Chronic Illness Benefit medicine list (formulary)

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1 Chronic Illness Benefit medicine list (formulary) 2014 Page 1 of 22 01/2014

2 Chronic Illness Benefit 2014 Contents Page Explanation of terms 3 The Prescribed Minimum Benefits medicine list 4 Important information you need to know We may change the information contained in this document from time to time. We will communicate any changes to the way we pay medicines when we make these changes. The Chronic Illness Benefit (CIB) is managed by the BMW Employees Medical Aid Society 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. BMW Employees Medical Aid Society and Discovery Health (Pty) Ltd reserve the right to change the benefit at any time. Page 2 of 22 01/2014

3 Explanation of terms Benefit year A benefit year refers to the benefits a member is entitled to during a calendar year, that is to say 1 January to 31 December. This medicine list (formulary) and Chronic Drug Amounts are applicable for 2014 only. Chronic Drug Amount (CDA) The CDA is a monthly 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. Medicine class This describes medicines that have similar chemical structures or similar therapeutic effects. Active ingredient This is the main substance in a medicine that is responsible for the clinical action on a human body. Page 3 of 22 01/2014

4 Chronic Illness Benefit 2014 The Prescribed Minimum Benefits (PMB) medicine list The PMB medicine list applies to BMW Employees Medical Aid Society for the 2014 benefit year. Prescribed Minimum Addison s disease R150 Systemic corticosteroids: Hydrocortisone R105 Systemic corticosteroids: Mineralocorticoids Asthma R325 Adrenergics - Formoterol combinations R140 R375 R325 R30 R125 R195 Adrenergics: Long acting - Formoterol Adrenergics: Long acting - Salmeterol Adrenergics: Salmeterol combinations Adrenergics: Short acting - Salbutamol Anti-asthmatics: Systemic xanthines Inhaled anti-cholinergics: Ipratropium bromide Hydrocortisone Covocort 10mg Fludrocortisone Florinef acetate 0.1mg Formoterol and Symbicord turbohaler 160/4.5mcg other drugs for obstructive 60 dose Symbicord turbohaler 320/9mcg airway diseases 60dose Formoterol Foratec dp-caps 12mcg Foratec hfa 120dose 12mcg/1dose Salmeterol Serevent accuhaler 60 dose 50mcg Serevent CFC free 120 dose 25mcg Salmeterol and Foxair accuhaler 50/100; 50/250; 50/500 other drugs for 60 dose obstructive Sereflo hfa 25/50; 25/125; 25/250 airway diseases 120 dose Salbutamol Venteze CFC free 200 dose 100mcg Theophylline Ipratropium bromide Sandoz Theophylline anhydrous ; 300mg Atrovent HFA 200dose Ipvent HFA 200 dose Page 4 of 22 01/ mcg 40mcg/1dose R330 Inhaled Glucocorticoids Beclometasone Beceze 200dose CFC free 100mcg Beclate 200 dose 100mcg; 200mcg Budesonide Budeflam dp-caps 200mcg Budeflam HFA 300dose 100mcg; 200mcg Inflammide novolizer complete 200 dose 200mcg Inflammide novolizer complete 100 dose 400mcg Inflammide novolizer refill 200 dose 200mcg Inflammide novolizer refill 100 dose 400mcg Pulmicort turbuhaler 200dose 100mcg; 200mcg R350 Surgical item Inhaler device Dp haler device Paediatric Spacer Glaxohaler R10 Systemic corticosteroids: Prednisone Be-Tabs Prednisone Prednisone Panafcort Trolic

5 Bipolar mood disorder R330 Anti-depressants: SSRIs R345 R365 R375 Anti-epileptics: Carboxamide derivatives Anti-epileptics: Fatty acid derivatives Anti-epileptics: Other agents Citalopram Adco-Talomil Arrow Citalopram ; Auro-Citalopram Austell-Citalopram Cilate Citalohexal Citalopram Actor Citalopram-Winthrop Mylan Citalopram Escitalopram Citraz 10mg; Escitalopram Be-Tabs 10mg; Zytomil 10mg; Fluoxetine A-Lennon Fluoxetine Deprozan Fluoxetine Actor Ranflocs Rezak Zydus Fluoxetine Paroxetine Adco-Paroxetine Paroxetine Unicorn Serrapress Sertraline Austell-Sertraline 50mg; Serdep 50mg; Zylin 50mg Carbamazepine Degranol Sandoz Carbamazepine Sandoz Carbamazepine CR Zeptol ; 400mg Valproic acid Convulex 150mg Convulex syrup Epilim crushable 250mg/5ml Epilim sugar-free syrup /5ml Epilizine CR ; 300mg; 500mg Navalpro CR ; 300mg; 500mg Lamotrigine Dyna-Lamotrigine 2; 50mg; ; Lamidus Sandoz Lamotrigine 50mg; ; 50mg; ; R95 R1 000 R305 R605 R345 Butyrophenone derivatives Clozapine Lithium Olanzapine Phenothiazines with aliphatic side-chain Haloperidol Sandoz Haloperidol 1.; Clozapine Aspen Clozapine 2; Cloment 2; Lithium Camcolit 250mg; 400mg Quilonum retard 450mg Olanzapine Oleanz ; 10mg Olexar ; 10mg Redilanz ; 10mg Chlorpromazine Largactil 2; 50mg; Page 5 of 22 01/2014

