Motohealth Custom Chronic Medicine Formulary

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1 Motohealth Custom Chronic Medicine Formulary 2018 Chronic application forms must accompany all first-time applications. All applications MUST include valid ICD10 codes. Risk Equalisation Fund criteria must be met. If the prescriber or patient insists on a non-formulary Product, where a therapeutic equivalent is available on the formulary, a co-pay will be levied at the point of dispensing. Reference pricing is applied. If a product is prescribed that is more expensive than the reference price, the patient will need to pay the difference in price at the point of dispensing. The examples below serve as a guide to the prescriber. Other generic products not specifically listed will be reimbursed in full if the price falls within the reference price range for that group. A clinically relevant motivation is required when prescribing any product which does not appear on this list. The formulary is subject to regular review. CareCross Health reserves the right to update and change the formulary when new information becomes available, prices change or when new medicines are released While every effort has been made to ensure that products listed are available on the market, it is possible that some products may be discontinued by the manufacturers during the course of the year. Ingredient Nappi Product Name Strength Form Restriction ADDISON'S DISEASE The PMB is applicable to primary Addisons disease only. Please provide Practice number and name of diagnosing specialist Fludrocortisone FLORINEF ACETATE 0,1MG TAB Hydrocortisone COVOCORT 10MG TAB Prednisolone LENISOLONE 5MG TAB Prednisone TROLIC 5MG TAB Prednisone PANAFCORT 5MG TAB Prednisone BE-TABS PREDNISONE 5MG TAB ASTHMA MASK BABY CIPLA ZZZ SPACER ZEROSTAT VT ZZZ Prednisone BE-TABS PREDNISONE 5MG TAB Only for severe persistent asthma (motivation required) Prednisone PANAFCORT 5MG TAB Only for severe persistent asthma (motivation required)

2 Prednisone TROLIC 5MG TAB Only for severe persistent asthma (motivation required) Salbutamol VENTEZE CFC FREE 200 DOSE 100MCG INH Limited to 3 inhalers per year if no inhaled steroid Salbutamol ASTHAVENT ECOHALER CFC-FREE 300DO100MCG INH Limited to 3 inhalers per year if no inhaled steroid Salbutamol ASTHAVENT ECOHALER 200DOSE 100MCG INH Limited to 3 inhalers per year if no inhaled steroid Salmeterol/ fluticasone SEREFLO 25/125 HFA 120 DOSE INH Only for moderate & severe persistent asthma (motivation required) Salmeterol/ fluticasone SEREFLO 25/250 HFA 120 DOSE INH Only for moderate & severe persistent asthma (motivation required) Salmeterol/ fluticasone SEREFLO 25/50 HFA 120 DOSE INH Only for moderate & severe persistent asthma (motivation required) Salbutamol/ Ipratropium DUOLIN HFA 200DOSE INH Beclometasone BECEZE DOSE 50MCG INH Beclometasone BECEZE 100 CFC FREE 200DOSE 100MCG INH Beclometasone BECLATE 200DOSE 50MCG INH Beclometasone BECLATE 200DOSE 100MCG INH Beclometasone BECLATE 200DOSE 200MCG INH Budesonide PULMICORT TURBUHALER 200DOSE 100MCG TBH Budesonide PULMICORT TURBUHALER 200DOSE 200MCG TBH Budesonide BUDEFLAM HFA 300DOSE 100MCG INH Budesonide BUDEFLAM HFA 300DOSE 200MCG INH Salbutamol VENTEZE 2MG/5ML SYR Salbutamol ASTHAVENT 2MG/5ML SYR Theophylline SANDOZ THEOPHYLLINE ANHYDROUS 200MG SRT Theophylline SANDOZ THEOPHYLLINE ANHYDROUS 300MG SRT BRONCHIECTASIS Please provide a sensitivity report if a different antibiotic is required

3 Doxycycline DOXYCYL 100MG CAP Doxycycline CYCLIDOX 100MG CAP Doxycycline A-LENNON DOXYCYCLINE HCL 100MG CAP Amoxicillin AUSTELL-AMOXICILLIN 500MG CAP Amoxicillin BETAMOX 500MG CAP Amoxicillin MOXYPEN 250MG CAP Amoxicillin MOXYPEN 500MG CAP CARDIAC DYSRHYTHMIAS Please provide a specific diagnosis and /or the relevant ICD10 code Warfarin CIPLA-WARFARIN 5MG TAB Warfarin CIPLA-WARFARIN 1MG TAB Digoxin LANOXIN 0,25MG TAB Digoxin PURGOXIN 0,25MG TAB Quinidine QUINIDINE SULPH 200MG TAB Amiodarone HEXARONE 100MG TAB Amiodarone HEXARONE 200MG TAB Amiodarone ARYCOR 200MG TAB Amiodarone ARYCOR 100MG TAB Atenolol BIO-ATENOLOL (WAS IVAX-ATENOLOL) 50MG TAB Atenolol TEN-BLOKA 50MG TAB Atenolol TEN-BLOKA 100MG TAB Atenolol B-BLOCK 100MG TAB Atenolol B-BLOCK 50MG TAB Atenolol TENOPRESS 25MG TAB Atenolol SANDOZ ATENOLOL 50MG TAB Atenolol HEXA-BLOK 50MG TAB Bisoprolol ZIAPRO 10MG TAB Bisoprolol ZIAPRO 5MG TAB Bisoprolol BILOCOR 5MG TAB Bisoprolol BILOCOR 10MG TAB Verapamil VERAHEXAL 240 SR 240MG SRT Verapamil VASOMIL 40MG TAB Verapamil VASOMIL 80MG TAB Diltiazem ADCO-ZILDEM 90MG TAB Diltiazem ADCO-ZILDEM SR 180MG SRC Diltiazem ADCO-ZILDEM SR 240MG SRC

