thiazide Diuretic, Thiazide Diuretics, K+ Sparing Diuretics, K+ Sparing Diuretics, K+ Sparing Diuretics, K+ Sparing Antihypertensives, Misc Antihypertensives, Misc Antihypertensives, Misc Diuretic, Thiazide Diuretic, Thiazide Coronary Vasodilator
12/23/2013
CBM ABW Formulary

Isordil Isordil Isordil Isordil SL Isordil SL Imdur Imdur Imdur Vasodilan Zestril Zestril Zestril Zestril Zestril Zestril Zestoretic Zestoretic Zestoretic Mevacor Mevacor Mevacor Enduron Aldomet Aldomet Aldomet Lopressor Lopressor Lopressor Corgard Corgard Corgard Cardene Cardene Adalat/Procardia Nitro-Bid Nitro-Dur Nitro-Dur
Isosorbide dinitrate Isosorbide dinitrate Isosorbide dinitrate Isosorbide dinitrate SL Isosorbide dinitrate SL Isosorbide Mononitrate Isosorbide Mononitrate Isosorbide Mononitrate Isoxsuprine Lisinopril Lisinopril Lisinopril Lisinopril Lisinopril Lisinopril Lisinopril/HCTZ Lisinopril/HCTZ Lisinopril/HCTZ Lovastatin Lovastatin Lovastatin Methclothiazide Methyldopa Methyldopa Methyldopa Metoprolol Tar Metoprolol Tar Metoprolol Tar Nadolol Nadolol Nadolol Nicardipine Nicardipine Nifedepine Nitroglycerin Nitroglycerin Nitroglycerin
10mg 40mg 5mg 5mg 2.5mg 60mg 120mg 30mg 20mg 5mg 10mg 20mg 40mg 2.5mg 30mg 20/12.5 20/25 10/12.5 20mg 40mg 10mg 5mg 125mg 250mg 500mg 25mg 100mg 50mg 40mg 80mg 20mg 20mg 30mg 20mg 2% 0.4mg 0.1mg
tab tab tab tab tab tab tab tab tab tab tab tab tab tab tab tab tab tab tab tab tab tab tab tab tab tab tab tab tab tab tab tab tab cap Oint patch patch
Coronary Vasodilator Coronary Vasodilator Coronary Vasodilator Coronary Vasodilator Coronary Vasodilator Coronary Vasodilator Coronary Vasodilator Coronary Vasodilator Peripheral Vasodilator ACE Inhibitor ACE Inhibitor ACE Inhibitor ACE Inhibitor ACE Inhibitor ACE Inhibitor ACE Inhibitor/Diuretic ACE Inhibitor/Diuretic ACE Inhibitor/Diuretic Statin Statin Statin Diuretic, Thiazide Antihypertensives, Misc Antihypertensives, Misc Antihypertensives, Misc Beta Blocker Beta Blocker Beta Blocker Beta Blocker Beta Blocker Beta Blocker Calcium Channel Blocker Calcium Channel Blocker Calcium Channel Blocker Coronary Vasodilator Coronary Vasodilator Coronary Vasodilator
QL - 1/Day QL - 1/Day QL - 1/Day
12/23/2013
CBM ABW Formulary