6 Bipolar mood disorder R550 Quetiapine Dopaquel 2; ; ; 300mg Quetiapine Mylan Quetiapine 2; ; ; 300mg Psyquet 2; ; ; 300mg Quetoser 2; ; ; 300mg Serez 2; ; ; 300mg R620 Flupenthixol Fluanxol 0.; 1mg Thioxanthene derivatives Fluanxol depot 1ml Fluanxol depot 2ml Zuclopenthixol Clopixol 2mg; 10mg Clopixol depot R990 Other anti-psychotics Risperidone DRL-Risperidone 0.; 1mg; 2mg Perizal 0.; 1mg; 2mg; 3mg Risnia 0.; 1mg; 2mg; 3mg Schizorol 0.; 1mg; 2mg Zoxadon 0.; 1mg; 2mg Bronchiectasis R30 Adrenergics: Salbutamol Venteze CFC free 200 dose 100mcg Short acting - Salbutamol R195 Inhaled anti-cholinergics: Ipratropium Atrovent HFA 200dose 20mcg Ipratropium bromide bromide Ipvent HFA 200 dose 40mcg/1dose R10 Systemic corticosteroids: Prednisone Be-Tabs Prednisone Prednisone Panafcort Trolic Cardiac failure R115 Enalapril and Enap co 20/12. ACE inhibitors and Pharmapress co 20/12. Lisinopril and Adco-Zetomax co 10/12.; 20/12. Hexal-Lisinopril co 10/12.;20/12. Lisinopril co Unicorn 10/12.; 20/12. Lisinozide 10/12.; 20/12. Lisoretic 10/12.; 20/12. R110 ACE inhibitors: plain Lisozide 20/12. Captopril Adco-Captomax 2; 50mg Bio-Captopril 2 Mylan Captopril 2; 50mg Enalapril Alapren ; 10mg; Enalapril Unicorn 10mg; Enap ; 10mg; Hr-Enalapril ; 10mg; Lisinopril Austell-Lisinopril 10mg; Sinopren ; 10mg; Perindopril Acti-Prex Auro Perindopril Bindace Ciplasyl Pearinda ; 8mg ; 8mg Page 6 of 22 01/2014

7 Cardiac failure R110 ACE inhibitors: plain Perindopril Perindopril Unicorn Ran-Perindopril Zydus Perindopril Quinapril Accumax 10mg; R225 R115 R115 Alpha and Beta blocking agents Angiotensin II antagonists, Combinations: Losartan and Angiotensin II antagonists: plain Carvedilol Carvedilol Unicorn 6.2; 12.; 2 Carvetrend 6.2; 12.; 2 Vediblok 6.2; 12.; 2 Losartan and Austell Losartan co 50/12. Ciplazar co 100/2 Hytenza co Lohype Forte Plus Losaar Plus Losacar co Losartan co Unicorn Netrasol co 50/12.; 100/2 100/2 50/12.; 100/2 50/12. 50/12.; 100/2 50/12.; 100/2 Sartoc-co 100/2 Zartan co 100/2 Losartan Ciplazar Hytenza Spec-Losartan Zartan Valsartan Diolo 80mg; 160mg R80 Arteriolar smooth muscle Hydralazine Hyperphen 10mg; 50mg agents: Hydrazinophthalazine derivatives Sandoz Hydralazine 2 R75 Beta blocking agents: Bisoprolol Adco-Bisocor ; 10mg selective Betacor ; 10mg Bilocor ; 10mg Bisohexal ; 10mg Bisoprolol Unicorn ; 10mg Ziapro ; 10mg R25 Cardiac glycosides: Digoxin Lanoxin 0.062; 0.2 Digoxin Lanoxin paed syrup 0.0/1ml R40 High-ceiling Furosemide Beurises Dino-Retic Diuresix Mylan Furosemide R15 Low-ceiling : Hydrochloro- Hexazide 2 Thiazides, plain thiazide Ridaq 12. R20 Low-ceiling : Indapamide Cipla-Indapamide 2. excluding Thiazides Daptril 2. Mylan Indapamide 2. R90 Potassium sparing agents Spironolactone Aldactone 2 Sandoz Spironolactone 2 Spiractin 2 Page 7 of 22 01/2014

8 Cardiac failure R85 Potassium supplements Potassium Plenish K 600mg chloride Sandoz K mg R170 Vasodilators in cardiac Glyceryl trinitrate Angised 0. disease: Isosorbide Sandoz Isosorbide dinitrate ; 10mg; 30mg Organic nitrates dinitrate Isosorbide Elantan mononitrate Elantan LA 50mg Monicor SR 60mg R70 Influenza vaccines Influenza, purified antigen Fluarix pre-filled syringe 0.5ml Fluvax pre-filled syringe 0.5ml R135 Pneumococcus vaccines Pneumococcus, Imovax pneumo 23 purified polysaccharides antigen Cardiomyopathy R115 ACE inhibitors and Enalapril and Enap co 20/12. Pharmapress co 20/12. Lisinopril and Adco-Zetomax co 10/12.; 20/12. Hexal-Lisinopril co 10/12.; 20/12. Lisinopril co Unicorn 10/12.; 20/12. Lisinozide 10/12.; 20/12. Lisoretic 10/12.; 20/12. Lisozide 20/12. R110 ACE inhibitors: Captopril Adco-Captomax 2; 50mg plain Bio-Captopril 2 Mylan Captopril 2; 50mg Enalapril Alapren ; 10mg; Enalapril Unicorn 10mg; Enap ; 10mg; Hr-Enalapril ; 10mg; Lisinopril Austell-Lisinopril 10mg; Sinopren ; 10mg; Perindopril Acti-Prex Auro Perindopril Bindace Ciplasyl Pearinda Perindopril Unicorn ; 8mg ; 8mg R225 Alpha and Beta blocking agents Ran-Perindopril Zydus perindopril Quinapril Accumax 10mg; Carvedilol Carvedilol Unicorn 6.2; 12.; 2 Carvetrend 6.2; 12.; 2 Vediblok 6.2; 12.; 2 Page 8 of 22 01/2014

