CareCross Chronic Medicine Formulary

Transcription

1 CareCross Chronic Medicine Formulary 2013 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 PRESCRIBED MINIMUM BENEFIT CHRONIC CONDITIONS The PMB is applicable to primary Addisons disease only. Please provide Practice number and name of diagnosing specialist Fludrocortisone FLORINEF ACETATE 0,1MG Hydrocortisone COVOCORT 10MG Prednisolone LENISOLONE 5MG Prednisolone CAPSOID 5MG Prednisone TROLIC 5MG Prednisone PANAFCORT 5MG Prednisone BE-S PREDNISONE 5MG

2 ASTHMA MASK BABY CIPLA ZZZ SPACER ZEROSTAT VT ZZZ DP HALER DEVICE ZZZ Prednisone PANAFCORT 5MG Only for severe persistent asthma (motivation required) Prednisone BE-S PREDNISONE 5MG Only for severe persistent asthma (motivation required) Prednisone TROLIC 5MG Only for severe persistent asthma (motivation required) Formoterol FORATEC DP-CAPS 12MCG CPS Will only be approved if prescribed together with an inhaled steroid Formoterol FORATEC HFA 120DOSE 12MCG/1DOSE INH Will only be approved if prescribed together with an inhaled steroid Salbutamol ASTHAVENT ECOHALER CFC-FREE 300DOSE Salbutamol VENTEZE CFC FREE 200 DOSE Salbutamol ASTHAVENT ECOHALER 200DOSE Fenoterol/ Ipratropium DUOVENT HFA 200DOSE INH Salmeterol/ Fluticasone SEREFLO 25/50 HFA 120 DOSE Beclometasone BECLATE 200DOSE 50MCG INH Beclometasone BECLATE 200DOSE 100MCG INH Beclometasone BECLATE 200DOSE 200MCG INH Budesonide BUDEFLAM HFA 300DOSE 100MCG INH Limited to 3 inhalers per year if no inhaled steroid 100MCG INH Limited to 3 inhalers per year if no inhaled steroid 100MCG INH Limited to 3 inhalers per year if no inhaled steroid 100MCG INH INH Only for Paediatric use for moderate & severe persistent asthma (motivation required)

3 Budesonide BUDEFLAM HFA 300DOSE 200MCG Budesonide BUDEFLAM DP-CAPS 200MCG CPS Salbutamol VENTEZE 2MG/5ML SYR only for children under 5 years Salbutamol ASTHAVENT 2MG/5ML SYR only for children under 5 years Theophylline Theophylline SANDOZ THEOPHYLLINE ANHYDROUS SANDOZ THEOPHYLLINE ANHYDROUS 200MG 300MG Theophylline ALCOPHYLLIN 26,67MG/5ML SYR BIPOLAR MOOD DISORDER Carbamazepine INH SRT SRT Please provide a report from a psychiatrist that confirms the diagnosis, based on DSM lv Diagnostic Criteria SANDOZ CARBAMAZEPINE 200MG Valproic acid CONVULEX 150MG CAP Valproic acid CONVULEX 300MG CAP Valproic acid CONVULEX 500MG CAP Valproic acid EPILIM CR 200MG SRT Valproic acid EPILIM CR 300MG SRT Valproic acid EPILIM CR 500MG SRT Lamotrigine LAMIDUS 100MG Lamotrigine EPITEC 25MG Lamotrigine LAMITOR 100MG Lamotrigine SANDOZ LAMOTRIGINE 25MG Lamotrigine DYNA-LAMOTRIGINE 25MG Lamotrigine DYNA-LAMOTRIGINE 50MG Lamotrigine DYNA-LAMOTRIGINE 100MG

4 Lamotrigine DYNA-LAMOTRIGINE 200MG Lamotrigine LAMIDUS 50MG Haloperidol SANDOZ HALOPERIDOL 5MG Haloperidol SANDOZ HALOPERIDOL 1,5MG Haloperidol SERENACE 0,5MG CAP Clozapine CLOMENT 25MG WCC required 6 monthly Clozapine CLOMENT 100MG WCC required 6 monthly Quetiapine QUETOSER 200MG Treatment to be initiated by a psychiatrist Quetiapine QUETOSER 300MG Treatment to be initiated by a psychiatrist Quetiapine DOPAQUEL 100MG Treatment to be initiated by a psychiatrist Quetiapine MYLAN QUETIAPINE 100MG Treatment to be initiated by a psychiatrist Quetiapine DOPAQUEL 200MG Treatment to be initiated by a psychiatrist Quetiapine MYLAN QUETIAPINE 200MG Treatment to be initiated by a psychiatrist Quetiapine DOPAQUEL 25MG Treatment to be initiated by a psychiatrist Quetiapine MYLAN QUETIAPINE 25MG Treatment to be initiated by a psychiatrist Quetiapine DOPAQUEL 300MG Treatment to be initiated by a psychiatrist Lithium QUILONUM RETARD 450MG Treatment to be initiated by a psychiatrist Lithium CAMCOLIT 250MG Treatment to be initiated by a psychiatrist Lithium CAMCOLIT 400MG Treatment to be initiated by a psychiatrist Risperidone ZOXADON 0,5MG Treatment to be initiated by a psychiatrist Risperidone ZOXADON 1MG Treatment to be initiated by a psychiatrist Risperidone SCHIZOROL 0,5MG Treatment to be initiated by a psychiatrist Risperidone SCHIZOROL 1MG Treatment to be initiated by a psychiatrist Risperidone SCHIZOROL 2MG Treatment to be initiated by a psychiatrist Risperidone RISPERIDONE HEXAL 3MG Treatment to be initiated by a psychiatrist Risperidone ZOXADON 2MG Treatment to be initiated by a psychiatrist

5 Amitriptyline TREPILINE 25MG Will only be approved if prescribed together with a mood stabiliser Amitriptyline TREPILINE 10MG Will only be approved if prescribed together with a mood stabiliser Amitriptyline SANDOZ AMITRIPTYLINE 25MG Will only be approved if prescribed together with a mood stabiliser Dothiepin THADEN 25MG CAP Will only be approved if prescribed together with a mood stabiliser Dothiepin THADEN 75MG Will only be approved if prescribed together with a mood stabiliser Dothiepin SANDOZ DOTHIEPIN HCL 75MG Will only be approved if prescribed together with a mood stabiliser Imipramine ETHIPRAMINE 10MG Will only be approved if prescribed together with a mood stabiliser Imipramine ETHIPRAMINE 25MG Will only be approved if prescribed together with a mood stabiliser Citalopram DEPRAMIL 40MG Will only be approved if prescribed together with a mood stabiliser Citalopram CITALOPRAM-WINTHROP 20MG Will only be approved if prescribed together with a mood stabiliser Citalopram ARROW CITALOPRAM 20MG Will only be approved if prescribed together with a mood stabiliser Escitalopram ZYTOMIL 10MG Will only be approved if prescribed together with a mood stabiliser Fluoxetine RANFLOCS 20MG CAP Will only be approved if prescribed together with a mood stabiliser Fluoxetine A-LENNON FLUOXETINE 20MG CAP Will only be approved if prescribed together with a mood stabiliser Sertraline SERDEP 100MG Will only be approved if prescribed together with a mood stabiliser

