Chronic Illness Benefit medicine list (formulary)

Transcription

1 Chronic Illness Benefit medicine list (formulary) 2013

2 Chronic Illness Benefit 2013 Contents Page Explanation of terms 3 The Prescribed Minimum Benefits medicine list (for all plan types) 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 Discovery Health Medical Scheme 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. Discovery Health Medical Scheme reserves the right to change the benefit at any time. Page 2 of 27 07/2013

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 2013 only. Chronic Drug Amount (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 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. 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 27 07/2013

4 Chronic Illness Benefit 2013 The Prescribed Minimum Benefits (PMB) medicine list (for all plan types) The PMB medicine list applies to all Discovery Health Medical Scheme for the 2013 benefit year. The CDA (Chronic Drug Amount) does not apply to KeyCare. * Soon this will be removed from the medicine list **Soon this will no longer be available on KeyCare plans ***Soon this will only be available on plans Prescribed Minimum Addison s disease R140 R140 Systemic corticosteroids: Hydrocortisone R105 R105 Systemic corticosteroids: Mineralocorticoids Asthma R135 R135 Adrenergics: Long acting - Formoterol R265 R360 Adrenergics: Long acting - Salmeterol R320 R320 Adrenergics: Salmeterol combinations R30 R30 Adrenergics: Short acting - Salbutamol R120 Anti-asthmatics: Systemic xanthines R185 R185 Inhaled anticholinergics: Ipratropium bromide R260 R315 Inhaled Glucocorticoids Hydrocortisone Covocort 10mg Fludrocortisone Florinef acetate 0.1mg Formoterol Foratec dp-caps 12mcg Foratec hfa 120dose Page 4 of 27 07/ mcg/1dose Salmeterol Serevent accuhaler 60 dose 50mcg Salmeterol and other drugs for obstructive airway diseases 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 Venteze cfc free 200 dose 100mcg Theophylline Sandoz Theophylline anhydrous 200mg; 300mg Ipratropium bromide Atrovent HFA 200dose Ipvent HFA 200 dose 20mcg 40mcg/1dose 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 Pulmicort turbuhaler 200dose 200mcg Pulmicort turbuhaler 100dose 400mcg R350 R350 Surgical item Inhaler device Dp haler device Paediatric Spacer Glaxohaler R10 R10 Systemic Prednisone Be-Tabs Prednisone corticosteroids: Panafcort Prednisone Trolic

5 Bipolar mood disorder R115 R315 Antidepressants: SSRIs R260 R330 Antiepileptics: Carboxamide R470 R495 Antiepileptics: Fatty acid R270 R400 Antiepileptics: Other agents R90 R90 Antipsychotics: Butyrophenone R655 R980 Antipsychotics: Clozapine R295 R295 Antipsychotics: Lithium R580 R580 Antipsychotics: Olanzapine R330 R330 Antipsychotics: Phenothiazines with aliphatic side-chain Citalopram Adco-Talomil * Arrow Citalopram ; Auro-Citalopram Austell-Citalopram Cilate Citalohexal Citalopram Actor Citalopram-Winthrop Mylan Citalopram Escitalopram Aspen Escitalopram 10mg Citraz 10mg; Escitalopram Be-tabs 10mg; Zytomil 10mg; Fluoxetine A-Lennon Fluoxetine Fluoxetine Actor Ranflocs Rezak Trizac * Zydus Fluoxetine Paroxetine Adco-Paroxetine Serrapress Sertraline Austell-Sertraline 50mg; Serdep 50mg; Zylin 50mg Carbamazepine Degranol 200mg Sandoz Carbamazepine Sandoz Carbamazepine CR 200mg 200mg; 400mg Valproic acid Convulex 150mg; 300mg; Lamotrigine Convulex syrup Epilim CR * Epilim crushable 250mg/5ml 200mg; 300mg; Epilim sugar-free syrup 200mg/5ml Epilizine CR 200mg; 300mg; Navalpro CR 200mg; 300mg; Dyna-Lamotrigine 2; 50mg; ; 200mg Lamidus 50mg; ; 200mg Lamitor 50mg; ; 200mg 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 27 07/2013

6 Bipolar mood disorder R475 R475 Antipsychotics: Quetiapine Dopaquel 2; ; 200mg; 300mg Quetiapine Mylan Quetiapine 2; ; 200mg; 300mg Psyquet 2; ; 200mg; 300mg Quetoser 2; ; 200mg; 300mg Serez 2; ; 200mg; 300mg R485 R620 Antipsychotics: Flupenthixol Fluanxol 0.; 1mg Thioxanthene Fluanxol depot 1ml Fluanxol depot 2ml R450 R970 Other antipsychotics Risperidone Aspen Risperidone DRL-Risperidone 0.; 1mg; 2mg Perizal 0.; 1mg; 2mg; 3mg Risnia 0.; 1mg; 2mg; 3mg Rispacor * Risperidone Hexal 3mg Rutra 3mg; Schizorol 0.; 1mg; 2mg Zoxadon 0.; 1mg; 2mg Bronchiectasis R30 R30 Adrenergics: Salbutamol Venteze cfc free 200 dose 100mcg Short acting - Salbutamol R185 R185 Inhaled Ipratropium Atrovent HFA 200dose 20mcg anticholinergics: Ipratropium bromide Ipvent HFA 200 dose 40mcg/1dose bromide R10 R10 Systemic Prednisone Be-Tabs Prednisone corticosteroids: Panafcort Prednisone Trolic Cardiac failure R110 R110 ACE inhibitors and Enalapril and Enap co 20/12. Pharmapress co 20/12. Lisinopril and Adco-Zetomax co 10/12.; 20/12. Auro-Lisinopril co * 10/12. Auro-Lisinopril co 20/12. Diace co 20/12. Hexal-Lisinopril co 10/12.; 20/12. Lisinopril co Unicorn 10/12.; 20/12. Lisinozide 20/12. Lisoretic 10/12.; 20/12. Lisozide ** 20/12. R70 R100 ACE inhibitors, plain Captopril Adco-Captomax 2; 50mg Bio-Captopril 2 Mylan Captopril 2; 50mg Enalapril Alapren ; 10mg; Enap *** ; 10mg; Envas * ; 10mg Hr-Enalapril *** ; 10mg; Lisinopril Austell-Lisinopril 10mg; Lysin * Simayla Lisinopril * Sinopren ; 10mg; ; 10mg; Perindopril Acti-Prex Auro Perindopril Bindace Page 6 of 27 07/2013