9 Cardiomyopathy R115 Angiotensin II antagonists, Combinations: Losartan and R115 R75 R80 Angiotensin II antagonists: plain Anti-thrombotic agents: Vitamin K antagonists Arteriolar smooth muscle agents: Hydrazinophthalazine derivatives Losartan and R20 Aspirin Acetylsalicylic acid Austell Losartan co Ciplazar co Hytenza co Lohype Forte Plus Losaar Plus Losacar co Losartan co Unicorn Netrasol co Sartoc co Zartan co 50/ /2 50/12.; 100/2 100/2 50/12.; 100/2 50/12. 50/12.; 100/2 50/12.; 100/2 100/2 100/2 Losartan Ciplazar Hytenza Spec-Losartan Zartan Valsartan Diolo 80mg; 160mg Warfarin Cipla-Warfarin 1mg; 3mg; Hydralazine Hyperphen 10mg; 50mg Sandoz Hydralazine Aspirin Gulf Aspirin 2 300mg 300mg R75 Beta blocking agents: Bisoprolol Adco-Bisocor ; 10mg selective Betacor ; 10mg Bilocor ; 10mg Bisohexal ; 10mg Bisoprolol Unicorn ; 10mg Ziapro ; 10mg R25 Cardiac glycosides: Digoxin Lanoxin 0.062; 0.2 Digoxin Lanoxin paed syrup 0.0/1ml R40 High-ceiling Furosemide Beurises Dino-Retic Diuresix Mylan Furosemide R15 Low-ceiling : Hydrochlorothiazide Hexazide 2 Thiazides, plain Ridaq 12. R20 Low-ceiling : Indapamide Cipla-Indapamide 2. excluding Thiazides Daptril 2. Mylan Indapamide 2. R90 Potassium sparing agents Spironolactone Aldactone 2 Sandoz Spironolactone 2 Spiractin 2 R85 Potassium supplements Potassium Plenish K 600mg chloride Sandoz K mg R170 Vasodilators in cardiac disease: Organic nitrates Glyceryl trinitrate Angised 0. Page 9 of 22 01/2014

10 Cardiomyopathy R170 Vasodilators in cardiac disease: Organic nitrates Chronic obstructive pulmonary disease (COPD) Isosorbide dinitrate Isosorbide mononitrate R70 Influenza vaccines Influenza, purified antigen R135 Pneumococcus vaccines Pneumococcus, purified polysaccharides antigen R155 Adrenergics: Salbutamol and Salbutamol combinations other drugs for obstructive airway diseases R30 Adrenergics: Short acting - Salbutamol R125 Anti-asthmatics: Theophylline Systemic xanthines R195 R685 R10 Inhaled anti-cholinergics: Ipratropium bromide Surgical item: Oxygen concentrator Systemic corticosteroids: Prednisone Sandoz Isosorbide dinitrate Elantan Elantan LA Monicor SR Fluarix pre-filled syringe 0.5ml Fluvax pre-filled syringe 0.5ml Imovax pneumo 23 Duolin hfa ; 10mg; 30mg 50mg 60mg 200 dose Salbutamol Venteze CFC free 200 dose 100mcg Ipratropium bromide Oxygen R70 Influenza vaccines Influenza, purified antigen Chronic renal disease R115 ACE inhibitors and Enalapril and Lisinopril and R110 ACE inhibitors: plain Sandoz Theophylline anhydrous ; 300mg Atrovent HFA 200dose Ipvent HFA 200 dose Oxygen concentrator rental 20mcg 40mcg/1dose Prednisone Be-Tabs Prednisone Panafcort Trolic Fluarix pre-filled syringe 0.5ml Fluvax pre-filled syringe 0.5ml Enap co Pharmapress co Adco-Zetomax co Hexal-Lisinopril co Lisinopril co Unicorn Lisinozide 20/12. 20/12. 10/12.; 20/12. 10/12.; 20/12. 10/12.; 20/12. 10/12.; 20/12. Lisoretic 10/12.; 20/12. Lisozide 20/12. Captopril Adco-Captomax 2; 50mg Bio-Captopril 2 Mylan Captopril 2; 50mg Enalapril Alapren ; 10mg; Enalapril Unicorn 10mg; Enap ; 10mg; Hr-Enalapril ; 10mg; Lisinopril Austell-Lisinopril 10mg; Sinopren ; 10mg; Perindopril Acti-Prex Auro Perindopril Bindace Page 10 of 22 01/2014