6 Sertraline SERDEP 50MG Will only be approved if prescribed together with a mood stabiliser BRONCHIECTASIS Doxycycline CYCLIDOX 100MG CAP Doxycycline A-LENNON DOXYCYCLINE HCL 100MG Oxytetracycline NUCOTET 250MG CAP Oxytetracycline OXYPAN 250MG CAP Oxytetracycline BE-OXYTET 250MG CAP Amoxicillin BETAMOX 500MG CAP Amoxicillin AUSTELL-AMOXICILLIN 500MG CAP CARDIAC FAILURE AND CARDIOMYOPATHY Potassium chloride PLENISH K 600MG For documented hypokalaemia Potassium chloride SANDOZ K MG For documented hypokalaemia Warfarin CIPLA-WARFARIN 5MG Warfarin CIPLA-WARFARIN 1MG Warfarin CIPLA-WARFARIN 3MG Digoxin PURGOXIN 0,25MG Digoxin LANOXIN 0,25MG Isosorbide dinitrate Isosorbide dinitrate SANDOZ ISOSORBIDE DINITRATE SANDOZ ISOSORBIDE DINITRATE 10MG 30MG Hydralazine SANDOZ HYDRALAZINE 25MG Hydralazine SANDOZ HYDRALAZINE 50MG Hydralazine HYPERPHEN 10MG CAP

7 Hydralazine HYPERPHEN 50MG Hydrochlorothiazide HEXAZIDE 25MG Furosemide MYLAN FUROSEMIDE 40MG Furosemide SANDOZ FUROSEMIDE 40MG Furosemide PURESIS 40MG Spironolactone SPIRACTIN 25MG Spironolactone SANDOZ SPIRONOLACTONE 25MG Bisoprolol ADCO-BISOCOR 10MG Bisoprolol ADCO-BISOCOR 5MG Bisoprolol ZIAPRO 5MG Bisoprolol ZIAPRO 10MG Carvedilol ASPEN CARVEDILOL 25MG Carvedilol CARVETREND 25MG Captopril MYLAN CAPTOPRIL 25MG Captopril MYLAN CAPTOPRIL 50MG Captopril ADCO-CAPTOMAX 25MG Captopril ADCO-CAPTOMAX 50MG Enalapril HR-ENALAPRIL 20MG Enalapril PHARMAPRESS 10MG Enalapril ALAPREN 5MG Enalapril ALAPREN 10MG Enalapril ALAPREN 20MG Enalapril CIPLATEC 5MG Enalapril CIPLATEC 10MG Enalapril PHARMAPRESS 5MG

8 Enalapril CIPLATEC 20MG Enalapril ENVAS 5MG Enalapril ENVAS 10MG Perindopril CIPLASYL 8 8MG Perindopril CIPLASYL 4 4MG Perindopril PEARINDA 4MG Perindopril PEARINDA 8MG Losartan ZARTAN 100MG Losartan ZARTAN 50MG Motivation required - please specify Losartan LOSARTAN-WINTHROP 50MG Motivation required - please specify Losartan LOS-ARB 50MG Motivation required - please specify Telmisartan PRITOR 40MG Motivation required - please specify Telmisartan PRITOR 80MG Motivation required - please specify Valsartan ZOMEVEK 80MG Motivation required - please specify Valsartan ZOMEVEK 160MG Motivation required - please specify Valsartan TAREG 160MG Motivation required - please specify

9 Valsartan TAREG 80MG Motivation required - please specify Pneumococcal vaccine IMOVAX PNEUMO 23 VAC Once only Acetylsalicylic acid BE-S ASPIRIN (WHITE) 300MG Acetylsalicylic acid GULF ASPIRIN 300MG Acetylsalicylic acid ASPIRIN JUNIOR 60MG 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 For use with Cipla Medpro Inhalers DP HALER DEVICE ZZZ For use with Cipla Medpro DP caps Prednisone BE-S PREDNISONE 5MG Prednisone TROLIC 5MG Prednisone PANAFCORT 5MG Formoterol FORATEC DP-CAPS 12MCG CPS Salbutamol ASTHAVENT ECOHALER 200DOSE Salbutamol VENTEZE CFC FREE 200 DOSE Salbutamol ASTHAVENT ECOHALER CFC-FREE 300DOSE 100MCG 100MCG 100MCG Fenoterol / Ipratropium DUOVENT HFA 200DOSE INH Beclometasone BECLATE 200DOSE 50MCG INH For Stage ll & lll COPD only Beclometasone BECLATE 200DOSE 100MCG INH For Stage ll & lll COPD only Beclometasone BECLATE 200DOSE 200MCG INH For Stage ll & lll COPD only INH INH INH

10 Budesonide BUDEFLAM HFA 300DOSE Budesonide BUDEFLAM HFA 300DOSE 100MCG INH For Stage ll & lll COPD only 200MCG INH For Stage ll & lll COPD only Budesonide BUDEFLAM DP-CAPS 200MCG CPS For Stage ll & lll COPD only Ipratropium bromide IPVENT HFA 200 DOSE 40MCG/1DOSE INH Theophylline SANDOZ THEOPHYLLINE ANHYDROUS 200MG Theophylline SANDOZ THEOPHYLLINE 300MG SRT CHRONIC RENAL FAILURE Creatinine clearance required Calcium carbonate TITRALAC Alfacalcidol ONE ALPHA 0,25MCG CAP Alfacalcidol ONE ALPHA 1MCG CAP Potassium chloride PLENISH K 600MG For documented hypokalaemia Potassium chloride SANDOZ K MG For documented hypokalaemia Saccharated iron oxide VENOFER 20MG/1ML INJ Motivation and Hb and iron studies required Ferrous fumarate PREGAMAL Various combinations AUTRIN CAP Various combinations FOLIGLOBIN Motivation and Hb and iron studies required Various combinations GULF FERROUS SULPHATE COMPOUND Folic acid BE-S FOLIC ACID 5MG Erythropoietin EPREX PREFILL 4000U/0,4ML INJ Motivation and Hb and iron studies required Erythropoietin EPREX PREFILL 2000U/0,5ML INJ Motivation and Hb and iron studies required SRT

11 Erythropoietin RECORMON 6000 IU/0. PRE-FILLED SYRIN Erythropoietin Erythropoietin RECORMON 2000 PRE- FILLED SYRINGE RECORMON 4000 IU/0. PREFILLED SYRINGE Hydrochlorothiazide HEXAZIDE 25MG Furosemide MYLAN FUROSEMIDE 40MG Furosemide SANDOZ FUROSEMIDE 40MG Furosemide PURESIS 40MG 6000IU INJ Motivation and Hb and iron studies required 2000UNIT INJ Motivation and Hb and iron studies required 4000U/0, INJ Motivation and Hb and iron studies required Propranolol PURBLOKA 10MG Fourth line agents for hypertension as per SA Hypertension Guidelines 2006 Propranolol PURBLOKA 40MG Fourth line agents for hypertension as per SA Hypertension Guidelines 2006 Propranolol INDOBLOK 10MG Fourth line agents for hypertension as per SA Hypertension Guidelines 2006 Propranolol INDOBLOK 40MG Fourth line agents for hypertension as per SA Hypertension Guidelines 2006 Atenolol HEXA-BLOK 50MG Fourth line agents for hypertension as per SA Hypertension Guidelines 2006 Atenolol SANDOZ ATENOLOL 50MG Fourth line agents for hypertension as per SA Hypertension Guidelines 2006 Atenolol SANDOZ ATENOLOL 100MG Fourth line agents for hypertension as per SA Hypertension Guidelines 2006 Atenolol BIO-ATENOLOL (WAS IVAX-ATENOLOL) 50MG Fourth line agents for hypertension as per SA Hypertension Guidelines 2006 Atenolol TENOPRESS 25MG Fourth line agents for hypertension as per SA Hypertension Guidelines 2006 Atenolol TENOPRESS 100MG Fourth line agents for hypertension as per SA Hypertension Guidelines 2006