4 Acetylsalicylic acid DISPRIN 300MG EFT CARDIAC FAILURE AND CARDIOMYOPATHY Potassium chloride SANDOZ K MG TAB For documented hypokalaemia Potassium chloride PLENISH K 600MG TAB For documented hypokalaemia Warfarin CIPLA-WARFARIN 5MG TAB Warfarin CIPLA-WARFARIN 1MG TAB Digoxin LANOXIN 0,25MG TAB Digoxin PURGOXIN 0,25MG TAB Isosorbide dinitrate SANDOZ ISOSORBIDE DINITRATE 10MG TAB Hydrochlorothiazide HEXAZIDE 25MG TAB Furosemide SANDOZ FUROSEMIDE 40MG TAB Furosemide PURESIS 40MG TAB Furosemide MYLAN FUROSEMIDE 40MG TAB Spironolactone SPIRACTIN 25MG TAB Spironolactone SANDOZ SPIRONOLACTONE 25MG TAB Bisoprolol ZIAPRO 5MG TAB Bisoprolol ZIAPRO 10MG TAB Bisoprolol ADCO-BISOCOR 10MG TAB Bisoprolol ADCO-BISOCOR 5MG TAB Bisoprolol BILOCOR 5MG TAB Bisoprolol BILOCOR 10MG TAB Carvedilol CARVETREND 25MG TAB Carvedilol ASPEN CARVEDILOL 25MG TAB Carvedilol CARVETREND 6,25MG TAB Carvedilol CARVETREND 12,5MG TAB Carvedilol ASPEN CARVEDILOL 6,25MG TAB Carvedilol ASPEN CARVEDILOL 12,5MG TAB Carvedilol VEDIBLOK 6,25MG TAB Carvedilol VEDIBLOK 12,5MG TAB Carvedilol VEDIBLOK 25MG TAB Atenolol and other diuretics TENCHLOR 100MG/25MG TAB Atenolol and other diuretics TENCHLOR HS 50MG/12.5MG TAB Captopril ADCO-CAPTOMAX 25MG TAB Captopril ADCO-CAPTOMAX 50MG TAB Captopril MYLAN CAPTOPRIL 25MG TAB Captopril MYLAN CAPTOPRIL 50MG TAB

5 Enalapril PHARMAPRESS 20MG TAB Enalapril ENAP 20MG TAB Enalapril ENAP 5MG TAB Enalapril ENAP 10MG TAB Enalapril PHARMAPRESS 5MG TAB Perindopril PREXUM 5MG TAB Perindopril ACESYL 4MG TAB Perindopril CIPLA-PERINDOPRIL 8MG TAB Perindopril PEARINDA 4MG TAB Perindopril PEARINDA 8MG TAB Perindopril and diuretics PREXUM PLUS 5MG/1.25MG TAB Losartan HYTENZA 50MG TAB Motivation required - please specify Losartan ZARTAN 50MG TAB Motivation required - please specify Losartan ZARTAN 100MG TAB Motivation required - please specify Losartan HYTENZA 100MG TAB Motivation required - please specify Acetylsalicylic acid DISPRIN 300MG EFT Pneumococcus, purified po IMOVAX PNEUMO 23 VAC Once only CHRONIC OBSTRUCTIVE PULMONARY DISEASE Please attach a lung function test report (The REF Entry criteria are in line with the GOLD classification) SPACER ZEROSTAT VT ZZZ Prednisone PANAFCORT 5MG TAB Prednisone BE-TABS PREDNISONE 5MG TAB Prednisone TROLIC 5MG TAB Formoterol FORATEC HFA 120DOSE 12MCG/1DOSE INH Salbutamol VENTEZE CFC FREE 200 DOSE 100MCG INH Salbutamol ASTHAVENT ECOHALER CFC-FREE 100MCG INH 300DOSE Salbutamol ASTHAVENT ECOHALER 200DOSE 100MCG INH

6 SALBUTAMOL AND IPRATR DUOLIN HFA 200DOSE INH Beclometasone BECLATE 200DOSE 50MCG INH Steroid inhalers are reserved for patients who are experiencing frequent exacerbations. Please provide a clinical history Beclometasone BECLATE 200DOSE 100MCG INH Steroid inhalers are reserved for patients who are experiencing frequent exacerbations. Please provide a clinical history Beclometasone BECLATE 200DOSE 200MCG INH Steroid inhalers are reserved for patients who are experiencing frequent exacerbations. Please provide a clinical history Budesonide PULMICORT TURBUHALER 200DOSE 100MCG TBH Steroid inhalers are reserved for patients who are experiencing frequent exacerbations. Please provide a clinical history Budesonide PULMICORT TURBUHALER 200DOSE 200MCG TBH Steroid inhalers are reserved for patients who are experiencing frequent exacerbations. Please provide a clinical history Budesonide BUDEFLAM HFA 300DOSE 100MCG INH Steroid inhalers are reserved for patients who are experiencing frequent exacerbations. Please provide a clinical history Budesonide BUDEFLAM HFA 300DOSE 200MCG INH Steroid inhalers are reserved for patients who are experiencing frequent exacerbations. Please provide a clinical history Ipratropium bromide IPVENT HFA 200 DOSE 40MCG/1DOSE INH Theophylline SANDOZ THEOPHYLLINE ANHYDROUS 200MG SRT Theophylline SANDOZ THEOPHYLLINE ANHYDROUS 300MG SRT CHRONIC RENAL FAILURE Creatinine clearance required Calcium carbonate ENO TUMS ASSORTED FRUIT FLAVOURS CHU Calcium carbonate ENO TUMS PEPPERMINT FLAVOUR CHU