11 Chronic renal disease R110 ACE inhibitors: plain Perindopril Ciplasyl ; 8mg Pearinda ; 8mg Perindopril Unicorn Ran-Perindopril Zydus perindopril Quinapril Accumax 10mg; R115 Angiotensin II antagonists, Combinations: Losartan and Losartan and Austell Losartan co Ciplazar co 50/ /2 Hytenza co Lohype Forte Plus 50/12.; 100/2 100/2 Losaar Plus Losacar co Losartan co Unicorn Netrasol co Sartoc co 50/12.; 100/2 50/12. 50/12.; 100/2 50/12.; 100/2 100/2 R115 Angiotensin II antagonists: plain Zartan co 100/2 Losartan Ciplazar Hytenza Spec-Losartan Zartan Valsartan Diolo 80mg; 160mg R215 Calcium supplements Calcium B-cal carbonate R5 Folic acid and derivatives Folic acid Aha Folic acid R65 R570 R4 000 Iron in combination with folic acid Iron trivalent, parenteral preparations Other anti-anaemic preparations Ferrous fumarate Be-Tabs Folic acid Folic acid Pregamal 0. Ferricoxidedextrancomplex Cosmofer ampoule 50mg/1ml Saccharated iron oxide Venofer /1ml Darbepoetin Alfa Aranesp pre-filled syringe 0.4ml 10mcg/0.4ml Aranesp pre-filled syringe 0.5ml Aranesp pre-filled syringe 0.3ml Aranesp pre-filled syringe 0.4ml Aranesp pre-filled syringe 0.5ml Aranesp pre-filled syringe 0.3ml 20mcg/0.5ml 30mcg/0.3ml 40mcg/0.4ml 50mcg/0.5ml 60mcg/0.3ml Page 11 of 22 01/2014

12 Chronic renal disease R4 000 Other anti-anaemic Erythropoietin Eprex pre-fill 2000U/0.5ml preparations Eprex pre-fill 4000U/0.4ml Recormon pre-filled syringe 500U/0.3ml Recormon pre-filled syringe 2000U/0.3ml Recormon pre-filled syringe 4000U/0.3ml Repotin 1ml 2000IU Repotin 1ml 4000IU Methoxy Mircera pre-filled syringe 0.3ml 30mcg/0.3ml polyethylene-glycol- Mircera pre-filled syringe 0.3ml 50mcg/0.3ml epoetin beta Mircera pre-filled syringe 0.3ml 75mcg/0.3ml Mircera pre-filled syringe 0.3ml 100mcg/0.3ml Mircera pre-filled syringe 0.3ml 120mcg/0.3ml Mircera pre-filled syringe 0.3ml 150mcg/0.3ml Mircera pre-filled syringe 0.3ml 200mcg/0.3ml Mircera pre-filled syringe 0.3ml 250mcg/0.3ml R365 Vitamin D and analogues Alfacalcidol One alpha 0.25mcg; 1mcg Coronary artery disease R20 Aspirin Acetylsalicylic acid Aspirin 300mg Gulf Aspirin 300mg R170 Beta blocking agents: Propranolol Indoblok 10mg; non-selective Prodorol 10mg; Purbloka 10mg; R75 Beta blocking agents: Atenolol B-Block 50mg; selective Bio-Atenolol 50mg; Gulf Atenolol 50mg; Sandoz Atenolol 50mg; Tenopress R255 Selective calcium Diltiazem Adco-Zildem 60mg channel blockers with Adco-Zildem SR 180mg; 2 direct cardiac effects Verapamil Vasomil ; 80mg Verahexal SR 2 R170 Selective calcium Amlodipine Almadin ; 10mg channel blockers with Amlodac mainly vascular effects Gulf Amlodipine ; 10mg Indo Amlodipine Lomanor ; 10mg Pharma Dynamics Amlodipine besylate ; 10mg Felodipine Felodipine-Hexal ; 10mg Nifedipine Adco-Vascard SR Cipalat Retard Nifedalat SR R170 Vasodilators in cardiac Glyceryl trinitrate Angised 0. disease: Isosorbide dinitrate Sandoz Isosorbide dinitrate ; 10mg; 30mg Organic nitrates Isosorbide Elantan mononitrate Elantan LA 50mg Monicor SR 60mg Crohn s disease R5 Folic acid and derivatives Folic acid Aha Folic acid Be-Tabs Folic acid Folic acid 0. Page 12 of 22 01/2014

13 Medicine class Crohn s disease R680 Intestinal anti-inflammatories: Aminosalicylic acid and similar agents R2 285 R590 R65 R10 Intestinal anti-inflammatories: Corticosteroids Other immunosuppressive agents: Azathioprine Other immunosuppressive agents: Methotrexate Systemic corticosteroids: Prednisone Diabetes insipidus R1 600 Posterior pituitary hormones: Vasopressin and analogues Diabetes mellitus Type 1 R720 Anti-diabetic agents: Insulins and analogues R280 Blood glucose monitoring agents Active ingredient Medicine name and strength Mesalazine Asacol 400mg; 500mg; 800mg Pentasa Salofalk 500mg; 1000mg 1000mg Olsalazine Dipentum 250mg Sulfasalazine Salazopyrin 500mg Budesonide Salazopyrin EN Entocord enema 500mg Azathioprine Azamun 50mg Azathioprine PCH 50mg Methotrexate Abitrexate 2. Methotrexate 2. Prednisone Be-Tabs Prednisone Panafcort Trolic Desmopressin Ddavp 0.1mg; 0.2mg Ddavp nasal spray 5ml 0.1mg/1ml Insulin Actraphane hm(ge) - vial 10ml Apidra - solostar disposable pens 3ml Biosulin cartridge 3ml Biosulin l cartridge 3ml Biosulin n cartridge 3ml Biosulin r cartridge 3ml Humalog vial 10ml Humalog cartridge 3ml Humalog kwikpen - penset 3ml Humalog mix 25 kwikpen - penset 3ml Humalog mix 25 - cartridge 3ml; vial 10ml) Humalog mix 50 - cartridge 3ml Humalog mix 50 - kwikpen 3ml Humulin 30/70 - cartridge 3ml; disposable pens 3ml; vial 10ml Humulin n - cartridge 3ml; disposable pen 3ml; vial 10ml Humulin r - cartridge 3ml; vial 10ml Insuman comb 30/70 - cartridge 3ml Novomix 30 - flexpen 3ml; penfill 3ml Novorapid - penfill 3ml Glucose strips Accu-chek active strips Caresens ii/pop test strip 29g Caresens n test strips 29g Glucocheck strips 50s Glucoplus Glucoplus provider strips Glucose test strips free style optium Onetouch select glucose test strips On-call plus ez strips (all sizes) Page 13 of 22 01/2014

