Chronic Illness Benefit medicine list (formulary)

Transcription

1 Chronic Illness Benefit medicine list (formulary) 2015

2 Chronic Illness Benefit 2015 Contents Page Explanation of terms 3 The Prescribed Minimum Benefits medicine list (for all plan types) 4 Frequently asked questions 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. Please visit for the updated version of this document. Contact us For additional information about this benefit, members may contact us by ing healthinfo@discovery.co.za, call or visit Page 2 of 29 01/2015

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 2015 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 29 01/2015

4 Chronic Illness Benefit 2015 The Prescribed Minimum Benefits (PMB) medicine list (for all plan types) The PMB medicine list applies to all Discovery Health Medical Scheme for the 2015 benefit year. The CDA (Chronic Drug Amount) does not apply to KeyCare. Prescribed Minimum Addison s disease R105 R105 Systemic corticosteroids: Mineralocorticoids Asthma R350 R350 Adrenergics - Formoterol combinations R150 R150 Adrenergics: Long acting - Formoterol R280 R395 Adrenergics: Long acting - Salmeterol R350 R350 Adrenergics: Salmeterol combinations R30 R30 Adrenergics: Short acting - Salbutamol R90 R130 Anti-asthmatics: Systemic xanthines R205 R205 Inhaled anti-cholinergics: Ipratropium bromide R300 R345 Inhaled Glucocorticoids Fludrocortisone Florinef acetate 0.1mg Formoterol and Symbicord turbohaler 160/4.5mcg Budesonide 60 dose Symbicord turbohaler 320/9mcg 60dose Vannair 80/4.5mcg 120 dose Vannair 160/4.5mcg 120 dose Formoterol Foratec dp-caps 12mcg Foratec hfa 120dose 12mcg/1dose Salmeterol Serevent accuhaler 60 dose 50mcg Salmeterol and Fluticasone Serevent CFC free 120 dose 25mcg Foxair accuhaler 50/100; 50/250; 50/ dose Sereflo hfa 25/50; 25/125; 25/ dose Salbutamol Asthavent ecohaler 200 dose 100mcg Venteze CFC free 200 dose 100mcg Theophylline Sandoz Theophylline anhydrous 200mg; 300mg Ipratropium bromide Beclomethasone Atrovent HFA 200 dose Ipvent HFA 200 dose Beceze 200 dose CFC free Beclate 200 dose 20mcg 40mcg/1dose 100mcg 100mcg; 200mcg Budesonide Budeflam dp-caps 200mcg Budeflam HFA 300dose 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 R10 R10 Systemic corticosteroids: Prednisone Paediatric Spacer Glaxohaler 100mcg; 200mcg Prednisone Be-Tabs Prednisone Panafcort Trolic Page 4 of 29 01/2015

5 Bipolar mood disorder R115 R330 Anti-depressants: SSRIs R290 R360 Anti-epileptics: Carboxamide R395 R395 Anti-epileptics: Fatty acid R270 R365 Anti-epileptics: Other agents R100 R100 Anti-psychotics: Butyrophenone R685 R1 100 Anti-psychotics: Clozapine R320 R320 Anti-psychotics: Lithium Citalopram Adco-Talomil Arrow Citalopram ; 40mg Bio Citalopram Cilate Escitalopram Accord Escitalopram 10mg; Escitalopram Be-Tabs 10mg; Zytomil 10mg; Fluoxetine A-Lennon Fluoxetine Deprozan Fluoxetine Actor Prolax Ranflocs Rezak Zydus Fluoxetine Paroxetine Adco-Paroxetine Auro Paroxetine Serrapress Xet Sertraline Austell-Sertraline ; Dyna Sertraline ; Serdep ; Serlife Zolid Zylin Carbamazepine Degranol 200mg Sandoz Carbamazepine Sandoz Carbamazepine CR Zeptol 200mg 200mg; 400mg 200mg Valproic acid Convulex 1 Lamotrigine Convulex syrup Epilim crushable 2/5ml Epilim sugar-free syrup 200mg/5ml Epilizine CR 200mg; 300mg; 500mg Navalpro CR 200mg; 300mg; 500mg Vanapro 300mg; 500mg Dyna-Lamotrigine 2; ; ; 200mg Epitec 2; ; ; 200mg Lamidus ; ; 200mg Sandoz Lamotrigine ; ; 200mg Haloperidol Gulf Haloperidol Sandoz Haloperidol 1.; Clozapine Aspen Clozapine 2; Cloment 2; Lithium Camcolit 2; 400mg Quilonum retard 4 Page 5 of 29 01/2015

6 Bipolar mood disorder R605 R605 Anti-psychotics: Olanzapine R360 R360 Anti-psychotics: Phenothiazines with aliphatic side-chain Olanzapine Mylan Olanzapine ; 10mg Oleanz ; 10mg Olexar ; 10mg Prexolan odt ; 10mg Redilanz ; 10mg Chlorpromazine Largactil 2; R390 R390 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 Sizonorm 2; ; 200mg; 300mg R515 R650 Anti-psychotics: Flupenthixol Fluanxol 0.; 1mg Thioxanthene Fluanxol depot 1ml Fluanxol depot 2ml 40mg Zuclopenthixol Clopixol 2mg; 10mg Clopixol depot 200mg R400 R1 005 Other anti-psychotics Risperidone DRL-Risperidone 0.; 1mg; 2mg Perizal 0.; 1mg; 2mg; 3mg Risnia 0.; 1mg; 2mg; 3mg Rispacor 0.; 1mg; 2mg; 3mg Rispevon 3mg; Risponz 1mg; 2mg; 3mg; Schizorol 0. Zoxadon 0.; 1mg; 2mg Bronchiectasis R30 R30 Adrenergics: Salbutamol Asthavent ecohaler 200 dose 100mcg Short acting - Salbutamol Venteze CFC free 200 dose 100mcg R205 R205 Inhaled anti-cholinergics: Ipratropium bromide R10 R10 Systemic corticosteroids: Prednisone Cardiac failure R115 R120 ACE inhibitors and R80 R115 ACE inhibitors: plain Ipratropium Atrovent HFA 200 dose 20mcg bromide Ipvent HFA 200 dose 40mcg/1dose Prednisone Be-Tabs Prednisone Panafcort Trolic Enalapril and Enap co 20/12. Pharmapress co 20/12. Lisinopril and Adco-Zetomax co 10/12. Adco-Zetomax co 20/12. Lisinopril co Unicorn 20/12. Lisoretic 10/12.; 20/12. Zestoretic 10/12.; 20/12. Perindopril and Zydus Perindopril co 4/1.2 Captopril Adco-Captomax 2; Bio-Captopril 2 Mylan Captopril 2; Enalapril Alapren ; 10mg; Enalapril Unicorn 10mg; Enap ; 10mg; Envas ; 10mg Hr-Enalapril ; 10mg; Lisinopril Austell-Lisinopril 10mg; Sinopren ; 10mg; Page 6 of 29 01/2015

