Chronic Illness Benefit medicine list (formulary)

Transcription

1 Chronic Illness Benefit medicine list (formulary) 2014

2 Chronic Illness Benefit 2014 Contents Page Explanation of terms 3 The Prescribed Minimum Benefits medicine list (for all plan types) 4 Important information you need to know We may change the information contained in this document from time to time. We will communicate any changes to the way we pay medicines when we make these changes. The Chronic Illness Benefit (CIB) is managed by the Discovery Health Medical Scheme Rules. The use of the benefits and programmes linked with the Chronic Illness Benefit are subject to specific conditions and rules. Members must make sure that they know these rules and conditions. Any instructions or advice on medicines and the management of the member s condition are intended to add to, and not replace, the knowledge, expertise, skill and judgement of the member s doctor, pharmacist or other healthcare professional. Discovery Health Medical Scheme reserves the right to change the benefit at any time. Page 2 of 26 01/2014

3 Explanation of terms Benefit year A benefit year refers to the benefits a member is entitled to during a calendar year, that is to say 1 January to 31 December. This medicine list (formulary) and Chronic Drug Amounts are applicable for 2014 only. Chronic Drug Amount (CDA) The CDA is a monthly amount we pay up to for a medicine class. This applies to medicine that is not listed on the medicine list (formulary). The Chronic Drug Amount includes VAT and the dispensing fee. Prescribed Minimum s (PMB conditions) These are conditions which all medical schemes are required to cover by the Council for Medical Schemes for any setting according to clinical guidelines. Chronic Disease List (CDL) A defined list of chronic conditions we cover according to the Prescribed Minimum Benefits. This describes medicines that have similar chemical structures or similar therapeutic effects. This is the main substance in a medicine that is responsible for the clinical action on a human body. Page 3 of 26 01/2014

4 Chronic Illness Benefit 2014 The Prescribed Minimum Benefits (PMB) medicine list (for all plan types) The PMB medicine list applies to all Discovery Health Medical Scheme for the 2014 benefit year. The CDA (Chronic Drug Amount) does not apply to KeyCare. Prescribed Minimum Addison s disease R150 R150 Systemic corticosteroids: Hydrocortisone R105 R105 Systemic corticosteroids: Mineralocorticoids Asthma R325 R325 Adrenergics - Formoterol combinations R140 R140 Adrenergics: Long acting - Formoterol R280 R375 Adrenergics: Long acting - Salmeterol R325 R325 Adrenergics: Salmeterol combinations R30 R30 Adrenergics: Short acting - Salbutamol R125 Anti-asthmatics: Systemic xanthines R195 R195 Inhaled anti-cholinergics: Ipratropium bromide R275 R330 Inhaled Glucocorticoids Hydrocortisone Covocort 10mg Fludrocortisone Florinef acetate 0.1mg Formoterol and Symbicord turbohaler 160/4.5mcg other drugs for obstructive 60 dose Symbicord turbohaler 320/9mcg airway diseases 60dose Formoterol Foratec dp-caps 12mcg Foratec hfa 120dose 12mcg/1dose Salmeterol Serevent accuhaler 60 dose 50mcg Salmeterol and other drugs for obstructive airway diseases Serevent CFC free 120 dose 25mcg Foxair accuhaler 50/100; 50/250; 50/ dose Sereflo hfa 25/50; 25/125; 25/ dose Salbutamol Venteze CFC free 200 dose 100mcg Theophylline Sandoz Theophylline anhydrous 200mg; 300mg Ipratropium bromide Atrovent HFA 200dose Ipvent HFA 200 dose 20mcg 40mcg/1dose Beclometasone Beceze 200dose CFC free 100mcg Beclate 200 dose 100mcg; 200mcg Budesonide Budeflam dp-caps 200mcg Budeflam HFA 300dose 100mcg; 200mcg Inflammide novolizer complete 200 dose 200mcg Inflammide novolizer complete 100 dose 400mcg Inflammide novolizer refill 200 dose 200mcg Inflammide novolizer refill 100 dose 400mcg Pulmicort turbuhaler 200dose 100mcg; 200mcg R350 R350 Surgical item Inhaler device Dp haler device Paediatric Spacer Glaxohaler R10 R10 Systemic Prednisone Be-Tabs Prednisone corticosteroids: Panafcort Prednisone Trolic Page 4 of 26 01/2014

5 Bipolar mood disorder R115 R330 Anti-depressants: SSRIs R265 R345 Anti-epileptics: Carboxamide R365 R365 Anti-epileptics: Fatty acid R255 R375 Anti-epileptics: Other agents R95 R95 Anti-psychotics: Butyrophenone R685 R1 000 Anti-psychotics: Clozapine R305 R305 Anti-psychotics: Lithium R605 R605 Anti-psychotics: Olanzapine R345 R345 Anti-psychotics: Phenothiazines with aliphatic side-chain Citalopram Adco-Talomil Arrow Citalopram ; Auro-Citalopram Austell-Citalopram Cilate Citalohexal Citalopram Actor Citalopram-Winthrop Mylan Citalopram Escitalopram Citraz 10mg; Escitalopram Be-Tabs 10mg; Zytomil 10mg; Fluoxetine A-Lennon Fluoxetine Deprozan Fluoxetine Actor Ranflocs Rezak Zydus Fluoxetine Paroxetine Adco-Paroxetine Paroxetine Unicorn Serrapress Sertraline Austell-Sertraline 50mg; Serdep 50mg; Zylin 50mg Carbamazepine Degranol 200mg Sandoz Carbamazepine Sandoz Carbamazepine CR Zeptol 200mg 200mg; 400mg 200mg Valproic acid Convulex 150mg Lamotrigine Convulex syrup Epilim crushable 250mg/5ml Epilim sugar-free syrup 200mg/5ml Epilizine CR 200mg; 300mg; 500mg Navalpro CR 200mg; 300mg; 500mg Dyna-Lamotrigine 2; 50mg; ; 200mg Lamidus 50mg; ; 200mg Sandoz Lamotrigine 50mg; ; 200mg Haloperidol Sandoz Haloperidol 1.; Clozapine Aspen Clozapine 2; Cloment 2; Lithium Camcolit 250mg; 400mg Quilonum retard 450mg Olanzapine Oleanz ; 10mg Olexar ; 10mg Redilanz ; 10mg Chlorpromazine Largactil 2; 50mg; Page 5 of 26 01/2014

6 Bipolar mood disorder R550 R550 Anti-psychotics: Quetiapine Dopaquel 2; ; 200mg; 300mg Quetiapine Mylan Quetiapine 2; ; 200mg; 300mg Psyquet 2; ; 200mg; 300mg Quetoser 2; ; 200mg; 300mg Serez 2; ; 200mg; 300mg R490 R620 Anti-psychotics: Flupenthixol Fluanxol 0.; 1mg Thioxanthene Fluanxol depot 1ml Fluanxol depot 2ml Zuclopenthixol Clopixol 2mg; 10mg Clopixol depot 200mg R455 R990 Other anti-psychotics Risperidone DRL-Risperidone 0.; 1mg; 2mg Perizal 0.; 1mg; 2mg; 3mg Risnia 0.; 1mg; 2mg; 3mg Schizorol 0.; 1mg; 2mg Zoxadon 0.; 1mg; 2mg Bronchiectasis R30 R30 Adrenergics: Salbutamol Venteze CFC free 200 dose 100mcg Short acting - Salbutamol R195 R195 Inhaled Ipratropium Atrovent HFA 200dose 20mcg anti-cholinergics: Ipratropium bromide bromide Ipvent HFA 200 dose 40mcg/1dose R10 R10 Systemic Prednisone Be-Tabs Prednisone corticosteroids: Panafcort Prednisone Trolic Cardiac failure R110 R115 ACE inhibitors and Enalapril and Enap co 20/12. Pharmapress co 20/12. Lisinopril and Adco-Zetomax co 10/12. Adco-Zetomax co 20/12. Hexal-Lisinopril co 10/12. Hexal-Lisinopril co 20/12. Lisinopril co Unicorn 10/12.; 20/12. Lisinozide 10/12. Lisinozide 20/12. Lisoretic 10/12.; 20/12. R75 R110 ACE inhibitors: plain Lisozide 20/12. Captopril Adco-Captomax 2; 50mg Bio-Captopril 2 Mylan Captopril 2; 50mg Enalapril Alapren ; 10mg; Enalapril Unicorn 10mg; Enap ; 10mg; Hr-Enalapril ; 10mg; Lisinopril Austell-Lisinopril 10mg; Sinopren ; 10mg; Perindopril Acti-Prex Auro Perindopril Bindace Ciplasyl ; 8mg Pearinda ; 8mg Page 6 of 26 01/2014