14 Diabetes mellitus Type 1 R350 Surgical item Devices Biosulin pen device Lancets Lancets glucoplus 66 x 44 x 78mm Needles BD microfine pen needle 32g 4mm BD microfine pen needle 31g 5mm Needle novofine Needle pen bd microfine 30g 8mm Diabetes mellitus Type 2 R60 Anti-diabetic agents: Metformin Accord Metformin 500mg; 850mg Biguanides Arrow Metformin 500mg; 850mg Austell-Metformin 500mg; 850mg Bigsens 500mg; 850mg; 1000mg Diaformin 500mg Diaformin forte 850mg Diamin 500mg; 850mg Gluconorm 500mg; 850mg Mengen 500mg; 850mg; 1000mg Metchek 500mg; 850mg Metforal 500mg; 850mg Metored 500mg; 850mg; 1000mg Metphage 500mg; 850mg Mylan Metformin 500mg; 850mg Sandoz Metformin 500mg Sandoz Metformin FCT 500mg R720 Anti-diabetic agents: Insulins and analogues Insulin Actraphane hm(ge) - vial 10ml Apidra - solostar disposable pens 3ml Biosulin cartridge 3ml Biosulin l cartridge 3ml Biosulin n cartridge 3ml Biosulin r cartridge 3ml Humalog vial 10ml Humalog cartridge 3ml Humalog kwikpen - penset 3ml Humalog mix 25 kwikpen - penset 3ml Humalog mix 25 - cartridge 3ml; vial 10ml Humalog mix 50 - cartridge 3ml Humalog mix 50 kwikpen 3ml Humulin 30/70 - cartridge 3ml; disposable pens 3ml; vial 10ml Humulin n - cartridge 3ml; disposable pen 3ml; vial 10ml Humulin r - cartridge 3ml; vial 10ml Insuman comb 30/70 - cartridge 3ml Novomix 30 - flexpen 3ml; penfill 3ml Novorapid - penfill 3ml R100 Anti-diabetic agents: Glibenclamide Bio-Glibenclamide Sulfonamides, urea Diacare derivatives Glycomin Sandoz Glibenclamide Gliclazide Adco-Glucomed 80mg Arrow Gliclazide 80mg Austell-Gliclazide 80mg Diaglucide 80mg Page 14 of 22 01/2014

15 Diabetes mellitus Type 2 R100 Anti-diabetic agents: Sulfonamides, urea derivatives R180 R280 Anti-diabetic agents: Thiazolidinediones Blood glucose monitoring agents Gliclazide Diaran MR 30mg Dyna Gliclazide SR 30mg Glycron 80mg Glygard 80mg Sandoz Gliclazide 80mg Pioglitazone Accord Pioglitazone 1; 30mg Glucose strips Cipla-Pioglitazone Accu-chek active strips Caresens ii/pop test strip 29g Caresens n test strips 29g Glucocheck strips 50s Glucoplus Glucoplus provider strips Glucose test strips free style optium Onetouch select glucose test strips On-call plus ez strips (all sizes) R350 Surgical item Devices Biosulin pen device Dysrhythmias R605 Anti-arrhythmics: class Ic R380 Anti-arrhythmics: class III - Amiodarone Lancets Needles Lancets glucoplus 66 x 44 x 78mm BD microfine pen needle 32g 4mm BD microfine pen needle 31g 5mm Needle novofine Needle pen bd microfine 30g 8mm 1; 30mg Flecainide Tambocor Tambocor CR ; Propafenone Rythmol 150mg; 300mg Amiodarone Arycor ; Bio-Amiodarone Hexarone ; R75 Anti-thrombotic agents: Warfarin Cipla-Warfarin 1mg; 3mg; Vitamin K antagonists R20 Aspirin Acetylsalicylic Aspirin 300mg acid Gulf Aspirin 300mg R170 R75 R25 R255 Beta blocking agents: non-selective Beta blocking agents: selective Cardiac glycosides: Digoxin Selective calcium channel blockers with direct cardiac effects Propranolol Indoblok 10mg; Prodorol 10mg; Purbloka 10mg; Sotalol Sotahexal 80mg; 160mg Atenolol B-Block 50mg; Bio-Atenolol Gulf Atenolol Sandoz Atenolol Tenopress 50mg; 50mg; 50mg; Digoxin Lanoxin 0.062; 0.2 Lanoxin paed syrup 0.0/1ml Verapamil Vasomil ; 80mg Verahexal SR 2 Page 15 of 22 01/2014