Nitro-Dur Nitro-Dur Nitrostat Nitrostat Nitrostat Nitro-Bid Nitro-Bid Nitro-Bid Pavabid Visken Visken Kaon K-DUR K-DUR K-Tab Micro-K Micro-K Slow-K Pravachol Pravachol Pravachol Pravachol Minipres Minipres Minipres Procainamide Procainamide Procainamide Inderal Inderal Inderal Inderal Inderal Inderal Quinidine Quinidine Zocor
Nitroglycerin Nitroglycerin Nitroglycerin SL Nitroglycerin SL Nitroglycerin SL Nitroglyerin SA Nitroglyerin SA Nitroglyerin SA Papaverine Pindolol Pindolol Potassium Chloride Potassium Chloride Potassium Chloride Potassium Chloride Potassium Chloride Potassium Chloride Potassium Chloride Pravastatin Pravastatin Pravastatin Pravastatin Prazosin Prazosin Prazosin Procainamide Procainamide Procainamide SA Propranolol Propranolol Propranolol Propranolol Propranolol Propranolol Quinidine Sulf Quinidine Sulf Simvastatin
0.2mg 0.6mg 0.3mg 0.4mg 0.6mg 2.5mg 6.5mg 9mg 150mg 10mg 5mg 20meq/15ml 10mEq 20mEq 10meq 8meq 10meq 8meq 80mg 40mg 10mg 20mg 1mg 2mg 5mg 250mg 500mg 750mg 10mg 20mg 40mg 60mg 80mg 90mg 200mg 300mg 5mg
patch patch tab tab tab cap cap cap cap tab tab elixir tab tab tab cap cap cap tab tab tab tab cap cap cap tab tab tab tab tab tab tab tab tab tab tab tab
Coronary Vasodilator Coronary Vasodilator Coronary Vasodilator Coronary Vasodilator Coronary Vasodilator Coronary Vasodilator Coronary Vasodilator Coronary Vasodilator Peripheral Vasodilator Beta Blocker Beta Blocker Potassium Supplements Potassium Supplements Potassium Supplements Potassium Supplements Potassium Supplements Potassium Supplements Potassium Supplements Statin Statin Statin Statin Alpha Blocker Alpha Blocker Alpha Blocker Antiarrhythmic Antiarrhythmic Antiarrhythmic Beta Blocker Beta Blocker Beta Blocker Beta Blocker Beta Blocker Beta Blocker Antiarrhythmic Antiarrhythmic Lipitropics
12/23/2013
CBM ABW Formulary

Zocor Zocor Zocor Zocor Sotalol Sotalol Sotalol Sotalol Aldactone Aldactazide Hytrin Hytrin Hytrin Hytrin Calan Calan Calan Calan SR Calan SR Calan SR Coumadin Coumadin Coumadin Coumadin Coumadin Coumadin Coumadin Coumadin Coumadin Garamycin Garamycin Diprosone Diprosone Diprosone Valisone Valisone Valisone
Simvastatin Simvastatin Simvastatin Simvastatin Sotalol Sotalol Sotalol Sotalol Spironolactone Spironolactone/HCTZ Terazosin Terazosin Terazosin Terazosin Verapamil Verapamil Verapamil Verapamil SA Verapamil SA Verapamil SA Warfarin Warfarin Warfarin Warfarin Warfarin Warfarin Warfarin Warfarin Warfarin Gentamicin Sulf Gentamicin Sulf Betamethasone Dip Betamethasone Dip Betamethasone Dip Betamethasone Val Betamethasone Val Betamethasone Val
10mg 20mg 40mg 80mg 160mg 80mg 240mg 120mg 25mg 25/25 1mg 2mg 5mg 10mg 120mg 80mg 40mg 240mg 180mg 120mg 10mg 2mg 1mg 5mg 2.5mg 7.5mg 3mg 4mg 6mg 0.10% 0.10% 0.05% 0.05% 0.05% 0.10% 0.10% 0.10%
tab tab tab tab Tab Tab Tab Tab tab tab cap cap cap cap tab tab tab tab tab tab tab tab tab tab tab tab tab tab tab cream oint cr Oint lot cr Oint lot
Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Dematologic Dematologic Dermatological Dermatological Dermatological Dermatological Dermatological Dermatological
Lipitropics Lipitropics Lipitropics Lipitropics Beta-Adrenergic Blocker Beta-Adrenergic Blocker Beta-Adrenergic Blocker Beta-Adrenergic Blocker Diuretics, K+ Sparing Diuretics, K+ Sparing Alpha Blocker Alpha Blocker Alpha Blocker Alpha Blocker Calcium Channel Blocker Calcium Channel Blocker Calcium Channel Blocker Calcium Channel Blocker Calcium Channel Blocker Calcium Channel Blocker Anticoagulant Anticoagulant Anticoagulant Anticoagulant Anticoagulant Anticoagulant Anticoagulant Anticoagulant Anticoagulant Anti-Infective Anti-Infective Corticosteroid Corticosteroid Corticosteroid Corticosteroid Corticosteroid Corticosteroid
50/50 not covered - use 2 tabs 25/25
12/23/2013
CBM ABW Formulary