7 Calcium carbonate ENO TUMS ORANGE FLAVOUR CHU Potassium chloride SANDOZ K MG TAB For documented hypokalaemia Potassium chloride PLENISH K 600MG TAB For documented hypokalaemia Ferrous fumarate PREGAMAL TAB Various combinations GULF FERROUS SULPHATE COMPOUND TAB Folic acid BE-TABS FOLIC ACID 5MG TAB Hydrochlorothiazide HEXAZIDE 25MG TAB Furosemide SANDOZ FUROSEMIDE 40MG TAB Furosemide PURESIS 40MG TAB Furosemide MYLAN FUROSEMIDE 40MG TAB Atenolol TEN-BLOKA 100MG TAB Atenolol TENOPRESS 25MG TAB Atenolol SANDOZ ATENOLOL 50MG TAB Atenolol HEXA-BLOK 50MG TAB Atenolol BIO-ATENOLOL (WAS IVAX-ATENOLOL) 50MG TAB Atenolol TEN-BLOKA 50MG TAB Bisoprolol ZIAPRO 10MG TAB Bisoprolol ZIAPRO 5MG TAB Bisoprolol ADCO-BISOCOR 5MG TAB Bisoprolol ADCO-BISOCOR 10MG TAB Bisoprolol BILOCOR 5MG TAB Bisoprolol BILOCOR 10MG TAB Verapamil VERAHEXAL 240 SR 240MG SRT Verapamil VASOMIL 40MG TAB Captopril MYLAN CAPTOPRIL 25MG TAB Captopril MYLAN CAPTOPRIL 50MG TAB Enalapril PHARMAPRESS 20MG TAB Enalapril ENAP 20MG TAB Enalapril ENAP 5MG TAB Enalapril ENAP 10MG TAB Enalapril PHARMAPRESS 5MG TAB Perindopril ACESYL 4MG TAB Perindopril CIPLASYL 4 4MG TAB Perindopril CIPLASYL 8 8MG TAB Perindopril PREXUM 5MG TAB Perindopril PEARINDA 4MG TAB Perindopril PEARINDA 8MG TAB

8 Losartan HYTENZA 50MG TAB Motivation required - please specify Losartan ZARTAN 50MG TAB Motivation required - please specify Losartan ZARTAN 100MG TAB Motivation required - please specify Losartan HYTENZA 100MG TAB Motivation required - please specify CORONARY ARTERY DISEASE Stress ECG report & details of history of previous cardiovascular events (if applicable) is required Warfarin CIPLA-WARFARIN 5MG TAB Warfarin CIPLA-WARFARIN 1MG TAB Isosorbide dinitrate SANDOZ ISOSORBIDE DINITRATE 5MG SLT Isosorbide dinitrate SANDOZ ISOSORBIDE DINITRATE 10MG TAB Atenolol TEN-BLOKA 100MG TAB Atenolol TENOPRESS 25MG TAB Atenolol SANDOZ ATENOLOL 50MG TAB Atenolol HEXA-BLOK 50MG TAB Atenolol BIO-ATENOLOL (WAS IVAX-ATENOLOL) 50MG TAB Atenolol TEN-BLOKA 50MG TAB Bisoprolol ZIAPRO 10MG TAB Bisoprolol ZIAPRO 5MG TAB Bisoprolol BILOCOR 5MG TAB Bisoprolol BILOCOR 10MG TAB Amlodipine AMLODAC 10MG TAB Amlodipine AMLODAC 5MG TAB Amlodipine NORCARD 5MG TAB Amlodipine AMLOC 10MG TAB Amlodipine PHARMA DYNAMICS AMLODIPINE BESYLA5MG TAB Amlodipine PHARMA DYNAMICS AMLODIPINE BESYLA10MG TAB Amlodipine NORCARD 10MG TAB Amlodipine ALMADIN 5MG TAB

9 Amlodipine ALMADIN 10MG TAB Nifedipine ADCO-VASCARD 20 SR 20MG SRC Nifedipine FEDALOC SR 30MG SRT Verapamil VERAHEXAL 240 SR 240MG SRT Verapamil VASOMIL 40MG TAB Diltiazem ADCO-ZILDEM 60MG TAB Diltiazem ADCO-ZILDEM 90MG TAB Diltiazem ADCO-ZILDEM SR 180MG SRC Diltiazem ADCO-ZILDEM SR 240MG SRC Perindopril PREXUM 5MG TAB Perindopril and diuretics PREXUM PLUS 5MG/1.25MG TAB Acetylsalicylic acid DISPRIN 300MG EFT CROHN'S DISEASE Practice number and name of the diagnosing specialist (physician or gastroenterologist) required. Sulfasalazine SALAZOPYRIN 500MG TAB Folic acid BE-TABS FOLIC ACID 5MG TAB Prednisone PANAFCORT 5MG TAB Prednisone BE-TABS PREDNISONE 5MG TAB Prednisone TROLIC 5MG TAB Ciprofloxacin DYNAFLOC 500MG TAB Ciprofloxacin ORPIC 500MG TAB Ciprofloxacin CIPROL 500MG TAB Ciprofloxacin CIPROL 250MG TAB Ciprofloxacin ORPIC 250MG TAB Ciprofloxacin CPL ALLIANCE CIPROFLOXACIN 250MG TAB Ciprofloxacin CPL ALLIANCE CIPROFLOXACIN 500MG TAB Ciprofloxacin CIPROGEN 500MG TAB Ciprofloxacin DYNAFLOC 250MG TAB Azathioprine AZAPRESS 50MG TAB Azathioprine AZATHIOPRINE PCH 50MG TAB Methotrexate ABITREXATE 2,5MG TAB Metronidazole TRICHAZOLE 200MG TAB Metronidazole BIO-METRONIDAZOLE 200MG TAB Metronidazole BIO-METRONIDAZOLE 400MG TAB Metronidazole METAZOL 200MG TAB Metronidazole METAZOL 400MG TAB

