Chronic Illness Benefit medicine list (formulary)

Transcription

1 Chronic Illness Benefit medicine list (formulary) 2012

2 Discovery Health Chronic Illness Benefit 2012 Contents Page Explanation of terms 2 The Prescribed s medicine formulary (for all plan types) 3 s for plans 24 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. The Chronic Illness Benefit (CIB) is governed by the Discovery Health Medical Scheme Rules. The utilisation of the benefits and programmes associated with the CIB are subject to specific s and rules. Members must ensure that they are familiar with these rules and s. Any instructions or advice on medicines and the management of the member s are 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. Discovery Health reserves the right to change the benefit at any time. Page 2 of 26

3 Explanation of terms Benefit year A benefit year refers to the benefits a member is entitled to during a calendar year, ie from 1 January to 31 December. This medicine list (formulary) and s are applicable for 2012 only. (CDA) The CDA is a monthly amount we pay up to for a medicine class. This applies to medicine that is not listed on the medicine list (formulary). The CDA includes VAT and the dispensing fee. Prescribed s (PMB s) These are s that the Council for Medical Schemes has determined for coverage by all medical schemes, in any setting, as per clinical guidelines. Chronic Disease List (CDL) A specified list of chronic s we cover according to the Prescribed Minimum Benefits. This describes medicines that have similar chemical structures or similar therapeutic effects. This is the main substance in a medicine that is responsible for the clinical action on a human body. Page 3 of 26

4 Chronic Illness Benefit 2012 The Prescribed s (PMB) medicine list (for all plan types) The PMB medicine list applies to all Discovery Health for the 2012 benefit year. The CDA ( ) does not apply to KeyCare. Prescribed and Saver Addison s disease R150 R150 Systemic corticosteroids: Hydrocortisone R105 R105 Systemic corticosteroids: Mineralocorticoid s Asthma R135 R135 Adrenergics: Long acting - Formoterol R265 R355 Adrenergics: Long acting - Salmeterol R315 R315 Adrenergics: Salmeterol combinations Page 4 of 26 R30 R30 Adrenergics: Short acting - Salbutamol R80 R115 Anti-asthmatics: Systemic xanthines R180 R180 Inhaled anticholinergics: Ipratropium bromide R260 R310 Inhaled Glucocorticoids Hydrocortiso ne Fludrocortiso ne Covocort Florinef acetate 10mg 0.1mg Formoterol Foratec dp-caps 12mcg Foratec hfa 120dose 12mcg/1dose Salmeterol Serevent accuhaler 60 dose 50mcg Fluticasone/ Salmeterol Serevent CFC-free 120 dose 25mcg Foxair 25/50; 25/125; 25/ dose Foxair accuhaler 50/100; 50/250; 50/ dose Sereflo hfa 25/50; 25/125; 25/ dose Salbutamol Asthavent 200 dose 100mcg Venteze cfc free 200 dose 100mcg Theophylline Ipratropium bromide Sandoz Theophylline anhydrous 200mg; 300mg Atrovent HFA 200dose Ipvent HFA 200 dose 20mcg 40mcg/1dose Beclometaso Beclate 200 dose 100mcg; 200mcg ne 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 Pulmicort turbuhaler 200dose 200mcg Pulmicort turbuhaler 100dose R350 R350 Surgical item Inhaler device Dp haler device R10 R10 Systemic corticosteroids: Prednisone 400mcg Prednisone Be-Tabs Prednisone Panafcort Trolic

5 Bipolar mood disorder Page 5 of 26 and Saver R115 R310 Antidepressants: SSRIs R260 R325 Antiepileptics: Carboxamide R460 R485 Antiepileptics: Fatty acid R315 R450 Antiepileptics: Other agents R90 R90 Antipsychotics: Butyrophenone R690 R980 Antipsychotics: Clozapine R315 R315 Antipsychotics: Lithium R630 R630 Antipsychotics: Olanzapine R455 R455 Antipsychotics: Phenothiazines with aliphatic side-chain R630 R630 Antipsychotics: Quetiapine R450 R610 Antipsychotics: Thioxanthene Citalopram Arrow Citalopram ; Auro-Citalopram Citalohexal Citalopram-Winthrop Depramil Escitalopram Aspen Escitalopram 10mg Citraz Zytomil 10mg; Fluoxetine A-Lennon Fluoxetine Ranflocs Rezak Zydus Fluoxetine Paroxetine Serrapress Sertraline Apex-Sertraline 100mg Austell-Sertraline 50mg; 100mg Serdep 50mg Zylin 50mg Carbamazepi Sandoz Carbamazepine 200mg ne Sandoz Carbamazepine CR 400mg Valproic acid Convulex 150mg; 300mg; 500mg Convulex syrup Epilim CR Epilim crushable 250mg/5ml 200mg; 300mg; 500mg 100mg Epilim sugar-free syrup 200mg/5ml Lamotrigine Arrow Lamotrigine 50mg; 100mg Dyna-Lamotrigine 2; 50mg; 100mg; 200mg Lamidus 50mg; 100mg; 200mg Lamitor 50mg; 100mg; 200mg Haloperidol Sandoz Haloperidol 1.; Clozapine Cloment 2; 100mg Lithium Camcolit 250mg; 400mg Quilonum retard 450mg Olanzapine Olexar ; 10mg Chlorpromazi ne Redilanz Largactil ; 10mg 2; 50mg; 100mg Quetiapine Dopaquel 2; 100mg; 200mg; 300mg Serez 2; 100mg; 200mg; 300mg Flupenthixol Fluanxol 0.; 1mg Fluanxol depot 1ml Fluanxol depot 2ml

