Oncology supportive medicine list (formulary) 2016

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1 Oncology supportive medicine list (formulary) 2016 Who we are Glencore Medical Scheme (referred to as 'the Scheme"), registration number 1253, is a non-profit organisation, registered with the Council for Medical Schemes. Discovery Health (Pty) Ltd (referred to as "the administrator"), is a separate company and an authorised financial services provider (registration number 1997/013480/07), that administers the Glencore Medical Scheme. General contact details You can call us on or visit for more information

2 Disclaimer The Oncology Programme is governed by the Glencore Medical Scheme rules. The use of the benefits and programmes associated with the Oncology Programme is subject to specific conditions and rules. Members must ensure that they are familiar with these rules and conditions. The Scheme rules are available on Any instruction or advice we give about medicines and the management of the member s condition is intended as a supplement to, and not a substitute for the knowledge, expertise, skill and judgement of the member s doctor, pharmacist or other healthcare professional. Glencore Medical Scheme reserves the right to change the benefit at any time. We will communicate any changes to the way we pay medicines when we make these. The updated version of this document is available on our website at all times. Glencore Medical Scheme will fund for supportive medication that is not on the supportive formulary at 80% of MMAP (Maximum Medical Aid Price). The member will be liable for a 20% co-payment. About some of the terms we use in this document There may be some terms we refer to in the document that you may not be familiar with. Here are the meanings of these terms: Terminology Active ingredient Code MMAP Description This is the main substance in a medicine that is responsible for the clinical action on a human body. This is a unique identifier for medicines, surgical or consumable products. This is the Maximum Medical Aid Price that medical schemes will reimburse for an interchangeable multi-source pharmaceutical product. Oncology supportive medicine list (formulary) 2016 Condition Reflux Probitor 20mg CAP Omeprazole Reflux Cimetidine 100mg/ml 2ml 100mg/2mL INJ Cimetidine Reflux Pharma-q cimetidine ampoule 2ml 200mg/2mL INJ Cimetidine Reflux Bio-cimetidine 200mg TAB Cimetidine Reflux Cimlok 200mg TAB Cimetidine Reflux Adco-cimetidine 200mg TAB Cimetidine Reflux Secadine 200mg TAB Cimetidine Reflux Lenamet 400mg TAB Cimetidine Reflux Adco-cimetidine 400mg TAB Cimetidine Reflux Cimlok 400mg TAB Cimetidine Reflux Secadine 400mg TAB Cimetidine

3 Reflux Bio-cimetidine 400mg TAB Cimetidine Reflux Austac 150mg TAB Ranitidine Reflux Cpl alliance ranitidine 150mg TAB Ranitidine Reflux Gulf ranitidine 150mg TAB Ranitidine Reflux Ranitidine biotech 150mg TAB Ranitidine Reflux R-loc 50mg/2mL INJ Ranitidine Reflux Cpl alliance ranitidine 300mg TAB Ranitidine Reflux Austac 300mg TAB Ranitidine Reflux Ranit 300mg TAB Ranitidine Reflux Histak 300mg TAB Ranitidine Reflux Gulf ranitidine 300mg TAB Ranitidine Reflux Nozer 20mg CAP Omeprazole Reflux Lokit 20mg CAP Omeprazole Reflux Sandoz omeprazole 20mg CAP Omeprazole Reflux Adco-roznal 30mg CAP Lansoprazole Reflux Lancap 30mg CAP Lansoprazole Grantryl Ampoule 3ml*** 3mg/3ml INJ Granisetron Grantryl Ampoule 1ml 1mg/1ml INJ Granisetron Emend combi pack (1 x 125mg cap & 2 x 80mg cap) ** Aprepitant Emistop ampoule 2ml 4mg/2ml INJ Ondansetron Emistop ampoule 4ml 8mg/4ml INJ Ondansetron Clomax 10mg TAB Metoclopramide Adco-contromet 10mg TAB Metoclopramide Setin 10mg TAB Metoclopramide Bio metoclopramide 10mg TAB Metoclopramide Metoclopramide amp st111 2ml Pharma-q metoclopramide ampoule 2ml 5mg/1mL INJ Metoclopramide 5mg/1mL INJ Metoclopramide Alepet ampoule 2ml 4mg/2mL INJ Ondansetron Mylan ondansetron 4mg/2mL INJ Ondansetron