12 Bisoprolol ADCO-BISOCOR 5MG Fourth line agents for hypertension as per SA Hypertension Guidelines 2006 Bisoprolol ADCO-BISOCOR 10MG Fourth line agents for hypertension as per SA Hypertension Guidelines 2006 Bisoprolol ZIAPRO 10MG Fourth line agents for hypertension as per SA Hypertension Guidelines 2006 Bisoprolol ZIAPRO 5MG Fourth line agents for hypertension as per SA Hypertension Guidelines 2006 Verapamil VERAHEXAL 240 SR 240MG SRT Captopril ADCO-CAPTOMAX 50MG Captopril ADCO-CAPTOMAX 25MG Captopril MYLAN CAPTOPRIL 25MG Captopril MYLAN CAPTOPRIL 50MG Enalapril ALAPREN 5MG Enalapril ALAPREN 10MG Enalapril ALAPREN 20MG Enalapril HR-ENALAPRIL 20MG Enalapril PHARMAPRESS 10MG Enalapril CIPLATEC 5MG Enalapril CIPLATEC 10MG Enalapril CIPLATEC 20MG Enalapril PHARMAPRESS 5MG Enalapril ENVAS 5MG Enalapril ENVAS 10MG Perindopril CIPLASYL 4 4MG Perindopril CIPLASYL 8 8MG Perindopril PEARINDA 4MG

13 Perindopril PEARINDA 8MG Losartan ZARTAN 50MG Motivation required - please specify Losartan LOSARTAN-WINTHROP 50MG Motivation required - please specify Losartan LOS-ARB 50MG Motivation required - please specify Losartan ZARTAN 100MG Motivation required - please specify Telmisartan PRITOR 40MG Motivation required - please specify Telmisartan PRITOR 80MG Motivation required - please specify Valsartan ZOMEVEK 80MG Motivation required - please specify Valsartan ZOMEVEK 160MG Motivation required - please specify Valsartan TAREG 160MG Motivation required - please specify Valsartan TAREG 80MG Motivation required - please specify

14 CORONARY ARTERY DISEASE Stress ECG report & details of history of previous cardiovascular events (if applicable) is required Warfarin CIPLA-WARFARIN 5MG Warfarin CIPLA-WARFARIN 1MG Warfarin CIPLA-WARFARIN 3MG Isosorbide dinitrate Isosorbide dinitrate Isosorbide dinitrate SANDOZ ISOSORBIDE DINITRATE SANDOZ ISOSORBIDE DINITRATE SANDOZ ISOSORBIDE DINITRATE 5MG 10MG 30MG Propranolol PURBLOKA 10MG Propranolol PURBLOKA 40MG Propranolol INDOBLOK 10MG Propranolol INDOBLOK 40MG Atenolol HEXA-BLOK 50MG Atenolol BIO-ATENOLOL (WAS IVAX-ATENOLOL) 50MG Atenolol SANDOZ ATENOLOL 50MG Atenolol SANDOZ ATENOLOL 100MG Atenolol TENOPRESS 25MG Atenolol TENOPRESS 100MG Bisoprolol ADCO-BISOCOR 5MG Bisoprolol ADCO-BISOCOR 10MG Bisoprolol ZIAPRO 10MG Bisoprolol ZIAPRO 5MG Amlodipine ALMADIN 5MG SLT

15 Amlodipine ALMADIN 10MG Amlodipine PENDINE 5MG Amlodipine PENDINE 10MG Nifedipine FEDALOC SR 30MG SRT Nifedipine FEDALOC SR 60MG SRT Nifedipine MACOREL SR 30MG SRT Nifedipine MACOREL SR 60MG SRT Nifedipine NIFEDALAT 20SR 20MG SRT Nifedipine CIPALAT RETARD 20MG Verapamil VERAHEXAL 240 SR 240MG SRT Diltiazem ADCO-ZILDEM SR 180MG SRC Diltiazem ADCO-ZILDEM SR 240MG SRC Diltiazem ADCO-ZILDEM 60MG Diltiazem ADCO-ZILDEM 90MG Acetylsalicylic acid ASPIRIN JUNIOR 60MG Acetylsalicylic acid GULF ASPIRIN 300MG Acetylsalicylic acid BE-S ASPIRIN 300MG CROHN'S DISEASE Practice number and name of the diagnosing specialist (physician or gastroenterologist) required. Mesalazine ASACOL 400MG Treatment to be initiated by a specialist Mesalazine ASACOL 500MG SUP Treatment to be initiated by a specialist Mesalazine PENTASA 500MG Treatment to be initiated by a specialist Olsalazine DIPENTUM 250MG CAP Treatment to be initiated by a specialist Sulfasalazine SALAZOPYRIN 500MG Treatment to be initiated by a specialist Folic acid BE-S FOLIC ACID 5MG Treatment to be initiated by a specialist Prednisone PANAFCORT 5MG Treatment to be initiated by a specialist

16 Prednisone BE-S PREDNISONE 5MG Treatment to be initiated by a specialist Prednisone TROLIC 5MG Treatment to be initiated by a specialist Ciprofloxacin Ciprofloxacin Ciprofloxacin Ciprofloxacin AUSTELL CIPROFLOXACIN AUSTELL CIPROFLOXACIN CPL ALLIANCE CIPROFLOXACIN CPL ALLIANCE CIPROFLOXACIN 500MG Treatment to be initiated by a specialist 250MG Treatment to be initiated by a specialist 250MG Treatment to be initiated by a specialist 500MG Treatment to be initiated by a specialist Azathioprine AZATHIOPRINE PCH 50MG Treatment to be initiated by a specialist Azathioprine ZAPRINE 50MG Treatment to be initiated by a specialist Methotrexate ABITREXATE (WAS EMTHEXATE) 2,5MG Treatment to be initiated by a specialist Methotrexate METHOTREXATE 2,5MG Treatment to be initiated by a specialist Metronidazole BIO-METRONIDAZOLE 200MG Treatment to be initiated by a specialist Metronidazole BIO-METRONIDAZOLE 400MG Treatment to be initiated by a specialist Metronidazole METAZOL 200MG Treatment to be initiated by a specialist Metronidazole METAZOL 400MG Treatment to be initiated by a specialist DIABETES INSIPIDUS Please provide the practice number and name of the diagnosing specialist (physician, paediatrician or endocrinologist) Desmopressin DDAVP 0,2MG Treatment to be initiated by a specialist Desmopressin DDAVP 2.5ML NOD Treatment to be initiated by a specialist Desmopressin DDAVP NASAL SPRAY 5ML 0,1MG/1ML NSS Treatment to be initiated by a specialist Desmopressin DDAVP 0,1MG Treatment to be initiated by a specialist