7 Cardiac failure R70 R100 ACE inhibitors, plain Perindopril Ciplasyl ; 8mg Cipla-Perindopril * 8mg Pearinda ; 8mg Perindopril Unicorn ; 8mg Ran-Perindopril Quinapril Accumax 10mg; Quinagen * R190 R220 Alpha and Beta Carvedilol Carvedilol Unicorn 6.2; 12.; 2 blocking agents Carvetrend 6.2; 12.; 2 Vediblok 6.2; 12.; 2 R110 R115 Angiotensin II Losartan and Ciplazar co ** 100/2 antagonists, Hytenza co 50/12. Combinations: Losartan and Lohype Forte Plus 100/2 Losaar Plus 50/12.; 100/2 R70 R115 Angiotensin II antagonists: plain R75 R75 Arteriolar smooth muscle Hydrazinophthalazine R75 Beta blocking selective R15 R15 Cardiac glycosides: Digoxin R20 R40 High-ceiling R15 R15 Low-ceiling : Thiazides, plain R20 R20 Low-ceiling : excluding Thiazides Losacar co Netrasol co 50/12. 50/12. Sartoc 100/2 Zartan co 50/12. Losartan Ciplazar * Hytenza Spec-Losartan Zartan * Valsartan Diolo 80mg; 160mg Hydralazine Hyperphen 10mg; 50mg Sandoz Hydralazine 2 Bisoprolol Adco-Bisocor ; 10mg Betacor ; 10mg Bilocor ; 10mg Bisohexal * ; 10mg Bisoprolol Unicorn ; 10mg Ziapro ; 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 2. Merck-Indapamide 2. Page 7 of 27 07/2013

8 C DA for Cardiac failure R90 R90 Potassium sparing agents Potassium supplements R160 R160 Vasodilators in cardiac disease: Organic nitrates Spironolactone Aldactone 2 Potassium chloride Glyceryl trinitrate Isosorbide dinitrate Isosorbide mononitrate R65 R65 Influenza vaccines Influenza, inactivated, whole virus R135 R135 Pneumococcus vaccines Cardiomyopathy R110 R110 ACE inhibitors and R70 R100 ACE inhibitors: plain Sandoz Spironolactone Spiractin Plenish K Sandoz K-600 Angised Sandoz Isosorbide dinitrate Elantan Elantan LA Monicor SR Fluarix prefilled syringe 0.5ml X-flu prefilled 0.5ml syringe * mg 600mg 0. ; 10mg; 30mg 50mg 60mg Pneumococcus, Imovax pneumo 23 purified polysaccharides antigen conjugated Enalapril and Enap co 20/12. Pharmapress co 20/12. Lisinopril and Adco-Zetomax co 10/12.; 20/12. Auro-lisinopril co * 10/12. Auro-Lisinopril co 20/12. Diace co 20/12. Hexal-Lisinopril co 10/12.; 20/12. Lisinopril co Unicorn 10/12.; 20/12. Lisinozide 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; Enap *** ; 10mg; Envas * ; 10mg Hr-Enalapril *** ; 10mg; Lisinopril Austell-Lisinopril 10mg; Lysin * ; Simayla Lisinopril * 10mg; Sinopren ; 10mg; Perindopril Acti-Prex Auro Perindopril Bindace Cipla-perindopril * 8mg Ciplasyl ; 8mg Pearinda ; 8mg Page 8 of 27 07/2013

9 Cardiomyopathy R70 R100 ACE inhibitors: plain R190 R220 Alpha and Beta blocking agents R110 R115 Angiotensin II antagonists, Combinations: Losartan and R70 R115 Angiotensin II antagonists: plain Perindopril Perindopril Unicorn ; 8mg Ran-Perindopril Quinapril Accumax 10mg; Quinagen * Carvedilol Carvedilol Unicorn 6.2; 12.; 2 Losartan and Carvetrend Vediblok Ciplazar co ** 6.2; 12.; 2 6.2; 12.; 2 100/2 Hytenza co 50/12. Lohype Forte Plus 100/2 Losaar Plus 50/12.; 100/2 Losacar co Netrasol co 50/12. 50/12. Sartoc 100/2 Zartan co 50/12. Losartan Ciplazar * Hytenza Spec-Losartan Zartan * Valsartan Diolo 80mg; 160mg R70 R70 Antithrombotic Warfarin Cipla-Warfarin Vitamin K antagonists R75 R75 Arteriolar smooth Hydralazine Hyperphen 10mg; 50mg muscle Hydrazinophthalazine Sandoz Hydralazine 2 R10 R20 Aspirin Acetylsalicylic Aspirin 300mg acid Be-Tabs Aspirin (white) 300mg R75 Beta blocking selective R15 R15 Cardiac glycosides: Digoxin R20 R40 High-ceiling Gulf Aspirin 300mg Bisoprolol Adco-Bisocor ; 10mg Betacor Bilocor Bisohexal * Bisoprolol Unicorn Ziapro ; 10mg ; 10mg ; 10mg ; 10mg ; 10mg Digoxin Lanoxin 0.062; 0.2 Lanoxin paed syrup 0.0/1ml Furosemide Beurises Dino-Retic Mylan Furosemide Page 9 of 27 07/2013

10 Cardiomyopathy R15 R15 Low-ceiling : Thiazides, plain R20 R20 Low-ceiling : excluding Thiazides Chronic obstructive pulmonary disease (COPD) R90 R90 Potassium sparing agents Potassium supplements R160 R160 Vasodilators in cardiac disease: Organic nitrates Hydrochlorothiazide Hexazide Ridaq Indapamide Cipla-Indapamide 2. Daptril Merck-Indapamide Spironolactone Aldactone 2 Potassium chloride Glyceryl trinitrate Isosorbide dinitrate Isosorbide mononitrate R65 R65 Influenza vaccines Influenza, inactivated, whole virus R135 R135 Pneumococcus vaccines R30 R30 Adrenergics: Short acting - Salbutamol R120 Anti-asthmatics: Systemic xanthines R185 R185 Inhaled anticholinergics: Ipratropium bromide R650 R650 Surgical item: Oxygen concentrator R10 R10 Systemic corticosteroids: Prednisone Sandoz Spironolactone Spiractin Plenish K Sandoz K-600 Angised Sandoz Isosorbide dinitrate Elantan Elantan LA Monicor SR Fluarix prefilled syringe 0.5ml X-flu prefilled 0.5ml syringe * mg 600mg 0. ; 10mg; 30mg 50mg 60mg Pneumococcus, Imovax pneumo 23 purified polysaccharides antigen conjugated Salbutamol Venteze cfc free 200 dose 100mcg Theophylline Ipratropium bromide Oxygen R65 R65 Influenza vaccines Influenza, inactivated, whole virus Chronic renal disease R110 R110 ACE inhibitors and Sandoz Theophylline anhydrous 200mg; 300mg Atrovent HFA 200dose Ipvent HFA 200 dose Oxygen concentrator 20mcg 40mcg/1dose Prednisone Be-Tabs Prednisone Enalapril and Lisinopril and Panafcort Trolic Fluarix prefilled syringe 0.5ml X-flu prefilled 0.5ml syringe * Enap co Pharmapress co Adco-Zetomax co 20/12. 20/12. 10/12.; 20/12. Auro-Lisinopril co * 10/12. Auro-Lisinopril co 20/12. Diace co 20/12. Hexal-Lisinopril co 10/12.; 20/12. Lisinopril co Unicorn Lisinozide Lisoretic Lisozide ** 10/12.; 20/12. 20/12. 10/12.; 20/12. 20/12. Page 10 of 27 07/2013