16 Epilepsy R260 Anti-epileptics: Benzodiazepine derivatives R345 Anti-epileptics: Carboxamide derivatives R365 R60 R375 Anti-epileptics: Fatty acid derivatives Anti-epileptics: Hydantoin derivatives Anti-epileptics: Other agents R25 Anti-epileptics: Barbiturates and derivatives Glaucoma R170 Anti-glaucoma agents: Carbonic anhydrase inhibitors R225 Anti-glaucoma agents: Prostaglandin analogues Clonazepam Rivotril 0.; 2mg Carbamazepine Degranol Sandoz Carbamazepine Sandoz Carbamazepine CR ; 400mg Zeptol Valproic acid Convulex 150mg Convulex syrup 250mg/5ml Epilim crushable Epilim sugar-free syrup /5ml Epilizine CR ; 300mg; 500mg Navalpro CR ; 300mg; 500mg Phenytoin Phenytoin sod Lamotrigine Dyna-Lamotrigine 2; 50mg; ; Lamidus 50mg; ; Sandoz Lamotrigine 50mg; ; Topiramate Epitoz 2; 50mg; Sandoz Topiramate 50mg; Phenobarbital Lethyl 30mg Sedabarb 30mg Dorzolamide Trusopt 5ml owi 2% Bimatoprost Lumigan 0.01% Latanoprost Ocuprost 3ml 50mcg/1ml Travoprost Travatan 2.5ml 0.004% R245 Anti-glaucoma agents: Brimonidine Alphagan purite 5ml 1./1ml Sympathomimetics R85 Anti-glaucoma Beta Timolol Glaucosan 5ml 0.5% blocking agents: Timolol R240 Anti-glaucoma Beta blocking agents: Timolol, combinations Azarga 5ml Combigan 5ml 2mg/ Timolol, combinations Cosopt 5ml 0.5% Duotrav 2.5ml Ganfort 3ml Haemophilia R5 Analgesics: Paracetamol Adco-Napamol 500mg Paracetamol Adco-Prolief 500mg Cetapon 500mg Painogesic 500mg R195 Anti-fibrinolytics: Tranexamic acid Tranexamic acid medwich 500mg Amino acids Tranic 500mg R Blood coagulation factors Coagulation factor IX Haemosolvex IX 500U Coagulation factor VIII Haemosolvate VIII 300U; 500U; 1000U R1 600 Posterior pituitary hormones: Vasopressin and analogues Hyperlipidaemia R245 Lipid modifying agents: Fibrates Desmopressin Ddavp 0.1mg; 0.2mg Ddavp nasal spray 5ml 0.1mg/1ml Bezafibrate Dyna-Bezafibrate SR 400mg Sandoz Bezafibrate 400mg Page 16 of 22 01/2014

17 Hyperlipidaemia R55 Lipid modifying agents: Statins Atorvastatin Adco Atorvastatin 10mg; ; Aspavor Atolip 10mg; ; 10mg; ; Dynator 10mg; ; ; 80mg Lipogen 80mg Simvastatin Adco-Simvastatin Arrow Simvastatin Austell-Simvastatin 10mg; ; Biovac Simvastatin Choleste Cipla-Simvastatin 10mg; ; Redicor 10mg; ; Simvacor Simzor 10mg; ; Zysim 10mg; ; Hypertension R115 ACE inhibitors and Enalapril and Enap co 20/12. Pharmapress co 20/12. Lisinopril and Adco-Zetomax co 10/12.; 20/12. Hexal-Lisinopril co 10/12.; 20/12. Lisinopril co Unicorn 10/12.; 20/12. Lisinozide 10/12.; 20/12. Lisoretic 10/12.; 20/12. Lisozide 20/12. R110 ACE inhibitors: Captopril Adco-Captomax 2; 50mg plain Bio-Captopril 2 Mylan Captopril 2; 50mg Enalapril Alapren ; 10mg; Enalapril Unicorn 10mg; Enap ; 10mg; Hr-Enalapril ; 10mg; Lisinopril Austell-Lisinopril 10mg; Sinopren ; 10mg; Perindopril Acti-Prex Auro Perindopril Bindace Ciplasyl Pearinda Ran-Perindopril Zydus Perindopril ; 8mg ; 8mg R110 R225 ACE inhibitors: plain Alpha and Beta blocking agents Quinapril Accumax 10mg; Carvedilol Carvedilol Unicorn 6.2; 12.; 2 Carvetrend 6.2; 12.; 2 Vediblok 6.2; 12.; 2 Page 17 of 22 01/2014