Temovate Clobetasol Temovate Clobetasol Temovate Clobetasol Lotrimin Clotrimazole Lotrimin Clotrimazole Synalar Fluocinolone Ace Synalar Fluocinolone Ace Synalar Fluocinolone Ace Lidex Fluocinonide Lidex Fluocinonide Lidex Fluocinonide Lidex Fluocinonide Lidex E Fluocinonide Anusol HC Hydrocortisone Hytone Hydrocortisone Hytone Hydrocortisone Hytone Hydrocortisone Hytone Hydrocortisone Hytone Hydrocortisone Hytone Hydrocortisone Hytone Hydrocortisone Hytone Hydrocortisone Mycostatin Nystatin Mycostatin Nystatin Mycolog Nystatin/Triamcin Mycolog Nystatin/Triamcin Elimite Permethrin Aristicort Triamcinolone Acetonide Aristicort Triamcinolone Acetonide Aristicort Triamcinolone Acetonide Aristicort Triamcinolone Acetonide Aristicort Triamcinolone Acetonide Kenalog Triamcinolone Acetonide Ascencia Blood Glucose Blood Strips Glucose Strips Diabinese Chlorpropamide Diabinese Chlorpropamide Amaryl Glimepiride
0.05% 0.05% 0.05% 1% 1% 0.01% 0.01% 0.01% 0.05% 0.05% 0.05% 0.05% 0.05% 25mg 0.50% 1% 2.50% 0.50% 1% 2.50% 1% 2.50% 100 mu 100 mu
5% 0.025% 0.10% 0.025% 0.10% 0.10% 0.025% 100mg 250mg 1mg
soln Oint cr Cr soln cr soln soln gel cr Oint soln cr Supp cr cr cr Oint cr Oint lot lot cr Oint cr Oint cr cr cr oint oint lot lot tab tab tab
Dermatological Dermatological Dermatological Dermatological Dermatological Dermatological Dermatological Dermatological Dermatological Dermatological Dermatological Dermatological Dermatological Dermatological Dermatological Dermatological Dermatological Dermatological Dermatological Dermatological Dermatological Dermatological Dermatological Dermatological Dermatological Dermatological Dermatological Dermatological Dermatological Dermatological Dermatological Dermatological Dermatological Diabetes Diabetes Diabetes Diabetes
Corticosteroid Corticosteroid Corticosteroid Antifungal Antifungal Corticosteroid Corticosteroid Corticosteroid Corticosteroid Corticosteroid Corticosteroid Corticosteroid Corticosteroid Rectal Prep Corticosteroid Corticosteroid Corticosteroid Corticosteroid Corticosteroid Corticosteroid Corticosteroid Corticosteroid Antifungal Antifungal Antifungal Antifungal Antiparasitic Corticosteroid Corticosteroid Corticosteroid Corticosteroid Corticosteroid Corticosteroid Supplies Sulfonylureas Sulfonylureas Sulfonylureas
QL - 100
10
12/23/2013
CBM ABW Formulary