10 Metronidazole TRICHAZOLE 400MG TAB Metronidazole METRAZOLE 400MG TAB DIABETES INSIPIDUS Please provide the practice number and name of the diagnosing specialist (physician, paediatrician or endocrinologist) Desmopressin DDAVP 2.5ML NOD Desmopressin DDAVP NASAL SPRAY 5ML 0,1MG/1ML NSS Desmopressin DDAVP 0,1MG TAB Desmopressin DDAVP 0,2MG TAB DIABETES MELLITUS TYPE ACCU-CHEK ACTIVE STRIPS STR SOFTCLIX LANCETS ZZZ Insulin (human) BIOSULIN R CARTRIDGE 3ML 100U/1ML INJ Insulin (human) HUMULIN R CARTRIDGE 3ML 100U/1ML INJ Insulin aspart NOVORAPID FLEXPEN PENSET 3ML 100U/1ML INJ Insulin aspart NOVORAPID PENFILL 3ML 100U/1ML INJ Insulin glulisine APIDRA SOLOSTAR DISPOSABLE PENS 3M100U/1ML INJ Insulin lispro HUMALOG CARTRIDGE 3ML 100U/1ML INJ Insulin (human) PROTAPHANE FLEXPEN 3ML 100U/1ML INJ Insulin (human) HUMULIN N CARTRIDGE 3ML 100U/1ML INJ Insulin (human) BIOSULIN N CARTRIDGE 3ML 100U/1ML INJ Insulin (human) BIOSULIN L CARTRIDGE 3ML 100U/1ML INJ Insulin (human) BIOSULIN CARTRIDGE 3ML 100U/1ML INJ Insulin (human) HUMULIN 30/70 CARTRIDGE 3ML 100U/1ML INJ Insulin (human) INSUMAN COMB 30/70 CARTRIDGE 3ML 100U/1ML INJ Insulin (human) ACTRAPHANE HM (GE) FLEXPEN 3ML 100U/1ML INJ Insulin aspart NOVOMIX 30 FLEXPEN 3ML 100U/1ML INJ Insulin aspart NOVOMIX 30 PENFILL 3ML 100U/1ML INJ Insulin lispro HUMALOG MIX 25 CARTRIDGE 3ML 100U/1ML INJ DIABETES MELLITUS TYPE ACCU-CHEK ACTIVE STRIPS STR SOFTCLIX LANCETS ZZZ Insulin (human) HUMULIN R CARTRIDGE 3ML 100U/1ML INJ Insulin (human) BIOSULIN R CARTRIDGE 3ML 100U/1ML INJ Insulin aspart NOVORAPID FLEXPEN PENSET 3ML 100U/1ML INJ

11 Insulin aspart NOVORAPID PENFILL 3ML 100U/1ML INJ Insulin glulisine APIDRA SOLOSTAR DISPOSABLE PENS 3M100U/1ML INJ Insulin lispro HUMALOG CARTRIDGE 3ML 100U/1ML INJ Insulin (human) BIOSULIN L CARTRIDGE 3ML 100U/1ML INJ Insulin (human) BIOSULIN N CARTRIDGE 3ML 100U/1ML INJ Insulin (human) PROTAPHANE FLEXPEN 3ML 100U/1ML INJ Insulin (human) HUMULIN N CARTRIDGE 3ML 100U/1ML INJ Insulin (human) HUMULIN 30/70 CARTRIDGE 3ML 100U/1ML INJ Insulin (human) BIOSULIN CARTRIDGE 3ML 100U/1ML INJ Insulin (human) INSUMAN COMB 30/70 CARTRIDGE 3ML 100U/1ML INJ Insulin (human) ACTRAPHANE HM (GE) FLEXPEN 3ML 100U/1ML INJ Insulin aspart NOVOMIX 30 FLEXPEN 3ML 100U/1ML INJ Insulin aspart NOVOMIX 30 PENFILL 3ML 100U/1ML INJ Insulin lispro HUMALOG MIX 25 CARTRIDGE 3ML 100U/1ML INJ Metformin ACCORD METFORMIN 500MG TAB Fasting glucose results may be Metformin ACCORD METFORMIN 850MG TAB Fasting glucose results may be Metformin ARROW METFORMIN 500MG TAB Fasting glucose results may be Metformin ARROW METFORMIN 850MG TAB Fasting glucose results may be Metformin BIGSENS 1000MG TAB Fasting glucose results may be Metformin BIGSENS 500MG TAB Fasting glucose results may be Metformin BIGSENS 850MG TAB Fasting glucose results may be

12 Metformin DIAPHAGE 1000MG TAB Fasting glucose results may be Metformin DIAPHAGE 500MG TAB Fasting glucose results may be Metformin DIAPHAGE 850MG TAB Fasting glucose results may be Metformin GLUCONORM 500MG TAB Fasting glucose results may be Metformin GLUCONORM 850MG TAB Fasting glucose results may be Metformin METCHEK 500MG TAB Fasting glucose results may be Metformin METCHEK 850MG TAB Fasting glucose results may be Metformin METORED 1000MG TAB Fasting glucose results may be Metformin METORED 500MG TAB Fasting glucose results may be Metformin METORED 850MG TAB Fasting glucose results may be Metformin MYLAN METFORMIN 500MG TAB Fasting glucose results may be Metformin MYLAN METFORMIN 850MG TAB Fasting glucose results may be Glibenclamide GLYCOMIN 5MG TAB