4 Danset ampoule 2ml 4mg/2mL INJ Ondansetron Vomiz ampoule 2ml 4mg/2mL INJ Ondansetron Ondansetron fresenius ampoule 4mg/2mL INJ Ondansetron Alepet ampoule 4ml 8mg/4mL INJ Ondansetron Mylan ondansetron 8mg/4mL INJ Ondansetron Danset ampoule 4ml 8mg/4mL INJ Ondansetron Ondansetron fresenius ampoule 8mg/4mL INJ Ondansetron Cipla-ondansetron 4mg TAB Ondansetron Zofer 4mg TAB Ondansetron Mylan ondansetron 4mg TAB Ondansetron Vomiz 4mg TAB Ondansetron Cipla-ondansetron 8mg TAB Ondansetron Zofer 8mg TAB Ondansetron Mylan ondansetron 8mg TAB Ondansetron Vomiz 8mg TAB Ondansetron Granitril vial 1ml 1mg/1mL INJ Granisetron Adco-granisetron ampoule 1ml 1mg/1mL INJ Granisetron Granisetron teva 1 1mg/1mL INJ Granisetron Granisetron teva 3 *** 3mg/3mL INJ Granisetron Onicit vial 5ml **** 50mcg/1mL INJ Palonosetron Emend ** 125mg CAP Aprepitant Emend ** 80mg CAP Aprepitant Nauzine 50mg TAB Cyclizine Covamet 50mg TAB Cyclizine

5 Stemetil 25mg SUP Prochlorperazine Stemetil 1ml 12,5mg/1mL INJ Prochlorperazine Scripto-metic 5mg TAB Prochlorperazine Sandoz granisetron vial 3ml 3mg/3mL INJ Granisetron fresenius ampoule 3ml 1mg/1mL INJ Granisetron Granisetron Warfarin * 5mg TAB Warfarin Cipla Warfarin * 1mg TAB Warfarin Heparin sodium fresenius ampoule 1ml * Heparin sodium fresenius vial 5ml * 1000u/1mL INJ Heparin 1000u/1mL INJ Heparin Heparin sod 1ml-fresenius * 5000u/1mL INJ Heparin Cipla-warfarin 5mg TAB Warfarin Pain management Amdocin 25mg CAP Indometacin Pain management Oxycontin 10mg SRT Oxycodone Pain management Oxycontin 20mg SRT Oxycodone Pain management Oxycontin 5mg SRT Oxycodone Pain management Arthrexin 100mg SUP Indometacin Pain management Methocaps 25mg CAP Indometacin Pain management Betacin 25mg CAP Indometacin Pain management Gulf indomethacin 25mg CAP Indometacin Pain management Mylan diclofenac 25mg TAB Diclofenac Pain management Sandoz diclofenac 25mg TAB Diclofenac Pain management A-lennon diclofenac 25mg TAB Diclofenac Pain management Diclofenac biotech 25mg TAB Diclofenac Pain management A-lennon diclofenac 50mg TAB Diclofenac Pain management Mylan diclofenac 50mg TAB Diclofenac Pain management Ibucine (was Ibumax) 200mg TAB Ibuprofen Pain management Ibunate 200mg TAB Ibuprofen Pain management Betaprofen 200mg TAB Ibuprofen Pain management Ibusor 200mg TAB Ibuprofen Pain management Bren 400mg TAB Ibuprofen