7 Cardiac failure R80 R115 ACE inhibitors: plain R210 R235 Alpha and Beta blocking agents R110 R115 Angiotensin II antagonists, Combinations R80 R120 Angiotensin II antagonists: plain R85 R85 Arteriolar smooth muscle Hydrazinophthalazine Perindopril Acti-Prex Auro Perindopril Bindace Ciplasyl ; 8mg Pearinda ; 8mg Perindopril Unicorn Prexum Ran-Perindopril Spec-Perindopril ; 8mg Zydus Perindopril Quinapril Accumax 10mg; Carvedilol Carvedilol Unicorn 6.2; 12.; 2 Carvetrend 6.2; 12.; 2 Vediblok 6.2; 12.; 2 Irbesartan Isart co 150/12.; 300/12. and Losartan and Austell Losartan co 50/12. Hytenza co 50/12. 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 Zartan co 100/2 Valsartan and Dynaval co 80/12.; 160/12.; 160/2 Irbesartan Dynarb 1; 300mg Isart 1; 300mg Losartan Auro Losartan Austell Losartan Ciplazar Hytenza Losartan Unicorn Spec-Losartan Zartan Valsartan Diolo 80mg; 160mg Hydralazine Hyperphen 10mg; Sandoz Hydralazine 2 Page 7 of 29 01/2015

8 Cardiac failure R65 R75 Beta blocking Bisoprolol Adco-Bisocor ; 10mg selective Bilocor ; 10mg Bisohexal ; 10mg Bisoprolol Zydus ; 10mg Ziapro ; 10mg R25 R25 Cardiac glycosides: Digoxin Lanoxin 0.062; 0.2 Digoxin Lanoxin paed syrup 0.0/1ml R20 R40 High-ceiling Furosemide Dino-Retic 40mg Diuresix 40mg Furobe 40mg Mylan Furosemide 40mg R15 R15 Low-ceiling : Hydrochloro- Hexazide 2 Thiazides, plain thiazide Ridaq 12. R20 R20 Low-ceiling : Indapamide Cipla-Indapamide 2. excluding Thiazides Daptril 2. Mylan Indapamide 2. R95 R95 Potassium sparing Spironolactone Aldactone 2 agents Sandoz Spironolactone 2 Spiractin 2 R90 R90 Potassium supplements Potassium Plenish K 600mg chloride Potassium Chloride Unicorn 600mg Sandoz K mg Ultipot 600mg R180 R180 Vasodilators in cardiac Glyceryl Angised 0. disease: Organic nitrates trinitrate Isosorbide Isordil 30mg dinitrate Sandoz Isosorbide dinitrate ; 10mg Isosorbide Elantan mononitrate Elantan LA Monicor SR 60mg R80 R80 Influenza vaccines Influenza, purified antigen Fluvax pre-filled syringe 0.5ml Influvac 0.5ml Mutagrip single dose 0.5ml R145 R145 Pneumococcus vaccines Pneumococcus, Imovax pneumo 23 purified polysaccharides antigen Cardiomyopathy R115 R120 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. Lisinopril co Unicorn 20/12. R80 R115 ACE inhibitors: plain Lisoretic Zestoretic 10/12.; 20/12. 10/12.; 20/12. Perindopril and Zydus Perindopril co 4/1.2 Captopril Adco-Captomax 2; Bio-Captopril 2 Mylan Captopril 2; Enalapril Alapren ; 10mg; Enalapril Unicorn 10mg; Enap ; 10mg; Envas ; 10mg Hr-Enalapril ; 10mg; Lisinopril Austell-Lisinopril 10mg; Sinopren ; 10mg; Page 8 of 29 01/2015

9 Cardiomyopathy R80 R115 ACE inhibitors: plain R210 R235 Alpha and Beta blocking agents R110 R115 Angiotensin II antagonists, Combinations R80 R120 Angiotensin II antagonists: plain R75 R75 Anti-thrombotic Vitamin K antagonists R85 R85 Arteriolar smooth muscle Hydrazinophthalazine Perindopril Acti-Prex Auro Perindopril Bindace Ciplasyl ; 8mg Pearinda ; 8mg Perindopril Unicorn Prexum Ran-Perindopril Spec-Perindopril ; 8mg Zydus Perindopril Quinapril Accumax 10mg; Carvedilol Carvedilol Unicorn 6.2; 12.; 2 Carvetrend 6.2; 12.; 2 Vediblok 6.2; 12.; 2 Irbesartan Isart co 150/12.; 300/12. and Losartan and Austell Losartan co 50/12. Hytenza co 50/12. 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 Zartan co 100/2 Valsartan and Dynaval co 80/12.; 160/12.; 160/2 Irbesartan Dynarb 1; 300mg Isart 1; 300mg Losartan Auro Losartan Austell Losartan Ciplazar Hytenza Losartan Unicorn Spec-Losartan Zartan Valsartan Diolo 80mg; 160mg Warfarin Cipla-Warfarin 1mg; Hydralazine Hyperphen 10mg; Sandoz Hydralazine 2 Page 9 of 29 01/2015

10 Cardiomyopathy R10 R20 Aspirin Acetylsalicylic Aspirin 300mg acid Be-Tabs Aspirin (white) 300mg Gulf Aspirin 300mg R65 R75 Beta blocking Bisoprolol Adco-Bisocor ; 10mg selective Bilocor ; 10mg Bisohexal ; 10mg Bisoprolol Zydus ; 10mg Ziapro ; 10mg R25 R25 Cardiac glycosides: Digoxin Lanoxin 0.062; 0.2 Digoxin Lanoxin paed syrup 0.0/1ml R20 R40 High-ceiling Furosemide Dino-Retic 40mg Diuresix 40mg Furobe 40mg Mylan Furosemide 40mg R15 R15 Low-ceiling : Hydrochlorothiazide Hexazide 2 Thiazides, plain Ridaq 12. R20 R20 Low-ceiling : Indapamide Cipla-Indapamide 2. excluding Thiazides Daptril 2. Mylan Indapamide 2. R95 R95 Potassium sparing agents Spironolactone Aldactone 2 Sandoz Spironolactone 2 Spiractin 2 R90 R90 Potassium supplements Potassium Plenish K 600mg chloride Potassium Chloride Unicorn 600mg Sandoz K mg Ultipot 600mg R180 R180 Vasodilators in cardiac Glyceryl Angised 0. disease: Organic nitrates trinitrate Isosorbide Isordil 30mg dinitrate Sandoz Isosorbide dinitrate ; 10mg Isosorbide Elantan mononitrate Elantan LA Monicor SR 60mg R80 R80 Influenza vaccines Influenza, purified antigen Fluvax pre-filled syringe 0.5ml Influvac 0.5ml Mutagrip single dose 0.5ml R145 R145 Pneumococcus vaccines Pneumococcus, purified polysaccharides antigen Imovax pneumo 23 Chronic obstructive pulmonary disease (COPD) R165 R165 Adrenergics: Salbutamol combinations R30 R30 Adrenergics: Short acting - Salbutamol R90 R130 Anti-asthmatics: Systemic xanthines R205 R205 Inhaled anti-cholinergics: Ipratropium bromide R713 R713 Surgical item: Oxygen concentrator R10 R10 Systemic corticosteroids: Prednisone Salbutamol and Ipratropium bromide Duolin hfa 200 dose Salbutamol Asthavent ecohaler 200 dose 100mcg Theophylline Ipratropium bromide Oxygen R80 R80 Influenza vaccines Influenza, purified antigen Chronic renal disease R115 R120 ACE inhibitors and Venteze CFC free 200 dose 100mcg Sandoz Theophylline anhydrous 200mg; 300mg Atrovent HFA 200 dose Ipvent HFA 200 dose Oxygen concentrator rental 20mcg 40mcg/1dose Prednisone Be-Tabs Prednisone Panafcort Trolic Fluvax pre-filled syringe 0.5ml Influvac 0.5ml Mutagrip single dose 0.5ml Enalapril and Lisinopril and Enap co Pharmapress co Adco-Zetomax co Adco-Zetomax co Lisinopril co Unicorn 20/12. 20/12. 10/12. 20/12. 20/12. Page 10 of 29 01/2015