13 Glibenclamide BIO-GLIBENCLAMIDE 5MG TAB Gliclazide GLYCRON 80MG TAB Gliclazide DYNA GLICLAZIDE SR 30MG SRT Pioglitazone ACCORD PIOGLITAZONE 15MG TAB Motivation Required Pioglitazone ACCORD PIOGLITAZONE 30MG TAB Motivation Required EPILEPSY Phenobarbital LETHYL 30MG TAB Phenytoin PHENYTOIN SOD 100MG TAB Phenytoin EPANUTIN 100MG CAP Clonazepam RIVOTRIL 0,5MG TAB Severe and uncontrolled epilepsy only, not responding to first-line s. Motivation Required Clonazepam RIVOTRIL 2MG TAB Severe and uncontrolled epilepsy only, not responding to first-line s. Motivation Required Carbamazepine DEGRANOL 200MG TAB Valproic acid EPROLEP CR MG SRT Valproic acid EPROLEP CR MG SRT Valproic acid NAVALPRO CR 200MG SRT Valproic acid NAVALPRO CR 300MG SRT Valproic acid NAVALPRO CR 500MG SRT Valproic acid CONVULEX 150MG CAP Valproic acid CONVULEX 300MG CAP Valproic acid EPILIM SUGAR FREE 200MG/5ML SYR Valproic acid CONVULEX 250MG/5ML SYR Valproic acid CONVULEX 500MG CAP Lamotrigine LAMIDUS 50MG TAB Lamotrigine EPITEC 25MG TAB Lamotrigine ASPEN LAMOTRIGINE 100MG TAB Lamotrigine DYNA-LAMOTRIGINE 25MG TAB Lamotrigine DYNA-LAMOTRIGINE 50MG TAB Lamotrigine DYNA-LAMOTRIGINE 200MG TAB Lamotrigine DYNA-LAMOTRIGINE 100MG TAB GLAUCOMA Please provide the name and practice of the diagnosisng ophthalmologist Brimonidine ALPHAGAN PURITE 5ML 1,5MG/1ML OPD

14 Pilocarpine ISOPTO CARPINE 2% 15ML 2% OPD Pilocarpine ISOPTO CARPINE 4% 15ML 4% OPD Pilocarpine ISOPTO CARPINE 1% 15ML 1% OPD Acetazolamide AZOMID 250MG TAB Brinzolamide AZOPTIC 5ML EYE SUSPENSION 1% OPD Dorzolamide TRUSOPT 5ML OWI 2% OPD Betaxolol BETOPTIC 5ML OPD Levobunolol BETAGAN 7.5ML 0,5% OPD Timolol TIMOPTOL 5ML 0,25% OPD Timolol TIMOPTOL-XE 2.5ML 0,5% OPD Timolol GLAUCOSAN 5ML 0,5% OPD Timolol, combinations AZARGA 5ML OPD Timolol, combinations CO-ATANA 2.5ML OPD Timolol, combinations COMBIGAN 2MG/5MG 5ML OPD Timolol, combinations GLAUMIDE-CO 0,5% OPD Bimatoprost LUMIGAN 3ML 0,03% OPD Latanoprost ATANA 2.5ML 50MCG/1ML OPD Travoprost TRAVATAN 2,5ML 0,004% OPD HYPERLIPIDAEMIA Treatment subject to criteria for Lipid Lowering Therapy being met. (For Primary prevention - Framingham 2012 score > 15%).Assessment requires completed Risk Evaluation Report as well as diagnostic & latest Lipograms Atorvastatin ADCO ATORVASTATIN 10MG TAB Atorvastatin ADCO ATORVASTATIN 20MG TAB Atorvastatin ADCO ATORVASTATIN 40MG TAB Atorvastatin ASPAVOR 10MG TAB Atorvastatin ASPAVOR 20MG TAB Atorvastatin ASPAVOR 40MG TAB Atorvastatin ASTOR 10MG TAB Atorvastatin ASTOR 20MG TAB Atorvastatin ASTOR 40MG TAB Atorvastatin ASTOR 80MG TAB Atorvastatin ATORVASTATIN UNICORN 10MG TAB Atorvastatin ATORVASTATIN UNICORN 20MG TAB Atorvastatin ATORVASTATIN UNICORN 40MG TAB Atorvastatin DYNATOR 10MG TAB Atorvastatin DYNATOR 20MG TAB

15 Atorvastatin DYNATOR 40MG TAB Atorvastatin DYNATOR 80MG TAB Simvastatin ARROW SIMVASTATIN 10MG TAB Simvastatin ARROW SIMVASTATIN 20MG TAB Simvastatin ARROW SIMVASTATIN 40MG TAB Simvastatin CHOLESTE 20MG TAB Simvastatin CHOLESTE 40MG TAB Simvastatin SIMVACOR 10MG TAB Simvastatin SIMVACOR 20MG TAB Simvastatin SIMVACOR 40MG TAB Simvastatin ZYSIM 10MG TAB Simvastatin ZYSIM 20MG TAB Simvastatin ZYSIM 40MG TAB Bezafibrate DYNA-BEZAFIBRATE SR 400MG SRT HYPERTENSION Please provide current blood pressure and bp at time of diagnosis Potassium chloride SANDOZ K MG TAB For documented hypokalaemia Potassium chloride PLENISH K 600MG TAB Reserpine RESERPINE 0,25MG TAB Methyldopa (levorotatory) HYPOTONE 250MG TAB Methyldopa (levorotatory) SANDOZ METHYLDOPA 250MG TAB Methyldopa (levorotatory) MYLAN METHYLDOPA 250MG TAB Doxazosin CARDUGEN (WAS MERCK-DOXAZOSIN) 1MG TAB Doxazosin CARDUGEN (WAS MERCK-DOXAZOSIN) 4MG TAB Doxazosin CARZIN XL 4MG FCR Prazosin PRATSIOL 1MG TAB Prazosin PRATSIOL 2MG TAB Hydrochlorothiazide HEXAZIDE 25MG TAB Hydrochlorothiazide and po URIREX-K 50MG/300MG 50MG;300MG TAB Indapamide CIPLA-INDAPAMIDE 2,5MG TAB Indapamide DAPTRIL 2,5MG TAB Indapamide MYLAN INDAPAMIDE 2,5MG TAB Furosemide SANDOZ FUROSEMIDE 40MG TAB Furosemide PURESIS 40MG TAB Furosemide MYLAN FUROSEMIDE 40MG TAB Spironolactone SPIRACTIN 25MG TAB Spironolactone SANDOZ SPIRONOLACTONE 25MG TAB