6 Pain management Betaprofen fc 400mg TAB Ibuprofen Pain management Ibucine (was Ibumax) 400mg TAB Ibuprofen Pain management Ranfen 400mg TAB Ibuprofen Pain management Ibupain forte 460mg CAP Ibuprofen, combinations Pain management Gen-payne CAP Ibuprofen, combinations Pain management Dentopain forte CAP Ibuprofen, combinations Pain management Mybulen CAP Ibuprofen, combinations Pain management Ibupain forte blister pack CAP Ibuprofen, combinations Pain management Srm rhotard 100mg SRT Morphine Pain management Srm rhotard 10mg SRT Morphine Pain management Mylan morphine 15mg/1mL INJ Morphine Pain management Srm rhotard 30mg SRT Morphine Pain management Srm rhotard 60mg SRT Morphine Pain management Df mg TAB Dihydroine Pain management Omnopon 1mlfresenius 20 20mg/1mL INJ Morphine, combinations Pain management Pain management Pharma-q pethidine ampoule 1ml Pharma-q pethidine ampoule 1ml 25mg/1mL INJ Pethidine 50mg/1mL INJ Pethidine Pain management Sabax pethidine ampoule 1ml 50mg/1mL INJ Pethidine Pain management Pethidine hcl 1ml-fresenius 50mg/1mL INJ Pethidine Pain management Temgesic sublingual 0,2mg TAB Buprenorphine Pain management Oxynorm 5mg CAP Oxycodone Pain management Oxynorm 10mg CAP Oxycodone Pain management Oxynorm 20mg CAP Oxycodone Pain management Dolotram 100mg INJ Tramadol Pain management Tramazac 100mg/2mL INJ Tramadol Pain management Tramaspen amp 2ml 100mg/2mL INJ Tramadol Pain management Domadol 50mg CAP Tramadol Pain management Dolotram 50mg CAP Tramadol Pain management Austell-tramadol 50mg CAP Tramadol Pain management Tramazac 50mg CAP Tramadol Pain management Painogesic 500mg TAB Paracetamol Pain management Cetapon 500mg TAB Paracetamol Pain management Adco-prolief 500mg TAB Paracetamol Pain management Adco-napamol 500mg TAB Paracetamol Pain management Antalgic 500mg TAB Paracetamol

7 Pain management Nucopain TAB Pain management Adco-salterpyn TAB Paracetamol, combinations with psycholeptics Paracetamol, combinations with psycholeptics Pain management Morphine sulphate PDR Morphine Depression Ethipramine 25mg TAB Imipramine Depression Sandoz amitriptyline 25mg TAB Amitriptyline Depression Gulf amitriptyline 25mg TAB Amitriptyline Depression Venlafaxine unicorn xr 150mg SCR Venlafaxine Depression Venlafaxine unicorn xr 75mg SCR Venlafaxine Depression Fluoxetine actor 20mg CAP Fluoxetine Depression A-lennon fluoxetine 20mg CAP Fluoxetine Depression Ranflocs 20mg CAP Fluoxetine Depression Prolax 20mg CAP Fluoxetine Depression Deprozan 20mg CAP Fluoxetine Depression Efegen xr 150mg SRC Venlafaxine Depression Odiven 37,5mg TAB Venlafaxine Depression Efegen xr 75mg SRC Venlafaxine Depression Odiven 75mg TAB Venlafaxine Depression Zydus fluoxetine 20mg CAP Fluoxetine Constipation Anlac 3300mg/5mL SYR Lactulose Constipation Aculax 3,3g/5mL SYR Lactulose Constipation Adco-liquilax 3300mg/5mL SYR Lactulose Constipation Lacson 3300mg/5mL SYR Lactulose Constipation Laxette 3300mg/5mL SYR Lactulose Diarrhoea Norimode 2mg TAB Loperamide Diarrhoea Adco-prodium 2mg TAB Loperamide Epilepsy Degranol 200mg TAB Carbamazepine Epilepsy Zeptol 200mg TAB Carbamazepine Epilepsy Convulex 150mg CAP Valproic acid Epilepsy Convulex 250mg/5mL SYR Valproic acid Epilepsy Epilim crushable 100mg TAB Valproic acid Epilepsy Epilim sugar free 200mg/5mL SYR Valproic acid Epilepsy Epilizine cr 200mg SRT Valproic acid Epilepsy Epilizine cr 300mg SRT Valproic acid Epilepsy Epilizine cr 500mg SRT Valproic acid