6 Bipolar mood disorder Page 6 of 26 and Saver R445 R950 Other antipsychotics Bronchiectasis R30 R30 Adrenergics: Short acting - Salbutamol R180 R180 Inhaled anticholinergics: Ipratropium bromide R10 R10 Systemic corticosteroids: Prednisone Cardiac failure R110 R110 ACE inhibitors and diuretics R70 R100 ACE inhibitors, plain Risperidone Aspen Risperidone 4mg Auropidone 0.; 1mg; 2mg; 3mg; 4mg DRL-Risperidone 0.; 1mg; 2mg; 3mg Perizal 0.; 1mg; 2mg; 3mg Rispacor 3mg; 4mg Risperidone Hexal 3mg Schizorol 0.; 1mg; 2mg Zoxadon 0.; 1mg; 2mg Salbutamol Asthavent 200 dose 100mcg Venteze cfc free 200 dose 100mcg Ipratropium bromide Atrovent HFA 200dose Ipvent HFA 200 dose 20mcg 40mcg/1dose Prednisone Be-Tabs Prednisone Panafcort Trolic Enalapril and Enap co 20/12. diuretics Pharmapress co 20/12. Lisinopril and Adco-Zetomax co 10/12.; 20/12. diuretics Auro-Lisinopril co 10/12.; 20/12. Diace co 20/12. Hexal-Lisinopril co 10/12. Hexal-Lisinopril co 20/12. Lisinozide 10/12.; 20/12. Lisoretic 10/12.; 20/12. Lisozide 20/12. Zestozide 20/12. Captopril Adco-Captomax 2; 50mg Bio-Captopril 2 Mylan Captopril 2; 50mg Enalapril Alapren ; 10mg; Ciplatec ; Enap ; 10mg; Envas ; 10mg Hr-Enalapril 10mg; Pharmapess Lisinopril Austell-Lisinopril 10mg; Sinopren ; 10mg; Perindopril Acti-Prex 4mg Cipla-Perindopril 8mg Ciplasyl 8mg Pearinda 4mg; 8mg Ran-Perindopril 4mg Quinapril Accumax 10mg; Quinagen

7 and Saver Cardiac failure R190 R220 Alpha and Beta blocking agents R110 R120 Angiotensin II antagonists, Combinations: Losartan and diuretics R70 R100 Angiotensin II antagonists: plain R80 R80 Arteriolar smooth muscle Hydrazinophthalazine R60 R110 Beta blocking selective R15 R15 Cardiac glycosides: Digoxin R20 R40 High-ceiling diuretics R25 R25 Low-ceiling diuretics: Thiazides, plain R20 R20 Low-ceiling diuretics: excluding Thiazides R85 R85 Potassium sparing agents R80 R80 Potassium supplements Carvedilol Aspen Carvedilol 6.2 Carvedilol-Hexal 6.2 Carvetrend 6.2; 12.; 2 Vediblok 6.2; 12.; 2 Losartan and Lohype Forte Plus 100/2 diuretics Lohype Plus 50/12. Losaar Plus 50/12.; 100/2 Lozaan Co 50/12.; 100/2 Netrasol Co 50/12. Sartoc 50/12. Losartan Cipla-Losartan 100mg Spec-Losartan 100mg Zartan 100mg Hydralazine Hyperphen 10mg; 50mg Sandoz Hydralazine 2 Bisoprolol Adco-Bisocor ; 10mg Bilocor ; 10mg Bisohexal ; 10mg Bisoprolol hexal Bisoprolol Unicorn ; 10mg Digoxin Lanoxin 0.062; 0.2 Lanoxin paed syrup 0.0/1ml Furosemide Beurises Dino-Retic Mylan Furosemide Hydrochloro- Hexazide 2 thiazide Ridaq 12. Indapamide Cipla-Indapamide 2. Daptril Merck-Indapamide Spironolactone Aldactone 2 Sandoz Spironolactone 2 Spiractin 2 Potassium Plenish K 600mg chloride Sandoz K mg Page 7 of 26

8 and Saver Cardiac failure R160 R175 Vasodilators in cardiac disease: Organic nitrates Glyceryl trinitrate Isosorbide dinitrate Isosorbide mononitrate R65 R65 Influenza vaccines Influenza, inactivated, whole virus R130 R130 Pneumococcus vaccines Cardiomyopathy R110 R110 ACE inhibitors and diuretics R70 R100 ACE inhibitors: plain Pneumococcu s, purified polysaccharid es antigen conjugated Enalapril and diuretics Angised Sandoz Isosorbide dinitrate Elantan Elantan LA Monicor SR Fluarix prefilled syringe 0.5ml X-flu prefilled 0,5ml syringe Imovax pneumo 23 Enap co Pharmapress co 0. ; 10mg; 30mg 50mg 60mg 20/12. 20/12. Lisinopril and Adco-Zetomax co 10/12.; 20/12. diuretics Auro-Lisinopril co 10/12.; 20/12. Diace co 20/12. Hexal-Lisinopril co 10/12. Hexal-Lisinopril co 20/12. Lisinozide 10/12.; 20/12. Lisoretic 10/12.; 20/12. Lisozide 20/12. Zestozide 20/12. Captopril Adco-Captomax 2; 50mg Bio-Captopril 2 Mylan Captopril 2; 50mg Enalapril Alapren ; 10mg; Ciplatec ; Enap ; 10mg; Envas ; 10mg Hr-Enalapril 10mg; Pharmapress Lisinopril Austell-Lisinopril 10mg; Sinopren ; 10mg; Perindopril Acti-Prex 4mg Cipla-Perindopril 8mg Ciplasyl 8mg Pearinda 4mg; 8mg Ran-Perindopril 4mg Quinapril Accumax 10mg; Quinagen Page 8 of 26