Amaryl Amaryl Glucotorol Glucotorol Diabeta Diabeta Insulin Syringes Lancets Glucophage Glucophage Glucophage Glucophage XR Humulin Humulin Humulin N Humulin R Levemir Lac-Hydrin Lac-Hydrin Sprintec Tri-Sprintec Donnatal Donnatal Tagamet Tagamet Tagamet Citra-2 Librax Bentyl Bentyl Lomotil Lomotil Pepcid Pepcid Levsin Levsin SL Levsinex
Glimepiride Glimepiride Glipizide Glipizide Glyburide Glyburide Insulin Syringes Lancets Metformin Metformin Metformin Metformin
2mg 4mg 5mg 10mg 1.25mg 2.5mg
tab tab tab tab tab tab
Ammonium Lactate Ammonium Lactate Sprintec Tri-Sprintec Belladona Alk/Pb Belladona Alk/Pb Cimetidine Cimetidine Cimetidine Citric Acid/Sod. Citrate Clindinium Br/CDP Dicyclomine Dicyclomine Diphenoxylate/Atropine Su Diphenoxylate/Atropine Su Famotidine Famotidine Hyoscyamine Sulf Hyoscyamine Sulf Hyoscyamine Sulf
500mg 850mg 1000mg 500mg 50/50 70/30 U-100 U-100 U-100 12% 12%
300mg/5 300mg 400mg 334-500mg 20mg 10mg
20mg 40mg 0.125mg/ml 0.125mg/ml 0.375mg
tab tab tab tab ml ml ml ml ml lotion cream tab tab elixir tab liquid tab tab soln cap cap tab syrup tab tab tab drops tab cap
Diabetes Diabetes Diabetes Diabetes Diabetes Diabetes Diabetes Diabetes Diabetes Diabetes Diabetes Diabetes Diabetes Diabetes Diabetes Diabetes Diabetes Emollients Emollients Endocrine Endocrine Gastrointestinal Gastrointestinal Gastrointestinal Gastrointestinal Gastrointestinal Gastrointestinal Gastrointestinal Gastrointestinal Gastrointestinal Gastrointestinal Gastrointestinal Gastrointestinal Gastrointestinal Gastrointestinal Gastrointestinal Gastrointestinal
Sulfonylureas Sulfonylureas Sulfonylureas Sulfonylureas Sulfonylureas Sulfonylureas Supplies Supplies Biguanide Biguanide Biguanide Biguanide Insulin Insulin Insulin Insulin Insulin Emollients Emollients Contraceptive Contraceptive Antispasmotic/Anticholingergics Antispasmotic/Anticholingergics H-2 Antagonist H-2 Antagonist H-2 Antagonist Urinary PH Modifier Antispasmotic/Anticholingergics Antispasmotic/Anticholingergics Antispasmotic/Anticholingergics Antidiarrheal Antidiarrheal H-2 Antagonist H-2 Antagonist Antispasmotic/Anticholingergics Antispasmotic/Anticholingergics Antispasmotic/Anticholingergics
QL - 100
vial only vial only vial only vial only vial only
11
12/23/2013
CBM ABW Formulary