7 Cardiac failure R75 R110 ACE inhibitors: plain R200 R225 Alpha and Beta blocking agents R110 R115 Angiotensin II antagonists, Combinations: Losartan and R75 R115 Angiotensin II antagonists: plain R80 R80 Arteriolar smooth muscle Hydrazinophthalazine R60 R75 Beta blocking selective R25 R25 Cardiac glycosides: Digoxin R20 R40 High-ceiling R15 R15 Low-ceiling : Thiazides, plain R20 R20 Low-ceiling : excluding Thiazides R90 R90 Potassium sparing agents Perindopril Perindopril Unicorn Ran-Perindopril Zydus Perindopril Quinapril Accumax 10mg; Carvedilol Carvedilol Unicorn 6.2; 12.; 2 Carvetrend 6.2; 12.; 2 Vediblok 6.2; 12.; 2 Losartan and Austell Losartan co 50/12. Ciplazar co 100/2 Hytenza co 50/12.; 100/2 Lohype Forte Plus 100/2 Losaar Plus 50/12.; 100/2 Losacar co 50/12. Losartan co Unicorn 50/12. Losartan co Unicorn 100/2 Netrasol co 50/12.; 100/2 Sartoc-co 100/2 Zartan co 100/2 Losartan Ciplazar Hytenza Spec-Losartan Zartan Valsartan Diolo 80mg; 160mg Hydralazine Hyperphen 10mg; 50mg Sandoz Hydralazine 2 Bisoprolol Adco-Bisocor ; 10mg Betacor ; 10mg Bilocor ; 10mg Bisohexal ; 10mg Bisoprolol Unicorn ; 10mg Ziapro ; 10mg Digoxin Lanoxin 0.062; 0.2 Lanoxin paed syrup 0.0/1ml Furosemide Beurises Dino-Retic Diuresix Mylan Furosemide Hydrochloro- Hexazide 2 thiazide Ridaq 12. Indapamide Cipla-Indapamide 2. Daptril 2. Merck-Indapamide 2. Spironolactone Aldactone 2 Sandoz Spironolactone 2 Spiractin 2 Page 7 of 26 01/2014

8 C DA for Cardiac failure Potassium supplements R170 R170 Vasodilators in cardiac disease: Organic nitrates Potassium chloride Glyceryl trinitrate Isosorbide dinitrate Isosorbide mononitrate R70 R70 Influenza vaccines Influenza, purified antigen R135 R135 Pneumococcus Pneumococcus, vaccines purified polysaccharides antigen Cardiomyopathy R110 R115 ACE inhibitors and Enalapril and Lisinopril and R75 R110 ACE inhibitors: plain R200 R225 Alpha and Beta blocking agents Plenish K Sandoz K-600 Angised Sandoz Isosorbide dinitrate Elantan Elantan LA Monicor SR Fluarix pre-filled syringe 0.5ml Fluvax pre-filled syringe 0.5ml Imovax pneumo mg 600mg 0. ; 10mg; 30mg 50mg 60mg Enap co 20/12. Pharmapress co 20/12. Adco-Zetomax co 10/12. Adco-Zetomax co 20/12. Hexal-Lisinopril co 10/12. Hexal-Lisinopril co 20/12. Lisinopril co Unicorn 10/12.; 20/12. Lisinozide 10/12. Lisinozide 20/12. Lisoretic 10/12.; 20/12. Lisozide 20/12. Captopril Adco-Captomax 2; 50mg Bio-Captopril 2 Mylan Captopril 2; 50mg Enalapril Alapren ; 10mg; Enalapril Unicorn 10mg; Enap ; 10mg; Hr-Enalapril ; 10mg; Lisinopril Austell-Lisinopril 10mg; Sinopren ; 10mg; Perindopril Acti-Prex Auro Perindopril Bindace Ciplasyl ; 8mg Pearinda ; 8mg Perindopril Unicorn Ran-Perindopril Zydus perindopril Quinapril Accumax 10mg; Carvedilol Carvedilol Unicorn 6.2; 12.; 2 Carvetrend 6.2; 12.; 2 Vediblok 6.2; 12.; 2 Page 8 of 26 01/2014

9 Cardiomyopathy R110 R115 Angiotensin II antagonists, Combinations: Losartan and R75 R115 Angiotensin II antagonists: plain Losartan and Austell Losartan co 50/12. Ciplazar co 100/2 Hytenza co 50/12.; 100/2 Lohype Forte Plus 100/2 Losaar Plus 50/12.; 100/2 Losacar co 50/12. Losartan co Unicorn 50/12. Losartan co Unicorn 100/2 Netrasol co 50/12.; 100/2 Sartoc co 100/2 Zartan co 100/2 Losartan Ciplazar Hytenza Spec-Losartan Zartan Valsartan Diolo 80mg; 160mg R60 R75 Beta blocking selective R25 R25 Cardiac glycosides: Digoxin R20 R40 High-ceiling R15 R15 Low-ceiling : Thiazides, plain R20 R20 Low-ceiling : excluding Thiazides R90 R90 Potassium sparing agents Potassium supplements R170 R170 Vasodilators in cardiac disease: Organic nitrates R75 R75 Anti-thrombotic Warfarin Cipla-Warfarin 1mg; 3mg; Vitamin K antagonists R80 R80 Arteriolar smooth Hydralazine Hyperphen 10mg; 50mg muscle Hydrazinophthalazine Sandoz Hydralazine 2 R10 R20 Aspirin Acetylsalicylic Aspirin 300mg acid Gulf Aspirin 300mg Bisoprolol Adco-Bisocor ; 10mg Betacor ; 10mg Bilocor ; 10mg Bisohexal ; 10mg Bisoprolol Unicorn ; 10mg Ziapro ; 10mg Digoxin Lanoxin 0.062; 0.2 Lanoxin paed syrup 0.0/1ml Furosemide Beurises Dino-Retic Diuresix Mylan Furosemide Hydrochlorothiazide Hexazide 2 Ridaq 12. Indapamide Cipla-Indapamide 2. Daptril 2. Merck-Indapamide 2. Spironolactone Aldactone 2 Sandoz Spironolactone 2 Spiractin 2 Potassium Plenish K 600mg chloride Sandoz K mg Glyceryl Angised 0. trinitrate Page 9 of 26 01/2014

10 Cardiomyopathy R170 R170 Vasodilators in cardiac disease: Organic nitrates Chronic obstructive pulmonary disease (COPD) Isosorbide dinitrate Isosorbide mononitrate R70 R70 Influenza vaccines Influenza, purified antigen R135 R135 Pneumococcus Pneumococcus, vaccines purified polysaccharides antigen R155 R155 Adrenergics: Salbutamol combinations R30 R30 Adrenergics: Short acting - Salbutamol R125 Anti-asthmatics: Systemic xanthines R195 R195 Inhaled anti-cholinergics: Ipratropium bromide R685 R685 Surgical item: Oxygen concentrator R10 R10 Systemic corticosteroids: Prednisone Sandoz Isosorbide dinitrate Elantan Elantan LA Monicor SR Fluarix pre-filled syringe 0.5ml Fluvax pre-filled syringe 0.5ml Imovax pneumo 23 ; 10mg; 30mg 50mg 60mg Salbutamol and other drugs for obstructive airway diseases Duolin hfa 200 dose Salbutamol Venteze CFC free 200 dose 100mcg Theophylline Ipratropium bromide Oxygen R70 R70 Influenza vaccines Influenza, purified antigen Sandoz Theophylline anhydrous 200mg; 300mg Atrovent HFA 200dose Ipvent HFA 200 dose Oxygen concentrator rental 20mcg 40mcg/1dose Prednisone Be-Tabs Prednisone Panafcort Trolic Fluarix pre-filled syringe 0.5ml Fluvax pre-filled syringe 0.5ml Chronic renal disease R110 R115 ACE inhibitors and R75 R110 ACE inhibitors: plain Enalapril and Lisinopril and Enap co Pharmapress co Adco-Zetomax co Adco-Zetomax co Hexal-Lisinopril co 20/12. 20/12. 10/12. 20/12. 10/12. Hexal-Lisinopril co 20/12. Lisinopril co Unicorn 10/12.; 20/12. Lisinozide 10/12. Lisinozide 20/12. Lisoretic 10/12.; 20/12. Lisozide 20/12. Captopril Adco-Captomax 2; 50mg Bio-Captopril 2 Mylan Captopril 2; 50mg Enalapril Alapren ; 10mg; Enalapril Unicorn 10mg; Enap ; 10mg; Hr-Enalapril ; 10mg; Lisinopril Austell-Lisinopril 10mg; Sinopren ; 10mg; Perindopril Acti-Prex Auro Perindopril Bindace Page 10 of 26 01/2014