11 Chronic renal disease R115 R120 ACE inhibitors and R80 R115 ACE inhibitors: plain R110 R115 Angiotensin II antagonists, Combinations R80 R120 Angiotensin II antagonists: plain Lisinopril and Lisoretic 10/12.; 20/12. Zestoretic 10/12.; 20/12. Perindopril and Zydus Perindopril co 4/1.2 Captopril Adco-Captomax 2; Bio-Captopril 2 Mylan Captopril 2; Enalapril Alapren ; 10mg; Enalapril Unicorn 10mg; Enap ; 10mg; Envas ; 10mg Hr-Enalapril ; 10mg; Lisinopril Austell-Lisinopril 10mg; Sinopren ; 10mg; Perindopril Acti-Prex Auro Perindopril Bindace Ciplasyl ; 8mg Pearinda ; 8mg Perindopril Unicorn Prexum Ran-Perindopril Spec-Perindopril ; 8mg Zydus Perindopril Quinapril Accumax 10mg; Irbesartan and Isart co 150/12.; 300/12. Losartan and Austell Losartan co 50/12. Hytenza co 50/12. Losaar Plus Losacar co 50/12.; 100/2 50/12. Losartan co Unicorn 50/12. Losartan co Unicorn 100/2 Netrasol co Zartan co 50/12.; 100/2 100/2 Valsartan and Dynaval co 80/12.; 160/12.; 160/2 Irbesartan Dynarb 1; 300mg Isart 1; 300mg Losartan Auro Losartan Austell Losartan Ciplazar Page 11 of 29 01/2015

12 Chronic renal disease R80 R120 Angiotensin II antagonists: plain R215 R215 Calcium supplements R5 R5 Folic acid and R40 R40 Iron in combination with folic acid R550 R550 Iron trivalent, parenteral preparations R4 000 R4 000 Other anti-anaemic preparations R375 R375 Vitamin D and analogues Coronary artery disease R10 R20 Aspirin Acetylsalicylic acid R190 Beta blocking non-selective R65 R75 Beta blocking selective R200 R285 Selective calcium channel blockers with direct cardiac effects R130 R190 Selective calcium channel blockers with mainly vascular effects Losartan Hytenza Losartan Unicorn Spec-Losartan Zartan Valsartan Diolo 80mg; 160mg Calcium B-cal carbonate Folic acid Aha Folic acid Be-Tabs Folic acid Folic acid 0. Ferrous Pregamal fumarate Iron, parenteral Cosmofer ampoule 2ml /1ml preparations Rautevene ampoule 5ml /5ml Sucrofer /1ml Zypiron vial 5ml /1ml Darbepoetin Aranesp pre-filled syringe 0.4ml 10mcg/0.4ml Alfa Aranesp pre-filled syringe 0.5ml 20mcg/0.5ml Aranesp pre-filled syringe 0.3ml 30mcg/0.3ml Aranesp pre-filled syringe 0.4ml 40mcg/0.4ml Aranesp pre-filled syringe 0.5ml 50mcg/0.5ml Aranesp pre-filled syringe 0.3ml 60mcg/0.3ml Erythropoietin Eprex pre-fill 2000U/0.5ml 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 Alfacalcidol One alpha 0.25mcg; 1mcg Aspirin 300mg Be-Tabs Aspirin (white) 300mg Gulf Aspirin 300mg Propranolol Indoblok 10mg; 40mg Prodorol 10mg; 40mg Purbloka 10mg; 40mg Atenolol B-Block ; Bio-Atenolol ; Gulf Atenolol ; Sandoz Atenolol ; Tenopress ; Zetenol ; Diltiazem Adco-Zildem 60mg Adco-Zildem SR 180mg; 240mg Verapamil Vasomil 40mg; 80mg Verahexal SR 240mg Amlodipine Amlodac ; 10mg Amtas ; 10mg Gulf Amlodipine ; 10mg Indo Amlodipine Page 12 of 29 01/2015

13 Coronary artery disease R130 R190 Selective calcium channel blockers with mainly vascular effects R180 R180 Vasodilators in cardiac disease: Organic nitrates Crohn s disease R5 R5 Folic acid and R710 R710 Intestinal antiinflammatories: Aminosalicylic acid and similar agents R2 415 R2 415 Intestinal antiinflammatories: Corticosteroids R625 R625 Other immunosuppressive Azathioprine Other immunosuppressive Methotrexate R10 R10 Systemic corticosteroids: Prednisone Diabetes insipidus R1 450 R1 700 Posterior pituitary hormones: Vasopressin and analogues Diabetes mellitus Type 1 R680 R720 Anti-diabetic Insulins and analogues Amlodipine Lomanor ; 10mg Pharma Dynamics Amlodipine besylate ; 10mg Felodipine Felodipine-Hexal 10mg Plendil 2.; Nifedipine Adco-Vascard SR Cipalat Retard Nifedalat SR Glyceryl Angised 0. trinitrate Isosorbide Isordil 30mg dinitrate Sandoz Isosorbide dinitrate ; 10mg Isosorbide Elantan mononitrate Elantan LA Monicor SR 60mg Folic acid Aha Folic acid Be-Tabs Folic acid Folic acid 0. Mesalazine Asacol 400mg; 500mg; 800mg Pentasa 500mg; 1000mg Salofalk 1000mg Olsalazine Dipentum 2 Sulfasalazine Salazopyrin 500mg Salazopyrin EN 500mg Budesonide Entocord enema Azathioprine Azamun Azathioprine PCH Methotrexate Abitrexate 2. Methotrexate 2. Prednisone Be-Tabs Prednisone Panafcort Trolic Desmopressin Ddavp 0.1mg; 0.2mg Insulin 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 cartridge 3ml; vial 10ml Humalog kwikpen 3ml Humalog mix 25 kwikpen 3ml Humalog mix 25 - cartridge 3ml Humalog mix 25 vial 10ml Humalog mix 50 - cartridge 3ml Humalog mix 50 - kwikpen 3ml Humulin 30/70 - cartridge 3ml; kwikpen 3ml; vial 10ml Humulin n - cartridge 3ml; kwikpen 3ml; vial 10ml Humulin r - cartridge 3ml; vial 10ml Page 13 of 29 01/2015