11 Chronic renal disease R70 R100 ACE inhibitors: plain R110 R115 Angiotensin II antagonists, Combinations: Losartan and R70 R115 Angiotensin II antagonists: plain R230 R230 Calcium supplements R5 R5 Folic acid and R65 R65 Iron in combination with folic acid R580 R580 Iron trivalent, parenteral preparations Captopril Adco-Captomax 2; 50mg Bio-Captopril 2 Mylan Captopril 2; 50mg Enalapril Alapren ; 10mg; Enap *** Envas * Hr-Enalapril *** ; 10mg; ; 10mg ; 10mg; Lisinopril Austell-Lisinopril 10mg; Lysin * ; Simayla Lisinopril * 10mg; Sinopren ; 10mg; Perindopril Acti-Prex Auro Perindopril Bindace Cipla-Perindopril * 8mg Ciplasyl ; 8mg Pearinda ; 8mg Perindopril Unicorn ; 8mg Ran-Perindopril Quinapril Accumax 10mg; Quinagen * Losartan and Ciplazar co ** 100/2 Hytenza co 50/12. Lohype Forte Plus 100/2 Losaar Plus 50/12.; 100/2 Losacar co Netrasol co 50/12. 50/12. Sartoc 100/2 Zartan co 50/12. Losartan Ciplazar * Hytenza Spec-Losartan Zartan * Valsartan Diolo 80mg; 160mg Calcium Titralac carbonate Folic acid Aha Folic acid Ferrous fumarate Ferricoxidedextrancomplex Saccharated iron oxide Be-Tabs Folic acid Folic acid Pregamal Cosmofer ampoule Venofer 0. 50mg/1ml /1ml Page 11 of 27 07/2013

12 Chronic renal disease R4 000 R4 000 Other anti-anaemic preparations R335 R335 Vitamin D and analogues Coronary artery disease R10 R20 Aspirin Acetylsalicylic acid R170 Beta blocking non-selective R75 Beta blocking selective R170 R240 Selective calcium channel blockers with direct cardiac effects R125 R170 Selective calcium channel blockers with mainly vascular effects R160 R160 Vasodilators in cardiac disease: Organic nitrates Darbepoetin Aranesp prefilled syringe 0.4ml 10mcg/0.4ml Alfa Aranesp prefilled syringe 0.5ml 20mcg/0.5ml Aranesp prefilled syringe 0.3ml 30mcg/0.3ml Aranesp prefilled syringe 0.4ml 40mcg/0.4ml Aranesp prefilled syringe 0.5ml 50mcg/0.5ml Aranesp prefilled syringe 0.3ml 60mcg/0.3ml Erythropoietin Eprex prefill 2000U/0.5ml Eprex prefill 4000U/0.4ml Recormon 500U/0.3ml Recormon 2000U pre-filled syringe Recormon 4000U/0.3ml Repotin 1ml 2000IU Repotin 1ml 4000IU Methoxy Mircera prefilled syringe 0.3ml 30mcg/0.3ml polyethyleneglycol- Mircera prefilled syringe 0.3ml 50mcg/0.3ml Mircera prefilled syringe 0.3ml 75mcg/0.3ml epoetin beta Mircera prefilled syringe 0.3ml 100mcg/0.3ml Mircera prefilled syringe 0.3ml 120mcg/0.3ml Mircera prefilled syringe 0.3ml 150mcg/0.3ml Mircera prefilled syringe 0.3ml 200mcg/0.3ml Mircera prefilled syringe 0.3ml 250mcg/0.3ml 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; Bio-Atenolol 50mg; Gulf Atenolol 50mg; Sandoz Atenolol 50mg; Tenopress Diltiazem Adco-Zildem 60mg Adco-Zildem SR 180mg; 2 Verapamil Vasomil ; 80mg Verahexal SR 2 Amlodipine Almadin ** ; 10mg Corvadil * ; 10mg Gulf Amlodipine ; 10mg Indo Amlodipine Klodip Lomanor ; 10mg Pharma Dynamics Amlodipine besylate ; 10mg Felodipine Felodipine-Hexal ; 10mg Nifedipine Adco-Vascard SR Glyceryl trinitrate Isosorbide dinitrate Isosorbide mononitrate Cipalat Retard Nifedalat SR Angised Sandoz Isosorbide dinitrate Elantan Elantan LA Monicor SR 0. ; 10mg; 30mg 50mg 60mg Page 12 of 27 07/2013

13 Crohn s disease R5 R5 Folic acid and R650 R650 Intestinal antiinflammatories: Aminosalicylic acid and similar agents R2 165 R2 165 Intestinal antiinflammatories: Corticosteroids R565 R565 Other immunosuppressive Azathioprine Other immunosuppressive Methotrexate R10 R10 Systemic corticosteroids: Prednisone Diabetes insipidus R1 415 R1 520 Posterior pituitary hormones: Vasopressin and analogues Diabetes mellitus Type 1 R680 R720 Anti-diabetic Insulins and analogues R200 R280 Blood glucose monitoring agents Folic acid Aha Folic acid Be-Tabs Folic acid Folic acid 0. Mesalazine Asacol 400mg; ; 800mg Pentasa ; 1000mg Salofalk * Salofalk 1000mg Olsalazine Dipentum 250mg Sulfasalazine Salazopyrin Salazopyrin EN Budesonide Entocord enema Azathioprine Azamun 50mg Azathioprine pch 50mg Methotrexate Abitrexate 2. Methotrexate 2. Prednisone Be-Tabs Prednisone Panafcort Trolic Desmopressin Ddavp 0.1mg; 0.2mg Insulin Glucose strips Ddavp nasal spray 5ml 0.1mg/1ml 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 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 - disposable pen 3ml ; vial 10ml Insuman comb 30/70 - cartridge 3ml Novomix 30 - flexpen 3ml; penfill 3ml Novorapid - penfill 3ml Accu-chek active strips Caresens ii/pop test strip 29g Caresens n test strips 29g Glucocheck strips 50s Glucoplus Glucoplus provider strips Page 13 of 27 07/2013

14 Diabetes mellitus Type 1 R200 R280 Blood glucose monitoring agents Glucose strips Glucose test strips free style optium Onetouch select glucose test strips On-call plus ez strips (all sizes) R350 R350 Surgical item Lancets Lancets glucoplus 66 x 44 x 78mm Needles Needle novofine Needle pen bd microfine 30g 8mm BD microfine pen needle 32g 4mm BD microfine pen needle 31g 5mm Diabetes mellitus Type 2 R55 Anti-diabetic Metformin Accord Metformin ; 850mg Arrow Metformin Biguanides Bigsens ; 850mg; 1000mg Diaformin Diamin ; 850mg Gluconorm Mengen ; 850mg; 1000mg Metchek Metforal * Metforal 850mg Metored ; 850mg; 1000mg Metphage ; 850mg Mylan Metformin * Mylan Metformin 850mg Sandoz Metformin Sandoz Metformin FCT R680 R720 Anti-diabetic Insulins and analogues R95 R95 Anti-diabetic Sulfonamides, urea 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 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 - disposable pen 3ml; vial 10ml Insuman comb 30/70 - cartridge 3ml Novomix 30 - flexpen 3ml; penfill 3ml Novorapid - penfill 3ml Glibenclamide Bio-Glibenclamide Diacare Glycomin Sandoz Glibenclamide Page 14 of 27 07/2013