11 Chronic renal disease R75 R110 ACE inhibitors: plain R110 R115 Angiotensin II antagonists, Combinations: Losartan and R75 R115 Angiotensin II antagonists: plain R215 R215 Calcium supplements R5 R5 Folic acid and Iron in combination with folic acid R570 R570 Iron trivalent, parenteral preparations R4 000 R4 000 Other anti-anaemic preparations Perindopril Ciplasyl ; 8mg Pearinda ; 8mg Perindopril Unicorn Ran-Perindopril Zydus perindopril Quinapril Accumax 10mg; Losartan and Austell Losartan co 50/12. Ciplazar co 100/2 Hytenza co 50/12.; 100/2 Lohype Forte Plus 100/2 Losaar Plus 50/12.; 100/2 Losacar co 50/12. Losartan co Unicorn 50/12. Losartan co Unicorn 100/2 Netrasol co 50/12.; 100/2 Sartoc co 100/2 Zartan co 100/2 Losartan Ciplazar Hytenza Spec-Losartan Zartan Valsartan Diolo 80mg; 160mg Calcium B-cal carbonate Folic acid Aha Folic acid Ferrous fumarate Ferricoxidedextrancomplex Saccharated iron oxide Darbepoetin Alfa Be-Tabs Folic acid Folic acid Pregamal Cosmofer ampoule Venofer Aranesp pre-filled syringe 0.4ml Aranesp pre-filled syringe 0.5ml Aranesp pre-filled syringe 0.3ml Aranesp pre-filled syringe 0.4ml Aranesp pre-filled syringe 0.5ml Aranesp pre-filled syringe 0.3ml 0. 50mg/1ml /1ml 10mcg/0.4ml 20mcg/0.5ml 30mcg/0.3ml 40mcg/0.4ml 50mcg/0.5ml 60mcg/0.3ml Page 11 of 26 01/2014

12 Chronic renal disease R4 000 R4 000 Other anti-anaemic Erythropoietin Eprex pre-fill 2000U/0.5ml preparations Eprex pre-fill 4000U/0.4ml Recormon pre-filled syringe 500U/0.3ml Recormon pre-filled syringe 2000U/0.3ml Recormon pre-filled syringe 4000U/0.3ml Repotin 1ml 2000IU Repotin 1ml 4000IU Methoxy Mircera pre-filled syringe 0.3ml 30mcg/0.3ml polyethyleneglycol- Mircera pre-filled syringe 0.3ml 50mcg/0.3ml Mircera pre-filled syringe 0.3ml 75mcg/0.3ml epoetin beta Mircera pre-filled syringe 0.3ml 100mcg/0.3ml Mircera pre-filled syringe 0.3ml 120mcg/0.3ml Mircera pre-filled syringe 0.3ml 150mcg/0.3ml Mircera pre-filled syringe 0.3ml 200mcg/0.3ml Mircera pre-filled syringe 0.3ml 250mcg/0.3ml R365 R365 Vitamin D and Alfacalcidol One alpha 0.25mcg; 1mcg analogues Coronary artery disease R10 R20 Aspirin Acetylsalicylic Aspirin 300mg acid Gulf Aspirin 300mg R60 R170 Beta blocking Propranolol Indoblok 10mg; Prodorol 10mg; non-selective Purbloka 10mg; R60 R75 Beta blocking Atenolol B-Block 50mg; Bio-Atenolol 50mg; selective Gulf Atenolol 50mg; Sandoz Atenolol 50mg; Tenopress R180 R255 Selective calcium Diltiazem Adco-Zildem 60mg channel blockers Adco-Zildem SR 180mg; 2 with direct cardiac Verapamil Vasomil ; 80mg effects Verahexal SR 2 R130 R170 Selective calcium Amlodipine Almadin ; 10mg channel blockers Amlodac with mainly vascular Gulf Amlodipine ; 10mg effects Indo Amlodipine Lomanor ; 10mg Pharma Dynamics Amlodipine besylate ; 10mg Felodipine Felodipine-Hexal ; 10mg Nifedipine Adco-Vascard SR Cipalat Retard Nifedalat SR R170 R170 Vasodilators in Glyceryl Angised 0. cardiac disease: Organic nitrates trinitrate Isosorbide Sandoz Isosorbide dinitrate ; 10mg; 30mg dinitrate Isosorbide Elantan mononitrate Elantan LA 50mg Monicor SR 60mg Crohn s disease R5 R5 Folic acid and Folic acid Aha Folic acid Be-Tabs Folic acid Folic acid 0. R680 R680 Intestinal antiinflammatories: Mesalazine Asacol 400mg; 500mg; 800mg Pentasa 500mg; 1000mg Aminosalicylic acid Salofalk 1000mg and similar agents Olsalazine Dipentum 250mg Sulfasalazine Salazopyrin 500mg Salazopyrin EN 500mg Page 12 of 26 01/2014

13 Crohn s disease R2 285 R2 285 Intestinal antiinflammatories: Corticosteroids R590 R590 Other immunosuppressive Azathioprine Other immunosuppressive Methotrexate R10 R10 Systemic corticosteroids: Prednisone Diabetes insipidus R1 380 R1 600 Posterior pituitary hormones: Vasopressin and analogues Diabetes mellitus Type 1 R680 R720 Anti-diabetic Insulins and analogues R200 R280 Blood glucose monitoring agents Budesonide Entocord enema Azathioprine Azamun 50mg Azathioprine PCH 50mg Methotrexate Abitrexate 2. Methotrexate 2. Prednisone Be-Tabs Prednisone Panafcort Trolic Desmopressin Ddavp 0.1mg; 0.2mg Insulin Glucose strips Ddavp nasal spray 5ml 0.1mg/1ml Actraphane hm(ge) - vial 10ml Apidra - solostar disposable pens 3ml Biosulin cartridge 3ml Biosulin l cartridge 3ml Biosulin n cartridge 3ml Biosulin r cartridge 3ml Humalog vial 10ml Humalog cartridge 3ml Humalog kwikpen - penset 3ml Humalog mix 25 kwikpen - penset 3ml Humalog mix 25 - cartridge 3ml; vial 10ml) Humalog mix 50 - cartridge 3ml Humalog mix 50 - kwikpen 3ml Humulin 30/70 - cartridge 3ml; disposable pens 3ml; vial 10ml Humulin n - cartridge 3ml; disposable pen 3ml; vial 10ml Humulin r - cartridge 3ml; vial 10ml Insuman comb 30/70 - cartridge 3ml Novomix 30 - flexpen 3ml; penfill 3ml Novorapid - penfill 3ml Accu-chek active strips Caresens ii/pop test strip 29g Caresens n test strips 29g Glucocheck strips 50s Glucoplus Glucoplus provider strips Glucose test strips free style optium Onetouch select glucose test strips On-call plus ez strips (all sizes) Page 13 of 26 01/2014