17 DIABETES MELLITUS TYPE 1 Test strips CONTOUR TS GLUCOSE TEST STRIPS Lancets GLUCOCHECK LANCETS ZZZ Test strips GLUCOCHECK STRIPS 50S Insulin (human) BIOSULIN R CARTRIDGE 100U/1ML INJ Insulin aspart NOVORAPID FLEXPEN PENSET 100U/1ML Insulin aspart NOVORAPID PENFILL 100U/1ML INJ Insulin glulisine APIDRA SOLOSTAR DISPOSABLE PENS 100U/1ML Insulin lispro HUMALOG PENSET 100U/1ML INJ Insulin lispro HUMALOG CARTRIDGE 100U/1ML INJ Insulin (human) HUMULIN N KWICKPEN 100U/1ML INJ Insulin (human) PROTAPHANE FLEXPEN 100U/1ML INJ Insulin (human) BIOSULIN N CARTRIDGE 100U/1ML INJ Insulin (human) BIOSULIN L CARTRIDGE 100U/1ML INJ Insulin (human) HUMULIN N CARTRIDGE 100U/1ML INJ Insulin (human) HUMULIN 30/70 KWIKPEN Insulin (human) INSUMAN COMB 30/70 CARTRIDGE Insulin (human) Insulin (human) ACTRAPHANE HM (GE) FLEXPEN ACTRAPHANE HM(GE) PENSET 3.0ML 100U/1ML 100U/1ML 100U/1ML 100U/1ML Insulin (human) BIOSULIN U/1ML INJ STR ZZZ INJ INJ INJ INJ INJ INJ

18 CARTRIDGE Insulin (human) HUMULIN 30/70 CARTRIDGE 100U/1ML Insulin aspart NOVOMIX 30 FLEXPEN 100U/1ML INJ Insulin aspart NOVOMIX 30 PENFILL 100U/1ML INJ Insulin lispro HUMALOG MIX 25 PENSET Insulin lispro HUMALOG MIX 25 CARTRIDGE DIABETES MELLITUS TYPE 2 100U/1ML 100U/1ML INJ INJ INJ Insulin only for patients who are uncontrolled on oral agents Lancets GLUCOCHECK LANCETS ZZZ Test strips Test strips GLUCOCHECK STRIPS 50S CONTOUR TS GLUCOSE TEST STRIPS Insulin (human) BIOSULIN R CARTRIDGE 100U/1ML INJ Insulin aspart NOVORAPID FLEXPEN PENSET 100U/1ML Insulin aspart NOVORAPID PENFILL 100U/1ML INJ Insulin glulisine APIDRA SOLOSTAR DISPOSABLE PENS 100U/1ML Insulin lispro HUMALOG PENSET 100U/1ML INJ Insulin lispro HUMALOG CARTRIDGE 100U/1ML INJ Insulin (human) HUMULIN N KWICKPEN 100U/1ML INJ Insulin (human) HUMULIN N CARTRIDGE 100U/1ML INJ Insulin (human) PROTAPHANE FLEXPEN 100U/1ML INJ Insulin (human) BIOSULIN L CARTRIDGE 100U/1ML INJ Insulin (human) BIOSULIN N CARTRIDGE 100U/1ML INJ ZZZ STR INJ INJ

19 Insulin (human) BIOSULIN CARTRIDGE Insulin (human) HUMULIN 30/70 KWIKPEN Insulin (human) HUMULIN 30/70 CARTRIDGE Insulin (human) ACTRAPHANE HM(GE) PENSET 3.0ML Insulin (human) INSUMAN COMB 30/70 CARTRIDGE Insulin (human) ACTRAPHANE HM (GE) FLEXPEN 100U/1ML 100U/1ML 100U/1ML 100U/1ML 100U/1ML 100U/1ML Insulin aspart NOVOMIX 30 FLEXPEN 100U/1ML INJ Insulin aspart NOVOMIX 30 PENFILL 100U/1ML INJ Insulin lispro HUMALOG MIX 25 PENSET Insulin lispro HUMALOG MIX 25 CARTRIDGE 100U/1ML 100U/1ML Metformin METPHAGE 500MG Fasting glucose results may be requested if prescribed as a single agent Metformin METPHAGE 850MG Fasting glucose results may be requested if prescribed as a single agent Metformin MYLAN METFORMIN 500MG Fasting glucose results may be requested if prescribed as a single agent Metformin MYLAN METFORMIN 850MG Fasting glucose results may be requested if prescribed as a single agent Glibenclamide SANDOZ GLIBENCLAMIDE Glibenclamide DIACARE 5MG Gliclazide ADCO-GLUCOMED 80MG 5MG INJ INJ INJ INJ INJ INJ INJ INJ

20 Gliclazide SANDOZ GLICLAZIDE 80MG Gliclazide DIAGLUCIDE 80MG Gliclazide GLYGARD 80MG Gliclazide DYNA GLICLAZIDE SR 30MG SRT Pioglitazone CIPLA-PIOGLITAZONE 15MG Motivation Required Pioglitazone CIPLA-PIOGLITAZONE 30MG Motivation Required CARDIAC DYSRHYTHMIAS Please provide a specific diagnosis and /or the relevant ICD10 code Warfarin CIPLA-WARFARIN 5MG Warfarin CIPLA-WARFARIN 1MG Warfarin CIPLA-WARFARIN 3MG Digoxin LANOXIN 0,25MG Digoxin PURGOXIN 0,25MG Quinidine QUINIDINE SULPH 200MG Amiodarone ARYCOR 200MG Amiodarone ARYCOR 100MG Amiodarone HEXARONE 100MG Amiodarone HEXARONE 200MG Propranolol INDOBLOK 10MG Propranolol INDOBLOK 40MG Propranolol PURBLOKA 10MG Propranolol PURBLOKA 40MG Atenolol TENOPRESS 25MG Atenolol TENOPRESS 100MG Atenolol HEXA-BLOK 50MG Atenolol SANDOZ ATENOLOL 50MG

21 Atenolol SANDOZ ATENOLOL 100MG Atenolol EPILEPSY BIO-ATENOLOL (WAS IVAX-ATENOLOL) 50MG Bisoprolol ADCO-BISOCOR 5MG Bisoprolol ADCO-BISOCOR 10MG Bisoprolol ZIAPRO 10MG Bisoprolol ZIAPRO 5MG Verapamil VERAHEXAL 240 SR 240MG SRT Verapamil VASOMIL 40MG Verapamil VASOMIL 80MG Diltiazem ADCO-ZILDEM SR 180MG SRC Diltiazem ADCO-ZILDEM SR 240MG SRC Diltiazem ADCO-ZILDEM 90MG Acetylsalicylic acid GULF ASPIRIN 300MG Acetylsalicylic acid BE-S ASPIRIN (WHITE) 300MG Acetylsalicylic acid ASPIRIN JUNIOR 60MG Phenobarbital LETHYL 30MG Phenytoin EPANUTIN 100MG CAP Phenytoin PHENYTOIN SOD 100MG Ethosuximide ZARONTIN 250MG/5ML SYR Severe and uncontrolled epilepsy only, not responding to first-line agents. Motivation Required Clonazepam RIVOTRIL 0,5MG Severe and uncontrolled epilepsy only, not responding to first-line agents. Clonazepam RIVOTRIL 2MG Severe and uncontrolled epilepsy only,