18 Hypertension R115 Angiotensin II antagonists, Combinations: Losartan and R115 R130 Angiotensin II antagonists: plain Anti-adrenergic agents: Alpha-adrenoreceptor antagonists Anti-adrenergic agents: Methyldopa Losartan and Austell Losartan co 50/12. Ciplazar co 100/2 Hytenza co 50/12.; 100/2 Lohype Forte Plus 100/2 Losaar Plus 50/12.; 100/2 Losacar co 50/12. Losartan co Unicorn 50/12.; 100/2 Netrasol co 50/12.; 100/2 Sartoc co 100/2 Zartan co 100/2 Losartan Ciplazar Hytenza Spec-Losartan Zartan Valsartan Diolo 80mg; 160mg Doxazosin Adco-Doxazosin 1mg; 2mg; Cardugen 1mg; R120 Methyldopa Hypotone 250mg Mylan Methyldopa 250mg Sandoz Methyldopa 250mg R25 Anti-adrenergic agents: Reserpine Reserpine 0.2 Rauwolfia alkaloids R80 Arteriolar smooth muscle Hydralazine Hyperphen 10mg; 50mg agents: Hydrazinophthalazine derivatives Sandoz Hydralazine 2 R170 Beta blocking agents: Propranolol Indoblok 10mg; non-selective Prodorol 10mg; Purbloka 10mg; R75 Beta blocking agents: Atenolol B-Block 50mg; selective Bio-Atenolol 50mg; Gulf Atenolol 50mg; Sandoz Atenolol 50mg; Tenopress R40 High-ceiling Furosemide Beurises Dino-Retic Diuresix Mylan Furosemide R15 Low-ceiling : Hydrochloro- Hexazide 2 Thiazides, plain thiazide Ridaq 12. R20 Low-ceiling : Indapamide Cipla-Indapamide 2. excluding Thiazides Daptril 2. Mylan Indapamide 2. R90 Potassium sparing agents Spironolactone Aldactone 2 Sandoz Spironolactone 2 Spiractin 2 R85 Potassium supplements Potassium Plenish K 600mg chloride Sandoz K mg R255 Selective calcium channel Diltiazem Adco-Zildem 60mg blockers with direct cardiac Adco-Zildem SR 180mg; 2 effects Verapamil Vasomil ; 80mg Verahexal SR 2 Page 18 of 22 01/2014

19 Medicine class Active ingredient Medicine name and strength Hypertension R170 Selective calcium channel Amlodipine Almadin ; 10mg blockers with mainly vascular Amlodac effects Gulf Amlodipine ; 10mg Indo Amlodipine Lomanor ; 10mg Pharma Dynamics Amlodipine besylate ; 10mg Felodipine Felodipine-Hexal ; 10mg Nifedipine Adco-Vascard SR Cipalat Retard Nifedalat SR Hypothyroidism R45 Thyroid hormones Levothyroxine Euthyrox 25mcg; 50mcg; 100mcg sodium Synthroid 50mcg; 88mcg; 100mcg; 112mcg Multiple sclerosis R65 Anti-depressants: Amitriptyline Sandoz Amitriptyline 2 Tricyclics Trepiline 10mg R Interferons Interferon beta- Avonex pre-filled syringe 0.5ml 30mcg/0.5ml 1a Rebif 22 pre-filled syringe 0.5ml 44mcg/1ml Rebif 22 rebidose pre-filled pen 0.5ml 44mcg/1ml Rebif 44 pre-filled syringe 0.5ml 88mcg/1ml Rebif 44 rebidose pre-filled pen 0.5ml 88mcg/1ml Interferon beta- 1b Betaferon pre-filled syringe 1ml u/1ml R1 030 Muscle relaxants: Baclofen Bio-Baclofen 10mg Other centrally acting agents Teva Baclofen 10mg R10 Systemic corticosteroids: Prednisone Be-Tabs Prednisone Prednisone Panafcort Trolic R230 Urinary Oxybutynin Lenditro anti-spasmodics Mylan Oxybutynin Parkinson's disease R305 Anti-cholinergic agents: Biperiden Akineton 2mg Tertiary Amines Lennon-Biperiden 2mg R775 Dopamine agonists Pramipexole Pexola 0.12; 0.2; 1mg Pramiola 0.12; 0.2 Ropinirole Requip 0.2; 0.; 1mg; 2mg; R610 Dopaminergic agents: Selegiline Parkilyne Monoamine oxidase B inhibitors: Selegiline R280 Dopaminergic agents: Adamantane derivatives Amantadine Symadin R650 Levodopa and decarboxylase inhibitor Rheumatoid arthritis R50 Anti-inflammatory agents: Acetic acid derivatives and related substances Levodopa and Carbilev 25/; 25/250mg decarboxylase Sinemet 25/; 25/250mg inhibitor Teva Carbi-Levo 25/; 25/250mg Diclofenac Adco-Diclofenac 50mg A-Lennon Diclofenac 2; 50mg Diclofenac Biotech 2 Mylan Diclofenac 2; 50mg Panamor AT 50mg Sandoz Diclofenac 2 Indomethacin Betacin 2 Gulf Indomethacin 2 Methocaps 2 Page 19 of 22 01/2014

20 Medicine class Active ingredient Medicine name and strength Rheumatoid arthritis R80 Anti-inflammatory agents: Meloxicam Adco-Meloxicam 7.; 1 Oxicams Arrow Meloxicam 7. Flamaryx 7. Flexocam 7. Medoxicam 7. Zydus-Meloxicam 7. Piroxicam Pyrocaps Roxifen R25 Anti-inflammatory agents: Ibuprofen Betaprofen Propionic acid derivatives Betaprofen FC 400mg Bren 400mg Ibu Ibucine ; 400mg Ibunate Ranfen 400mg Naproxen Be-tabs Naproxen 250mg Naproscript 250mg R85 Anti-rheumatic agents: Chloroquine Plasmoquine Chloroquine R5 Folic acid and derivatives Folic acid Aha Folic acid Be-Tabs Folic acid Folic acid 0. R680 Intestinal anti-inflammatories: Sulfasalazine Salazopyrin 500mg Aminosalicylic acid and similar agents Salazopyrin EN 500mg R590 Other immuno-suppressive agents: Azathioprine Azamun 50mg Azathioprine Azathioprine pch 50mg R65 Other immuno-suppressive agents: Methotrexate Abitrexate 2. Methotrexate Methotrexate 2. R10 Systemic corticosteroids: Prednisone Be-Tabs Prednisone Prednisone Panafcort Trolic Schizophrenia R330 Anti-depressants: Citalopram Adco-Talomil SSRIs Arrow Citalopram ; Auro-Citalopram Austell-Citalopram Cilate Citalohexal Citalopram Actor Citalopram-Winthrop Mylan Citalopram Escitalopram Citraz 10mg; Escitalopram Be-Tabs Zytomil 10mg; 10mg; Fluoxetine A-Lennon Fluoxetine Deprozan Fluoxetine Actor Ranflocs Rezak Zydus Fluoxetine Page 20 of 22 01/2014