14 Diabetes mellitus Type 1 R350 R350 Surgical item Devices Biosulin pen device Lancets Lancets glucoplus 66 x 44 x 78mm Needles BD microfine pen needle 32g 4mm BD microfine pen needle 31g 5mm Needle novofine Needle pen bd microfine 30g 8mm Diabetes mellitus Type 2 R60 R60 Anti-diabetic Metformin Accord Metformin 500mg; 850mg Arrow Metformin 500mg; 850mg Biguanides Austell-Metformin 500mg; 850mg Bigsens 500mg; 850mg; 1000mg Diaformin 500mg Diaformin forte 850mg Diamin 500mg; 850mg Gluconorm 500mg; 850mg Mengen 500mg; 850mg; 1000mg Metchek 500mg; 850mg Metforal 500mg; 850mg Metored 500mg; 850mg; 1000mg Metphage 500mg; 850mg Mylan Metformin 500mg; 850mg Sandoz Metformin 500mg Sandoz Metformin FCT 500mg R680 R720 Anti-diabetic Insulins and analogues Insulin Actraphane hm(ge) - vial 10ml Apidra - solostar disposable pens 3ml Biosulin cartridge 3ml Biosulin l cartridge 3ml Biosulin n cartridge 3ml Biosulin r cartridge 3ml Humalog vial 10ml Humalog cartridge 3ml Humalog kwikpen - penset 3ml Humalog mix 25 kwikpen - penset 3ml Humalog mix 25 - cartridge 3ml; vial 10ml Humalog mix 50 - cartridge 3ml Humalog mix 50 kwikpen 3ml Humulin 30/70 - cartridge 3ml; disposable pens 3ml; vial 10ml Humulin n - cartridge 3ml; disposable pen 3ml; vial 10ml Humulin r - cartridge 3ml; vial 10ml Insuman comb 30/70 - cartridge 3ml Novomix 30 - flexpen 3ml; penfill 3ml Novorapid - penfill 3ml R100 R100 Anti-diabetic Glibenclamide Bio-Glibenclamide Diacare Sulfonamides, urea Glycomin Sandoz Glibenclamide Gliclazide Adco-Glucomed 80mg Arrow Gliclazide 80mg Austell-Gliclazide 80mg Diaglucide 80mg Page 14 of 26 01/2014

15 Diabetes mellitus Type 2 R100 R100 Anti-diabetic Sulfonamides, urea R160 R180 Anti-diabetic Thiazolidinediones R200 R280 Blood glucose monitoring agents Gliclazide Diaran MR 30mg Dyna Gliclazide SR 30mg Glycron 80mg Glygard 80mg Sandoz Gliclazide 80mg Pioglitazone Accord Pioglitazone 1; 30mg Glucose strips Cipla-Pioglitazone Accu-chek active strips Caresens ii/pop test strip 29g Caresens n test strips 29g Glucocheck strips 50s Glucoplus Glucoplus provider strips Glucose test strips free style optium Onetouch select glucose test strips On-call plus ez strips (all sizes) R350 R350 Surgical item Devices Biosulin pen device Dysrhythmias R530 R605 Anti-arrhythmics: class Ic R380 R380 Anti-arrhythmics: class III - Amiodarone Lancets Needles Lancets glucoplus 66 x 44 x 78mm BD microfine pen needle 32g 4mm BD microfine pen needle 31g 5mm Needle novofine Needle pen bd microfine 30g 8mm 1; 30mg Flecainide Tambocor Tambocor CR ; 200mg Propafenone Rythmol 150mg; 300mg Amiodarone Arycor ; 200mg Bio-Amiodarone Hexarone 200mg ; 200mg R75 R75 Anti-thrombotic Warfarin Cipla-Warfarin 1mg; 3mg; Vitamin K antagonists R10 R20 Aspirin Acetylsalicylic Aspirin 300mg acid Gulf Aspirin 300mg R60 R170 Beta blocking non-selective R60 R75 Beta blocking selective R25 R25 Cardiac glycosides: Digoxin R180 R255 Selective calcium channel blockers with direct cardiac effects Propranolol Indoblok 10mg; Prodorol Purbloka 10mg; 10mg; Sotalol Sotahexal 80mg; 160mg Atenolol B-Block 50mg; Bio-Atenolol Gulf Atenolol Sandoz Atenolol Tenopress 50mg; 50mg; 50mg; Digoxin Lanoxin 0.062; 0.2 Lanoxin paed syrup 0.0/1ml Verapamil Vasomil ; 80mg Verahexal SR 2 Page 15 of 26 01/2014

16 Epilepsy R170 R260 Anti-epileptics: Benzodiazepine R265 R345 Anti-epileptics: Carboxamide R365 R365 Anti-epileptics: Fatty acid R60 R60 Anti-epileptics: Hydantoin R255 R375 Anti-epileptics: Other agents R25 R25 Anti-epileptics: Barbiturates and Glaucoma R170 R170 Anti-glaucoma Carbonic anhydrase inhibitors R225 R225 Anti-glaucoma Prostaglandin analogues R245 R245 Anti-glaucoma Sympathomimetics Anti-glaucoma Beta blocking Timolol R240 R240 Anti-glaucoma Beta blocking Timolol, combinations Haemophilia R5 R5 Analgesics: Paracetamol R195 R195 Anti-fibrinolytics: Amino acids R R Blood coagulation factors R1 380 R1 600 Posterior pituitary hormones: Vasopressin and analogues Hyperlipidaemia R245 R245 Lipid modifying Fibrates Clonazepam Rivotril 0.; 2mg Carbamazepine Degranol 200mg Sandoz Carbamazepine 200mg Sandoz Carbamazepine CR 200mg; 400mg Zeptol 200mg Valproic acid Convulex 150mg Convulex syrup 250mg/5ml Epilim crushable Epilim sugar-free syrup 200mg/5ml Epilizine CR 200mg; 300mg; 500mg Navalpro CR 200mg; 300mg; 500mg Phenytoin Phenytoin sod Lamotrigine Dyna-Lamotrigine 2; 50mg; ; 200mg Lamidus 50mg; ; 200mg Sandoz Lamotrigine 50mg; ; 200mg Topiramate Epitoz 2; 50mg; Sandoz Topiramate 50mg; 200mg Phenobarbital Lethyl 30mg Sedabarb 30mg Dorzolamide Trusopt 5ml owi 2% Bimatoprost Lumigan 0.01% Latanoprost Ocuprost 3ml 50mcg/1ml Travoprost Travatan 2.5ml 0.004% Brimonidine Alphagan purite 5ml 1./1ml Timolol Glaucosan 5ml 0.5% Timolol, combinations Azarga 5ml Combigan 5ml 2mg/ Cosopt 5ml 0.5% Duotrav 2.5ml Ganfort 3ml Paracetamol Adco-Napamol 500mg Adco-Prolief 500mg Cetapon 500mg Painogesic 500mg Tranexamic acid Tranexamic acid medwich 500mg Tranic 500mg Coagulation Haemosolvex IX 500U factor IX Coagulation Haemosolvate VIII 300U; 500U; 1000U factor VIII Desmopressin Ddavp 0.1mg; 0.2mg Ddavp nasal spray 5ml 0.1mg/1ml Bezafibrate Dyna-Bezafibrate SR 400mg Sandoz Bezafibrate 400mg Page 16 of 26 01/2014

17 Hyperlipidaemia R45 R55 Lipid modifying Statins Hypertension R110 R115 ACE inhibitors and R75 R110 ACE inhibitors: plain Atorvastatin Adco Atorvastatin 10mg; Adco Atorvastatin Aspavor 10mg; ; Atolip 10mg; ; Dynator 10mg; ; Dynator 80mg Lipogen 80mg Simvastatin Adco-Simvastatin Arrow Simvastatin Austell-Simvastatin 10mg; ; Biovac Simvastatin Choleste Cipla-Simvastatin 10mg; ; Redicor 10mg; Redicor Simvacor Simzor 10mg; Simzor Zysim 10mg; ; Enalapril and Enap co 20/12. Pharmapress co 20/12. Lisinopril and Adco-Zetomax co 10/12. Adco-Zetomax co 20/12. Hexal-Lisinopril co 10/12. Hexal-Lisinopril co 20/12. Lisinopril co Unicorn 10/12.; 20/12. Lisinozide 10/12. Lisinozide 20/12. Lisoretic 10/12.; 20/12. Lisozide 20/12. Captopril Adco-Captomax 2; 50mg Bio-Captopril 2 Mylan Captopril 2; 50mg Enalapril Alapren ; 10mg; Enalapril Unicorn 10mg; Enap ; 10mg; Hr-Enalapril ; 10mg; Lisinopril Austell-Lisinopril 10mg; Sinopren ; 10mg; Perindopril Acti-Prex Auro Perindopril Bindace Ciplasyl ; 8mg Pearinda ; 8mg Ran-Perindopril Zydus Perindopril Page 17 of 26 01/2014