16 Hydrochlorothiazide and po AMILORETIC 50MG/5MG 50MG;5MG TAB Hydrochlorothiazide and po ADCO-RETIC 50MG/5MG 50MG;5MG TAB Atenolol TEN-BLOKA 100MG TAB Atenolol B-BLOCK 100MG TAB Atenolol B-BLOCK 50MG TAB Atenolol TENOPRESS 25MG TAB Atenolol SANDOZ ATENOLOL 50MG TAB Atenolol HEXA-BLOK 50MG TAB Atenolol BIO-ATENOLOL (WAS IVAX-ATENOLOL) 50MG TAB Atenolol TEN-BLOKA 50MG TAB Bisoprolol ZIAPRO 10MG TAB Bisoprolol ZIAPRO 5MG TAB Bisoprolol BISOPROLOL UNICORN 10MG TAB Bisoprolol BISOPROLOL UNICORN 5MG TAB Bisoprolol BILOCOR 10MG TAB Bisoprolol BILOCOR 5MG TAB Atenolol and other diuretics TENCHLOR 100MG/25MG TAB Atenolol and other diuretics TENCHLOR HS 50MG/12.5MG TAB Amlodipine CALBLOC 5MG TAB Amlodipine CALBLOC 10MG TAB Amlodipine ALMADIN 5MG TAB Amlodipine PHARMA DYNAMICS AMLODIPINE BESYLA5MG TAB Amlodipine PHARMA DYNAMICS AMLODIPINE BESYLA10MG TAB Amlodipine AMLODAC 5MG TAB Amlodipine AMLODAC 10MG TAB Amlodipine CIPLAVASC 5MG TAB Amlodipine AMLOC 5MG TAB Amlodipine AMTAS 5MG TAB Amlodipine AMTAS 10MG TAB Amlodipine NORCARD 5MG TAB Amlodipine NORCARD 10MG TAB Amlodipine AMLOC 10MG TAB Nifedipine ADCO-VASCARD 20 SR 20MG SRC Nifedipine CIPALAT RETARD 20MG TAB Nifedipine FEDALOC SR 30MG SRT Verapamil VERAHEXAL 240 SR 240MG SRT Verapamil VASOMIL 40MG TAB

17 Captopril MYLAN CAPTOPRIL 25MG TAB Captopril MYLAN CAPTOPRIL 50MG TAB Enalapril ENALAPRIL UNICORN 10MG TAB Enalapril ENALAPRIL UNICORN 20MG TAB Enalapril PHARMAPRESS 5MG TAB Enalapril PHARMAPRESS 20MG TAB Enalapril ENAP 20MG TAB Enalapril ENAP 5MG TAB Enalapril ENAP 10MG TAB Lisinopril SINOPREN 5MG TAB Lisinopril SINOPREN 10MG TAB Lisinopril SINOPREN 20MG TAB Lisinopril AUSTELL-LISINOPRIL 20MG TAB Lisinopril AUSTELL-LISINOPRIL 10MG TAB Perindopril PERINDOPRIL UNICORN 4MG TAB Perindopril PREXUM 5MG TAB Perindopril ACESYL 4MG TAB Perindopril PEARINDA 4MG TAB Perindopril PEARINDA 8MG TAB Captopril and diuretics ZAPTO-CO 50MG/25MG 50MG;25MG TAB Enalapril and diuretics PHARMAPRESS CO 20MG/12.5MG TAB Enalapril and diuretics ENAP CO 20MG/12.5MG 20MG;12,5MG TAB Lisinopril and diuretics LISOZIDE 10MG/12.5MG TAB Lisinopril and diuretics ZESTORETIC 10MG/12.5MG 10MG;12,5MG TAB Lisinopril and diuretics LISOZIDE 20MG/12.5MG TAB Lisinopril and diuretics ZESTORETIC 20MG/12.5MG 20MG;12,5MG TAB Perindopril and diuretics PERINDOPRIL CO UNICORN 4MG/1.25MG TAB Perindopril and diuretics PREXUM PLUS 5MG/1.25MG TAB Perindopril and diuretics ACESYL CO 4MG/1.25MG TAB Perindopril and diuretics PEARINDA PLUS 4MG/1.25MG TAB Perindopril and diuretics ARIPREL PLUS 4MG/1.25MG TAB Perindopril and amlodipine COVERAM 5/10 TAB Perindopril and amlodipine COVERAM 10/10 TAB Perindopril and amlodipine COVERAM 10/5 TAB Perindopril and amlodipine COVERAM 5/5 TAB

18 Losartan Losartan Losartan Losartan Losartan and diuretics Losartan and diuretics Losartan and diuretics Losartan and diuretics Losartan and diuretics Losartan and diuretics Losartan and diuretics Losartan and diuretics HYTENZA 50MG TAB Motivation required - please specify ZARTAN 100MG TAB Motivation required - please specify ZARTAN 50MG TAB Motivation required - please specify HYTENZA 100MG TAB Motivation required - please specify HYTENZA CO 50MG/12.5MG TAB Motivation required - please specify HYTENZA CO 100MG/25MG TAB Motivation required - please specify SARTOC-CO 100MG/25MG TAB Motivation required - please specify ZARTAN CO 100MG/25MG TAB Motivation required - please specify ZARTAN CO 50MG/12.5MG TAB Motivation required - please specify LOSAAR PLUS 50MG/12.5MG TAB Motivation required - please specify LOSAAR PLUS 100MG/25MG TAB Motivation required - please specify LOSARTAN CO UNICORN 50MG/12.5MG TAB Motivation required - please specify