Cephulac Cephulac Reglan Reglan Reglan Zantac Zantac Decadron Decadron Decadron Decadron Decadron Decadron Decadron Decadron Cortef Cortef Cortef Levothroid Levothroid Levothroid Levothroid Levothroid Levothroid Levothroid Levothroid Levothroid Levothroid Levothroid Levothroid Levoxyl Levoxyl Levoxyl Levoxyl Levoxyl Levoxyl Levoxyl
Lactulose Lactulose Metoclopramide Metoclopramide Metoclopramide Ranitidine Ranitidine Dexamethasone Dexamethasone Dexamethasone Dexamethasone Dexamethasone Dexamethasone Dexamethasone Dexamethasone Hydrocortisone Hydrocortisone Hydrocortisone Levothyroxine Sodium Levothyroxine Sodium Levothyroxine Sodium Levothyroxine Sodium Levothyroxine Sodium Levothyroxine Sodium Levothyroxine Sodium Levothyroxine Sodium Levothyroxine Sodium Levothyroxine Sodium Levothyroxine Sodium Levothyroxine Sodium Levothyroxine Sodium Levothyroxine Sodium Levothyroxine Sodium Levothyroxine Sodium Levothyroxine Sodium Levothyroxine Sodium Levothyroxine Sodium
5mg/5 10mg 5mg 150mg 300mg 0.5mg/5 0.5mg 1mg 0.75mg 2mg 1.5mg 4mg 6mg 10mg 20mg 5mg 112 mcg 25 mcg 50 mcg 100 mcg 75 mcg 200 mcg 125 mcg 150 mcg 175 mcg 300 mcg 88 mcg 137 mcg 112 mcg 25 mcg 50 mcg 100 mcg 75 mcg 200 mcg 125 mcg
soln soln soln tab tab tab tab soln tab tab tab tab tab tab tab tab tab tab tab tab tab tab tab tab tab tab tab tab tab tab tab tab tab tab tab tab tab
Gastrointestinal Gastrointestinal Gastrointestinal Gastrointestinal Gastrointestinal Gastrointestinal Gastrointestinal Miscellaneous Miscellaneous Miscellaneous Miscellaneous Miscellaneous Miscellaneous Miscellaneous Miscellaneous Miscellaneous Miscellaneous Miscellaneous Miscellaneous Miscellaneous Miscellaneous Miscellaneous Miscellaneous Miscellaneous Miscellaneous Miscellaneous Miscellaneous Miscellaneous Miscellaneous Miscellaneous Miscellaneous Miscellaneous Miscellaneous Miscellaneous Miscellaneous Miscellaneous Miscellaneous
Laxative Laxative Anti-nausea Anti-nausea Anti-nausea H-2 Antagonist H-2 Antagonist Corticosteroid Corticosteroid Corticosteroid Corticosteroid Corticosteroid Corticosteroid Corticosteroid Corticosteroid Glucocorticoid Glucocorticoid Glucocorticoid Thyroid Thyroid Thyroid Thyroid Thyroid Thyroid Thyroid Thyroid Thyroid Thyroid Thyroid Thyroid Thyroid Thyroid Thyroid Thyroid Thyroid Thyroid Thyroid
12
12/23/2013
CBM ABW Formulary

Levoxyl Levoxyl Levoxyl Levoxyl Levoxyl Synthroid Synthroid Synthroid Synthroid Synthroid Synthroid Synthroid Synthroid Synthroid Synthroid Synthroid Synthroid Unithroid Unithroid Unithroid Unithroid Unithroid Unithroid Unithroid Unithroid Unithroid Unithroid Unithroid Unithroid Xylocaine Viscous Tapazole Tapazole Medrol DP Urised Ditropan Pyridium Pyridium
Levothyroxine Sodium Levothyroxine Sodium Levothyroxine Sodium Levothyroxine Sodium Levothyroxine Sodium Levothyroxine Sodium Levothyroxine Sodium Levothyroxine Sodium Levothyroxine Sodium Levothyroxine Sodium Levothyroxine Sodium Levothyroxine Sodium Levothyroxine Sodium Levothyroxine Sodium Levothyroxine Sodium Levothyroxine Sodium Levothyroxine Sodium Levothyroxine Sodium Levothyroxine Sodium Levothyroxine Sodium Levothyroxine Sodium Levothyroxine Sodium Levothyroxine Sodium Levothyroxine Sodium Levothyroxine Sodium Levothyroxine Sodium Levothyroxine Sodium Levothyroxine Sodium Levothyroxine Sodium Lidocaine Methimazole Methimazole Methylprednisolone Mth/Me Blue Oxybutynin Cl Phenazopyradine Phenazopyradine
150 mcg 175 mcg 300 mcg 88 mcg 137 mcg 112 mcg 25 mcg 50 mcg 100 mcg 75 mcg 200 mcg 125 mcg 150 mcg 175 mcg 300 mcg 88 mcg 137 mcg 112 mcg 25 mcg 50 mcg 100 mcg 75 mcg 200 mcg 125 mcg 150 mcg 175 mcg 300 mcg 88 mcg 137 mcg 2% 10mg 5mg 4mg 5mg 100mg 200mg
tab tab tab tab tab tab tab tab tab tab tab tab tab tab tab tab tab tab tab tab tab tab tab tab tab tab tab tab tab Soln tab tab tab tab tab tab tab
Miscellaneous Miscellaneous Miscellaneous Miscellaneous Miscellaneous Miscellaneous Miscellaneous Miscellaneous Miscellaneous Miscellaneous Miscellaneous Miscellaneous Miscellaneous Miscellaneous Miscellaneous Miscellaneous Miscellaneous Miscellaneous Miscellaneous Miscellaneous Miscellaneous Miscellaneous Miscellaneous Miscellaneous Miscellaneous Miscellaneous Miscellaneous Miscellaneous Miscellaneous Miscellaneous Miscellaneous Miscellaneous Miscellaneous Miscellaneous Miscellaneous Miscellaneous Miscellaneous
Thyroid Thyroid Thyroid Thyroid Thyroid Thyroid Thyroid Thyroid Thyroid Thyroid Thyroid Thyroid Thyroid Thyroid Thyroid Thyroid Thyroid Thyroid Thyroid Thyroid Thyroid Thyroid Thyroid Thyroid Thyroid Thyroid Thyroid Thyroid Thyroid Anesthetic Anti-Thyroid Anti-Thyroid Corticosteroid Urinary Tract Agents Urinary Tract Agents Urinary Tract Agents Urinary Tract Agents
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12/23/2013
CBM ABW Formulary