18 Hypertension R75 R110 ACE inhibitors: plain R200 R225 Alpha and Beta blocking agents R110 R115 Angiotensin II antagonists, Combinations: Losartan and R75 R115 Angiotensin II antagonists: plain R130 R130 Anti-adrenergic Alphaadrenoreceptor antagonists R120 R120 Anti-adrenergic Methyldopa R25 R25 Anti-adrenergic Rauwolfia alkaloids R80 R80 Arteriolar smooth muscle Hydrazinophthalazine R60 R170 Beta blocking non-selective R60 R75 Beta blocking selective R20 R40 High-ceiling R15 R15 Low-ceiling : Thiazides, plain Quinapril Accumax 10mg; Carvedilol Carvedilol Unicorn 6.2; 12.; 2 Carvetrend 6.2; 12.; 2 Vediblok 6.2; 12.; 2 Losartan and Austell Losartan co 50/12. Ciplazar co 100/2 Hytenza co 50/12.; 100/2 Lohype Forte Plus 100/2 Losaar Plus 50/12.; 100/2 Losacar co 50/12. Losartan co Unicorn 50/12. Losartan co Unicorn 100/2 Netrasol co 50/12.; 100/2 Sartoc co 100/2 Zartan co 100/2 Losartan Ciplazar Hytenza Spec-Losartan Zartan Valsartan Diolo 80mg; 160mg Doxazosin Adco-Doxazosin 1mg; 2mg; Cardugen 1mg; Methyldopa Hypotone 250mg Mylan Methyldopa 250mg Sandoz Methyldopa 250mg Reserpine Reserpine 0.2 Hydralazine Hyperphen 10mg; 50mg Sandoz Hydralazine 2 Propranolol Indoblok 10mg; Prodorol 10mg; Purbloka 10mg; Atenolol B-Block 50mg; Bio-Atenolol 50mg; Gulf Atenolol 50mg; Sandoz Atenolol 50mg; Tenopress Furosemide Beurises Dino-Retic Diuresix Mylan Furosemide Hydrochloro- Hexazide 2 thiazide Ridaq 12. Page 18 of 26 01/2014

19 Hypertension R20 R20 Low-ceiling Indapamide Cipla-Indapamide 2. : Daptril 2. excluding Thiazides Merck-Indapamide 2. R90 R90 Potassium sparing Spironolactone Aldactone 2 agents Sandoz Spironolactone 2 Spiractin 2 Potassium Potassium Plenish K 600mg supplements chloride Sandoz K mg R180 R255 Selective calcium Diltiazem Adco-Zildem 60mg channel blockers Adco-Zildem SR 180mg; 2 with direct cardiac Verapamil Vasomil ; 80mg effects Verahexal SR 2 R130 R170 Selective calcium Amlodipine Almadin ; 10mg channel blockers Amlodac with mainly vascular Gulf Amlodipine ; 10mg effects Indo Amlodipine Lomanor ; 10mg Pharma Dynamics Amlodipine besylate ; 10mg Felodipine Felodipine-Hexal ; 10mg Nifedipine Adco-Vascard SR Cipalat Retard Nifedalat SR Hypothyroidism R45 R45 Thyroid hormones Levothyroxine Euthyrox 25mcg; 50mcg; 100mcg sodium Synthroid 50mcg; 88mcg; 100mcg; 112mcg Multiple sclerosis Anti-depressants: Amitriptyline Sandoz Amitriptyline 2 Tricyclics Trepiline 10mg R R Interferons Interferon beta- 1a Avonex pre-filled syringe 0.5ml 30mcg/0.5ml Rebif 22 pre-filled syringe 0.5ml 44mcg/1ml Rebif 22 rebidose pre-filled pen 0.5ml 44mcg/1ml Rebif 44 pre-filled syringe 0.5ml 88mcg/1ml Rebif 44 rebidose pre-filled pen 0.5ml 88mcg/1ml Interferon beta- 1b Betaferon pre-filled syringe 1ml u/1ml R1 030 R1 030 Muscle relaxants: Baclofen Bio-Baclofen 10mg Other centrally acting agents Teva Baclofen 10mg R10 R10 Systemic Prednisone Be-Tabs Prednisone corticosteroids: Panafcort Prednisone Trolic R175 R230 Urinary Oxybutynin Lenditro anti-spasmodics Mylan Oxybutynin Parkinson's disease R305 R305 Anti-cholinergic Tertiary Amines Biperiden Akineton 2mg Lennon-Biperiden 2mg R775 R775 Dopamine agonists Pramipexole Pexola 0.12; 0.2; 1mg Pramiola 0.12; 0.2 Ropinirole Requip 0.2; 0.; 1mg; 2mg; R610 R610 Dopaminergic Selegiline Parkilyne Monoamine oxidase B inhibitors: Selegiline R280 R280 Dopaminergic Amantadine Symadin Adamantane R570 0 Levodopa and Levodopa and Carbilev 25/; 25/250mg decarboxylase decarboxylase Sinemet 25/; 25/250mg inhibitor inhibitor Teva Carbi-Levo 25/; 25/250mg Page 19 of 26 01/2014

20 Rheumatoid arthritis R45 R50 Anti-inflammatory Acetic acid and related substances R75 R80 Anti-inflammatory Oxicams R25 R25 Anti-inflammatory Propionic acid Anti-rheumatic Chloroquine R5 R5 Folic acid and R680 R680 Intestinal anti-inflammatories: Aminosalicylic acid and similar agents R590 R590 Other immunosuppressive Azathioprine Other immunosuppressive Methotrexate R10 R10 Systemic corticosteroids: Prednisone Schizophrenia R115 R330 Anti-depressants: SSRIs Diclofenac Adco-Diclofenac 50mg A-Lennon Diclofenac 2; 50mg Diclofenac Biotech 2 Mylan Diclofenac 2; 50mg Panamor AT 50mg Sandoz Diclofenac 2 Indomethacin Betacin 2 Gulf Indomethacin 2 Methocaps 2 Meloxicam Adco-Meloxicam 7.; 1 Arrow Meloxicam 7. Flamaryx 7. Flexocam 7. Medoxicam 7. Zydus-Meloxicam 7. Piroxicam Pyrocaps Roxifen Ibuprofen Betaprofen 200mg Betaprofen FC 400mg Bren 400mg Ibu 200mg Ibucine 200mg; 400mg Ibunate 200mg Ranfen 400mg Naproxen Be-tabs Naproxen 250mg Naproscript 250mg Chloroquine Plasmoquine 200mg Folic acid Aha Folic acid Be-Tabs Folic acid Folic acid 0. Sulfasalazine Salazopyrin 500mg Salazopyrin EN 500mg Azathioprine Azamun 50mg Azathioprine pch 50mg Methotrexate Abitrexate 2. Methotrexate 2. Prednisone Be-Tabs Prednisone Panafcort Trolic Citalopram Adco-Talomil Arrow Citalopram ; Auro-Citalopram Austell-Citalopram Cilate Citalohexal Citalopram Actor Citalopram-Winthrop Mylan Citalopram Escitalopram Citraz 10mg; Escitalopram Be-Tabs 10mg; Zytomil 10mg; Fluoxetine A-Lennon Fluoxetine Deprozan Fluoxetine Actor Ranflocs Rezak Zydus Fluoxetine Page 20 of 26 01/2014