8 Epilepsy Navalpro cr 200mg SRT Valproic acid Epilepsy Navalpro cr 300mg SRT Valproic acid Epilepsy Navalpro cr 500mg SRT Valproic acid Epilepsy Vanapro 300mg SRT Valproic acid Epilepsy Vanapro 500mg SRT Valproic acid Epilepsy Phenytoin sod 100mg TAB Phenytoin Epilepsy Dyna-lamotrigine 100mg TAB Lamotrigine Epilepsy Dyna-lamotrigine 200mg TAB Lamotrigine Epilepsy Dyna-lamotrigine 25mg TAB Lamotrigine Epilepsy Dyna-lamotrigine 50mg TAB Lamotrigine Epilepsy Epitec 100mg TAB Lamotrigine Epilepsy Epitec 200mg TAB Lamotrigine Epilepsy Epitec 25mg TAB Lamotrigine Epilepsy Epitec 50mg TAB Lamotrigine Epilepsy Lamidus 100mg TAB Lamotrigine Epilepsy Lamidus 200mg TAB Lamotrigine Epilepsy Lamidus 50mg TAB Lamotrigine Epilepsy Epitoz 100mg TAB Topiramate Epilepsy Epitoz 25mg TAB Topiramate Epilepsy Epitoz 50mg TAB Topiramate Epilepsy Lamitor 200mg TAB Lamotrigine Epilepsy Lamitor 25mg TAB Lamotrigine Epilepsy Lamitor 50mg TAB Lamotrigine Epilepsy Topirol 50mg TAB Topiramate Epilepsy Eprolep cr mg SRT Valproic acid Epilepsy Epimate 200mg TAB Topiramate Epilepsy Lethyl 30mg TAB Phenobarbital Epilepsy Sedabarb 30mg TAB Phenobarbital Epilepsy Clonam 2mg TAB Clonazepam Epilepsy Clonam 0,5mg TAB Clonazepam Epilepsy Tegretol cr 200mg SRT Carbamazepine Epilepsy Tegretol cr 400mg SRT Carbamazepine Epilepsy Eprolep cr mg SRT Valproic acid Epilepsy Eprolep cr mg SRT Valproic acid Epilepsy Lamitor 100mg TAB Lamotrigine

9 * We fund anticoagulation on approved treatment plans, if certain clinical entry criteria are met. **Emend We fund Emend on Glencore Medical Scheme if certain clinical entry criteria are met (A single dose of a 5- HT3 antagonist, dexamethasone and an aprepitant with selected highly emetogenic agents only). ***Granisetron (on approved treatment plans) We fund Granisetron on Glencore Medical Scheme. This is how we will fund Granisetron on approved treatment plans: Product name Strength Frequency Granisetron teva 3ml 3mg/3ml 1 per 3 days ****Onicit We fund Onicit on Glencore Medical Scheme. We fund Onicit where we have approved treatment. Because the registered recommendations state that repeat dosages within seven days are not recommended, we will fund one dose every seven days. This is how we will fund Onicit on approved treatment plans: Product name Strength Frequency Onicit vial 5ml 50mcg/1ml 1 every 7 days **** Special approval required with quantity restrictions applied for the below Product name Strength Frequency Grantryl ampoule 3ml 3mg/3mL 1 every 7 days Kytril iv 3ml 1mg/1mL 1 every 7 days Emend combi pack (1 x 125mg cap & 2 x 80mg cap) 1 every 7 days Venlafaxine unicorn xr 150mg Venlafaxine unicorn xr 75mg Maximum of 30 tabs per Gen Grouper Maximum of 30 tabs per Gen Grouper Other anti-emetic treatments not listed We will consider funding an alternate anti-emetic Zamanon on appeal if patient experiences asthenia or any other side effect from their anti-emetic.

10 Complaints process You may lodge a complaint or query with Glencore Medical Scheme directly on or address a complaint in writing to the Principal Officer at the Scheme s registered address. Should your complaint remain unresolved, you may lodge a formal dispute by following the Glencore Medical Scheme internal disputes process. You may, as a last resort, approach the Council for Medical Schemes for assistance. Council for Medical Schemes Complaints Unit, Block A, Eco Glades 2 Office Park, 420 Witch-Hazel Avenue, Eco Park, Centurion, 0157 / / complaints@medicalschemes.com/

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