22 Carbamazepine Carbamazepine Carbamazepine SANDOZ CARBAMAZEPINE SANDOZ CARBAMAZEPINE CR SANDOZ CARBAMAZEPINE CR 200MG 200MG 400MG SRT SRT not responding to first-line agents. Oxcarbazepine MYLAN OXCARBAZEPINE 300MG Severe and uncontrolled epilepsy only, not responding to first-line agents. Motivation Required Oxcarbazepine MYLAN OXCARBAZEPINE 600MG Severe and uncontrolled epilepsy only, not responding to first-line agents. Motivation Required 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 Valproic acid EPILIM CR 200MG SRT Valproic acid EPILIM CR 300MG SRT Valproic acid EPILIM CR 500MG SRT Lamotrigine DYNA-LAMOTRIGINE 25MG Lamotrigine DYNA-LAMOTRIGINE 50MG Lamotrigine DYNA-LAMOTRIGINE 200MG Lamotrigine EPITEC 25MG Lamotrigine LAMITOR 100MG Lamotrigine SANDOZ LAMOTRIGINE 25MG Lamotrigine ASPEN LAMOTRIGINE 100MG

23 GLAUCOMA Topiramate EPITOZ 100MG Severe and uncontrolled epilepsy only, not responding to first-line agents. Motivation Required Topiramate TOPLEP 200MG Severe and uncontrolled epilepsy only, not responding to first-line agents. Motivation Required Topiramate ADCO-TOPIRAMATE 25MG Severe and uncontrolled epilepsy only, not responding to first-line agents. Motivation Required Topiramate EPITOZ 50MG Severe and uncontrolled epilepsy only, not responding to first-line agents. Motivation Required Topiramate TOPLEP 50MG Severe and uncontrolled epilepsy only, not responding to first-line agents. Motivation Required Brimonidine ALPHAGAN PURITE 5ML 1,5MG/1ML OPD Pilocarpine ISOPTO CARPINE 2% 15ML Pilocarpine ISOPTO CARPINE 4% 15ML Pilocarpine ISOPTO CARPINE 1% 15ML 2% OPD 4% OPD 1% OPD Acetazolamide AZOMID 250MG Brinzolamide AZOPTIC 5ML EYE SUSPENSION 1% OPD Dorzolamide TRUSOPT 5ML OWI 2% OPD Betaxolol BETOPTIC 5ML OPD Carteolol TEOPTIC 5ML 2% OPD Levobunolol BETAGAN 7.5ML 0,5% OPD

24 Metipranolol BETA-OPHTIOLE 5ML 0,3% OPD Metipranolol BETA-OPHTIOLE 5ML 0,6% OPD Timolol GLAUCOSAN 5ML 0,5% OPD Timolol TIMOPTOL-XE 2.5ML 0,5% OPD Timolol TIMOPTOL 5ML 0,25% OPD Timolol, combinations COSOPT 5ML 0,5% OPD Timolol, combinations COMBIGAN 2MG/5MG 5ML Timolol, combinations XALACOM 2.5ML OPD Bimatoprost LUMIGAN 0,03% OPD Latanoprost OCUPROST 50MCG/1ML OPD Travoprost TRAVATAN 2,5ML 0,004% OPD HAEMOPHILLIA Tranexamic acid OPD Please provide laboratory reports confirming the diagnosis. Treatment to be initiated by Specialist Haematologist TRANEXAMIC ACID MEDWICH 500MG Treatment to be initiated by Specialist Haematologist Tranexamic acid TRANIC 500MG Treatment to be initiated by Specialist Haematologist Coagulation factor IX, II, VII and X in combination Coagulation factor VIII HAEMOSOLVEX IX 500U INJ Treatment to be initiated by Specialist Haematologist HAEMOSOLVATE VIII 2X10ML 1000U INJ Treatment to be initiated by Specialist Haematologist Coagulation factor VIII HAEMOSOLVATE VIII 300U INJ Treatment to be initiated by Specialist Haematologist Coagulation factor VIII HAEMOSOLVATE VIII 10ML 500U INJ Treatment to be initiated by Specialist Haematologist Desmopressin DDAVP 1ML INJ Treatment to be initiated by Specialist Haematologist

25 HYPERLIPIDAEMIA Treatment approval subject to criteria for Lipid Lowering Therapy being met. (For Primary prevention - Framingham score > 20%). Assessment requires completed Risk Evaluation Report as well as diagnostic & latest Lipograms Atorvastatin ATORVASTATIN WINTHROP 40MG Motivation required - please specify Atorvastatin ATOLIP 80MG Motivation required - please specify Atorvastatin Atorvastatin ATORVASTATIN WINTHROP ATORVASTATIN WINTHROP Lovastatin LOVACHOL 40MG Lovastatin LOVACHOL 20MG Simvastatin CIPLA-SIMVASTATIN 10MG Simvastatin CIPLA-SIMVASTATIN 20MG Simvastatin ADCO-SIMVASTATIN 20MG Simvastatin ADCO-SIMVASTATIN 40MG Simvastatin CIPLA-SIMVASTATIN 40MG Bezafibrate SANDOZ BEZAFIBRATE 400MG SRT Bezafibrate DYNA-BEZAFIBRATE SR 400MG SRT HYPERTENSION 20MG Motivation required - please specify 10MG Motivation required - please specify Please provide current blood pressure and blood pressure at time of diagnosis Potassium chloride PLENISH K 600MG for documented hypokalaemia only Potassium chloride SANDOZ K MG for documented hypokalaemia only Reserpine RESERPINE 0,25MG

26 Methyldopa SANDOZ METHYLDOPA 250MG For use in pregnancy only Methyldopa MYLAN METHYLDOPA 250MG For use in pregnancy only Methyldopa HYPOTONE 250MG For use in pregnancy only Doxazosin CARZIN XL 4MG FCR Doxazosin Doxazosin CARDUGEN (WAS MERCK-DOXAZOSIN) CARDUGEN (WAS MERCK-DOXAZOSIN) Prazosin PRATSIOL 1MG Prazosin PRATSIOL 2MG Prazosin PRATSIOL 5MG Hydralazine HYPERPHEN 10MG Hydralazine HYPERPHEN 50MG Hydralazine SANDOZ HYDRALAZINE 25MG Hydralazine SANDOZ HYDRALAZINE 50MG Hydrochlorothiazide HEXAZIDE 25MG Hydrochlorothiazide and potassium 1MG 4MG URIREX-K 50MG/300MG 50MG;300MG Indapamide DAPTRIL 2,5MG Indapamide MERCK-INDAPAMIDE 2,5MG Indapamide CIPLA-INDAPAMIDE 2,5MG Furosemide SANDOZ FUROSEMIDE 40MG Furosemide MYLAN FUROSEMIDE 40MG Furosemide PURESIS 40MG Spironolactone SPIRACTIN 25MG Spironolactone SANDOZ SPIRONOLACTONE 25MG