14 Diabetes mellitus Type 1 R680 R720 Anti-diabetic Insulins and analogues R200 R280 Blood glucose monitoring agents Insulin Glucose strips R350 R350 Surgical item Insulin pen device Lancets Diabetes mellitus Type 2 R60 R60 Anti-diabetic Biguanides R680 R720 Anti-diabetic Insulins and analogues Needles Insuman comb 30/70 - cartridge 3ml Novomix 30 - flexpen 3ml Novorapid - penfill 3ml Accu-check active mic strips Caresens II/pop test strip 29g Caresens n test strips 29g Freestyle optium glucose test strips Glucocheck strips 50s Glucoplus Glucoplus provider strips Glucose blood test strips diamond Onetouch select glucose test strips On-call plus ez strips (all sizes) Biosulin pen device Lancets 50's Lancets blood collection needles loris Lancets glucoplus 66 x 44 x 78mm Lancets solus v2 BD microfine pen needle 32g 4mm BD microfine pen needle 31g 5mm BD microfine pen needle 30g 8mm Needle novofine Metformin Accord Metformin 500mg; 8 Apex-Metformin 500mg Arrow Metformin 500mg; 8 Austell-Metformin 500mg; 8 Bigsens 500mg; 8; 1000mg Diaformin 500mg Diaformin forte 8 Diamin 500mg; 8 Diaphage 500mg; 8; 1000mg Gluconorm 500mg; 8 Mengen 500mg; 8; 1000mg Metchek 500mg; 8 Metforal 500mg; 8 Metformin Alkem 500mg; 8 Metored 500mg; 8; 1000mg Metphage 500mg; 8 Mylan Metformin 500mg; 8 Romidab 500mg; 8; 1000mg Sandoz Metformin 500mg Sandoz Metformin FCT 500mg; 8 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 cartridge 3ml; vial 10ml Humalog kwikpen 3ml Humalog mix 25 kwikpen 3ml Humalog mix 25 - cartridge 3ml Page 14 of 29 01/2015

15 Diabetes mellitus Type 2 R680 R720 Anti-diabetic Insulins and analogues R105 R105 Anti-diabetic Sulfonamides, urea R170 R190 Anti-diabetic Thiazolidinediones R200 R280 Blood glucose monitoring agents Insulin Humalog mix 25 vial 10ml Humalog mix 50 - cartridge 3ml Humalog mix 50 - kwikpen 3ml Humulin 30/70 - cartridge 3ml; kwikpen 3ml; vial 10ml Humulin n - cartridge 3ml; kwikpen 3ml; vial 10ml Humulin r - cartridge 3ml; vial 10ml Insuman comb 30/70 - cartridge 3ml Novomix 30 - flexpen 3ml Novorapid - penfill 3ml Glibenclamide Bio-Glibenclamide Diacare Glycomin Sandoz Glibenclamide Gliclazide Adco-Glucomed 80mg Arrow Gliclazide 80mg Austell-Gliclazide 80mg Diaglucide 80mg Diaran MR 30mg Dyna Gliclazide SR 30mg Glycron 80mg Glygard 80mg Sandoz Gliclazide 80mg Pioglitazone Accord Pioglitazone 1; 30mg; 4 Glucose strips R350 R350 Surgical item Insulin pen device Lancets Dysrhythmias R560 R635 Anti-arrhythmics: class Ic R400 R400 Anti-arrhythmics: class III - Amiodarone Needles Cipla-Pioglitazone Accu-check active mic strips Caresens II/pop test strip 29g Caresens n test strips 29g Freestyle optium glucose test strips Glucocheck strips 50s Glucoplus Glucoplus provider strips Glucose blood test strips diamond Onetouch select glucose test strips On-call plus ez strips (all sizes) Biosulin pen device Lancets 50's Lancets blood collection needles loris Lancets glucoplus 66 x 44 x 78mm Lancets solus v2 BD microfine pen needle 32g 4mm BD microfine pen needle 31g 5mm BD microfine pen needle 30g 8mm Needle novofine Page 15 of 29 01/2015 1; 30mg Flecainide Tambocor Tambocor CR ; 200mg Propafenone Rythmol 1; 300mg Amiodarone Arycor ; 200mg Bio-Amiodarone 200mg Hexarone ; 200mg

16 Dysrhythmias R75 R75 Anti-thrombotic Warfarin Cipla-Warfarin 1mg; Vitamin K antagonists R10 R20 Aspirin Acetylsalicylic Aspirin 300mg acid Be-Tabs Aspirin (white) 300mg Gulf Aspirin 300mg R190 Beta blocking Propranolol Indoblok 10mg; 40mg non-selective Prodorol 10mg; 40mg Purbloka 10mg; 40mg Sotalol Sotahexal 80mg; 160mg R65 R75 Beta blocking Atenolol B-Block ; selective Bio-Atenolol ; Gulf Atenolol ; Sandoz Atenolol ; Tenopress ; Zetenol ; R25 R25 Cardiac glycosides: Digoxin Lanoxin 0.062; 0.2 Digoxin Lanoxin paed syrup 0.0/1ml R200 R285 Selective calcium channel Verapamil Vasomil 40mg; 80mg blockers with direct Verahexal SR 240mg cardiac effects Epilepsy R170 R270 Anti-epileptics: Clonazepam Rivotril 0.; 2mg Benzodiazepine R290 R360 Anti-epileptics: Carbamazepine Degranol 200mg Carboxamide Sandoz Carbamazepine 200mg Sandoz Carbamazepine CR 200mg; 400mg Zeptol 200mg R395 R395 Anti-epileptics: Valproic acid Convulex 1 Fatty acid Convulex syrup 2/5ml Epilim crushable Epilim sugar-free syrup 200mg/5ml Epilizine CR 200mg; 300mg; 500mg Navalpro CR 200mg; 300mg; 500mg Vanapro 300mg; 500mg R60 R60 Anti-epileptics: Phenytoin Phenytoin sod Hydantoin R270 R365 Anti-epileptics: Lamotrigine Dyna-Lamotrigine 2; ; ; 200mg Other agents Epitec 2; ; ; 200mg Lamidus ; ; 200mg Sandoz Lamotrigine ; ; 200mg Topiramate Adco-Topiramate 2; ; Epitoz 2; ; Sandoz Topiramate ; 200mg R25 R25 Anti-epileptics: Phenobarbital Lethyl 30mg Barbiturates and Sedabarb 30mg Glaucoma R180 R180 Anti-glaucoma Dorzolamide Trusopt 5ml owi 2% Carbonic anhydrase inhibitors R235 R235 Anti-glaucoma Bimatoprost Lumigan 0.01% Prostaglandin analogues Latanoprost Ocuprost 3ml 50mcg/1ml Xalatan 2.5ml 50mcg/1ml Travoprost Travatan 2.5ml 0.004% R255 R255 Anti-glaucoma Brimonidine Alphagan purite 5ml 1./1ml Sympathomimetics R85 R85 Anti-glaucoma Beta blocking Timolol Timolol Glaucosan 5ml 0.5% R260 R260 Anti-glaucoma Beta blocking Timolol, combinations Timolol, combinations Azarga 5ml Combigan 5ml 2mg/ Cosopt 5ml 0.5% Duotrav 2.5ml Ganfort 3ml Xalacom 2.5ml Page 16 of 29 01/2015