15 Diabetes mellitus Type 2 R95 R95 Anti-diabetic Sulfonamides, urea R150 R175 Anti-diabetic Thiazolidinediones R200 R280 Blood glucose monitoring agents Gliclazide Adco-Glucomed 80mg Arrow Gliclazide 80mg Austell-Gliclazide 80mg Diaglucide 80mg Diaran MR * 30mg Dyna Gliclazide SR 30mg 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 R350 Surgical item Lancets Lancets glucoplus 66 x 44 x 78mm Dysrhythmias R505 5 Antiarrhythmics: class Ic R360 R360 Antiarrhythmics: class III - Amiodarone Needles Needle novofine Needle pen bd microfine 30g 8mm BD microfine pen needle 32g 4mm 1; 30mg BD microfine pen needle 31g 5mm Flecainide Tambocor Propafenone Rythmol 150mg; 300mg Amiodarone Arycor ; 200mg Bio-Amiodarone Hexarone 200mg ; 200mg R70 R70 Antithrombotic Warfarin Cipla-Warfarin Vitamin K antagonists R10 R20 Aspirin Acetylsalicylic Aspirin 300mg acid Be-Tabs Aspirin (white) 300mg R170 Beta blocking non-selective R75 Beta blocking selective R15 R15 Cardiac glycosides: Digoxin R170 R240 Selective calcium channel blockers with direct cardiac effects Gulf Aspirin 300mg Propranolol Indoblok 10mg; Prodorol Purbloka 10mg; 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 27 07/2013

16 Epilepsy R165 R250 Antiepileptics: Benzodiazepine R260 R330 Antiepileptics: Carboxamide R470 R495 Antiepileptics: Fatty acid Antiepileptics: Hydantoin R270 R400 Antiepileptics: Other agents R25 R25 Anti-epileptics: Barbiturates and Glaucoma R165 R165 Anti-glaucoma Carbonic anhydrase inhibitors R210 R210 Anti-glaucoma Prostaglandin analogues R235 R235 Anti-glaucoma Sympathomimetics Anti-glaucoma Beta blocking Timolol R230 R230 Anti-glaucoma Beta blocking Timolol, combinations Haemophilia R5 R5 Analgesics: Paracetamol R190 R190 Antifibrinolytics: Amino acids R R Blood coagulation factors R1 415 R1 520 Posterior pituitary hormones: Vasopressin and analogues Hyperlipidaemia R235 R235 Lipid modifying Fibrates Clonazepam Rivotril 0.; 2mg Carbamazepine Degranol 200mg Sandoz Carbamazepine 200mg Sandoz Carbamazepine CR 200mg; 400mg Valproic acid Convulex 150mg; 300mg; Convulex syrup 250mg/5ml Epilim CR * 200mg; 300mg; Epilim crushable Epilim sugar-free syrup 200mg/5ml Epilizine CR 200mg; 300mg; Navalpro CR 200mg; 300mg; Phenytoin Phenytoin sod Lamotrigine Dyna-Lamotrigine 2; 50mg; ; 200mg Lamidus 50mg; ; 200mg Lamitor 50mg; ; 200mg Topiramate Adco-Topiramate * 2; 50mg; Epitoz 2; 50mg; Pamiram 50mg Phenobarbital Lethyl 30mg Sedabarb 30mg Dorzolamide Trusopt - 5ml owi 2% Bimatoprost Lumigan 3ml 0.01%; 0.03% Latanoprost Ocuprost 3ml 50mcg/1ml Travoprost Travatan 2,5ml 0.004% Brimonidine Alphagan purite - 5ml 1./1ml Timolol Glaucosan - 5ml 0.5% Timolol, Combigan - 5ml 2mg/ combinations Cosopt - 5ml 0.5% Duotrav 2.5ml Ganfort 3ml Paracetamol Adco-Napamol Adco-Prolief Tranexamic acid Tranexamic acid medwich Tranic Coagulation Haemosolvex IX 500U factor IX Coagulation Haemosolvate VIII 300U; 500U; 1000U factor VIII Desmopressin Ddavp 0.1mg; 0.2mg Ddavp nasal spray 5ml 0.1mg/1ml Bezafibrate Dyna-Bezafibrate SR 400mg Sandoz Bezafibrate 400mg Page 16 of 27 07/2013

17 Hyperlipidaemia R45 R105 Lipid modifying Statins Hypertension R110 R110 ACE inhibitors and R70 R100 ACE inhibitors: plain Atorvastatin Adco Atorvastatin 10mg; Adco Atorvastatin Aspavor 10mg; ; Atolip * 10mg; ; ; 80mg Atorvastatin unicorn * 10mg; ; Atorvastatin Winthrop * 10mg; ; Dynator 10mg; ; Dynator 80mg Lipogen * 10mg; ; Lipogen 80mg Simvastatin Adco-Simvastatin * 10mg; Adco-Simvastatin Austell-Simvastatin 10mg; Cipla-Simvastatin 10mg; ; Cipla-Simvastatin * 80mg Michol * 80mg Redicor * 10mg; Redicor Simvacor * 10mg; Simvacor Simvotin * 10mg; Simzor * 10mg; Simzor Zysim 10mg; ; Zysim * 80mg Enalapril and Enap co 20/12. Pharmapress co 20/12. Lisinopril and Adco-Zetomax co 10/12.; 20/12. Auro-Lisinopril co * 10/12. Auro-Lisinopril co 20/12. Diace co 20/12. Hexal-Lisinopril co 10/12.; 20/12. Lisinopril co Unicorn 10/12.; 20/12. Lisinozide 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; Enap *** ; 10mg; Envas * ; 10mg Hr-Enalapril *** ; 10mg; Lisinopril Austell-Lisinopril 10mg; Lysin * ; Simayla Lisinopril * 10mg; Sinopren ; 10mg; Page 17 of 27 07/2013

18 Hypertension R70 R100 ACE inhibitors: plain R190 R220 Alpha and Beta blocking agents R110 R115 Angiotensin II antagonists, Combinations: Losartan and R70 R115 Angiotensin II antagonists: Plain R125 R125 Anti-adrenergic Alphaadrenoreceptor antagonists R120 R120 Anti-adrenergic Methyldopa R25 R25 Anti-adrenergic Rauwolfia alkaloids R75 R75 Arteriolar smooth muscle Hydrazinophthalazine R170 Beta blocking non-selective Perindopril Acti-Prex Auro Perindopril Bindace Cipla-Perindopril * 8mg Ciplasyl ; 8mg Pearinda ; 8mg Perindopril Unicorn 8mg Ran-Perindopril Quinapril Accumax 10mg; Quinagen * Carvedilol Carvedilol Unicorn 6.2; 12.; 2 Carvetrend 6.2; 12.; 2 Vediblok 6.2; 12.; 2 Losartan and Ciplazar co ** 100/2 Hytenza co 50/12. Lohype Forte Plus 100/2 Losaar Plus 50/12.; 100/2 Losacar co 50/12. Netrasol co 50/12. Sartoc 100/2 Zartan co 50/12. Losartan Ciplazar * Hytenza Spec-Losartan Zartan * Valsartan Diolo 80mg; 160mg Doxazosin Adco-Doxazosin 1mg; 2mg; Cardugen 1mg; 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; Page 18 of 27 07/2013