21 Schizophrenia R115 R330 Anti-depressants: SSRIs Systemic lupus erythematosus (SLE) R265 R345 Anti-epileptics: Carboxamide R95 R95 Anti-psychotics: Butyrophenone R685 R1 000 Anti-psychotics: Clozapine R605 R605 Anti-psychotics: Olanzapine R345 R345 Anti-psychotics: Phenothiazines with aliphatic sidechain R550 R550 Anti-psychotics: Quetiapine R490 R620 Anti-psychotics: Thioxanthene R455 R990 Other anti-psychotics R45 R50 Anti-inflammatory Acetic acid and related substances R75 R80 Anti-inflammatory Oxicams Paroxetine Adco-Paroxetine Paroxetine Unicorn Serrapress Sertraline Austell-Sertraline 50mg; Serdep 50mg; Zylin 50mg Carbamazepine Degranol 200mg Sandoz Carbamazepine Sandoz Carbamazepine CR Zeptol 200mg 200mg; 400mg 200mg Haloperidol Sandoz Haloperidol 1.; Clozapine Aspen Clozapine 2; Cloment 2; Olanzapine Oleanz ; 10mg Olexar Redilanz ; 10mg ; 10mg Chlorpromazine Largactil 2; 50mg; Quetiapine Dopaquel 2; ; 200mg; 300mg Mylan Quetiapine 2; ; 200mg;300mg Psyquet 2; ; 200mg;300mg Quetoser 2; ; 200mg; 300mg Serez 2; ; 200mg; 300mg Flupenthixol Fluanxol 0.; 1mg Fluanxol depot 1ml Fluanxol depot 2ml Zuclopenthixol Clopixol 2mg; 10mg Clopixol depot 200mg Risperidone DRL-Risperidone 0.; 1mg; 2mg Perizal 0.; 1mg; 2mg; 3mg Risnia 0.; 1mg; 2mg; 3mg Schizorol 0.; 1mg; 2mg Zoxadon 0.; 1mg; 2mg Diclofenac Adco-Diclofenac 50mg A-Lennon Diclofenac 2; 50mg Diclofenac Biotech 2 Mylan Diclofenac 2; 50mg Panamor AT 50mg Sandoz Diclofenac 2 Indomethacin Betacin 2 Gulf Indomethacin 2 Methocaps 2 Meloxicam Adco-Meloxicam 7.; 1 Arrow Meloxicam 7. Flamaryx 7. Flexocam 7. Medoxicam 7. Zydus-Meloxicam 7. Piroxicam Pyrocaps Roxifen Page 21 of 26 01/2014

22 Systemic lupus erythematosus (SLE) R25 R25 Anti-inflammatory Propionic acid Ibuprofen Betaprofen 200mg Betaprofen FC Bren Ibu Ibucine Ibunate Ranfen 400mg 400mg 200mg 200mg; 400mg 200mg 400mg Naproxen Be-Tabs Naproxen 250mg Naproscript 250mg Anti-rheumatic Chloroquine Plasmoquine 200mg Chloroquine R75 R75 Anti-thrombotic Warfarin Cipla-Warfarin 1mg; 3mg; Vitamin K antagonists R10 R20 Aspirin Acetylsalicylic acid Aspirin 300mg R25 R25 Emolients and protectives: Zinc products R5 R5 Folic acid and R590 R590 Other immunosuppressive Azathioprine Other immunosuppressive Methotrexate R10 R10 Systemic corticosteroids: Prednisone R25 R25 Topical corticosteroids: Group III Ulcerative colitis R5 R5 Folic acid and R680 R680 Intestinal anti-inflammatories: Aminosalicylic acid and similar agents R2 285 R2 285 Intestinal anti-inflammatories: Corticosteroids R590 R590 Other immunosuppressive Azathioprine Other immunosuppressive Methotrexate R10 R10 Systemic corticosteroids: Prednisone Zinc products Gulf Aspirin Zinc ointment bp 300mg Folic acid Aha Folic acid Be-Tabs Folic acid Folic acid 0. Azathioprine Azamun 50mg Azathioprine pch 50mg Methotrexate Abitrexate 2. Methotrexate 2. Prednisone Be-Tabs Prednisone Panafcort Trolic Betamethasone Repivate cream 0.1% Topivate cream 0.1% Vari-Betamethasone cream 0.1% Folic acid Aha Folic acid Be-Tabs Folic acid Folic acid 0. Mesalazine Asacol 400mg; 500mg; 800mg Pentasa Salofalk 500mg; 1000mg 1000mg Olsalazine Dipentum 250mg Sulfasalazine Salazopyrin 500mg Budesonide Salazopyrin EN Entocord enema 500mg Azathioprine Azamun 50mg Azathioprine pch 50mg Methotrexate Abitrexate 2. Methotrexate 2. Prednisone Be-Tabs Prednisone Panafcort Trolic Page 22 of 26 01/2014

23 Non-CDL condition Ankylosing spondylitis Behcet's disease Connective tissue disorder (mixed) Cushings syndrome Cystic fibrosis Chronic Drug Amounts for the Executive Plan and The Chronic Drug Amounts below apply to the Executive Plan and for non-cdl conditions. Chronic Drug Amount R50 R40 R290 R300 R75 R80 R25 R590 R680 R4 000 R5 R250 R590 R4 000 R50 R40 R290 R300 R75 R80 R25 R590 R5 R105 R30 R110 R100 R290 R405 R365 R375 0 or medicine Other Immunosuppressive Agents - Methotrexate Anti-inflammatory Agents - Acetic acid and related substances Anti-inflammatory Agents - Butylpyrazolidines Anti-inflammatory Agents - Coxibs Anti-inflammatory Agents - Fenamates Anti-inflammatory Agents - Other anti-inflammatory and antirheumatic agents, non-steroids Anti-inflammatory Agents - Oxicams Anti-inflammatory Agents - Propionic acid Other Immunosuppressive Agents - Azathioprine Intestinal Anti-inflammatories - Aminosalicylic Acid and similar agents Selective immunosuppressive agents Folic acid and Alkylating Agents -Nitrogen Mustard Analogues Other Immunosuppressive Agents - Azathioprine Selective immunosuppressive agents Anti-rheumatic Agents - Chloroquine Other Immunosuppressive Agents - Methotrexate Anti-inflammatory Agents - Acetic acid and related substances Anti-inflammatory Agents - Butylpyrazolidines Anti-inflammatory Agents - Coxibs Anti-inflammatory Agents - Fenamates Anti-inflammatory Agents - Other anti-inflammatory and antirheumatic agents, non-steroids Anti-inflammatory Agents - Oxicams Anti-inflammatory Agents - Propionic acid Other Immunosuppressive Agents - Azathioprine Folic acid and Systemic Corticosteroids - Mineralocorticoids Adrenergics - Short Acting - Salbutamol Other Plain Vitamin preparations Sodium Chloride for nebulisation Drugs for constipation Mucolytics Vitamin D and analogues Adrenergics - Long Acting - Salmeterol Nutritional Supplements Non-CDL condition Cystic fibrosis Delusional disorder R410 Other Antidepressants - Noradrenergic and Specific Serotonergic Agents - Mirtazapine R370 Other Antidepressants - Norepinephrine-Dopamine Re-uptake Inhibitors - Bupropion R495 Other Antidepressants - Serotonin-Norepinephrine Re-uptake Inhibitors - Venlafaxine R510 Other Antidepressants - Norepinephrine Re-uptake Inhibitors - Reboxetine R350 Other Antidepressants - Serotonin-Norepinephrine Re-uptake Inhibitors - Duloxetine R720 Other Antidepressants - Melatonergic Agents - Agomelatine R345 Antipsychotics - Phenothiazines with aliphatic sidechain Anti-rheumatic Agents - Chloroquine Dermatopolymyositis Generalised anxiety disorder Chronic Drug Amount R785 R200 R6 000 R305 R330 R580 R530 R460 or medicine Antifungal Agents, systemic Antibacterial Agents, systemic Digestive Enzymes Anticholinergic Agents - Tertiary Amines Antidepressants - SSRI's Antidepressants - Tricyclics Antidepressants - MAOI's - Non-selective Other Antidepressants - Noradrenergic and Specific Serotonergic Agents - Mianserin Other Antidepressants - Augmenters - Trazodone R590 R4 000 R5 R170 R330 R580 R530 R460 Other Immunosuppressive Agents - Methotrexate Other Immunosuppressive Agents - Azathioprine Selective immunosuppressive agents Folic acid and Beta blocking agents, non-selective Antidepressants - SSRI's Antidepressants - Tricyclics Antidepressants - MAOI's - Non-selective Other Antidepressants - Noradrenergic and Specific Serotonergic Agents - Mianserin Other Antidepressants - Augmenters - Trazodone R410 Other Antidepressants - Noradrenergic and Specific Serotonergic Agents - Mirtazapine R370 Other Antidepressants - Norepinephrine-Dopamine Re-uptake Inhibitors - Bupropion R495 Other Antidepressants - Serotonin-Norepinephrine Re-uptake Inhibitors - Venlafaxine R510 Other Antidepressants - Norepinephrine Re-uptake Inhibitors - Reboxetine R350 Other Antidepressants - Serotonin-Norepinephrine Re-uptake Inhibitors - Duloxetine R720 Other Antidepressants - Melatonergic Agents - Agomelatine R530 Other Anti-depressants - Noradrenergic and Specific Serotonergic Agents - Mianserin R460 Other Anti-depressants - Augmenters - Trazodone R410 Other Anti-depressants - Noradrenergic and Specific Serotonergic Agents - Mirtazapine Page 23 of 26 01/2014