Prednisone Prednisone Prednisone Prednisone Prednisone Prednisone Propylthiouracil Armour Thyroid Armour Thyroid Armour Thyroid Armour Thyroid Armour Thyroid Armour Thyroid Armour Thyroid Armour Thyroid Isopto Atropine Decadron Propine FML Garamycin Betagan Betagan Maxitrol Maxitrol Neosporin Cortisporin Pilocarpine Pilocarpine Pilocarpine Pilocarpine Pilocarpine Pilocarpine Pred Forte Bleph-10 Timoptic Timoptic Tobrex
Prednisone Prednisone Prednisone Prednisone Prednisone Prednisone Propylthiouracil Thyroid Thyroid Thyroid Thyroid Thyroid Thyroid Thyroid Thyroid Atropine Sulfate Dexamethasone Dipivefrin Fluromethalone Gentamicin Sulf Levobunolol Levobunolol Neomycin/Polymx/Dexamth Neomycin/Polymx/Dexamth Neomycin/Polymx/Gram Neomycin/Polymx/HC Pilocarpine Pilocarpine Pilocarpine Pilocarpine Pilocarpine Pilocarpine Prednisolone Acet Sulfacetamide Sodium Timolol Mal Timolol Mal Tobramycin
1mg 10mg 2.5mg 20mg 5mg 50mg 50mg 120mg 30mg 300mg 60mg 15mg 90mg 180mg 240mg 1% 0.05% 0.10% 0.10% 0.30% 0.50% 0.25%
0.50% 1% 2% 3% 4% 6% 1% 10% 0.25% 0.50% 0.30%
tab tab tab tab tab tab tab tab tab tab tab tab tab tab tab gtt Oint drops susp drops drops drops Oint drops drops Oint drops drops drops drops drops drops drops drops drops drops drops
Miscellaneous Miscellaneous Miscellaneous Miscellaneous Miscellaneous Miscellaneous Miscellaneous Miscellaneous Miscellaneous Miscellaneous Miscellaneous Miscellaneous Miscellaneous Miscellaneous Miscellaneous Ophthalmic Agents Ophthalmic Agents Ophthalmic Agents Ophthalmic Agents Ophthalmic Agents Ophthalmic Agents Ophthalmic Agents Ophthalmic Agents Ophthalmic Agents Ophthalmic Agents Ophthalmic Agents Ophthalmic Agents Ophthalmic Agents Ophthalmic Agents Ophthalmic Agents Ophthalmic Agents Ophthalmic Agents Ophthalmic Agents Ophthalmic Agents Ophthalmic Agents Ophthalmic Agents Ophthalmic Agents
Corticosteroid Corticosteroid Corticosteroid Corticosteroid Corticosteroid Corticosteroid Anti-Thyroid Thyroid Thyroid Thyroid Thyroid Thyroid Thyroid Thyroid Thyroid Mydriatic Corticosteroid Glaucoma Corticosteroid Anti-Infective Glaucoma Glaucoma Anti-Infective/Corticosteroid Anti-Infective/Corticosteroid Anti-Infective Anti-Infective Glaucoma Glaucoma Glaucoma Glaucoma Glaucoma Glaucoma Corticosteroid Anti-Infective Glaucoma Glaucoma Anti-Infective
new gcn 11/2012
14
12/23/2013
CBM ABW Formulary