27 Amiloride Co AMILORETIC 50MG/5MG 50MG;5MG Amiloride Co ADCO-RETIC 50MG/5MG 50MG;5MG Amiloride Co BETARETIC 50MG/5MG 50MG;5MG Atenolol TENOPRESS 25MG Certain beta-blockers (e.g. atenolol) are no longer considered as routine step 1 to 3 treatment, unless there are compelling indications for their use (refer to SA Hypertension Guidelines 2006) Atenolol TENOPRESS 100MG Certain beta-blockers (e.g. atenolol) are no longer considered as routine step 1 to 3 treatment, unless there are compelling indications for their use (refer to SA Hypertension Guidelines 2006) Atenolol BIO-ATENOLOL (WAS IVAX-ATENOLOL) 50MG Certain beta-blockers (e.g. atenolol) are no longer considered as routine step 1 to 3 treatment, unless there are compelling indications for their use (refer to SA Hypertension Guidelines 2006) Atenolol SANDOZ ATENOLOL 50MG Certain beta-blockers (e.g. atenolol) are no longer considered as routine step 1 to 3 treatment, unless there are compelling indications for their use (refer to SA Hypertension Guidelines 2006) Atenolol SANDOZ ATENOLOL 100MG Certain beta-blockers (e.g. atenolol) are no longer considered as routine step 1 to 3 treatment, unless there are compelling indications for their use (refer to SA Hypertension Guidelines 2006) Atenolol HEXA-BLOK 50MG Certain beta-blockers (e.g. atenolol) are no longer considered as routine step 1 to 3 treatment, unless there are compelling indications for their use (refer to SA Hypertension Guidelines 2006)

28 Bisoprolol ADCO-BISOCOR 5MG Bisoprolol ADCO-BISOCOR 10MG Bisoprolol ZIAPRO 10MG Bisoprolol ZIAPRO 5MG Bisoprolol and thiazides ZIAK 2.5MG/6.25MG 2,5MG/6,25MG Motivation Required Bisoprolol and thiazides ZIAK 5MG/6.25MG 5MG;6,25MG Motivation Required Bisoprolol and thiazides ZIAK 10MG/6.25MG 10MG;6,25MG Motivation Required Atenolol and other diuretics Atenolol and other diuretics SANDOZ CO-TENIDONE 50MG/12.5MG SANDOZ CO- TENIDONE100MG/25MG Amlodipine PENDINE 5MG Amlodipine PENDINE 10MG Amlodipine ALMADIN 5MG Amlodipine ALMADIN 10MG Nifedipine FEDALOC SR 30MG SRT Nifedipine FEDALOC SR 60MG SRT Nifedipine MACOREL SR 30MG SRT Nifedipine MACOREL SR 60MG SRT Beta-blocker comb with thiazide diuretic not recommended, esp in patients with abdominal obesity and hypertension, both classes of drugs have adverse metabolic effects and increase incidence of new diabetes (ref SA Hypertension Guideline 2006) Beta-blocker comb with thiazide diuretic not recommended, esp in patients with abdominal obesity and hypertension, both classes of drugs have adverse metabolic effects and increase incidence of new diabetes (ref SA Hypertension Guideline 2006)

29 Nifedipine NIFEDALAT 20SR 20MG SRT Nifedipine CIPALAT RETARD 20MG Verapamil VERAHEXAL 240 SR 240MG SRT Captopril ADCO-CAPTOMAX 25MG Captopril ADCO-CAPTOMAX 50MG Captopril MYLAN CAPTOPRIL 25MG Captopril MYLAN CAPTOPRIL 50MG Enalapril CIPLATEC 5MG Enalapril CIPLATEC 10MG Enalapril HR-ENALAPRIL 20MG Enalapril PHARMAPRESS 10MG Enalapril ALAPREN 5MG Enalapril ALAPREN 10MG Enalapril ALAPREN 20MG Enalapril CIPLATEC 20MG Enalapril PHARMAPRESS 5MG Enalapril ENVAS 5MG Enalapril ENVAS 10MG Perindopril CIPLASYL 4 4MG Perindopril CIPLASYL 8 8MG Perindopril CIPLA-PERINDOPRIL 8MG Perindopril PEARINDA 4MG Perindopril PEARINDA 8MG Captopril and diuretics ZAPTO-CO 50MG/25MG 50MG;25MG Enalapril and diuretics PHARMAPRESS CO 20MG/12.5MG

30 Perindopril and diuretics PERINDOPRIL CO UNICORN 4MG/1.25MG Perindopril and diuretics PEARINDA PLUS 4MG/1.25MG Losartan ZARTAN 50MG Motivation required - please specify Losartan ZARTAN 100MG Motivation required - please specify Telmisartan PRITOR 40MG Motivation required - please specify Telmisartan PRITOR 80MG Motivation required - please specify Valsartan ZOMEVEK 80MG Motivation required - please specify Valsartan ZOMEVEK 160MG Motivation required - please specify Valsartan TAREG 80MG Motivation required - please specify Valsartan TAREG 160MG Motivation required - please specify Losartan and diuretics SARTOC 100MG/25MG Motivation required - please specify Losartan and diuretics ZARTAN CO Motivation required - please specify

31 Losartan and diuretics 50MG/12.5MG ZARTAN CO 100MG/25MG Motivation required - please specify Telmisartan and diuretics CO-PRITOR 40/12.5 MG Motivation required - please specify Telmisartan and diuretics CO-PRITOR 80/12.5MG Motivation required - please specify Valsartan and diuretics CO-TAREG 80MG/12.5MG Motivation required - please specify Valsartan and diuretics Valsartan and diuretics Valsartan and diuretics Valsartan and diuretics Valsartan and diuretics CO-ZOMEVEK 80MG/12.5MG CO-ZOMEVEK 160MG/12.5MG CO-MIGROBEN 160MG/12.5MG CO-TAREG 160MG/12.5MG CO-TAREG PLUS 160MG/25MG Motivation required - please specify Motivation required - please specify Motivation required - please specify 160/12.5MG Motivation required - please specify Motivation required - please specify HYPOTHYROIDISM

32 Combinations of levothyroxine and liothyronine DIOTROXIN Levothyroxine sodium EUTHYROX 25MCG Levothyroxine sodium ELTROXIN 0,05MG Levothyroxine sodium ELTROXIN 0,1MG Levothyroxine sodium EUTHYROX 50MCG Levothyroxine sodium EUTHYROX 100MCG MULTIPLE SCLEROSIS Please provide the practice number and name of the diagnosing neurologist Oxybutynin LENDITRO 5MG Second Line - After adequate trial with Tricyclic Antidepressants Azathioprine ZAPRINE 50MG Treatment to be initiated by specialist Azathioprine AZATHIOPRINE PCH 50MG Treatment to be initiated by specialist Methotrexate ABITREXATE (WAS EMTHEXATE) 2,5MG Treatment to be initiated by specialist Methotrexate METHOTREXATE 2,5MG Treatment to be initiated by specialist Baclofen BIO-BACLOFEN (WAS NORTON-BACLOFEN) 10MG Treatment to be initiated by specialist Baclofen TEVA BACLOFEN 10MG Treatment to be initiated by specialist Carbamazepine SANDOZ CARBAMAZEPINE 200MG Treatment to be initiated by specialist Amitriptyline TREPILINE 25MG Treatment to be initiated by specialist Amitriptyline TREPILINE 10MG Treatment to be initiated by specialist Amitriptyline SANDOZ AMITRIPTYLINE 25MG Treatment to be initiated by specialist PARKINSON'S DISEASE