9 and Saver Cardiomyopathy R190 R220 Alpha and Beta blocking agents R110 R120 Angiotensin II antagonists, Combinations: Losartan and diuretics R70 R100 Angiotensin II antagonists: plain R10 R20 Aspirin Acetylsalicylic acid R60 R110 Beta blocking selective R15 R15 Cardiac glycosides: Digoxin R20 R40 High-ceiling diuretics R25 R25 Low-ceiling diuretics: Thiazides, plain R20 R20 Low-ceiling diuretics: excluding Thiazides R85 R85 Potassium sparing agents R80 R80 Potassium supplements Carvedilol Aspen Carvedilol 6.2 Carvedilol-Hexal Carvetrend Vediblok ; 12.; 2 6.2; 12.; 2 Losartan and Lohype Forte Plus 100/2 diuretics Lohype Plus 50/12. Losaar Plus 50/12.; 100/2 Lozaan co 50/12.; 100/2 Netrasol co 50/12. Sartoc 50/12. Losartan Cipla-Losartan 100mg Spec-Losartan 100mg Zartan 100mg Warfarin Cipla-Warfarin Hydralazine Hyperphen 10mg; 50mg Sandoz Hydralazine Aspirin Be-Tabs Aspirin (white) Gulf Aspirin 2 300mg 300mg 300mg Bisoprolol Adco-Bisocor ; 10mg Bilocor Bisohexal Bisoprolol Hexal Bisoprolol Unicorn ; 10mg ; 10mg ; 10mg Digoxin Lanoxin 0.062; 0.2 Lanoxin paed syrup 0.0/1ml Furosemide Beurises Dino-Retic R70 R70 Antithrombotic Vitamin K antagonists R80 R80 Arteriolar smooth muscle Hydrazinophthalazine Hydrochlorothiazide Mylan Furosemide Hexazide Ridaq Indapamide Cipla-Indapamide 2. Daptril 2. Merck-Indapamide 2. Spironolactone Aldactone 2 Potassium chloride Sandoz Spironolactone Spiractin Plenish K Sandoz K mg 600mg Page 9 of 26

10 and Saver Cardiomyopathy R160 R175 Vasodilators in cardiac disease: Organic Nitrates Chronic obstructive pulmonary disease (COPD) Chronic renal disease Glyceryl trinitrate Isosorbide dinitrate Isosorbide mononitrate R65 R65 Influenza vaccines Influenza, inactivated, whole virus R130 R130 Pneumococcus vaccines R30 R30 Adrenergics: Short acting - Salbutamol R80 R115 Anti-asthmatics: Systemic xanthines R180 R180 Inhaled anticholinergics: Ipratropium bromide R800 R800 Surgical item: Oxygen concentrator R10 R10 Systemic corticosteroids: Prednisone Angised Sandoz Isosorbide dinitrate Elantan Elantan LA Monicor SR Fluarix prefilled syringe 0.5ml X-flu prefilled 0,5ml syringe 0. ; 10mg; 30mg 50mg 60mg Pneumococcus, Imovax pneumo 23 purified polysaccharides antigen conjugated Salbutamol Asthavent 200 dose 100mcg Venteze cfc free 200 dose 100mcg Theophylline Sandoz Theophylline anhydrous 200mg; 300mg Ipratropium bromide Oxygen R65 R65 Influenza vaccines Influenza, inactivated, whole virus R110 R110 ACE inhibitors and Enalapril and diuretics diuretics Lisinopril and diuretics R70 R100 ACE inhibitors: plain Atrovent HFA 200dose Ipvent HFA 200 dose Oxygen concentrator 20mcg 40mcg/1dose Prednisone Be-Tabs Prednisone Panafcort Trolic Fluarix prefilled syringe 0.5ml X-flu prefilled 0,5ml syringe Enap co 20/12. Pharmapress co 20/12. Adco-Zetomax co 10/12.; 20/12. Auro-Lisinopril co 10/12.; 20/12. Diace co 20/12. Hexal-Lisinopril co 10/12. Hexal-Lisinopril co 20/12. Lisinozide 10/12.; 20/12. Lisoretic 10/12.; 20/12. Lisozide 20/12. Zestozide 20/12. Captopril Adco-Captomax 2; 50mg Bio-Captopril 2 Mylan Captopril 2; 50mg Page 10 of 26

11 Chronic renal disease and Saver R70 R100 ACE inhibitors: plain R110 R120 Angiotensin II antagonists, Combinations: Losartan and diuretics R70 R100 Angiotensin II antagonists: plain R230 R230 Calcium supplements R5 R5 Folic acid and R65 R65 Iron in combination with folic acid R4 000 R4000 Other antianaemic preparations Enalapril Alapren ; 10mg; Ciplatec Enap Envas Hr-Enalapril Pharmapress ; ; 10mg; ; 10mg 10mg; Lisinopril Austell-Lisinopril 10mg; Sinopren ; 10mg; Perindopril Acti-Prex 4mg Cipla-Perindopril 8mg Ciplasyl 8mg Pearinda 4mg; 8mg Ran-Perindopril 4mg Quinapril Accumax 10mg; Quinagen Losartan and Lohype Forte Plus 100/2 diuretics Lohype Plus 50/12. Losaar Plus 50/12.; 100/2 Lozaan co 50/12.; 100/2 Netrasol co 50/12. Sartoc 50/12. Losartan Cipla-Losartan 100mg Spec-Losartan 100mg Zartan 100mg Calcium Titralac carbonate Folic acid Aha Folic acid Ferrous fumarate Darbepoetin Alfa Be-Tabs Folic acid Folic acid Pregamal Aranesp prefilled syringe 0.4ml Aranesp prefilled syringe 0.5ml Aranesp prefilled syringe 0.3ml Aranesp prefilled syringe 0.4ml Aranesp prefilled syringe 0.5ml Aranesp prefilled syringe 0.3ml 0. 10mcg/0.4ml 20mcg/0.5ml 30mcg/0.3ml 40mcg/0.4ml 50mcg/0.5ml 60mcg/0.3ml Page 11 of 26