24 Non-CDL condition Huntington's diseaser Antipsychotics - Phenothiazines with aliphatic sidechain Calcium Supplements Hypoparathyroidism Major depression Motor neuron disease Muscular dystrophy Chronic Drug Amount R260 R60 R330 R305 R345 R365 R580 R550 R530 R460 or medicine Antiepileptics - Benzodiazepine Antiepileptics - Hydantoin Antidepressants - SSRI's Antipsychotics - Lithium Antidepressants - Tricyclics Antiepileptics - Carboxamide Antiepileptics - Fatty acid Antidepressants - MAOI's - Non-selective Antiepileptics - Succinimide Other Antidepressants - Noradrenergic and Specific Serotonergic Agents - Mianserin Other Antidepressants - Augmenters - Trazodone R410 Other Antidepressants - Noradrenergic and Specific Serotonergic Agents - Mirtazapine R370 Other Antidepressants - Norepinephrine-Dopamine Re-uptake Inhibitors - Bupropion R495 Other Antidepressants - Serotonin-Norepinephrine Re-uptake Inhibitors - Venlafaxine R510 Other Antidepressants - Norepinephrine Re-uptake Inhibitors - Reboxetine R350 Other Antidepressants - Serotonin-Norepinephrine Re-uptake Inhibitors - Duloxetine R720 Other Antidepressants - Melatonergic Agents - Agomelatine R375 Antiepileptics - Other Agents R345 R215 R365 R305 R60 R330 R305 R990 R620 R345 R365 R580 R550 R530 R460 Vitamin D and analogues Anti-cholinergic Agents - Tertiary Amines Anti-epileptics - Hydantoin Anti-depressants - SSRI's Anti-psychotics - Lithium Anti-psychotics - Benzamides Anti-psychotics - Thioxanthene Anti-depressants - Tricyclics Anti-epileptics - Carboxamide Antie-pileptics - Fatty acid Anti-depressants - MAOI's - Non-selective Anti-epileptics - Succinimide Other Anti-depressants - Noradrenergic and Specific Serotonergic Agents - Mianserin Other Anti-depressants - Augmenters - Trazodone R410 Other Anti-depressants - Noradrenergic and Specific Serotonergic Agents - Mirtazapine R370 Other Anti-depressants - Norepinephrine-Dopamine Re-uptake Inhibitors - Bupropion R495 Other Anti-depressants - Serotonin-Norepinephrine Re-uptake Inhibitors - Venlafaxine R510 Other Anti-depressants - Norepinephrine Re-uptake Inhibitors - Reboxetine R350 Other Anti-depressants - Serotonin-Norepinephrine Re-uptake Inhibitors - Duloxetine R720 Other Anti-depressants - Melatonergic Agents - Agomelatine R375 Anti-epileptics - Other Agents R260 R535 R4 850 Anti-epileptics - Benzodiazepine Anti-depressants - Tricyclics Muscle Relaxants - Carbamic acid esters Other nervous system drugs Non-CDL condition Muscular dystrophy Myasthenia gravis Obsessive compulsive disorder Chronic Drug Amount R260 or medicine Anti-epileptics - Benzodiazepine Page 24 of 26 01/2014 R535 R250 R590 R1 385 R4 000 R5 R305 R60 R330 R305 R345 R365 R580 R550 R530 R460 Muscle Relaxants - Carbamic acid esters Other Immunosuppressive Agents - Methotrexate Alkylating Agents -Nitrogen Mustard Analogues Other Immunosuppressive Agents - Azathioprine Parasympathomimetics - Anticholinesterases Selective immunosuppressive agents Folic acid and Anti-cholinergic Agents - Tertiary Amines Anti-epileptics - Hydantoin Anti-depressants - SSRIs Anti-psychotics - Lithium Anti-depressants - Tricyclics Anti-epileptics - Carboxamide Anti-epileptics - Fatty acid Anti-depressants - MAOIs - Non-selective Anti-epileptics - Succinimide Other Anti-depressants - Noradrenergic and Specific Serotonergic Agents - Mianserin Other Anti-depressants - Augmenters - Trazodone R410 Other Anti-depressants - Noradrenergic and Specific Serotonergic Agents - Mirtazapine R370 Other Anti-depressants - Norepinephrine-Dopamine Re-uptake Inhibitors - Bupropion R495 Other Anti-depressants - Serotonin-Norepinephrine Re-uptake Inhibitors - Venlafaxine R510 Other Anti-depressants - Norepinephrine Re-uptake Inhibitors - Reboxetine R350 Other Anti-depressants - Serotonin-Norepinephrine Re-uptake Inhibitors - Duloxetine R720 Other Anti-depressants - Melatonergic Agents - Agomelatine R375 Anti-epileptics - Other Agents Organ Per Approved Treatment Plan transplantation Osteoporosis R280 Drugs Treating Bone Disorders -Bisphosphonates R575 R495 R280 Anti-parathyroid Agents - Calcitonin preparations Selective estrogen receptor modulators Other Drugs Treating Bone Disorders Paget's 280 Drugs Treating Bone Disorders -Bisphosphonates disease Panic disorder R330 Anti-depressants - SSRIs R580 Anti-depressants - Tricyclics Anti-depressants - MAOIs - Non-selective R530 Other Anti-depressants - Noradrenergic and Specific Serotonergic Agents - Mianserin R460 Other Anti-depressants - Augmenters - Trazodone R410 Other Anti-depressants - Noradrenergic and Specific Serotonergic Agents - Mirtazapine R370 Other Anti-depressants - Norepinephrine-Dopamine Re-uptake Inhibitors - Bupropion R495 Other Anti-depressants - Serotonin-Norepinephrine Re-uptake Inhibitors - Venlafaxine R510 Other Anti-depressants - Norepinephrine Re-uptake Inhibitors - Reboxetine R350 Other Anti-depressants - Serotonin-Norepinephrine Re-uptake Inhibitors - Duloxetine R720 Other Anti-depressants - Melatonergic Agents - Agomelatine