Vosol Domeboro Otogesic Cortisporin Cortisporin Sinemet Sinemet Sinemet Folic Acid Berocca Fosamax Fosamax Fosamax Fosamax Fosamax Estrace Estrace Estrace Ogen Ogen Ogen Provera Provera Monistat-3 Mycostatin
Acetic Acid Acetic Acid/Alum Ace Anitpyrine/Benzocaine/Glycerin Neomy/Pmx/HC Neomy/Pmx/HC Carbidopa/Levadopa Carbidopa/Levadopa Carbidopa/Levadopa Folic Acid Vitamin B Comp w/C Alendronate Alendronate Alendronate Alendronate Alendronate Estradiol Estradiol Estradiol Estropipate Estropipate Estropipate Medroxyprogesterone Medroxyprogesterone Miconazole nitrate Nystatin
2% 2%
10/100 25/100 25/250 1mg 35mg 10mg 40mg 5mg 70mg 1mg 2mg 0.5mg 0.75mg 1.5mg 3mg 10mg 2.5mg 200mg 100mu
drops drops drops soln susp tab tab tab tab tab tab tab tab tab tab tab tab tab tab tab tab tab tab supp tab
Otic Agents Otic Agents Otic Agents Otic Agents Otic Agents Psychotherapeutic Psychotherapeutic Psychotherapeutic Vitamin Supplements Vitamin Supplements Women's Health Women's Health Women's Health Women's Health Women's Health Women's Health Women's Health Women's Health Women's Health Women's Health Women's Health Women's Health Women's Health Women's Health Women's Health
Anti-Infective Miscellaneous Anesthetic Anti-Infective/Corticosteroid Anti-Infective/Corticosteroid Antiparkinson's Antiparkinson's Antiparkinson's Miscellaneous Miscellaneous Bone Resporption Inh Bone Resporption Inh Bone Resporption Inh Bone Resporption Inh Bone Resporption Inh Estrogen Estrogen Estrogen Estrogen Estrogen Estrogen Progesterone Progesterone Antifungal Women's Health - Antiinfective
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12/23/2013

CBM Oakland Health Plan Formulary

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CBM Oakland Health Plan Formulary

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Formatos disponibles

CBM ABW Formulary

QL - 480 ml/month QL - 120 Tabs QL - 120 Tabs

CBM ABW Formulary

QL - 120 Tabs QL - 120 Tabs

CBM ABW Formulary

CBM ABW Formulary

QL - 1/Day QL - 1/Day QL - 1/Day

CBM ABW Formulary

CBM ABW Formulary

CBM ABW Formulary

QL - 1/Day QL - 1/Day QL - 1/Day

CBM ABW Formulary

CBM ABW Formulary

50/50 not covered - use 2 tabs 25/25

CBM ABW Formulary

5% 0.025% 0.10% 0.025% 0.10% 0.10% 0.025% 100mg 250mg 1mg

CBM ABW Formulary

2mg 4mg 5mg 10mg 1.25mg 2.5mg

tab tab tab tab tab tab

300mg/5 300mg 400mg 334-500mg 20mg 10mg

20mg 40mg 0.125mg/ml 0.125mg/ml 0.375mg

CBM ABW Formulary

CBM ABW Formulary

CBM ABW Formulary

0.50% 1% 2% 3% 4% 6% 1% 10% 0.25% 0.50% 0.30%

new gcn 11/2012

CBM ABW Formulary

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