21 Schizophrenia R330 Anti-depressants: SSRIs Systemic lupus erythematosus (SLE) R345 R95 R1 000 R605 R345 Anti-epileptics: Carboxamide derivatives Butyrophenone derivatives Clozapine Olanzapine Phenothiazines with aliphatic side-chain Quetiapine Paroxetine Adco-Paroxetine Paroxetine Unicorn Serrapress Sertraline Austell-Sertraline 50mg; Serdep 50mg; Zylin 50mg Carbamazepine Degranol Sandoz Carbamazepine Sandoz Carbamazepine CR ; 400mg Zeptol Haloperidol Sandoz Haloperidol 1.; Clozapine Aspen Clozapine 2; Cloment 2; Olanzapine Oleanz ; 10mg Olexar ; 10mg Redilanz ; 10mg Chlorpromazine Largactil 2; 50mg; R550 Quetiapine Dopaquel 2; ; ; 300mg Mylan Quetiapine 2; ; ;300mg Psyquet 2; ; ;300mg Quetoser 2; ; ; 300mg Serez 2; ; ; 300mg R620 Flupenthixol Fluanxol 0.; 1mg Thioxanthene derivatives Fluanxol depot 1ml Fluanxol depot 2ml Zuclopenthixol Clopixol 2mg; 10mg Clopixol depot R990 Other anti-psychotics Risperidone DRL-Risperidone 0.; 1mg; 2mg Perizal 0.; 1mg; 2mg; 3mg Risnia 0.; 1mg; 2mg; 3mg Schizorol 0.; 1mg; 2mg Zoxadon 0.; 1mg; 2mg R50 Anti-inflammatory agents: Diclofenac Adco-Diclofenac 50mg Acetic acid derivatives and A-Lennon Diclofenac 2; 50mg related substances Diclofenac Biotech 2 Mylan Diclofenac 2; 50mg Panamor AT 50mg Sandoz Diclofenac 2 Indomethacin Betacin 2 Gulf Indomethacin 2 Methocaps 2 R80 Anti-inflammatory agents: Meloxicam Adco-Meloxicam 7.; 1 Oxicams Arrow Meloxicam 7. Flamaryx 7. Flexocam 7. Medoxicam 7. Zydus-Meloxicam 7. Piroxicam Pyrocaps Roxifen Page 21 of 22 01/2014

22 Systemic lupus erythematosus (SLE) R25 Anti-inflammatory agents: Propionic acid derivatives Ibuprofen Betaprofen Betaprofen FC Bren Ibu Ibucine Ibunate Ranfen 400mg 400mg ; 400mg 400mg Naproxen Be-Tabs Naproxen 250mg Naproscript 250mg R85 Anti-rheumatic agents: Chloroquine Plasmoquine Chloroquine R75 Anti-thrombotic agents: Warfarin Cipla-Warfarin 1mg; 3mg; Vitamin K antagonists R20 Aspirin Acetylsalicylic acid Aspirin 300mg Gulf Aspirin 300mg R25 Emolients and protectives: Zinc products Zinc ointment bp Zinc products R5 Folic acid and derivatives Folic acid Aha Folic acid Be-Tabs Folic acid R590 R65 R10 R25 Other immuno-suppressive agents: Azathioprine Other immuno-suppressive agents: Methotrexate Systemic corticosteroids: Prednisone Topical corticosteroids: Group III Folic acid 0. Azathioprine Azamun 50mg Azathioprine pch 50mg Methotrexate Abitrexate 2. Methotrexate 2. Prednisone Be-Tabs Prednisone Panafcort Trolic Betamethasone Repivate cream 0.1% Topivate cream 0.1% Vari-Betamethasone cream 0.1% Ulcerative colitis R5 Folic acid and derivatives Folic acid Aha Folic acid Be-Tabs Folic acid Folic acid 0. R680 Intestinal anti-inflammatories: Mesalazine Asacol 400mg; 500mg; 800mg Aminosalicylic acid and similar Pentasa 500mg; 1000mg agents Salofalk 1000mg R2 285 R590 R65 R10 Intestinal anti-inflammatories: Corticosteroids Other immuno-suppressive agents: Azathioprine Other immuno-suppressive agents: Methotrexate Systemic corticosteroids: Prednisone Olsalazine Dipentum 250mg Sulfasalazine Salazopyrin 500mg Salazopyrin EN 500mg Budesonide Entocord enema Azathioprine Azamun 50mg Azathioprine pch 50mg Methotrexate Abitrexate 2. Methotrexate 2. Prednisone Be-Tabs Prednisone Panafcort Trolic Page 22 of 22 01/2014

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