12 Chronic renal disease Coronary artery disease and Saver R4 000 R4 000 Other antianaemic preparations R495 R495 Vitamin D and analogues R10 R20 Aspirin Acetylsalicylic acid R60 R170 Beta blocking non-selective R60 R110 Beta blocking selective R170 R260 Selective calcium channel blockers with direct cardiac effects R125 R165 Selective calcium channel blockers with mainly vascular effects R160 R175 Vasodilators in cardiac disease: Organic nitrates Erythropoietin Eprex prefill 2000U/0.5ml Eprex prefill 4000U/0.4ml Mircera prefilled syringe 0.3ml 50mcg/0.3ml Mircera prefilled syringe 0.3ml 75mcg/0.3ml Mircera prefilled syringe 0.3ml 100mcg/0.3ml Mircera prefilled syringe 0.3ml 150mcg/0.3ml Recormon 500U/0.3ml Recormon 2000U pre-filled syringe Recormon 4000U/0.3ml Repotin 1ml 2000IU Repotin 1ml 4000IU Alfacalcidol One alpha 0.25mcg; 1mcg Aspirin 300mg Be-Tabs Aspirin (white) 300mg Gulf Aspirin 300mg Propranolol Indoblok 10mg; Prodorol 10mg; Purbloka 10mg; Atenolol B-Block 50mg; 100mg Bio-Atenolol 50mg; 100mg Sandoz Atenolol 50mg; 100mg Tenopress 100mg Diltiazem Adco-Zildem 60mg Adco-Zildem SR 180mg; 2 Verapamil Vasomil ; 80mg Verahexal SR 2 Amlodipine Almadin ; 10mg Auro-Amlodipine ; 10mg Corvadil ; 10mg Gulf Amlodipine ; 10mg Indo Amlodipine Keysal ; 10mg Klodip Lomanor ; 10mg Pharma Dynamics Amlodipine besylate ; 10mg Felodipine Felodipine-Hexal ; 10mg Nifedipine Adco-Vascard SR Cipalat Retard Nifedalat SR Glyceryl Angised 0. trinitrate Isosorbide Sandoz Isosorbide dinitrate ; 10mg; 30mg dinitrate Isosorbide Elantan mononitrate Elantan LA 50mg Monicor SR 60mg Page 12 of 26

13 and Saver Crohn s disease R5 R5 Folic acid and R635 R900 Intestinal antiinflammatories: Aminosalicylic acid and similar agents R2 120 R2 120 Intestinal antiinflammatories: Corticosteroids R565 R565 Other immunosuppressive Azathioprine R45 R45 Other immunosuppressive Methotrexate R10 R10 Systemic corticosteroids: Prednisone Diabetes insipidus R1 300 R1 500 Posterior pituitary hormones: Vasopressin and analogues Diabetes mellitus Type 1 R680 R720 Anti-diabetic Insulins and analogues Folic acid Aha Folic acid Be-Tabs Folic acid Folic acid 0. Mesalazine Asacol 400mg; 800mg Pentasa 500mg Olsalazine Dipentum 250mg Sulfasalazine Salazopyrin 500mg Salazopyrin EN 500mg Budesonide Entocord enema Azathioprine Azamun 50mg Azathioprine pch 50mg Methotrexate Abitrexate (was Emthexate) 2. Methotrexate 2. Prednisone Be-Tabs Prednisone Panafcort Trolic Desmopressin Ddavp 0.1mg; 0.2mg Insulin Ddavp nasal spray 5ml 0.1mg/1ml Actraphane hm(ge) - vial 10ml Apidra - cartridges 3ml; solostar disposable pens 3ml Biosulin cartridge 3ml Biosulin l cartridge 3ml Biosulin n cartridge 3ml Biosulin r cartridge 3ml Humalog cartridge 3ml Humalog kwikpen (was mirio pen) - penset 3ml Humalog mix 25 kwikpen (was mirio pen) - penset 3ml Humalog mix 25 - cartridge 3ml; vial 10ml Humalog mix 50 - cartridge 3ml Humulin 30/70 - cartridge 3ml; disposable pens 3ml; vial 10ml Humulin n - disposable pen 3ml; vial 10ml Humulin r - vial 10ml Insuman comb 30/70 - cartridge 3ml Novomix 30 - flexpen 3ml; penfill 3ml Novorapid - penfill 3ml Page 13 of 26

14 Diabetes mellitus Type 1 Diabetes mellitus Type 2 and Saver R200 R280 Blood glucose monitoring agents Glucose strips Accu-chek active strips Caresens ii/pop test strip 29g Caresens n test strips 29g Caresens pop test strip 29g Glucocheck strips 50s Glucoplus Glucoplus provider strips Glucose test strips onetouch select R350 R350 Surgical item Lancets Lancets glucoplus 66 x 44 x 78mm Needles Needle novofine Needle pen bd microfine 30g 8mm R55 R60 Anti-diabetic Metformin Accord Metformin 500mg; 850mg Auro-Metformin 500mg; 850mg; 1000mg Biguanides Austell-Metformin 500mg; 850mg Bigsens 1000mg Diamin 500mg; 850mg Gluconorm 500mg Metforal 500mg; 850mg Metored 500mg; 850mg; 1000mg Mylan Metformin 500mg; 850mg Sandoz Metformin 500mg Sandoz Metformin FCT 500mg R680 R720 Anti-diabetic Insulins and analogues Insulin Actraphane hm(ge) - vial 10ml Apidra - cartridges 3ml; solostar disposable pens 3ml Biosulin cartridge 3ml Biosulin l cartridge 3ml Biosulin n cartridge 3ml Biosulin r cartridge 3ml Humalog cartridge 3ml Humalog kwikpen (was mirio pen) - penset 3ml Humalog mix 25 kwikpen (was mirio pen) - penset 3ml Humalog mix 25 - cartridge 3ml; vial 10ml Humalog mix 50 - cartridge 3ml Humulin 30/70 - cartridge 3ml; disposable pens 3ml; vial 10ml Humulin n - disposable pen 3ml; vial 10ml Humulin r - vial 10ml Insuman comb 30/70 - cartridge 3ml Novomix 30 - flexpen 3ml; penfill 3ml Novorapid - penfill 3ml Page 14 of 26