19 Hypertension R75 Beta blocking selective R20 R40 High-ceiling R15 R15 Low-ceiling : Thiazides, plain R20 R20 Low-ceiling : excluding Thiazides R90 R90 Potassium sparing agents Potassium supplements R170 R240 Selective calcium channel blockers with direct cardiac effects R125 R170 Selective calcium channel blockers with mainly vascular effects Hypothyroidism R40 R40 Thyroid hormones Levothyroxine sodium Multiple sclerosis R65 R65 Antidepressants: Tricyclics R9 900 R9 900 Interferons Interferon beta- 1a R980 R980 Muscle relaxants: Other centrally acting agents R10 R10 Systemic corticosteroids: Prednisone R165 R225 Urinary antispasmodics Atenolol B-Block 50mg; Bio-Atenolol 50mg; Gulf Atenolol 50mg; Sandoz Atenolol 50mg; Tenopress Furosemide Beurises Dino-Retic Mylan Furosemide Hydrochloro- Hexazide 2 thiazide Ridaq 12. Indapamide Cipla-Indapamide 2. Daptril 2. Merck-Indapamide 2. 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 Corvadil* ; 10mg Gulf Amlodipine ; 10mg Indo Amlodipine Klodip Lomanor ; 10mg Pharma Dynamics Amlodipine besylate ; 10mg Felodipine Felodipine-Hexal ; 10mg Nifedipine Adco-Vascard SR Cipalat Retard Nifedalat SR Eltroxin 50mcg; 100mcg Euthyrox 25mcg; 50mcg; 100mcg Synthroid 50mcg; 88mcg; 100mcg; 112mcg Amitriptyline Sandoz Amitriptyline 2 Trepiline 10mg Avonex pre-filled syringe 30mcg 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- Betaferon pre-filled syringe 1ml 1b u/1ml Baclofen Bio-Baclofen 10mg Teva Baclofen 10mg Prednisone Be-Tabs Prednisone Panafcort Trolic Oxybutynin Lenditro Mylan Oxybutynin Page 19 of 27 07/2013

20 Parkinson's disease R290 R290 Anti-cholinergic Biperiden Akineton 2mg Tertiary Amines R740 R740 Dopamine agonists Pramipexole Pexola 0.12; 0.2; 1mg Pramiola 0.12; 0.2 Ropinirole Resure * 0.2; 0.; 1mg; 2mg; Requip 0.2; 0.; 1mg; 2mg; R580 R580 Dopaminergic Monoamine oxidase B inhibitors: Selegiline Selegiline Parkilyne R280 R280 Dopaminergic Adamantane R565 R610 Levodopa and decarboxylase inhibitor Rheumatoid arthritis R40 R50 Anti-inflammatory Acetic acid and related substances R50 R50 Anti-inflammatory Oxicams R25 R25 Anti-inflammatory Propionic acid Antirheumatic Chloroquine R5 R5 Folic acid and R650 R650 Intestinal antiinflammatories: Aminosalicylic acid and similar agents R565 R565 Other immunosuppressive Azathioprine Other immunosuppressive Methotrexate R10 R10 Systemic corticosteroids: Prednisone Adamantane Symadin 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 Mylan Diclofenac 2; 50mg Panamor AT 50mg Sandoz Diclofenac 2 Indomethacin Betacin 2 Gulf Indomethacin 2 Methocaps 2 Meloxicam Adco-Meloxicam 7.; 1 Arrow Meloxicam 7. Flamaryx 7. Flexocam 7. Piroxicam Pyrocaps Roxifen Ibuprofen Betaprofen 200mg Betaprofen FC 400mg Bren 400mg Ibu 200mg Ibucine 200mg; 400mg Ibunate 200mg Ranfen 400mg Chloroquine Plasmoquine 200mg Folic acid Aha Folic acid Be-Tabs Folic acid Folic acid 0. Sulfasalazine Salazopyrin Salazopyrin EN Azathioprine Azamun 50mg Azathioprine pch 50mg Methotrexate Abitrexate 2. Methotrexate 2. Prednisone Be-Tabs Prednisone Panafcort Trolic Page 20 of 27 07/2013

21 Schizophrenia R115 R315 Antidepressants: SSRIs R260 R330 Anti-epileptics: Carboxamide R90 R90 Antipsychotics: Butyrophenone R655 R980 Antipsychotics: Clozapine R580 R580 Antipsychotics: Olanzapine R330 R330 Antipsychotics: Phenothiazines with aliphatic sidechain R475 R475 Antipsychotics: Quetiapine R485 R620 Antipsychotics: Thioxanthene Citalopram Adco-Talomil * Arrow Citalopram Auro-Citalopram Austell-Citalopram Cilate Citalohexal Citalopram Actor Citalopram-Winthrop Mylan Citalopram ; Escitalopram Aspen Escitalopram 10mg Citraz 10mg; Escitalopram Be-tabs 10mg; Zytomil 10mg; Fluoxetine A-Lennon Fluoxetine Fluoxetine Actor Ranflocs Rezak Zydus Fluoxetine Paroxetine Adco-Paroxetine Serrapress Sertraline Austell-Sertraline 50mg; Serdep 50mg; Zylin 50mg Carbamazepine Degranol 200mg Sandoz Carbamazepine Sandoz Carbamazepine CR 200mg 200mg; 400mg Haloperidol Sandoz Haloperidol 1.; Clozapine Aspen Clozapine 2; Cloment 2; Olanzapine Oleanz ; 10mg Olexar Redilanz ; 10mg ; 10mg Chlorpromazine Largactil 2; 50mg; Quetiapine Dopaquel 2; ; 200mg; 300mg Mylan Quetiapine 2; ; 200mg;300mg Psyquet 2; ; 200mg;300mg Quetoser 2; ; 200mg; 300mg Serez 2; ; 200mg; 300mg Flupenthixol Fluanxol 0.; 1mg Fluanxol depot 1ml Fluanxol depot 2ml Page 21 of 27 07/2013