25 Non-CDL condition Chronic Drug Amount or medicine Paraplegia R20 Aspirin - Cardiovascular R75 R80 R305 R60 R170 R290 R330 R305 R50 R40 R290 R300 R75 R80 R25 R345 R365 R580 R550 R200 R530 R460 Antithrombotic Agents - Vitamin K antagonists H2-receptor antagonists Anticholinergic Agents - Tertiary Amines Antiepileptics - Hydantoin Proton pump inhibitors Drugs for constipation Antidepressants - SSRI's Antipsychotics - Lithium Anti-inflammatory Agents - Acetic acid and related substances Anti-inflammatory Agents - Butylpyrazolidines Anti-inflammatory Agents - Coxibs Anti-inflammatory Agents - Fenamates Anti-inflammatory Agents - Other anti-inflammatory and antirheumatic agents, non-steroids Anti-inflammatory Agents - Oxicams Anti-inflammatory Agents - Propionic acid Antidepressants - Tricyclics Antiepileptics - Carboxamide Antiepileptics - Fatty acid Antidepressants - MAOI's - Non-selective Antiepileptics - Succinimide Antibacterial Agents, systemic Other Antidepressants - Noradrenergic and Specific Serotonergic Agents - Mianserin Other Antidepressants - Augmenters - Trazodone R410 Other Antidepressants - Noradrenergic and Specific Serotonergic Agents - Mirtazapine R370 Other Antidepressants - Norepinephrine-Dopamine Re-uptake Inhibitors - Bupropion R495 Other Antidepressants - Serotonin-Norepinephrine Reuptake Inhibitors - Venlafaxine R510 Other Antidepressants - Norepinephrine Re-uptake Inhibitors - Reboxetine R350 Other Antidepressants - Serotonin-Norepinephrine Reuptake Inhibitors - Duloxetine R720 Other Antidepressants - Melatonergic Agents - Agomelatine R375 Antiepileptics - Other Agents R1 000 R535 Stomi equipment Muscle Relaxants - Carbamic acid esters Pemphigus Peripheral atherosclerotic disease Pituitary microadenomas R590 R20 R75 R170 R20 R45 R540 R660 R1 600 Other Immunosuppressive Agents - Azathioprine Aspirin - Cardiovascular Antithrombotic Agents - Vitamin K antagonists Selective Calcium Channel Blockers With Mainly Vascular Effects Antithrombotic Agents - Dipyridamole Thyroid hormones Androgens - 3-Oxoandrosten (4) Derivatives Gynaecologicals - Prolactine Inhibitors Posterior Pituitary Hormones - Vasopressin and analogues Non-CDL condition Pituitary microadenomas Polyarteritis nodosa Post traumatic stress disorder Psoriatic arthritis Pulmonary interstitial fibrosis Chronic Drug Amount R8 200 R R590 R680 R5 R330 R580 R530 R460 or medicine Anterior Pituitary Hormones - Somatropin and somatropin agonists Hypothalamic Hormones - Antigrowth hormone Anti-rheumatic Agents - Chloroquine Other Immunosuppressive Agents - Methotrexate Other Immunosuppressive Agents - Azathioprine Intestinal Anti-inflammatories - Aminosalicylic Acid and similar agents Folic acid and Antidepressants - SSRI's Antidepressants - Tricyclics Antidepressants - MAOI's - Non-selective Other Antidepressants - Noradrenergic and Specific Serotonergic Agents - Mianserin Other Antidepressants - Augmenters - Trazodone R410 Other Antidepressants - Noradrenergic and Specific Serotonergic Agents - Mirtazapine R370 Other Antidepressants - Norepinephrine-Dopamine Re-uptake Inhibitors - Bupropion R495 Other Antidepressants - Serotonin-Norepinephrine Re-uptake Inhibitors - Venlafaxine R510 Other Antidepressants - Norepinephrine Re-uptake Inhibitors - Reboxetine R350 Other Antidepressants - Serotonin-Norepinephrine Re-uptake Inhibitors - Duloxetine R720 Other Antidepressants - Melatonergic Agents - Agomelatine Anti-rheumatic Agents - Chloroquine R50 R40 R290 R300 R75 R80 R25 R590 R680 R5 R30 R250 R330 R375 R195 R590 Other Immunosuppressive Agents - Methotrexate Anti-inflammatory Agents - Acetic acid and related substances Anti-inflammatory Agents - Butylpyrazolidines Anti-inflammatory Agents - Coxibs Anti-inflammatory Agents - Fenamates Anti-inflammatory Agents - Other anti-inflammatory and antirheumatic agents, non-steroids Anti-inflammatory Agents - Oxicams Anti-inflammatory Agents - Propionic acid Other Immunosuppressive Agents - Azathioprine Intestinal Anti-inflammatories - Aminosalicylic Acid and similar agents Folic acid and Adrenergics - Short Acting - Salbutamol Anti-rheumatic Agents - Chloroquine Other Immunosuppressive Agents - Methotrexate Alkylating Agents -Nitrogen Mustard Analogues Inhaled Glucocorticoids Adrenergics - Long Acting - Salmeterol Inhaled Anticholinergics - Ipratropium bromide Other Immunosuppressive Agents - Azathioprine Page 25 of 26 01/2014

26 Non-CDL condition Pulmonary interstitial fibrosis Chronic Drug Amount R680 R5 or medicine Intestinal Anti-inflammatories - Aminosalicylic Acid and similar agents Folic acid and Quadriplegia R20 Aspirin - Cardiovascular R75 R80 R305 R60 R170 R290 R330 R305 R50 R40 R290 R300 R75 R80 R25 R345 R365 R580 R550 R200 R530 R460 Antithrombotic Agents - Vitamin K antagonists H2-receptor antagonists Anticholinergic Agents - Tertiary Amines Antiepileptics - Hydantoin Proton pump inhibitors Drugs for constipation Antidepressants - SSRI's Antipsychotics - Lithium Anti-inflammatory Agents - Acetic acid and related substances Anti-inflammatory Agents - Butylpyrazolidines Anti-inflammatory Agents - Coxibs Anti-inflammatory Agents - Fenamates Anti-inflammatory Agents - Other antiinflammatory and antirheumatic agents, nonsteroids Anti-inflammatory Agents - Oxicams Anti-inflammatory Agents - Propionic acid Antidepressants - Tricyclics Antiepileptics - Carboxamide Antiepileptics - Fatty acid Antidepressants - MAOI's - Non-selective Antiepileptics - Succinimide Antibacterial Agents, systemic Other Antidepressants - Noradrenergic and Specific Serotonergic Agents - Mianserin Other Antidepressants - Augmenters - Trazodone R410 Other Antidepressants - Noradrenergic and Specific Serotonergic Agents - Mirtazapine R370 Other Antidepressants - Norepinephrine- Dopamine Re-uptake Inhibitors - Bupropion R495 Other Antidepressants - Serotonin- Norepinephrine Re-uptake Inhibitors - Venlafaxine R510 Other Antidepressants - Norepinephrine Reuptake Inhibitors - Reboxetine R350 Other Antidepressants - Serotonin- Norepinephrine Re-uptake Inhibitors - Duloxetine R720 Other Antidepressants - Melatonergic Agents - Agomelatine R375 Antiepileptics - Other Agents R1 000 R535 Stomi equipment Muscle Relaxants - Carbamic acid esters Stroke R20 Aspirin - Cardiovascular R25 R75 R110 R170 R115 Cardiac Glycosides - Digoxin Antithrombotic Agents - Vitamin K antagonists Ace Inhibitors, Plain Selective Calcium Channel Blockers With Mainly Vascular Effects ACE inhibitors and Non-CDL condition Chronic Drug Amount or medicine Stroke R170 Beta blocking agents, non-selective Systemic sclerosis Thrombocytopaenia purpura Valvular heart disease Wegener's granulomatosis R20 R185 R40 R90 R170 R230 R535 R170 R250 R170 R50 R40 R290 R300 R75 R80 R25 R590 R1 300 R2 050 R5 R590 R5 R20 R25 R75 R110 R170 R115 R90 R170 R130 R380 R605 R590 R5 Antithrombotic Agents - Dipyridamole Antithrombotic Agents - Clopidogrel Antithrombotic Agents - Combinations Potassium Sparing Agents Vasodilators in Cardiac Disease - Organic Nitrates Drugs for urinary frequency and incontinence Muscle Relaxants - Carbamic acid esters Anti-rheumatic Agents - Chloroquine Other Immunosuppressive Agents - Methotrexate Selective Calcium Channel Blockers With Mainly Vascular Effects Alkylating Agents -Nitrogen Mustard Analogues Proton pump inhibitors Anti-inflammatory Agents - Acetic acid and related substances Anti-inflammatory Agents - Butylpyrazolidines Anti-inflammatory Agents - Coxibs Anti-inflammatory Agents - Fenamates Anti-inflammatory Agents - Other anti-inflammatory and antirheumatic agents, non-steroids Anti-inflammatory Agents - Oxicams Anti-inflammatory Agents - Propionic acid Other Immunosuppressive Agents - Azathioprine Anti-rheumatic Agents - Penicillamine and similar agents Antimetabolites - Purine Analogues Folic acid and Other Immunosuppressive Agents - Methotrexate Other Immunosuppressive Agents - Azathioprine Folic acid and Aspirin - Cardiovascular Cardiac Glycosides - Digoxin Antithrombotic Agents - Vitamin K antagonists Ace Inhibitors, Plain Selective Calcium Channel Blockers With Mainly Vascular Effects ACE inhibitors and Potassium Sparing Agents Vasodilators in Cardiac Disease - Organic Nitrates Antiadrenergic agents - Alpha-adrenoreceptor antagonists Antiarrhythmics, class III Antiarrhythmics, class Ic Other Immunosuppressive Agents - Methotrexate Other Immunosuppressive Agents - Azathioprine Folic acid and Page 26 of 26 01/2014