33 Orphenadrine (chloride) DISIPAL 50MG Levodopa and decarboxylase inhibitor Levodopa and decarboxylase inhibitor TEVA CARBI-LEVO 25/ TEVA CARBI-LEVO 25/250 Ropinirole REQUIP 0,25MG Motivation Required Ropinirole REQUIP 0,5MG Motivation Required Ropinirole REQUIP 1MG Motivation Required Ropinirole REQUIP 2MG Motivation Required Ropinirole REQUIP 5MG Motivation Required Selegiline PARKILYNE 5MG RHEUMATOID ARTHRITIS 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 Sulfasalazine SALAZOPYRIN EN 500MG ECT Folic acid BE-S FOLIC ACID 5MG Prednisone BE-S PREDNISONE 5MG Prednisone PANAFCORT 5MG Prednisone TROLIC 5MG Cyclophosphamide ENDOXAN 50MG Treatment to be initiated by a specialist Azathioprine ZAPRINE 50MG Treatment to be initiated by a specialist Azathioprine AZATHIOPRINE PCH 50MG Treatment to be initiated by a specialist Methotrexate METHOTREXATE 2,5MG Treatment to be initiated by a specialist Methotrexate ABITREXATE (WAS EMTHEXATE) 2,5MG Treatment to be initiated by a specialist Diclofenac MYLAN DICLOFENAC 25MG Will only be approved if prescribed with a DMARD

34 Diclofenac MYLAN DICLOFENAC 50MG Will only be approved if prescribed with a DMARD Diclofenac SANDOZ DICLOFENAC SODIUM 100 SIMPLE REG 100MG SRT Will only be approved if prescribed with a DMARD Diclofenac DICLOHEXAL 25MG Will only be approved if prescribed with a DMARD Diclofenac A-LENNON DICLOFENAC 25MG Will only be approved if prescribed with a DMARD Diclofenac A-LENNON DICLOFENAC 50MG Will only be approved if prescribed with a DMARD Indometacin ARTHREXIN 25MG CAP Will only be approved if prescribed with a DMARD Indometacin SANDOZ INDOMETHACIN 25MG CAP Will only be approved if prescribed with a DMARD Indometacin ADCO-INDOMETHACIN 25MG CAP Will only be approved if prescribed with a DMARD Meloxicam FLEXOCAM 7,5MG Will only be approved if prescribed with a DMARD Meloxicam ADCO-MELOXICAM 7,5MG Will only be approved if prescribed with a DMARD Piroxicam ROXIFEN 20MG CAP Will only be approved if prescribed with a DMARD Piroxicam XYCAM 20MG CAP Will only be approved if prescribed with a DMARD Piroxicam PYROCAPS 20MG CAP Will only be approved if prescribed with a DMARD Ibuprofen INZA 200MG Will only be approved if prescribed with a DMARD Ibuprofen RANFEN 400MG Will only be approved if prescribed with a DMARD

35 Ibuprofen BETAPROFEN FC 400MG Will only be approved if prescribed with a DMARD Ibuprofen SANDOZ IBUPROFEN 600MG Will only be approved if prescribed with a DMARD Ibuprofen IBUNATE 200MG Will only be approved if prescribed with a DMARD Ibuprofen BETAPROFEN 200MG Will only be approved if prescribed with a DMARD Naproxen NAPROSCRIPT 250MG Will only be approved if prescribed with a DMARD Naproxen MYLAN NAPROXEN 250MG Will only be approved if prescribed with a DMARD Paracetamol GENCETAMOL Paracetamol PAINAMOL (GREEN) 500MG Chloroquine NIVAQUINE 200MG Treatment to be initiated by a specialist SCHIZOPHRENIA Carbamazepine Please provide a report from a psychiatrist that confirms the diagnosis, based on DSM lv Diagnostic Criteria. Treatment to be initiated by a psychiatrist SANDOZ CARBAMAZEPINE 200MG Valproic acid CONVULEX 150MG CAP Valproic acid CONVULEX 300MG CAP Valproic acid CONVULEX 500MG CAP Valproic acid EPILIM CR 200MG SRT Valproic acid EPILIM CR 300MG SRT Valproic acid EPILIM CR 500MG SRT Lamotrigine DYNA-LAMOTRIGINE 25MG Lamotrigine DYNA-LAMOTRIGINE 50MG

36 Lamotrigine DYNA-LAMOTRIGINE 100MG Lamotrigine DYNA-LAMOTRIGINE 200MG Lamotrigine ASPEN LAMOTRIGINE 100MG Orphenadrine (chloride) DISIPAL 50MG Chlorpromazine LARGACTIL 25MG Chlorpromazine LARGACTIL 50MG Chlorpromazine LARGACTIL 100MG Fluphenazine MODECATE 1ML 25MG/1ML INJ Haloperidol SERENACE 0,5MG CAP Haloperidol SANDOZ HALOPERIDOL 5MG Haloperidol SANDOZ HALOPERIDOL 1,5MG Flupentixol FLUANXOL DEPOT 1ML 20MG INJ Depot Preparations Only - 2nd Line Zuclopenthixol CLOPIXOL DEPOT 200MG INJ Depot Preparations Only - 2nd Line Clozapine CLOMENT 25MG WCC required 6 monthly Clozapine CLOMENT 100MG WCC required 6 monthly Olanzapine REDILANZ 10MG Olanzapine REDILANZ 2,5MG Olanzapine REDILANZ 5MG Risperidone SCHIZOROL 0,5MG Risperidone SCHIZOROL 1MG Risperidone SCHIZOROL 2MG Risperidone RISPERIDONE HEXAL 3MG Risperidone ZOXADON 0,5MG Risperidone ZOXADON 1MG Risperidone ZOXADON 2MG Amitriptyline TREPILINE 25MG

37 Amitriptyline TREPILINE 10MG Amitriptyline SANDOZ AMITRIPTYLINE 25MG Dothiepin THADEN 25MG CAP Dothiepin THADEN 75MG Dothiepin SANDOZ DOTHIEPIN HCL 75MG Imipramine ETHIPRAMINE 10MG Imipramine ETHIPRAMINE 25MG Citalopram CITALOHEXAL 20MG Citalopram DEPRAMIL 40MG Citalopram CITALOPRAM-WINTHROP 20MG Fluoxetine RANFLOCS 20MG CAP Fluoxetine A-LENNON FLUOXETINE 20MG CAP Sertraline SERDEP 100MG Sertraline SERDEP 50MG SYSTEMIC LUPUS ERYTHEMATOSUS Please provide a report from a rheumatologist or specialist physician, confirming the diagnosis. Folic acid BE-S FOLIC ACID 5MG Prednisone TROLIC 5MG Prednisone PANAFCORT 5MG Prednisone BE-S PREDNISONE 5MG Cyclophosphamide ENDOXAN 50MG Treatment to be initiated by a specialist Azathioprine ZAPRINE 50MG Treatment to be initiated by a specialist Azathioprine AZATHIOPRINE PCH 50MG Treatment to be initiated by a specialist Methotrexate ABITREXATE (WAS EMTHEXATE) 2,5MG Treatment to be initiated by a specialist Methotrexate METHOTREXATE 2,5MG Treatment to be initiated by a specialist