22 Schizophrenia R450 R970 Other antipsychotics Risperidone Aspen Risperidone DRL-Risperidone 0,; 1mg; 2mg Perizal 0,; 1mg; 2mg; 3mg Risnia 0,; 1mg; 2mg; 3mg Rispacor * Risperidone Hexal 3mg Rutra 3mg; Schizorol 0.; 1mg; 2mg Trizac * Zoxadon 0.; 1mg; 2mg Systemic lupus R40 R50 Anti-inflammatory Diclofenac Adco-Diclofenac 50mg erythematosus (SLE) A-Lennon Diclofenac 2; 50mg Acetic acid Mylan Diclofenac 2; 50mg and Panamor AT 50mg related substances Sandoz Diclofenac 2 Indomethacin Betacin 2 R50 R50 Anti-inflammatory Oxicams R25 R25 Anti-inflammatory Propionic acid Gulf Indomethacin 2 Methocaps 2 Meloxicam Adco-Meloxicam 7.; 1 Arrow Meloxicam 7. Flamaryx 7. Flexocam 7. Piroxicam Pyrocaps Roxifen Ibuprofen Betaprofen 200mg Betaprofen FC Bren Ibu Ibucine Ibunate Ranfen 400mg 400mg 200mg 200mg; 400mg 200mg 400mg Antirheumatic Chloroquine Plasmoquine 200mg Chloroquine R70 R70 Antithrombotic Warfarin Cipla-Warfarin Vitamin K antagonists R10 R20 Aspirin Acetylsalicylic acid Aspirin 300mg R25 R25 Emolients and protectives: Zinc products R5 R5 Folic acid and R565 R565 Other immunosuppressive Azathioprine Other immunosuppressive Methotrexate R10 R10 Systemic corticosteroids: Prednisone R25 R25 Topical corticosteroids: Group III Zinc products Be-Tabs Aspirin (white) Gulf Aspirin Zinc ointment bp 300mg 300mg Folic acid Aha Folic acid Be-Tabs Folic acid 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% Page 22 of 27 07/2013

23 Ulcerative colitis R5 R5 Folic acid and R650 R650 Intestinal antiinflammatories: Aminosalicylic acid and similar agents R2 165 R2 165 Intestinal antiinflammatories: Corticosteroids R565 R565 Other immunosuppressive Azathioprine Other immunosuppressive Methotrexate R10 R10 Systemic corticosteroids: Prednisone Folic acid Aha Folic acid Be-Tabs Folic acid Folic acid 0. Mesalazine Asacol 400mg; ; 800mg Pentasa ; 1000mg Salofalk * Salofalk 1000mg Olsalazine Dipentum 250mg Sulfasalazine Salazopyrin Budesonide Salazopyrin EN Entocord enema Azathioprine Azamun 50mg Azathioprine pch 50mg Methotrexate Abitrexate 2. Methotrexate 2. Prednisone Be-Tabs Prednisone Panafcort Trolic Page 23 of 27 07/2013

24 Non-CDL condition Ankylosing spondylitis Behcet's disease Connective tissue disorder (Mixed) Cushing s syndrome Cystic fibrosis Chronic Drug Amount R50 R40 R285 R300 R75 R50 R25 R565 R650 R4 000 R5 R250 R565 R4 000 R50 R40 R285 R300 R75 R50 R25 R565 R5 R105 R30 R110 R100 R280 R370 R335 R360 R650 Chronic Drug Amounts for the Executive Plan and The Chronic Drug Amounts below apply to the Executive Plan and for non-cdl conditions. or medicine Other immunosuppressive agents - Methotrexate Anti-inflammatory agents - Acetic acid and related substances Anti-inflammatory agents - Butylpyrazolidines Anti-inflammatory agents - Coxibs Anti-inflammatory agents - Fenamates Anti-inflammatory agents - Other anti-inflammatory and antirheumatic agents, non-steroids Anti-inflammatory agents - Oxicams Anti-inflammatory agents - Propionic acid Other immunosuppressive agents - Azathioprine Intestinal anti-inflammatories - Aminosalicylic acid and similar agents Selective immunosuppressive agents Folic acid and Alkylating agents - Nitrogen mustard analogues Other immunosuppressive agents - Azathioprine Selective immunosuppressive agents Antirheumatic agents - Chloroquine Other immunosuppressive agents - Methotrexate Anti-inflammatory agents - Acetic acid and related substances Anti-inflammatory agents - Butylpyrazolidines Anti-inflammatory agents - Coxibs Anti-inflammatory agents - Fenamates Anti-inflammatory agents - Other anti-inflammatory and antirheumatic agents, non-steroids Anti-inflammatory agents - Oxicams Anti-inflammatory agents - Propionic acid Other immunosuppressive agents - Azathioprine Folic acid and Systemic corticosteroids - Mineralocorticoids Adrenergics Short-acting - Salbutamol Other plain vitamin preparations Sodium chloride for nebulisation Drugs for constipation Mucolytics Vitamin D and analogues Adrenergics Long-acting - Salmeterol Nutritional supplements Non-CDL condition Chronic Drug Amount or medicine Cystic fibrosis R785 Antifungal agents, systemic Delusional disorder R410 Other antidepressants - Noradrenergic and specific serotonergic agents - Mirtazapine R370 Other antidepressants Norepinephrine -Dopamine re-uptake inhibitors - Bupropion R495 Other antidepressants Serotonin - Norepinephrine re-uptake inhibitors - Venlafaxine R510 Other antidepressants - Norepinephrine re-uptake inhibitors - Reboxetine R350 Other antidepressants Serotonin - Norepinephrine re-uptake inhibitors - Duloxetine R720 Other antidepressants - Melatonergic agents - Agomelatine R330 Antipsychotics - Phenothiazines with aliphatic sidechain Anti-rheumatic agents - Chloroquine Dermatopolymyositis Generalised anxiety disorder Huntington s disease R200 R5 700 R290 R315 R65 R740 R530 R460 Antibacterial agents, systemic Digestive enzymes Anticholinergic agents - Tertiary amines Antidepressants SSRIs Antidepressants - Tricyclics Antidepressants MAOIs - Non-selective Other antidepressants - Noradrenergic and specific serotonergic agents - Mianserin Other antidepressants - Augmenters - Trazodone R565 R4 000 R5 R170 R315 R65 R740 R530 R460 Other immunosuppressive agents - Methotrexate Other immunosuppressive agents - Azathioprine Selective immunosuppressive agents Folic acid and Beta blocking agents, non-selective Antidepressants SSRIs Antidepressants - Tricyclics Antidepressants MAOIs - Non-selective Other antidepressants - Noradrenergic and specific serotonergic agents - Mianserin Other antidepressants - Augmenters - Trazodone R410 Other antidepressants - Noradrenergic and specific serotonergic agents - Mirtazapine R370 Other antidepressants Norepinephrine -Dopamine re-uptake inhibitors - Bupropion R495 Other antidepressants Serotonin - Norepinephrine re-uptake inhibitors - Venlafaxine R510 Other antidepressants - Norepinephrine re-uptake inhibitors - Reboxetine R350 Other antidepressants Serotonin - Norepinephrine re-uptake inhibitors - Duloxetine R720 Other antidepressants - Melatonergic agents - Agomelatine R250 Antiepileptics - Benzodiazepine R315 R295 Antiepileptics - Hydantoin Antidepressants SSRIs Antipsychotics - Lithium Page 24 of 27 07/2013