15 Diabetes mellitus Type 2 and Saver R100 R100 Anti-diabetic Sulfonamides, urea R145 R170 Anti-diabetic Thiazolidinediones R200 R280 Blood glucose monitoring agents Glibenclamid Bio-Glibenclamide e Diacare Glycomin Sandoz Glibenclamide Gliclazide Adco-Glucomed 80mg Arrow Gliclazide 80mg Austell-Gliclazide 80mg Diaglucide 80mg Diaglucide mr 30mg Glygard 80mg Sandoz Gliclazide 80mg Pioglitazone Cipla-Pioglitazone 1; 30mg Glucose strips Accu-chek active strips Caresens ii/pop test strip 29g Caresens n test strips 29g Caresens pop test strip 29g Glucocheck strips 50s Glucoplus Glucoplus provider strips Glucose test strips onetouch select R350 R350 Surgical item Lancets Lancets glucoplus 66 x 44 x 78mm Dysrhythmias R500 R600 Anti-arrhythmics: class Ic R360 R360 Anti-arrhythmics: class III - Amiodarone Needles Needle novofine Needle pen bd microfine 30g 8mm Flecainide Tambocor 100mg Propafenone Rythmol 150mg; 300mg Amiodarone Arycor 100mg; 200mg Bio-Amiodarone Hexarone 200mg 100mg; 200mg R70 R70 Antithrombotic Warfarin Cipla-Warfarin Vitamin K antagonists R10 R20 Aspirin Acetylsalicylic Aspirin 300mg acid Be-Tabs Aspirin (white) 300mg Gulf Aspirin 300mg Page 15 of 26

16 and Saver Dysrhythmias R60 R170 Beta blocking non-selective R60 R110 Beta blocking selective R15 R15 Cardiac glycosides: Digoxin R170 R260 Selective calcium channel blockers with direct cardiac effects Epilepsy R165 R250 Antiepileptics: Benzodiazepine R260 R325 Antiepileptics: Carboxamide R460 R485 Antiepileptics: Fatty acid R60 R60 Antiepileptics: Hydantoin R315 R450 Antiepileptics: Other agents R25 R25 Antiepileptics: Barbiturates and Glaucoma R160 R160 Antiglaucoma Carbonic anhydrase inhibitors R210 R210 Antiglaucoma Prostaglandin analogues R235 R235 Antiglaucoma Sympathomimetics R75 R75 Antiglaucoma Beta blocking Timolol Propranolol Indoblok 10mg; Prodorol 10mg; Purbloka 10mg; Sotalol Sotahexal 80mg; 160mg Atenolol B-Block 50mg; 100mg Bio-Atenolol 50mg; 100mg Sandoz Atenolol 50mg; 100mg Tenopress 100mg Digoxin Lanoxin 0.062; 0.2 Lanoxin paed syrup 0.0/1ml Verapamil Vasomil ; 80mg Verahexal SR 2 Clonazepam Rivotril 0.; 2mg Carbamazepine Sandoz Carbamazepine 200mg Sandoz Carbamazepine CR 400mg Valproic acid Convulex 150mg; 300mg; 500mg Convulex syrup 250mg/5ml Epilim CR 200mg; 300mg; 500mg Epilim crushable 100mg Epilim sugar-free syrup 200mg/5ml Phenytoin Phenytoin sod 100mg Lamotrigine Arrow Lamotrigine 50mg; 100mg Dyna-Lamotrigine 2; 50mg; 100mg; 200mg Lamidus 50mg; 100mg; 200mg Lamitor 50mg; 100mg; 200mg Phenobarbital Lethyl 30mg Sedabarb 30mg Dorzolamide Trusopt - 5ml owi 2% Bimatoprost Lumigan 3ml 0,03% Latanoprost Ocuprost 3ml 50mcg/1ml Brimonidine Alphagan purite - 5ml 1./1ml Timolol Glaucosan - 5ml 0.5% Page 16 of 26

17 and Saver Glaucoma R225 R235 Antiglaucoma Beta blocking Timolol, combinations Haemophilia R5 R5 Analgesics: Paracetamol R515 R515 Antifibrinolytics : Amino acids R R Blood coagulation factors R1 300 R1 500 Posterior pituitary hormones: Vasopressin and analogues Hyperlipidaemia R235 R235 Lipid modifying Fibrates R45 R110 Lipid modifying Statins Timolol, combinations Combigan - 5ml 2mg/ Cosopt - 5ml 0.5% Ganfort 3ml Paracetamol Adco-Napamol 500mg Adco-Prolief 500mg Tranexamic acid Tranexamic acid medwich 500mg Coagulation Haemosolvex IX 500U factor IX, II, VII and X in combination Coagulation factor VIII Haemosolvate VIII 300U; 500U; 1000U Desmopressin Ddavp 0.1mg; 0.2mg Ddavp nasal spray 5ml 0.1mg/1ml Bezafibrate Dyna-Bezafibrate SR 400mg Sandoz Bezafibrate 400mg Atorvastatin Atorvastatin Unicorn 10mg; ; Lipogen 10mg; ; ; 80mg Simvastatin Adco-Simvastatin 10mg; ; Aspen Simvastatin 10mg; ; Austell-Simvastatin 10mg; Biovac Simvastatin 10mg; ; Choleste ; Cipla-Simvastatin 10mg; ; 80mg Cipla-Simvastatin Michol 80mg Redicor 10mg; Redicor Simayla Simvastatin 10mg; ; Simvacor 10mg; Simvacor Simvotin 10mg; ; Simzor 10mg; Simzor Zysim 10mg; ; ; 80mg Page 17 of 26

18 and Saver Hypertension R110 R110 ACE inhibitors and diuretics R70 R100 ACE inhibitors: plain R190 R220 Alpha and Beta blocking agents R110 R120 Angiotensin II antagonists, Combinations: Losartan and diuretics Enalapril and Enap co 20/12. diuretics Pharmapress co 20/12. Lisinopril and Adco-Zetomax co 10/12.; 20/12. diuretics Auro-Lisinopril co 10/12.; 20/12. Diace co 20/12. Hexal-Lisinopril co 10/12. Hexal-Lisinopril co 20/12. Lisinozide 10/12.; 20/12. Lisoretic 10/12.; 20/12. Lisozide 20/12. Zestozide 20/12. Captopril Adco-Captomax 2; 50mg Bio-Captopril 2 Mylan Captopril 2; 50mg Enalapril Alapren ; 10mg; Ciplatec ; Enap ; 10mg; Envas ; 10mg Hr-Enalapril 10mg; Pharmapress Lisinopril Austell-Lisinopril 10mg; Sinopren ; 10mg; Perindopril Acti-Prex 4mg Cipla-Perindopril 8mg Ciplasyl 8mg Pearinda 4mg; 8mg Ran-Perindopril 4mg Quinapril Accumax 10mg; Quinagen Carvedilol Aspen Carvedilol 6.2 Carvedilol-Hexal 6.2 Carvetrend 6.2; 12.; 2 Vediblok 6.2; 12.; 2 Losartan and Lohype Forte Plus 100/2 diuretics Lohype Plus 50/12. Losaar Plus 50/12.; 100/2 Lozaan co 50/12.; 100/2 Netrasol co 50/12. Sartoc 50/12. Page 18 of 26