38 Diclofenac MYLAN DICLOFENAC 25MG Diclofenac MYLAN DICLOFENAC 50MG Diclofenac SANDOZ DICLOFENAC SODIUM 100 SIMPLE REG 100MG Diclofenac DICLOHEXAL 25MG Diclofenac A-LENNON DICLOFENAC 25MG Diclofenac A-LENNON DICLOFENAC 50MG Indometacin ARTHREXIN 25MG CAP Indometacin SANDOZ INDOMETHACIN 25MG CAP Indometacin ADCO-INDOMETHACIN 25MG CAP Meloxicam FLEXOCAM 7,5MG Meloxicam ADCO-MELOXICAM 7,5MG Piroxicam XYCAM 20MG CAP Piroxicam PYROCAPS 20MG CAP Piroxicam ROXIFEN 20MG CAP Ibuprofen BETAPROFEN 200MG Ibuprofen SANDOZ IBUPROFEN 600MG Ibuprofen INZA 200MG Ibuprofen RANFEN 400MG Ibuprofen BETAPROFEN FC 400MG Naproxen NAPROSCRIPT 250MG Naproxen MYLAN NAPROXEN 250MG Acetylsalicylic acid BE-S ASPIRIN (WHITE) 300MG Acetylsalicylic acid ASPIRIN JUNIOR 60MG Acetylsalicylic acid GULF ASPIRIN 300MG SRT

39 Chloroquine NIVAQUINE 200MG Treatment to be initiated by a specialist ULCERATIVE COLITIS Please provide a report from a specialist physician or gastroenterologist that confirms the diagnosis Budesonide ENTOCORD ENE Treatment to be initiated by a specialist Mesalazine ASACOL 400MG Treatment to be initiated by a specialist Mesalazine PENTASA 500MG Treatment to be initiated by a specialist Mesalazine ASACOL 500MG SUP Treatment to be initiated by a specialist Olsalazine DIPENTUM 250MG CAP Treatment to be initiated by a specialist Sulfasalazine SALAZOPYRIN 500MG Treatment to be initiated by a specialist Prednisone BE-S PREDNISONE 5MG Prednisone PANAFCORT 5MG Prednisone TROLIC 5MG Azathioprine ZAPRINE 50MG Treatment to be initiated by a specialist Azathioprine AZATHIOPRINE PCH 50MG Treatment to be initiated by a specialist Methotrexate MENOPAUSE ABITREXATE (WAS EMTHEXATE) 2,5MG Treatment to be initiated by a specialist Methotrexate METHOTREXATE 2,5MG Treatment to be initiated by a specialist OTHER CHRONIC DISEASES Conjugated estrogens PREMARIN VCR Conjugated estrogens PREMARIN 0,3MG Conjugated estrogens PREMARIN 0,625MG Conjugated estrogens PREMARIN 1,25MG Estradiol ESTRO-PAUSE 1MG Estradiol ESTRO-PAUSE 2MG Estradiol CLIMARA 50 PTD

40 ACNE Estradiol CLIMARA 100 PTD Estradiol Estradiol ESTRADERM TTS 100MCG/DAY ESTRADERM TTS 25MCG/DAY Estriol SYNAPAUSE-E3 2MG Medroxyprogesterone HEXAL-MPA 5MG Norethisterone and estrogen Medroxyprogesterone and estrogen Norethisterone and estrogen Norethisterone and estrogen PTD PTD ACTIVELLE PREMELLE-CYCLE TRISEQUENS ESTRO-PAUSE N Norgestrel and estrogen POSTOVAL Cyproterone and estrogen Doxycycline CLIMEN OTHER CHRONIC DISEASES - NOT APPLICABLE TO LIBERTY BONAPLUS, MOTOHEALTH and TOPMED A-LENNON DOXYCYCLINE HCL 100MG CAP Maximum 30 per month Doxycycline CYCLIDOX 100MG CAP Maximum 30 per month Oxytetracycline NUCOTET 250MG CAP Maximum 60 per month Oxytetracycline BE-OXYTET 250MG CAP Maximum 60 per month Oxytetracycline TETRACEM 250MG CAP Maximum 60 per month Oxytetracycline OXYPAN 250MG CAP Maximum 60 per month

41 Erythromycin PURMYCIN 250MG CAP Maximum 60 per month Erythromycin SPECTRASONE 250MG CAP Maximum 60 per month Erythromycin XERAMEL 250MG CAP Maximum 60 per month ALLERGIC RHINITIS Beclometasone Beclometasone BECLATE AQUANASE 150DOSE CLENIL AQUEOUS 200DOSE 50MCG 50MCG Fluticasone FLONASE 120 DOSE 50MCG AQS second line Fluticasone FLOMIST 120DOSE 50MCG AQS second line Cetirizine ZETOP 10MG Clinical motivation required if used with inhaled steroid CARDIAC ARRYTHMIA -non PMB Warfarin CIPLA-WARFARIN 5MG Warfarin CIPLA-WARFARIN 1MG Warfarin CIPLA-WARFARIN 3MG Digoxin LANOXIN 0,25MG Digoxin PURGOXIN 0,25MG Quinidine QUINIDINE SULPH 200MG Amiodarone HEXARONE 100MG Amiodarone HEXARONE 200MG Amiodarone ARYCOR 200MG Amiodarone ARYCOR 100MG Propranolol PURBLOKA 10MG Propranolol PURBLOKA 40MG Propranolol INDOBLOK 10MG AQS AQS

42 Propranolol INDOBLOK 40MG Atenolol HEXA-BLOK 50MG Atenolol SANDOZ ATENOLOL 50MG Atenolol SANDOZ ATENOLOL 100MG Atenolol BIO-ATENOLOL (WAS IVAX-ATENOLOL) 50MG Atenolol TENOPRESS 25MG Atenolol TENOPRESS 100MG Bisoprolol ADCO-BISOCOR 5MG Bisoprolol ADCO-BISOCOR 10MG Bisoprolol ZIAPRO 10MG Bisoprolol ZIAPRO 5MG Verapamil VERAHEXAL 240 SR 240MG SRT Verapamil VASOMIL 40MG Verapamil VASOMIL 80MG Diltiazem ADCO-ZILDEM SR 180MG SRC Diltiazem ADCO-ZILDEM SR 240MG SRC Diltiazem ADCO-ZILDEM 60MG Diltiazem ADCO-ZILDEM 90MG Acetylsalicylic acid GULF ASPIRIN 300MG Acetylsalicylic acid ASPIRIN JUNIOR 60MG Acetylsalicylic acid DEPRESSION, MAJOR BE-S ASPIRIN (WHITE) 300MG Amitriptyline TREPILINE 25MG Amitriptyline TREPILINE 10MG

43 Amitriptyline SANDOZ AMITRIPTYLINE 25MG Dothiepin THADEN 25MG CAP Dothiepin THADEN 75MG Dothiepin SANDOZ DOTHIEPIN HCL 75MG Imipramine ETHIPRAMINE 10MG Imipramine ETHIPRAMINE 25MG Citalopram DEPRAMIL 40MG Citalopram CITALOPRAM-WINTHROP 20MG Citalopram ARROW CITALOPRAM 20MG Fluoxetine RANFLOCS 20MG CAP Fluoxetine A-LENNON FLUOXETINE 20MG CAP Sertraline SERDEP 100MG Sertraline SERDEP 50MG GOUT Allopurinol LONOL 300MG Allopurinol SANDOZ ALLOPURINOL 100MG Allopurinol SANDOZ ALLOPURINOL 300MG Allopurinol PURICOS 100MG MIGRAINE (PROPHYLAXIS ONLY) Propranolol PURBLOKA 10MG Propranolol PURBLOKA 40MG Propranolol INDOBLOK 10MG Propranolol INDOBLOK 40MG Amitriptyline TREPILINE 25MG Amitriptyline TREPILINE 10MG