17 Haemophilia R5 R5 Analgesics: Paracetamol R195 R195 Anti-fibrinolytics: Amino acids R R Blood coagulation factors R1 450 R1 700 Posterior pituitary hormones: Vasopressin and analogues Hyperlipidaemia R255 R255 Lipid modifying Fibrates R45 R55 Lipid modifying Statins Hypertension R190 R190 ACE inhibitors and calcium channel blockers R115 R120 ACE inhibitors and R80 R115 ACE inhibitors: plain Paracetamol Adco-Napamol 500mg Adco-Prolief 500mg Cetapon 500mg Painogesic 500mg Tranexamic acid Morwak 500mg 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 Atorvastatin Adco Atorvastatin 10mg; ; 40mg Aspavor 10mg; ; 40mg Aspavor 80mg Astor 40mg Dynator 10mg; ; 40mg Dynator 80mg Lipogen 80mg Vastor 10mg; ; 40mg; 80mg Simvastatin Adco-Simvastatin 10mg; ; 40mg Austell-Simvastatin 10mg; ; 40mg Choleste 40mg Cipla-Simvastatin 10mg; ; 40mg Simvacor 10mg; ; 40mg Zysim 10mg; ; 40mg Perindopril and Coveram 5/; 10/; 5/10mg; 10/10mg Amlodipine Enalapril and Enap co 20/12. Pharmapress co 20/12. Lisinopril and Adco-Zetomax co 10/12. Adco-Zetomax co 20/12. Lisinopril co Unicorn 20/12. Lisoretic 10/12.; 20/12. Zestoretic 10/12.; 20/12. Perindopril and Zydus Perindopril co 4/1.2 Captopril Adco-Captomax 2; Bio-Captopril 2 Mylan Captopril 2; Enalapril Alapren ; 10mg; Enalapril Unicorn 10mg; Enap ; 10mg; Envas ; 10mg Hr-Enalapril ; 10mg; Page 17 of 29 01/2015

18 Hypertension R80 R115 ACE inhibitors: plain R210 R235 Alpha and Beta blocking agents R110 R115 Angiotensin II antagonists, Combinations R80 R120 Angiotensin II antagonists: plain R140 R140 Anti-adrenergic Alpha-adrenoreceptor antagonists Lisinopril Austell-Lisinopril 10mg; Sinopren ; 10mg; Perindopril Acti-Prex Auro Perindopril Bindace Ciplasyl ; 8mg Pearinda ; 8mg Perindopril Unicorn Prexum Ran-Perindopril Spec-Perindopril ; 8mg Zydus Perindopril Quinapril Accumax 10mg; Carvedilol Carvedilol Unicorn 6.2; 12.; 2 Carvetrend 6.2; 12.; 2 Vediblok 6.2; 12.; 2 Irbesartan and Isart co 150/12.; 300/12. Losartan and Austell Losartan co 50/12. Hytenza co 50/12. 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 Zartan co 100/2 Valsartan and Dynaval co 80/12.; 160/12.; 160/2 Irbesartan Dynarb 1; 300mg Isart 1; 300mg Losartan Auro Losartan Austell Losartan Ciplazar Hytenza Losartan Unicorn Spec-Losartan Zartan Valsartan Diolo 80mg; 160mg Doxazosin Adco-Doxazosin 1mg; 2mg; Cardugen 1mg; Page 18 of 29 01/2015

19 Hypertension R130 R130 Anti-adrenergic Methyldopa R25 R25 Anti-adrenergic Rauwolfia alkaloids R85 R85 Arteriolar smooth muscle Hydrazinophthalazine R190 Beta blocking non-selective Methyldopa Hypotone 2 Mylan Methyldopa 2 Sandoz Methyldopa 2 Reserpine Reserpine 0.2 Hydralazine Hyperphen 10mg; Sandoz Hydralazine Propranolol Indoblok 10mg; 40mg Prodorol 10mg; 40mg Purbloka 10mg; 40mg R65 R75 Beta blocking Atenolol B-Block ; selective Bio-Atenolol ; Gulf Atenolol ; Sandoz Atenolol ; Tenopress ; Zetenol ; R20 R40 High-ceiling Furosemide Dino-Retic 40mg Diuresix 40mg Furobe 40mg Mylan Furosemide 40mg R15 R15 Low-ceiling : Hydrochloro- Hexazide 2 Thiazides, plain thiazide Ridaq 12. R20 R20 Low-ceiling : Indapamide Cipla-Indapamide 2. excluding Thiazides Daptril 2. Mylan Indapamide 2. R95 R95 Potassium sparing Spironolactone Aldactone 2 agents Sandoz Spironolactone 2 Spiractin 2 R90 R90 Potassium Potassium Plenish K 600mg supplements chloride Potassium Chloride Unicorn 600mg Sandoz K mg Ultipot 600mg R200 R285 Selective calcium Diltiazem Adco-Zildem 60mg channel blockers with Adco-Zildem SR 180mg; 240mg direct cardiac effects Verapamil Vasomil 40mg; 80mg Verahexal SR 240mg R130 R190 Selective calcium Amlodipine Amlodac ; 10mg channel blockers with mainly vascular effects Amtas ; 10mg 2 Gulf Amlodipine ; 10mg Indo Amlodipine Lomanor ; 10mg Pharma Dynamics Amlodipine besylate ; 10mg Felodipine Felodipine-Hexal 10mg Plendil 2.; Nifedipine Adco-Vascard SR Cipalat Retard Nifedalat SR Hypothyroidism R45 R45 Thyroid hormones Levothyroxine Euthyrox 25mcg; 50mcg; 100mcg sodium Multiple sclerosis Anti-depressants: Amitriptyline Gulf Amitriptyline 2 Tricyclics Sandoz Amitriptyline 2 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 Page 19 of 29 01/2015

20 Multiple sclerosis R R Interferons Interferon beta-1a R1 090 R1 090 Muscle relaxants: Other centrally acting agents R10 R10 Systemic corticosteroids: Prednisone R185 R245 Urinary anti-spasmodics Parkinson's disease R315 R315 Anti-cholinergic Tertiary amines 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 Betaferon pre-filled syringe 1ml u/1ml Interferon beta-1b Baclofen Bio-Baclofen 10mg Teva Baclofen 10mg Prednisone Be-Tabs Prednisone Panafcort Trolic Oxybutynin Lenditro Mylan Oxybutynin Biperiden Akineton 2mg Lennon-Biperiden 2mg R565 R565 Dopamine agonists Pramipexole Oxpola 0.12; 0.2; 1mg Pramex 0.12; 0.2; 1mg Pramiola 0.12; 0.2 Ropinirole Accord Ropinirole 0.2; 0.; 1mg; 2mg; Requip 0.2; 0.; 1mg; 2mg; R645 R645 Dopaminergic Selegiline Parkilyne Monoamine oxidase B inhibitors: Selegiline R280 R280 Dopaminergic Amantadine Symadin Adamantane R620 R620 Levodopa and Levodopa and Carbilev 25/; 25/2 decarboxylase decarboxylase Sinemet 25/; 25/2 inhibitor inhibitor Teva Carbi-Levo 25/; 25/2 Rheumatoid arthritis R45 R55 Anti-inflammatory Diclofenac Adco-Diclofenac A-Lennon Diclofenac 2; Acetic acid Diclofenac Biotech 2 and Mylan Diclofenac 2; related substances Panamor AT Sandoz Diclofenac 2 Indomethacin Betacin 2 Gulf Indomethacin 2 Methocaps 2 R75 R90 Anti-inflammatory Meloxicam Adco-Meloxicam 7.; 1 Arrow Meloxicam 7. Oxicams Flamaryx 7. Flexocam 7. Medoxicam 7. Zydus-Meloxicam 7. Piroxicam Pyrocaps Roxifen R30 R30 Anti-inflammatory Ibuprofen Betaprofen 200mg Betaprofen FC 400mg Propionic acid Bren 400mg Ibu 200mg Ibucine 200mg; 400mg Ibunate 200mg Ranfen 400mg Naproxen Be-Tabs Naproxen 2 Naproscript 2 Page 20 of 29 01/2015