25 Non-CDL condition Huntington's disease Antipsychotics - Phenothiazines with aliphatic sidechain Calcium supplements Hypoparathyroidism Major depression Motor neuron disease Muscular dystrophy and other inherited myopathies Chronic Drug Amount R65 R330 R495 R740 R490 R530 R460 R410 R370 R495 R510 R350 R720 R400 R330 R230 R335 R290 R315 R295 R970 R620 R65 R330 R495 R740 R490 R530 R460 or medicine Antidepressants - Tricyclics Antiepileptics - Carboxamide Antiepileptics - Fatty acid Antidepressants MAOI s - Non-selective Antiepileptics - Succinimide Other antidepressants - Noradrenergic and specific serotonergic agents - Mianserin Other antidepressants - Augmenters - Trazodone Other antidepressants - Noradrenergic and specific serotonergic agents - Mirtazapine Other antidepressants Norepinephrine - Dopamine re-uptake inhibitors - Bupropion Other antidepressants Serotonin - Norepinephrine re-uptake inhibitors - Venlafaxine Other antidepressants - Norepinephrine re-uptake inhibitors - Reboxetine Other antidepressants Serotonin - Norepinephrine re-uptake inhibitors - Duloxetine Other antidepressants Melatonergic agents- Agomelatine Antiepileptics - Other agents Vitamin D and analogues Anticholinergic agents - Tertiary amines Antiepileptics - Hydantoin Antidepressants SSRIs Antipsychotics Lithium Antipsychotics - Benzamides Antipsychotics - Thioxanthene Antidepressants - Tricyclics Antiepileptics - Carboxamide Antiepileptics - Fatty acid Antidepressants MAOIs - Non-selective Antiepileptics - Succinimide Other antidepressants - Noradrenergic and specific serotonergic agents - Mianserin Other antidepressants - Augmenters - Trazodone R410 Other antidepressants - Noradrenergic and specific serotonergic agents - Mirtazapine R370 Other antidepressants Norepinephrine - Dopamine re-uptake inhibitors Bupropion R495 Other antidepressants Serotonin - Norepinephrine re-uptake inhibitors - Venlafaxine R510 Other antidepressants - Norepinephrine re-uptake inhibitors Reboxetine R350 Other antidepressants Serotonin - Norepinephrine re-uptake inhibitors - Duloxetine R720 Other antidepressants - Melatonergic agents - Agomelatine R400 Antiepileptics - Other agents R250 R65 R900 R4 600 R250 R900 Antiepileptics - Benzodiazepine Antidepressants Tricyclics Muscle relaxants - Carbamic acid esters Other nervous system drugs Antiepileptics - Benzodiazepine Muscle relaxants - Carbamic acid esters Non-CDL condition Myasthenia gravis Obsessive compulsive disorder Chronic Drug Amount R250 R565 R1 315 R4 000 R5 R290 R315 R295 R65 R330 R495 R740 R490 R530 R460 or medicine Other immunosuppressive agents - Methotrexate Alkylating agents - Nitrogen mustard analogues Other immunosuppressive agents - Azathioprine Parasympathomimetics - Anticholinesterases Selective immunosuppressive agents Folic acid and Anticholinergic agents - Tertiary amines Antiepileptics - Hydantoin Antidepressants SSRIs Antipsychotics Lithium Antidepressants - Tricyclics Antiepileptics - Carboxamide Antiepileptics - Fatty acid Antidepressants MAOIs - Non-selective Antiepileptics - Succinimide Other antidepressants - Noradrenergic and specific serotonergic agents - Mianserin Other antidepressants - Augmenters - Trazodone R410 Other antidepressants - Noradrenergic and specific serotonergic agents - Mirtazapine R370 Other antidepressants Norepinephrine - Dopamine re-uptake inhibitors - Bupropion R495 Other antidepressants - Serotonin-Norepinephrine re-uptake inhibitors - Venlafaxine R510 Other antidepressants - Norepinephrine re-uptake inhibitors - Reboxetine R350 Other antidepressants Serotonin - Norepinephrine re-uptake inhibitors - Duloxetine R720 Other antidepressants - Melatonergic agents- Agomelatine R400 Antiepileptics - Other agents Organ transplantation According to approved treatment plan Osteoporosis R280 Drugs treating bone disorders - Bisphosphonates R505 R495 R280 Anti-parathyroid agents - Calcitonin preparations Selective oestrogen receptor modulators Other drugs treating bone disorders Paget's R280 Drugs treating bone disorders - Bisphosphonates disease Panic disorder R315 Antidepressants SSRIs R65 R740 Antidepressants - Tricyclics Antidepressants MAOIs - Non-selective R530 Other antidepressants - Noradrenergic and specific serotonergic agents - Mianserin R460 Other antidepressants - Augmenters - Trazodone R410 Other antidepressants - Noradrenergic and specific serotonergic agents - Mirtazapine R370 Other antidepressants - Norepinephrine-Dopamine re-uptake inhibitors - Bupropion R495 Other antidepressants Serotonin - Norepinephrine re-uptake inhibitors - Venlafaxine R510 Other antidepressants - Norepinephrine re-uptake inhibitors - Reboxetine R350 Other antidepressants - Serotonin-Norepinephrine re-uptake inhibitors - Duloxetine R720 Other antidepressants - Melatonergic agents - Agomelatine Page 25 of 27 07/2013