19 and Saver Hypertension R70 R100 Angiotensin II antagonists: Plain R125 R125 Antiadrenergic Alphaadrenoreceptor antagonists R120 R120 Antiadrenergic Methyldopa R25 R25 Antiadrenergic Rauwolfia alkaloids R80 R80 Arteriolar smooth muscle Hydrazinophthalazine R60 R170 Beta blocking non-selective R60 R110 Beta blocking selective R20 R40 High-ceiling diuretics R25 R25 Low-ceiling diuretics: Thiazides, plain R20 R20 Low-ceiling diuretics: excluding Thiazides R85 R85 Potassium sparing agents R80 R80 Potassium supplements R170 R260 Selective calcium channel blockers with direct cardiac effects R125 R165 Selective calcium channel blockers with mainly vascular effects Losartan Cipla-Losartan 100mg Spec-Losartan 100mg Zartan 100mg Doxazosin Adco-Doxazosin 4mg Cardugen 1mg; 4mg Methyldopa Hypotone 250mg Mylan Methyldopa 250mg Sandoz Methyldopa 250mg Reserpine Reserpine 0.2 Hydralazine Hyperphen 10mg; 50mg Sandoz Hydralazine 2 Propranolol Indoblok 10mg; Prodorol 10mg; Purbloka 10mg; Atenolol B-Block 50mg; 100mg Bio-Atenolol 50mg; 100mg Sandoz Atenolol 50mg; 100mg Tenopress 100mg Furosemide Beurises Dino-Retic Mylan Furosemide Hydrochloro- Hexazide 2 thiazide Ridaq 12. Indapamide Cipla-Indapamide 2. Daptril Merck-Indapamide Spironolactone Aldactone 2 Sandoz Spironolactone 2 Spiractin 2 Potassium Plenish K 600mg chloride Sandoz K mg Diltiazem Adco-Zildem 60mg Adco-Zildem SR 180mg; 2 Verapamil Vasomil ; 80mg Verahexal SR 2 Amlodipine Almadin ; 10mg Auro-Amlodipine ; 10mg Corvadil ; 10mg Gulf Amlodipine ; 10mg Indo Amlodipine Keysal ; 10mg Klodip Lomanor ; 10mg Pharma Dynamics Amlodipine besylate ; 10mg Page 19 of 26

20 and Saver Hypertension R125 R165 Selective calcium channel blockers with mainly vascular effects Hypothyroidism R50 R50 Thyroid hormones Felodipine Felodipine-Hexal ; 10mg Nifedipine Adco-Vascard SR Cipalat Retard Nifedalat SR Levothyroxine Eltroxin 0.0; 0.1mg sodium Euthyrox 0.02; 0.0; 0.1mg Multiple sclerosis R65 R65 Antidepressants Amitriptyline Sandoz Amitriptyline 2 : Tricyclics Trepiline 10mg R9 800 R9 800 Interferons Interferon beta- Avonex pre-filled syringe 30mcg 1a Rebif 22 pre-filled syringe 0.5ml 44mcg/1ml Rebif 44 pre-filled syringe 0.5ml 88mcg/1ml Interferon beta- 1b Betaferon pre-filled syringe 1ml u/1ml R960 R960 Muscle Baclofen Bio-Baclofen 10mg relaxants: Other centrally acting Teva Baclofen 10mg agents R10 R10 Systemic Prednisone Be-Tabs Prednisone corticosteroids: Panafcort Prednisone Trolic R120 R160 Urinary Oxybutynin Lenditro antispasmodics Mylan Oxybutynin Parkinson's disease Rheumatoid arthritis R285 R285 Anticholinergic Tertiary Amines R360 R635 Dopamine agonists R570 R570 Dopaminergic Monoamine oxidase B inhibitors: Selegiline R605 R660 Levodopa and decarboxylase inhibitor R45 R50 Antiinflammatory Acetic acid and related substances R50 R65 Antiinflammatory Oxicams Biperiden Akineton 2mg Ropinirole Resure 0.2; 0.; 1mg; 2mg; Selegiline Parkilyne Levodopa and decarboxylase inhibitor Carbilev 25/100mg; 25/250mg Sinemet 25/100mg; 25/250mg Teva Carbi-Levo 25/100mg; 25/250mg Diclofenac Adco-Diclofenac 50mg A-Lennon Diclofenac 2; 50mg Mylan Diclofenac Panamor AT 2; 50mg 50mg Indomethacin Betacin 2 Gulf Indomethacin 2 Meloxicam Adco-Meloxicam 7. Flexocam 7. Piroxicam Pyrocaps Roxifen Page 20 of 26