21 Rheumatoid arthritis R85 R85 Anti-rheumatic Chloroquine R5 R5 Folic acid and R710 R710 Intestinal antiinflammatories: Aminosalicylic acid and similar agents R625 R625 Other immunosuppressive Azathioprine Other immunosuppressive Methotrexate R10 R10 Systemic corticosteroids: Prednisone Schizophrenia R115 R330 Anti-depressants: SSRIs R290 R360 Anti-epileptics: Carboxamide Chloroquine Plasmoquine 200mg Folic acid Aha Folic acid Be-Tabs Folic acid Folic acid 0. Sulfasalazine Salazopyrin 500mg Salazopyrin EN 500mg Azathioprine Azamun Azathioprine PCH Methotrexate Abitrexate 2. Methotrexate 2. Prednisone Be-Tabs Prednisone Panafcort Trolic Citalopram Adco-Talomil Arrow Citalopram ; 40mg Bio Citalopram Cilate Escitalopram Accord Escitalopram 10mg; Escitalopram Be-Tabs 10mg; Zytomil 10mg; Fluoxetine A-Lennon Fluoxetine Deprozan Fluoxetine Actor Prolax Ranflocs Rezak Zydus Fluoxetine Paroxetine Adco-Paroxetine Auro Paroxetine Serrapress Xet Sertraline Austell-Sertraline ; Dyna Sertraline ; Serdep ; Serlife Zolid Zylin Carbamazepine Degranol 200mg Sandoz Carbamazepine 200mg Page 21 of 29 01/2015

22 Schizophrenia R290 R360 Anti-epileptics: Carboxamide R100 R100 Anti-psychotics: Butyrophenone R685 R1 100 Anti-psychotics: Clozapine Systemic lupus erythematosus (SLE) R605 R605 Anti-psychotics: Olanzapine R360 R360 Anti-psychotics: Phenothiazines with aliphatic side-chain R390 R390 Anti-psychotics: Quetiapine R515 R650 Anti-psychotics: Thioxanthene R400 R1 005 Other anti-psychotics R45 R55 Anti-inflammatory Acetic acid and related substances R75 R90 Anti-inflammatory Oxicams R30 R30 Anti-inflammatory Propionic acid Carbamazepine Sandoz Carbamazepine CR 200mg; 400mg Zeptol 200mg Haloperidol Gulf Haloperidol Sandoz Haloperidol 1.; Clozapine Aspen Clozapine 2; Cloment 2; Olanzapine Mylan Olanzapine ; 10mg Oleanz Olexar Prexolan odt Redilanz ; 10mg ; 10mg ; 10mg ; 10mg Chlorpromazine Largactil 2; Quetiapine Dopaquel 2; ; 200mg; 300mg Mylan Quetiapine 2; ; 200mg; 300mg Psyquet 2; ; 200mg; 300mg Quetoser 2; ; 200mg; 300mg Serez Sizonorm 2; ; 200mg; 300mg 2; ; 200mg; 300mg Flupenthixol Fluanxol 0.; 1mg Fluanxol depot 1ml Fluanxol depot 2ml 40mg Zuclopenthixol Clopixol 2mg; 10mg Clopixol depot 200mg Risperidone DRL-Risperidone 0.; 1mg; 2mg Perizal 0.; 1mg; 2mg; 3mg Risnia Rispacor Rispevon Risponz Schizorol Zoxadon 0.; 1mg; 2mg; 3mg 0.; 1mg; 2mg; 3mg 3mg; 1mg; 2mg; 3mg; 0. 0.; 1mg; 2mg Diclofenac Adco-Diclofenac A-Lennon Diclofenac 2; Diclofenac Biotech 2 Mylan Diclofenac 2; Panamor AT 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 2 Naproscript 2 Page 22 of 29 01/2015

23 Systemic lupus erythematosus (SLE) R85 R85 Anti-rheumatic Chloroquine Plasmoquine 200mg Chloroquine R75 R75 Anti-thrombotic Warfarin Cipla-Warfarin 1mg; Vitamin K antagonists R10 R20 Aspirin Acetylsalicylic Aspirin 300mg acid Be-Tabs Aspirin (white) 300mg Gulf Aspirin 300mg R25 R25 Emolients and Zinc products Zinc ointment bp protectives: Zinc products R5 R5 Folic acid and Folic acid Aha Folic acid Be-Tabs Folic acid Folic acid 0. R625 R625 Other immunosuppressive Azathioprine Azamun Azathioprine Azathioprine PCH Other immunosuppressive Methotrexate Abitrexate 2. Methotrexate Methotrexate 2. R10 R10 Systemic Prednisone Be-Tabs Prednisone corticosteroids: Panafcort Prednisone Trolic R25 R25 Topical Betamethasone Repivate cream 0.1% corticosteroids: Topivate cream 0.1% Group III Vari-Betamethasone cream 0.1% Ulcerative colitis R5 R5 Folic acid and R710 R710 Intestinal anti-inflammatories: Aminosalicylic acid and similar agents R2 415 R2 415 Intestinal anti-inflammatories: Corticosteroids R625 R625 Other immunosuppressive Azathioprine Other immunosuppressive Methotrexate R10 R10 Systemic corticosteroids: Prednisone Folic acid Aha Folic acid Be-Tabs Folic acid Folic acid 0. Mesalazine Asacol 400mg; 500mg; 800mg Pentasa 500mg; 1000mg Salofalk 1000mg Olsalazine Dipentum 2 Sulfasalazine Salazopyrin 500mg Salazopyrin EN 500mg Budesonide Entocord enema Azathioprine Azamun Azathioprine PCH Methotrexate Abitrexate 2. Methotrexate 2. Prednisone Be-Tabs Prednisone Panafcort Trolic Page 23 of 29 01/2015