19 Losartan and diuretics LOSARTAN CO UNICORN 100MG/25MG TAB Motivation required - please specify HYPOTHYROIDISM Combinations of levothyrox DIOTROXIN TAB Levothyroxine sodium EUTHYROX 25MCG TAB Levothyroxine sodium EUTHYROX 50MCG TAB Levothyroxine sodium EUTHYROX 100MCG TAB MULTIPLE SCLEROSIS Please provide the practice number and name of the diagnosing neurologist. Treatment to be initiated by specialist Oxybutynin LENDITRO 5MG TAB Second Line - After adequate trial with Tricyclic Antidepressants Oxybutynin MYLAN OXYBUTYNIN 5MG TAB Azathioprine AZAPRESS 50MG TAB Azathioprine AZATHIOPRINE PCH 50MG TAB Methotrexate ABITREXATE 2,5MG TAB Baclofen TEVA BACLOFEN 10MG TAB Carbamazepine DEGRANOL 200MG TAB Amitriptyline TREPILINE 25MG TAB Amitriptyline TREPILINE 10MG TAB Amitriptyline SANDOZ AMITRIPTYLINE 25MG TAB PARKINSON'S DISEASE Orphenadrine (chloride) DISIPAL 50MG TAB Levodopa and decarboxyla TEVA CARBI-LEVO 25/250 TAB Levodopa and decarboxyla TEVA CARBI-LEVO 25/100 TAB Amantadine SYMADIN (WAS FLU-STOP) 100MG CAP RHEUMATOID ARTHRITIS Please provide the name and practice number of the diagnosisng specilaist The PMB chronic benefit only covers rheumatoid arthritis and excludes other closely related conditions. We therefore require copies of the relevant blood tests, reports and supportive clinical history confirming the diagnosis of rheumatoid arthritis. Sulfasalazine SALAZOPYRIN 500MG TAB Sulfasalazine SALAZOPYRIN EN 500MG ECT

20 Folic acid BE-TABS FOLIC ACID 5MG TAB Prednisone PANAFCORT 5MG TAB Prednisone BE-TABS PREDNISONE 5MG TAB Prednisone TROLIC 5MG TAB Azathioprine AZAPRESS 50MG TAB Azathioprine AZATHIOPRINE PCH 50MG TAB Methotrexate ABITREXATE 2,5MG TAB Diclofenac DICLOHEXAL 25MG TAB Diclofenac A-LENNON DICLOFENAC 25MG TAB Diclofenac A-LENNON DICLOFENAC 50MG TAB Diclofenac MYLAN DICLOFENAC 25MG TAB Diclofenac MYLAN DICLOFENAC 50MG TAB Diclofenac SANDOZ DICLOFENAC SODIUM 100 SIMPL100MG SRT Indometacin ARTHREXIN 25MG CAP Indometacin SANDOZ INDOMETHACIN 25MG CAP Meloxicam LOXIFLAM 7,5MG TAB Meloxicam FLEXOCAM 7,5MG TAB Meloxicam ADCO-MELOXICAM 7,5MG TAB Meloxicam M-CAM 7,5MG TAB Meloxicam ZYDUS-MELOXICAM 7,5MG TAB Meloxicam ARROW MELOXICAM 7,5MG TAB Piroxicam ROXIFEN 20MG CAP Piroxicam XYCAM 20MG CAP Piroxicam PYROCAPS 20MG CAP Ibuprofen SANDOZ IBUPROFEN 600MG TAB Ibuprofen INZA 200MG TAB Ibuprofen IBUCINE (WAS IBUMAX) 200MG TAB Ibuprofen IBUCINE (WAS IBUMAX) 400MG TAB Ibuprofen INZA 400MG TAB Naproxen NAPROSCRIPT 250MG TAB Naproxen MYLAN NAPROXEN 250MG TAB Paracetamol PAINAMOL (GREEN) 500MG TAB Paracetamol GENCETAMOL TAB Chloroquine NIVAQUINE 200MG TAB SCHIZOPHRENIA Please provide a report from a psychiatrist that confirms the diagnosis, based on DSM lv Diagnostic Criteria

21 Valproic acid EPILIZINE CR 200MG SRT Valproic acid EPILIZINE CR 300MG SRT Valproic acid EPILIZINE CR 500MG SRT Valproic acid NAVALPRO CR 200MG SRT Valproic acid NAVALPRO CR 300MG SRT Valproic acid NAVALPRO CR 500MG SRT Lamotrigine ASPEN LAMOTRIGINE 100MG TAB Lamotrigine DYNA-LAMOTRIGINE 25MG TAB Lamotrigine DYNA-LAMOTRIGINE 50MG TAB Lamotrigine DYNA-LAMOTRIGINE 100MG TAB Lamotrigine DYNA-LAMOTRIGINE 200MG TAB Orphenadrine (chloride) DISIPAL 50MG TAB Chlorpromazine LARGACTIL 25MG TAB Chlorpromazine LARGACTIL 50MG TAB Chlorpromazine LARGACTIL 100MG TAB Fluphenazine MODECATE 1ML 25MG/1ML INJ Haloperidol SERENACE 0,5MG CAP Flupentixol FLUANXOL DEPOT 1ML 20MG INJ Zuclopenthixol CLOPIXOL DEPOT 200MG INJ Amitriptyline TREPILINE 25MG TAB Amitriptyline TREPILINE 10MG TAB Amitriptyline SANDOZ AMITRIPTYLINE 25MG TAB Dosulepin THADEN 25MG CAP Dosulepin THADEN 75MG TAB Imipramine ETHIPRAMINE 10MG TAB Imipramine ETHIPRAMINE 25MG TAB Citalopram ARROW CITALOPRAM 40MG TAB Citalopram ARROW CITALOPRAM 20MG TAB Fluoxetine ZYDUS FLUOXETINE 20MG CAP Fluoxetine DEPROZAN 20MG CAP Fluoxetine A-LENNON FLUOXETINE 20MG CAP Fluoxetine LORIEN 20MG TAB SYSTEMIC LUPUS ERYTHEMATOSUS Please provide a report from a rheumatologist or specialist physician, confirming the diagnosis. Folic acid BE-TABS FOLIC ACID 5MG TAB Prednisone PANAFCORT 5MG TAB