21 Rheumatoid arthritis and Saver R25 R25 Antiinflammatory Propionic acid R80 R80 Anti-rheumatic Chloroquine R5 R5 Folic acid and R635 R900 Intestinal antiinflammatories: Aminosalicylic acid and similar agents R565 R565 Other immunosuppressive Azathioprine R45 R45 Other immunosuppressive Methotrexate R10 R10 Systemic corticosteroids: Prednisone Schizophrenia R115 R310 Antidepressants: SSRIs Ibuprofen Betaprofen 200mg Ibunate 200mg Ranfen 400mg Chloroquine Plasmoquine 200mg Folic acid Aha Folic acid Be-Tabs Folic acid Folic acid 0. Sulfasalazine Salazopyrin 500mg Salazopyrin EN 500mg Azathioprine Azamun 50mg Azathioprine pch 50mg Methotrexate Abitrexate (was Emthexate) 2. Methotrexate 2. Prednisone Be-Tabs Prednisone Panafcort Trolic Citalopram Arrow Citalopram ; Auro-Citalopram Citalohexal Citalopram-Winthrop Depramil Escitalopram Aspen Escitalopram 10mg Citraz Zytomil 10mg; Fluoxetine A-Lennon Fluoxetine Ranflocs Rezak Zydus Fluoxetine Paroxetine Serrapress Sertraline Apex-Sertraline 100mg Austell Sertraline 50mg; 100mg Serdep 50mg Zylin 50mg Page 21 of 26

22 and Saver Schizophrenia R260 R325 Antiepileptics: Carboxamide R90 R90 Antipsychotics: Butyrophenone R690 R980 Antipsychotics: Clozapine R630 R630 Antipsychotics: Olanzapine R455 R455 Antipsychotics: Phenothiazines with aliphatic side-chain R630 R630 Antipsychotics: Quetiapine R450 R610 Antipsychotics: Thioxanthene R445 R950 Other antipsychotics Systemic lupus erythematosus R45 R50 Antiinflammatory Acetic acid and related substances R50 R65 Antiinflammatory Oxicams Carbamazepine Sandoz Carbamazepine 200mg Sandoz Carbamazepine CR 400mg Haloperidol Sandoz Haloperidol 1.; Clozapine Cloment 2; 100mg Olanzapine Olexar ; 10mg Redilanz ; 10mg Chlorpromazine Largactil 2; 50mg; 100mg Quetiapine Dopaquel 2; 100mg; 200mg; 300mg Serez 2; 100mg; 200mg; 300mg Flupenthixol Fluanxol 0.; 1mg Fluanxol depot 1ml Fluanxol depot 2ml Risperidone Aspen Risperidone 4mg Auropidone 0.; 1mg; 2mg; 3mg; 4mg DRL-Risperidone 0,; 1mg; 2mg; 3mg Perizal 0,; 1mg; 2mg; 3mg Rispacor 3mg; 4mg Risperidone Hexal 3mg Schizorol 0.; 1mg; 2mg Zoxadon 0.; 1mg; 2mg Diclofenac Adco-Diclofenac 50mg A-Lennon Diclofenac 2; 50mg Mylan Diclofenac 2; 50mg Panamor AT 50mg Indomethacin Betacin 2 Gulf Indomethacin 2 Meloxicam Adco-Meloxicam 7. Flexocam 7. Piroxicam Pyrocaps Roxifen R25 R25 Antiinflammatory Ibuprofen Betaprofen 200mg Ibunate 200mg Propionic acid Ranfen 400mg R80 R80 Anti-rheumatic Chloroquine Plasmoquine 200mg Chloroquine R70 R70 Antithrombotic Warfarin Cipla-Warfarin Vitamin K antagonists R10 R20 Aspirin Acetylsalicylic Aspirin 300mg acid Be-Tabs Aspirin (white) 300mg R30 R30 Emolients and protectives: Zinc products Zinc products Gulf Aspirin Zinc ointment bp 300mg Page 22 of 26

23 Systemic lupus erythematosus and Saver R5 R5 Folic acid and R565 R565 Other immunosuppressive Azathioprine R45 R45 Other immunosuppressive Methotrexate R10 R10 Systemic corticosteroids: Prednisone R25 R30 Topical corticosteroids: Group III Ulcerative colitis R5 R5 Folic acid and R635 R900 Intestinal antiinflammatories: Aminosalicylic acid and similar agents R2 120 R2 120 Intestinal antiinflammatories: Corticosteroids R565 R565 Other immunosuppressive Azathioprine R45 R45 Other immunosuppressive Methotrexate R10 R10 Systemic corticosteroids: Prednisone Folic acid Aha Folic acid Be-Tabs Folic acid Folic acid 0. Azathioprine Azamun 50mg Azathioprine pch 50mg Methotrexate Abitrexate (was Emthexate) 2. Methotrexate 2. Prednisone Be-Tabs Prednisone Betamethasone Panafcort Trolic Topivate 0.1% cream Vari-Betamethasone 0.1% cream Folic acid Aha Folic acid Be-Tabs Folic acid Folic acid 0. Mesalazine Asacol 400mg; 800mg Pentasa 500mg Olsalazine Dipentum 250mg Sulfasalazine Salazopyrin 500mg Budesonide Salazopyrin EN Entocord enema 500mg Azathioprine Azamun 50mg Azathioprine pch 50mg Methotrexate Abitrexate (was Emthexate) 2. Methotrexate 2. Prednisone Be-Tabs Prednisone Panafcort Trolic Page 23 of 26