24 Non-CDL condition Ankylosing spondylitis Behcet's disease Cystic fibrosis Delusional disorder Chronic Drug Amount R90 R225 R55 R40 R305 R300 R75 R90 R30 R625 R710 R4 200 R5 R90 R250 R225 R625 R4 200 R30 R90 R110 R100 R225 R290 R410 R375 R395 R650 R785 R200 R6 500 R315 R330 R610 R560 R480 R425 R385 R450 R540 Chronic Drug Amounts for the Executive Plan and The Chronic Drug Amounts below apply to the Executive Plan and for non-cdl conditions. or medicine Other Immunosuppressive Agents - Methotrexate Potassium Supplements Systemic Corticosteroids - Betamethasone 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 anti-rheumatic 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 Potassium Supplements Alkylating Agents - Nitrogen Mustard Analogues Systemic Corticosteroids - Betamethasone Other Immunosuppressive Agents - Azathioprine Selective Immunosuppressive agents Adrenergics - Short Acting - Salbutamol Potassium Supplements Other Plain Vitamin preparations Sodium Chloride for nebulisation Systemic Corticosteroids - Betamethasone Drugs for constipation Mucolytics Vitamin D and analogues Adrenergics - Long Acting - Salmeterol Nutritional Supplements Anti-fungal Agents, systemic Anti-bacterial Agents, systemic Digestive Enzymes Anti-cholinergic Agents - Tertiary Amines Anti-depressants - SSRI's Anti-depressants - Tricyclics Anti-depressants - MAOI's - Non-selective Other Anti-depressants - Noradrenergic and Specific Serotonergic Agents - Mianserin Other Anti-depressants - Augmenters - Trazodone Other Anti-depressants - Noradrenergic and Specific Serotonergic Agents - Mirtazapine Other Anti-depressants - Norepinephrine-Dopamine Reuptake Inhibitors - Bupropion Other Anti-depressants - Serotonin-Norepinephrine Reuptake Inhibitors - Venlafaxine Other Anti-depressants - Norepinephrine Re-uptake Inhibitors - Reboxetine Non-CDL condition Delusional disorder Chronic or medicine Drug Amount R320 Other Anti-depressants - Serotonin-Norepinephrine Re-uptake Inhibitors - Duloxetine R720 Other Anti-depressants - Melatonergic Agents - Agomelatine R360 Anti-psychotics - Phenothiazines with aliphatic sidechain R85 Anti-rheumatic Agents - Chloroquine Dermatopolymyositis Generalised anxiety disorder Huntington's disease Page 24 of 29 01/2015 R90 R225 R625 R4 200 R5 R190 R330 R610 R560 R480 Other Immunosuppressive Agents - Methotrexate Potassium Supplements Systemic Corticosteroids - Betamethasone Other Immunosuppressive Agents - Azathioprine Selective Immunosuppressive agents Folic acid and Beta blocking agents, non-selective Anti-depressants - SSRI's Anti-depressants - Tricyclics Anti-depressants - MAOI's - Non-selective Other Anti-depressants - Noradrenergic and Specific Serotonergic Agents - Mianserin Other Anti-depressants - Augmenters - Trazodone R425 Other Anti-depressants - Noradrenergic and Specific Serotonergic Agents - Mirtazapine R385 Other Anti-depressants - Norepinephrine-Dopamine Re-uptake Inhibitors - Bupropion R450 Other Anti-depressants - Serotonin-Norepinephrine Re-uptake Inhibitors - Venlafaxine R540 Other Anti-depressants - Norepinephrine Re-uptake Inhibitors - Reboxetine R320 Other Anti-depressants - Serotonin-Norepinephrine Re-uptake Inhibitors - Duloxetine R720 Other Anti-depressants - Melatonergic Agents - Agomelatine R270 Anti-epileptics - Benzodiazepine R60 R330 R320 R360 R395 R610 R580 R560 R480 Anti-epileptics - Hydantoin Anti-depressants - SSRI's Anti-psychotics - Lithium Anti-depressants - Tricyclics Anti-epileptics - Carboxamide Anti-epileptics - 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 R425 Other Anti-depressants - Noradrenergic and Specific Serotonergic Agents - Mirtazapine R385 Other Anti-depressants - Norepinephrine-Dopamine Re-uptake Inhibitors - Bupropion R450 Other Anti-depressants - Serotonin-Norepinephrine Re-uptake Inhibitors - Venlafaxine R540 Other Anti-depressants - Norepinephrine Re-uptake Inhibitors - Reboxetine R320 Other Anti-depressants - Serotonin-Norepinephrine Re-uptake Inhibitors - Duloxetine R720 Other Anti-depressants - Melatonergic Agents - Agomelatine

25 Non-CDL condition Huntington's disease Isolated growth hormone deficiency in children under 18 years Major depression Motor neurone disease Muscular dystrophy Myasthenia gravis Obsessive compulsive disorder Chronic Drug Amount R365 R360 R8 700 R315 R60 R330 R320 R990 R650 R360 R395 R610 R580 R560 R480 or medicine Anti-epileptics - Other Agents Anti-psychotics - Phenothiazines with aliphatic sidechain Anterior Pituitary Hormones - Somatropin and somatropin agonists 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 Anti-epileptics - 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 R425 Other Anti-depressants - Noradrenergic and Specific Serotonergic Agents - Mirtazapine R385 Other Anti-depressants - Norepinephrine-Dopamine Re-uptake Inhibitors - Bupropion R450 Other Anti-depressants - Serotonin-Norepinephrine Re-uptake Inhibitors - Venlafaxine R540 Other Anti-depressants - Norepinephrine Re-uptake Inhibitors - Reboxetine R320 Other Anti-depressants - Serotonin-Norepinephrine Re-uptake Inhibitors - Duloxetine R720 Other Anti-depressants - Melatonergic Agents - Agomelatine R365 Anti-epileptics - Other Agents R270 R565 R5 130 R90 R225 R270 R565 R90 R250 R225 R625 R1 465 R4 200 R5 R315 R60 R330 R320 Anti-epileptics - Benzodiazepine Anti-depressants - Tricyclics Muscle Relaxants - Carbamic acid esters Other nervous system drugs Potassium Supplements Systemic Corticosteroids - Betamethasone Anti-epileptics - Benzodiazepine Muscle Relaxants - Carbamic acid esters Other Immunosuppressive Agents - Methotrexate Potassium Supplements Alkylating Agents - Nitrogen Mustard Analogues Systemic Corticosteroids - Betamethasone Other Immunosuppressive Agents - Azathioprine Parasympathomimetics - Anticholinesterases Selective Immunosuppressive agents Folic acid and Anti-cholinergic Agents - Tertiary Amines Anti-epileptics - Hydantoin Anti-depressants SSRI s Anti-psychotics - Lithium Anti-depressants - Tricyclics Non-CDL Chronic or medicine condition Drug Amount Obsessive R360 Anti-epileptics - Carboxamide compulsive R395 Anti-epileptics - Fatty acid disorder R610 Anti-depressants MAOI s - Non-selective R580 Anti-epileptics - Succinimide R560 Other Anti-depressants - Noradrenergic and Specific Serotonergic Agents - Mianserin R480 Other Anti-depressants - Augmenters - Trazodone R425 Other Anti-depressants - Noradrenergic and Specific Serotonergic Agents - Mirtazapine R385 Other Anti-depressants - Norepinephrine-Dopamine Re-uptake Inhibitors - Bupropion R450 Other Anti-depressants - Serotonin-Norepinephrine Re-uptake Inhibitors - Venlafaxine R540 Other Anti-depressants - Norepinephrine Re-uptake Inhibitors - Reboxetine R320 Other Anti-depressants - Serotonin-Norepinephrine Re-uptake Inhibitors - Duloxetine R720 Other Anti-depressants - Melatonergic Agents - Agomelatine R365 Anti-epileptics - Other Agents Osteoporosis R280 Drugs Treating Bone Disorders - Bisphosphonates R575 R545 R280 Anti-parathyroid Agents - Calcitonin preparations Selective estrogen receptor modulators Other Drugs Treating Bone Disorders Paget's disease 280 Drugs Treating Bone Disorders - Bisphosphonates Panic disorder R330 Anti-depressants SSRI s Anti-depressants - Tricyclics R610 Anti-depressants MAOI s - Non-selective R560 Other Anti-depressants - Noradrenergic and Specific Serotonergic Agents - Mianserin R480 Other Anti-depressants - Augmenters - Trazodone Polyarteritis nodosa Post traumatic stress disorder R425 Other Anti-depressants - Noradrenergic and Specific Serotonergic Agents - Mirtazapine R385 Other Anti-depressants - Norepinephrine-Dopamine Re-uptake Inhibitors - Bupropion R450 Other Anti-depressants - Serotonin-Norepinephrine Re-uptake Inhibitors - Venlafaxine R540 Other Anti-depressants - Norepinephrine Re-uptake Inhibitors - Reboxetine R320 Other Anti-depressants - Serotonin-Norepinephrine Re-uptake Inhibitors - Duloxetine R720 Other Anti-depressants - Melatonergic Agents - Agomelatine R85 Anti-rheumatic Agents - Chloroquine R90 R225 R625 R710 R5 R330 R610 R560 R480 R425 R385 R450 Other Immunosuppressive Agents - Methotrexate Potassium Supplements Systemic Corticosteroids - Betamethasone Other Immunosuppressive Agents - Azathioprine Intestinal Anti-inflammatories - Aminosalicylic Acid and similar agents Folic acid and Anti-depressants - SSRI's Anti-depressants - Tricyclics Anti-depressants - MAOI's - Non-selective Other Anti-depressants - Noradrenergic and Specific Serotonergic Agents - Mianserin Other Anti-depressants - Augmenters - Trazodone Other Anti-depressants - Noradrenergic and Specific Serotonergic Agents - Mirtazapine Other Anti-depressants - Norepinephrine-Dopamine Re-uptake Inhibitors - Bupropion Other Anti-depressants - Serotonin-Norepinephrine Re-uptake Inhibitors - Venlafaxine Page 25 of 29 01/2015