26 Non-CDL condition Chronic Drug Amount or medicine Paraplegia R20 Aspirin - Cardiovascular R70 R290 R160 R280 R315 R295 R50 R40 R285 R300 R75 R50 R25 R65 R330 R495 R740 R490 R200 R530 R460 Antithrombotic agents - Vitamin K antagonists H2-receptor antagonists Anticholinergic agents - Tertiary amines Antiepileptics - Hydantoin Proton pump inhibitors Drugs for constipation Antidepressants SSRIs Antipsychotics - Lithium Anti-inflammatory agents - Acetic acid and related substances Anti-inflammatory agents - Butylpyrazolidines Anti-inflammatory agents - Coxibs Anti-inflammatory agents - Fenamates Anti-inflammatory agents - Other anti-inflammatory and antirheumatic agents, non-steroids Anti-inflammatory agents - Oxicams Anti-inflammatory agents - Propionic acid Antidepressants - Tricyclics Antiepileptics - Carboxamide Antiepileptics - Fatty acid Antidepressants MAOIs - Non-selective Antiepileptics - Succinimide Antibacterial agents, systemic Other antidepressants - Noradrenergic and specific serotonergic agents - Mianserin Other antidepressants - Augmenters - Trazodone R410 Other antidepressants - Noradrenergic and specific serotonergic agents - Mirtazapine R370 Other antidepressants Norepinephrine - Dopamine re-uptake inhibitors - Bupropion R495 Other antidepressants Serotonin - Norepinephrine re-uptake inhibitors - Venlafaxine R510 Other antidepressants - Norepinephrine re-uptake inhibitors - Reboxetine R350 Other antidepressants Serotonin - Norepinephrine re-uptake inhibitors - Duloxetine R720 Other antidepressants - Melatonergic agents - Agomelatine R400 Antiepileptics - Other agents R1 000 R900 Stoma equipment Muscle relaxants - Carbamic acid esters Pemphigus Peripheral atherosclerotic disease Pituitary microadenomas R565 R20 R70 R170 R20 R40 R320 R8 000 R Other immunosuppressive agents - Azathioprine Aspirin Cardiovascular Antithrombotic agents - Vitamin K antagonists Selective calcium channel blockers with mainly vascular effects Antithrombotic agents - Dipyridamole Thyroid hormones Androgens - 3-Oxoandrosten (4) Anterior pituitary hormones - Somatropin and somatropin agonists Hypothalamic hormones - Antigrowth hormone Non-CDL condition Pituitary microadenomas Polyarteritis nodosa Post traumatic stress disorder Psoriatic arthritis Pulmonary intestinal fibrosis Chronic Drug Amount R610 R1 520 R565 R650 R5 R315 R65 R740 R530 R460 or medicine Gynaecologicals - Prolactine inhibitors Posterior pituitary hormones - Vasopressin and analogues Antirheumatic agents - Chloroquine Other immunosuppressive agents - Methotrexate Other immunosuppressive agents - Azathioprine Intestinal anti-inflammatories - Aminosalicylic acid and similar agents Folic acid and Antidepressants SSRIs Antidepressants - Tricyclics Antidepressants MAOIs - Non-selective Other antidepressants - Noradrenergic and specific serotonergic agents - Mianserin Other antidepressants - Augmenters - Trazodone R410 Other antidepressants - Noradrenergic and specific serotonergic agents - Mirtazapine R370 Other antidepressants - Norepinephrine-Dopamine re-uptake inhibitors - Bupropion R495 Other antidepressants Serotonin - Norepinephrine re-uptake inhibitors - Venlafaxine R510 Other antidepressants - Norepinephrine re-uptake inhibitors - Reboxetine R350 Other antidepressants - Serotonin-Norepinephrine re-uptake inhibitors - Duloxetine R720 Other antidepressants - Melatonergic agents - Agomelatine Antirheumatic agents Chloroquine R50 R40 R285 R300 R75 R50 R25 R565 R650 R5 R30 R250 R315 R360 R185 R565 Other immunosuppressive agents - Methotrexate Anti-inflammatory agents - Acetic acid and related substances Anti-inflammatory agents - Butylpyrazolidines Anti-inflammatory agents - Coxibs Anti-inflammatory agents - Fenamates Anti-inflammatory agents - Other anti-inflammatory and antirheumatic agents, non-steroids Anti-inflammatory agents - Oxicams Anti-inflammatory agents - Propionic acid Other immunosuppressive agents - Azathioprine Intestinal anti-inflammatories - Aminosalicylic acid and similar agents Folic acid and Adrenergics - Short -acting - Salbutamol Antirheumatic agents - Chloroquine Other immunosuppressive agents - Methotrexate Alkylating agents - Nitrogen mustard analogues Inhaled glucocorticoids Adrenergics Long-acting - Salmeterol Inhaled anticholinergics - Ipratropium bromide Other immunosuppressive agents - Azathioprine Page 26 of 27 07/2013

27 Non-CDL condition Pulmonary intestinal fibrosis Chronic Drug Amount R650 R5 or medicine Quadriplegia R20 Aspirin Cardiovascular R70 R290 R160 R280 R315 R295 R50 R40 R285 R300 R75 R50 R25 R65 R330 R495 R740 R490 R200 R530 R460 Intestinal anti-inflammatories - Aminosalicylic acid and similar agents Folic acid and Antithrombotic agents - Vitamin K antagonists H2-receptor antagonists Anticholinergic agents - Tertiary amines Antiepileptics - Hydantoin Proton pump inhibitors Drugs for constipation Antidepressants SSRIs Antipsychotics - Lithium Anti-inflammatory agents - Acetic acid and related substances Anti-inflammatory agents - Butylpyrazolidines Anti-inflammatory agents - Coxibs Anti-inflammatory agents - Fenamates Anti-inflammatory agents - Other anti-inflammatory and anti-rheumatic agents, non-steroids Anti-inflammatory agents - Oxicams Anti-inflammatory agents - Propionic acid Antidepressants - Tricyclics Antiepileptics - Carboxamide Antiepileptics - Fatty acid Antidepressants MAOIs - Non-selective Antiepileptics - Succinimide Antibacterial agents, systemic Other antidepressants - Noradrenergic and specific serotonergic agents - Mianserin Other antidepressants - Augmenters - Trazodone R410 Other antidepressants - Noradrenergic and specific serotonergic agents - Mirtazapine R370 Other antidepressants Norepinephrine - Dopamine re-uptake inhibitors - Bupropion R495 Other antidepressants Serotonin - Norepinephrine re-uptake inhibitors - Venlafaxine R510 Other antidepressants - Norepinephrine re-uptake inhibitors - Reboxetine R350 Other antidepressants Serotonin - Norepinephrine re-uptake inhibitors - Duloxetine R720 Other antidepressants - Melatonergic agents - Agomelatine R400 Antiepileptics - Other agents R1 000 R900 Stoma equipment Muscle relaxants - Carbamic acid esters Stroke R20 Aspirin Cardiovascular R15 R70 R100 R170 R110 R170 R20 R190 R40 Cardiac glycosides Digoxin Antithrombotic agents - Vitamin K antagonists Ace inhibitors, Plain Selective calcium channel blockers with mainly vascular effects ACE inhibitors and Beta blocking agents, non-selective Antithrombotic agents - Dipyridamole Antithrombotic agents - Clopidogrel Antithrombotic agents - Combinations Non-CDL condition Chronic Drug Amount or medicine Stroke R90 Potassium-sparing agents Systemic sclerosis Thrombocytopaenia purpura Valvular heart disease Wegener's granulomatosis R160 R225 R900 R170 R250 R160 R50 R40 R285 R300 R75 R50 R25 R565 R1 300 R2 050 R5 R565 R5 R20 R15 R70 R100 R170 R110 R95 R90 R160 R125 R360 5 R565 R5 Vasodilators in cardiac disease - Organic nitrates Drugs for urinary frequency and incontinence Muscle relaxants - Carbamic acid esters Antirheumatic agents - Chloroquine Other immunosuppressive agents - Methotrexate Selective calcium channel blockers with mainly vascular effects Alkylating agents - Nitrogen mustard analogues Proton pump inhibitors Anti-inflammatory agents - Acetic acid and related substances Anti-inflammatory agents - Butylpyrazolidines Anti-inflammatory agents - Coxibs Anti-inflammatory agents - Fenamates Anti-inflammatory agents - Other anti-inflammatory and antirheumatic agents, non-steroids Anti-inflammatory agents - Oxicams Anti-inflammatory agents - Propionic acid Other immunosuppressive agents - Azathioprine Anti-rheumatic agents - Penicillamine and similar agents Antimetabolites - Purine analogues Folic acid and Other immunosuppressive agents - Methotrexate Other immunosuppressive agents - Azathioprine Folic acid and Aspirin - Cardiovascular Cardiac glycosides - Digoxin Antithrombotic agents- Vitamin K antagonists Ace inhibitors, Plain Selective calcium channel blockers with mainly vascular effects ACE inhibitors and Beta blocking agents and other Potassium-sparing agents Vasodilators in cardiac disease - Organic nitrates Antiadrenergic agents - Alpha-adrenoreceptor antagonists Antiarrhythmics, class III Antiarrhythmics, class Ic Other immunosuppressive agents - Methotrexate Other immunosuppressive agents - Azathioprine Folic acid and Page 27 of 27 07/2013