24 Non-CDL Ankylosing Spondylitis s for These s apply to the for non-cdl s. * denotes medicine classes that have more than one CDA value. CDA Executive and Comp Multiple CDA Classes Non-CDL CDA Executive and Comp plans R565 R565 Azathioprine Dermatopolymyositis Azathioprine R5 Folic acid and R80 Chloroquine R900 Intestinal anti-inflammatories R5 Folic acid and R45 Methotrexate R45 Methotrexate R300 Non steroidal anti-inflammatories * R180 Oral corticosteroids * R180 Oral corticosteroids * R4000 Other immunosuppressant agents R4000 Other immunosuppressant agents R80 Potassium supplements R80 Potassium supplements Generalised R740 MAOI Behcet's Disease R565 Azathioprine Anxiety Disorder R720 Other antidepressants R250 Cyclophosphamide R310 SSRI R180 Oral corticosteroids * R65 Tricyclic antidepressants R4000 Other immunosuppressant agents R150 Anxiolytics - Azaspirodecanedione R80 Potassium supplements Huntington's R1500 Antipsychotics Connective Tissue Disorder (Mixed) R565 Azathioprine Disease R325 Carboxamide R80 Chloroquine R485 Fatty acid R5 Folic acid and R60 Hydantoin R45 Methotrexate R315 Lithium R300 Non steroidal anti-inflammatories * R740 MAOI R180 Oral corticosteroids * R720 Other antidepressants R80 Potassium supplements R450 Other antiepileptics Cushings R105 Mineralocorticoids R310 SSRI Syndrome R180 Oral corticosteroids * R490 Succinimide R80 Potassium supplements R65 Tricyclic antidepressants Cystic Fibrosis R200 Antibacterials R285 Anticholinergics R750 Antimycotics R25 Antiadrenergic agents - Rauwolfia alkaloids R30 Beta-2 agonists Hypoparathyroidism R230 Calcium supplements R5500 Digestive enzymes R495 Vitamin D supplements R315 Laxatives Major Depression R325 Carboxamide R355 Long acting beta-2 agonists R485 Fatty acid R350 Mucolytics R60 Hydantoin R650 Nutritional supplementation R315 Lithium R200 Calcium supplements R740 MAOI R180 Oral corticosteroids * R720 Other antidepressants R80 Potassium supplements R450 Other antiepileptics R100 Saline for nebulisation R310 SSRI R110 Vitamins R490 Succinimide R310 Inhaled Glucocorticoids R65 Tricyclic antidepressants R200 Calcium supplements Motor neuron R250 Benzodiazepine R170 Proton pump inhibitors disease R960 Centrally acting muscle relaxants Delusional R285 Anticholinergics R4500 Riluzole Disorder R1500 Antipsychotics Muscular R250 Benzodiazepine R740 MAOI Dystrophy and R960 Centrally acting muscle relaxants R720 Other antidepressants other inherited R180 Oral corticosteroids * R310 SSRI myopathies R80 Potassium supplements R65 Tricyclic antidepressants Multiple CDA Classes Page 24 of 26

25 Non-CDL Myasthenia Gravis Obsessive compulsive Disorder CDA Executive and Comp Multiple CDA Classes Non-CDL CDA Executive and Comp plans R565 Azathioprine Polyarteritis R565 Azathioprine R1300 Cholinergics Nodosa R80 Chloroquine R250 Cyclophosphamide R5 Folic acid and R5 Folic acid and R900 Intestinal anti-inflammatories R45 Methotrexate R45 Methotrexate R180 Oral corticosteroids * R180 Oral corticosteroids * R4000 Other immunosuppressant agents R80 Potassium supplements R80 Potassium supplements Post Traumatic R740 MAOI R60 Hydantoin Stress Disorder R720 Other antidepressants R315 Lithium R310 SSRI R740 MAOI R65 Tricyclic antidepressants R720 Other antidepressants R1500 Antipsychotics R310 SSRI Psoriatic arthritis R565 Azathioprine R65 Tricyclic antidepressants R80 Chloroquine Organ Per Approved Treatment Plan R5 Folic acid and Transplantation Osteoporosis R280 Biphosphonates R900 Intestinal anti-inflammatories R505 Calcitonin R45 Methotrexate R485 SERM's R300 Non steroidal anti-inflammatories * R280 Strontium R180 Oral corticosteroids * Paget's disease R280 Biphosphonates R80 Potassium supplements Panic Disorder R740 MAOI Pulmonary R565 Azathioprine R720 Other antidepressants Interstitial R30 Beta-2 agonists Fibrosis R310 SSRI R80 Chloroquine R65 Tricyclic antidepressants R250 Cyclophosphamide Paraplegia R200 Antibacterials R10 Folic acid and R285 Anticholinergics R180 Inhaled anticholinergics R20 Aspirin R310 Inhaled corticosteroids R960 Centrally acting muscle relaxants R355 Long acting beta-2 agonists R80 H2 receptor antagonists R45 Methotrexate R315 Laxatives R180 Oral corticosteroids * R300 Non steroidal anti-inflammatories * R80 Potassium supplements R170 Proton pump inhibitors R200 Antibacterial Agents, systemic R1000 Stoma products Quadriplegia R200 Antibacterials R65 Tricyclic antidepressants R285 Anticholinergics R70 Warfarin R20 Aspirin Pemphigus R565 Azathioprine R960 Centrally acting muscle relaxants Peripheral Atherosclerotic Disease Pituitary Microadenomas R180 Oral corticosteroids * R80 H2 receptor antagonists R80 Potassium supplements R315 Laxatives R45 Methotrexate R300 Non steroidal anti-inflammatories * R5 Folic acid and R170 Proton pump inhibitors R20 Aspirin R1000 Stoma products R260 Calcium channel blockers R65 Tricyclic antidepressants R20 Dipyridamole R70 Warfarin R70 Warfarin Stroke R20 Aspirin R190 Antithrombotic Agents-Clopidogrel R20 Dipyridamole R1000 Dopamine agonists R70 Warfarin R24000 Growth hormone release inhibitor R190 Antithrombotic Agents- R180 Oral corticosteroids * Clopidogrel R80 Potassium supplements Multiple CDA Classes Page 25 of 26

26 Non-CDL Systemic Sclerosis Thrombocytopaenia Purpura Valvular Heart Disease Wegener's Granulomatosis CDA Executive and Comp R565 R260 R80 R250 R5 R1685 R45 Azathioprine Calcium channel blockers Chloroquine Cyclophosphamide Folic acid and Mercaptopurine Methotrexate R300 Non steroidal anti-inflammatories * R180 Oral corticosteroids * R1300 Penicillamine R80 R170 R565 R5 R45 Potassium supplements Proton pump inhibitors Azathioprine Folic acid and Methotrexate R180 Oral corticosteroids * R80 Potassium supplements R600 R360 R20 R130 R260 R15 R70 R200 R565 R5 R45 Antiarrythmics; class ic Antiarrythmics; class iii Aspirin Beta blockers and combinations Calcium channel blockers Digoxin Warfarin Antibacterial Agents, systemic Azathioprine Folic acid and Methotrexate R180 Oral corticosteroids * R80 Potassium supplements * Multiple CDA Classes Page 26 of 26