26 Non-CDL condition Post traumatic stress disorder Psoriatic arthritis Pulmonary interstitial fibrosis Sjogren s syndrome Chronic Drug Amount R540 or medicine Other Anti-depressants - Norepinephrine Re-uptake Inhibitors - Reboxetine Non-CDL condition Systemic sclerosis Chronic Drug Amount R55 or medicine Anti-inflammatory Agents - Acetic acid and related substances R320 Other Anti-depressants - Serotonin-Norepinephrine Reuptake R40 Anti-inflammatory Agents - Butylpyrazolidines Inhibitors - Duloxetine R720 Other Anti-depressants - Melatonergic Agents - Agomelatine R305 Anti-inflammatory Agents - Coxibs R85 Anti-rheumatic Agents - Chloroquine R300 Anti-inflammatory Agents - Fenamates Other Immunosuppressive Agents - Methotrexate R75 Anti-inflammatory Agents - Other antiinflammatory and anti-rheumatic agents, nonsteroids R90 Potassium Supplements R90 Anti-inflammatory Agents - Oxicams R225 Systemic Corticosteroids - Betamethasone R30 Anti-inflammatory Agents - Propionic acid R55 Anti-inflammatory Agents - Acetic acid and R625 Other Immunosuppressive Agents - Azathioprine related substances R40 Anti-inflammatory Agents - Butylpyrazolidines R1 300 Anti-rheumatic Agents - Penicillamine and similar agents R305 Anti-inflammatory Agents - Coxibs R1 730 Anti-metabolites - Purine Analogues R300 Anti-inflammatory Agents - Fenamates R5 Folic acid and R75 Anti-inflammatory Agents - Other anti-inflammatory and anti-rheumatic agents, non-steroids Wegener's granulomatosis R90 Anti-inflammatory Agents - Oxicams R90 Potassium Supplements Other Immunosuppressive Agents - Methotrexate R30 Anti-inflammatory Agents - Propionic acid R225 Systemic Corticosteroids - Betamethasone R625 Other Immunosuppressive Agents - Azathioprine R625 Other Immunosuppressive Agents - Azathioprine R710 R5 R30 R85 R90 R250 R225 R345 R395 R205 R625 R710 R5 R55 R40 R305 R300 R75 R90 R30 R85 R225 R100 Intestinal Anti-inflammatories - Aminosalicylic Acid and similar agents Folic acid and Adrenergics - Short Acting - Salbutamol Anti-rheumatic Agents - Chloroquine Other Immunosuppressive Agents - Methotrexate Potassium Supplements Alkylating Agents - Nitrogen Mustard Analogues Systemic Corticosteroids - Betamethasone Inhaled Glucocorticoids Adrenergics - Long Acting - Salmeterol Inhaled Anti-cholinergics - Ipratropium bromide Other Immunosuppressive Agents - Azathioprine Intestinal Anti-inflammatories - Aminosalicylic Acid and similar agents Folic acid and 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 anti-rheumatic agents, non-steroids Anti-inflammatory Agents - Oxicams Anti-inflammatory Agents - Propionic acid Anti-rheumatic Agents - Chloroquine Other Immunosuppressive Agents - Methotrexate Systemic Corticosteroids - Betamethasone Other urologicals R5 Folic acid and Page 26 of 29 01/2015

27 Non-CDL condition Systemic sclerosis Chronic Drug Amount R85 R90 R190 R250 R225 R180 or medicine Anti-rheumatic Agents - Chloroquine Other Immunosuppressive Agents - Methotrexate Potassium Supplements Selective Calcium Channel Blockers With Mainly Vascular Effects Alkylating Agents - Nitrogen Mustard Analogues Systemic Corticosteroids - Betamethasone Proton pump inhibitors Page 27 of 29 01/2015

28 Frequently asked questions Why it is important for a member to be registered for chronic medicine cover? It is important for members to understand their condition and be compliant on their treatment. Registering for chronic illness benefits also opens a basket of care so that the member s healthcare providers can monitor and manage the condition appropriately. What happens when a member is not registered for chronic medicine cover? Claims will pay from the member s day-to-day benefit, if available on their chosen health plan. This leads to out-of-pocket expenses (Self-payment Gap) which can be easily avoided. It also leads to noncompliance when co-payments are not affordable. Who should be registered for chronic medicine cover; does each dependant on the member s medical scheme need to apply separately for chronic medicine cover and how many times does a member have to apply for the medicine? Each dependant who has been diagnosed with a CDL condition must register separately for cover. The application process only needs to be followed if the dependant is diagnosed with a new condition. Changes to medicines can be made telephonically by the treating doctor or dispensing pharmacist. In addition to the member, who else must complete and sign the registration form when applying for chronic medicine cover? The doctor need to complete certain sections and sign and date the Chronic Illness Benefit application form. What about any additional documents that are required to su pport the application? All the requirements for registration of a CDL condition are specified on the application form. This includes the type of doctor that can apply as well as the details of other information that is required. Where do members send the completed registration form ( ; fax or postal address)? Members can Fax the completed application form to , it to CIB_APP_FORMS@discovery.co.za or post it to Discovery Health, CIB Department, PO Box , Benmore, How do members know that their application has been approved; and what happens once a member s application is approved? They will receive the CIB decision letter, which is sent to them according to their communication channel preference. What is the process to be followed when a registered member updates any modification to the chronic medicine authorisation? They can fax or the updated prescription through to the Chronic Illness Benefit division, or the doctor or pharmacist can phone in to make the change. Page 28 of 29 01/2015