22 Prednisone BE-TABS PREDNISONE 5MG TAB Azathioprine AZAPRESS 50MG TAB Azathioprine AZATHIOPRINE PCH 50MG TAB Methotrexate ABITREXATE 2,5MG TAB Diclofenac MYLAN DICLOFENAC 25MG TAB Diclofenac MYLAN DICLOFENAC 50MG TAB Diclofenac SANDOZ DICLOFENAC SODIUM 100 SIMPL100MG SRT Diclofenac DICLOHEXAL 25MG TAB Diclofenac A-LENNON DICLOFENAC 25MG TAB Diclofenac A-LENNON DICLOFENAC 50MG TAB Indometacin ARTHREXIN 25MG CAP Indometacin SANDOZ INDOMETHACIN 25MG CAP Meloxicam FLEXOCAM 7,5MG TAB Meloxicam ADCO-MELOXICAM 7,5MG TAB Meloxicam M-CAM 7,5MG TAB Meloxicam ZYDUS-MELOXICAM 7,5MG TAB Meloxicam ARROW MELOXICAM 7,5MG TAB Piroxicam ROXIFEN 20MG CAP Piroxicam XYCAM 20MG CAP Piroxicam PYROCAPS 20MG CAP Ibuprofen SANDOZ IBUPROFEN 600MG TAB Ibuprofen IBUCINE (WAS IBUMAX) 400MG TAB Ibuprofen INZA 400MG TAB Ibuprofen BETAPROFEN 200MG TAB Ibuprofen RANFEN 400MG TAB Ibuprofen BETAPROFEN FC 400MG TAB Ibuprofen INZA 200MG TAB Ibuprofen IBUCINE (WAS IBUMAX) 100MG/5ML SUS Ibuprofen IBUCINE (WAS IBUMAX) 200MG TAB Naproxen NAPROSCRIPT 250MG TAB Naproxen MYLAN NAPROXEN 250MG TAB Acetylsalicylic acid DISPRIN 300MG EFT Chloroquine NIVAQUINE 200MG TAB ULCERATIVE COLITIS Please provide a report from a specialist physician or gastroenterologist that confirms the diagnosis Sulfasalazine SALAZOPYRIN 500MG TAB

23 Prednisone PANAFCORT 5MG TAB Prednisone BE-TABS PREDNISONE 5MG TAB Prednisone TROLIC 5MG TAB Azathioprine AZATHIOPRINE PCH 50MG TAB Azathioprine AZAPRESS 50MG TAB Azathioprine ZAPRINE 50MG TAB Methotrexate ABITREXATE 2,5MG TAB DEPRESSION, MAJOR Amitriptyline TREPILINE 25MG TAB Amitriptyline TREPILINE 10MG TAB Amitriptyline SANDOZ AMITRIPTYLINE 25MG TAB Dosulepin THADEN 25MG CAP Dosulepin THADEN 75MG TAB Imipramine ETHIPRAMINE 10MG TAB Imipramine ETHIPRAMINE 25MG TAB Citalopram ARROW CITALOPRAM 40MG TAB Citalopram BIO CITALOPRAM 20MG TAB Citalopram ARROW CITALOPRAM 20MG TAB Fluoxetine ZYDUS FLUOXETINE 20MG CAP Fluoxetine DEPROZAN 20MG CAP Fluoxetine A-LENNON FLUOXETINE 20MG CAP Fluoxetine LORIEN 20MG TAB Sertraline SERDEP 100MG TAB Sertraline SERDEP 50MG TAB Sertraline ARROW SERTRALINE 100MG TAB Sertraline ARROW SERTRALINE 50MG TAB MENOPAUSE Conjugated estrogens PREMARIN VCR Conjugated estrogens PREMARIN 0,3MG TAB Conjugated estrogens PREMARIN 0,625MG TAB Conjugated estrogens PREMARIN 1,25MG TAB Estradiol ESTRO-PAUSE 1MG TAB Estradiol ESTRO-PAUSE 2MG TAB Estradiol CLIMARA 50 PTD Estradiol CLIMARA 100 PTD

24 Estradiol ESTRADOT 37,5MCG PTD Estradiol ESTRADOT 50MCG PTD Estradiol ESTRADOT 75MCG PTD Estradiol ESTRADOT 100MCG PTD Estradiol ESTRADOT 25MCG PTD Estriol SYNAPAUSE-E3 2MG TAB Medroxyprogesterone HEXAL-MPA 5MG TAB Norethisterone and estroge ACTIVELLE TAB Medroxyprogesterone and PREMELLE-CYCLE 5 TAB Norethisterone and estroge TRISEQUENS TAB Norethisterone and estroge ESTRO-PAUSE N TAB Norgestrel and estrogen POSTOVAL TAB

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