Chronic Illness Benefit medicine list (formulary)

Transcription

1 Chronic Illness Benefit medicine list (formulary) 2017

2 Chronic Illness Benefit 2017 Important information you need to know The Discovery Health Medical Scheme Rules set out the requirements for the Chronic Illness Benefit (CIB). The utilisation of the benefits and programmes associated with the Chronic Illness Benefit is subject to specific s and rules. Members must ensure that they are familiar with these rules and s. The scheme rules are available on Any instruction or advice we give about medicines and the management of the member s is intended as a supplement to, and not a substitute for, the knowledge, expertise, skill and judgement of the member s doctor, pharmacist or other healthcare professional. Discovery Health Medical Scheme reserves the right to change the benefit at any time. We will communicate any changes to the way we pay medicines when we make these. The updated version of this document is available on our website at all times. The Chronic Illness Benefit (CIB) covers a comprehensive list of chronic s that includes asthma, diabetes, high cholesterol and high blood pressure. The Chronic Disease List (CDL) is a defined list of chronic s we cover according to the Prescribed s. You have full cover for approved medicine on the Scheme s medicine list or up to a set monthly Chronic Drug Amount for medicine not on the medicine list. The Chronic Drug Amount is a monthly maximum amount we pay for a class of medicine. The Chronic Drug Amount does not apply to Smart and KeyCare, you will have to pay medicine that is not on the medicine list. PAGE 2 OF 55

3 About some of the terms we use in this document There may be some terms we refer to in the document that you may not be familiar with. Here are the meanings of these terms. Terminology Benefit year Chronic Drug Amount (CDA) Description 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 2017 only. You get full cover for approved chronic medicine on our medicine list (formulary). For medicine not on the list, we cover up to a monthly rand amount called the Chronic Drug Amount (CDA). The CDA does not apply to Smart and KeyCare plans. In terms of the Medical Schemes Act of 1998 (Act No. 131 of 1998) and its Regulations, all medical schemes have to cover the costs related to the diagnosis, treatment and care of an emergency medical, a defined list of 270 diagnoses and a defined list of 27 chronic s. To access Prescribed s, there are rules that apply: Prescribed Minimum Benefit (PMB) Your medical must qualify for cover and be part of the defined list of Prescribed s The treatment needed must match the treatments in the defined benefits You must use designated service providers (DSPs) in our network. This does not apply in emergencies. However even in these cases, where appropriate and according to the rules of the Scheme, you may be transferred to a hospital or other service providers in our network, once your has stabilised. If your treatment doesn t meet the above criteria, we will pay up to 80% of the Discovery Health Rate (DHR). You will be responsible for the difference between what we pay and the actual cost of your treatment. Emergency medical Chronic Disease List (CDL) Medicine class Active ingredient An emergency medical, also referred to as an emergency, is the sudden and, at the time unexpected onset of a health that requires immediate medical and surgical treatment, where failure to provide medical or surgical treatment would result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part or would place the person s life in serious jeopardy. An emergency does not necessarily require a hospital admission. We may ask you for additional information to confirm the emergency. A defined 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 55

4 The Prescribed s Chronic Disease list (for all plan types) The PMB CDL medicine list applies to all Discovery Health Medical Scheme for the 2017 benefit year. The CDA (Chronic Drug Amount) does not apply to the KeyCare and Smart. Prescribed Addison s disease R175 R175 Systemic Corticosteroids: Hydrocortisone Hydrocortisone Covocort 10mg R110 R110 Systemic Corticosteroids: Mineralocorticoids Fludrocortisone Florinef acetate 0.1mg Asthma R170 R170 Adrenergics: Long acting - Formoterol Formoterol Foratec HFA 120 dose 12mcg/1dose R305 R440 Adrenergics: Long acting - Salmeterol R35 R35 Adrenergics: Short acting - Salbutamol Salmeterol Serevent accuhaler 60 dose 50mcg Serevent CFC free 120 dose 25mcg Salbutamol Asthavent ecohaler 200 dose 100mcg Venteze CFC free 200 dose 100mcg R95 R140 Anti-asthmatics: Systemic xanthines Theophylline Sandoz Theophylline anhydrous 200mg; 300mg R415 R415 Formoterol and Budesonide Formoterol and Budesonide Symbicord turbohaler 60 dose 160/4.5mcg; 320/9mcg Symbicord turbohaler 120 dose 160/4.5mcg Vannair 120 dose 80/4.5mcg; 160/4.5mcg R230 R230 Inhaled anticholinergics: Ipratropium bromide Ipratropium bromide Atrovent HFA 200 dose 20mcg Ipvent HFA 200 dose 40mcg/1dose R320 R370 Inhaled Glucocorticoids Beclomethasone Beceze CFC free 200 dose 100mcg Beclate 200 dose 100mcg; 200mcg Budesonide Budeflam HFA 300 dose 100mcg; 200mcg (Not available on KeyCare ) PAGE 4 OF 55

5 Asthma R320 R370 Inhaled Glucocorticoids Budesonide Inflammide novolizer complete 200mcg 200 dose (Not available on KeyCare ) Inflammide novolizer complete 100 dose Inflammide novolizer refill 200 dose Inflammide novolizer refill 100 dose Pulmicort turbuhaler 200 dose 400mcg 200mcg 400mcg 100mcg; 200mcg Ciclesonide Ciclovent 80mcg; 160mcg 60 dose (Not available on KeyCare ) Fluticasone Flixotide CFC free 50mcg; 125mcg; 250mcg 120 dose R85 R100 Nasal Corticosteroids Beclomethasone Beclate aquanase 150 dose 50mcg Clenil aqueous 200 dose 50mcg Fluticasone Flonase 120 dose 50mcg (Not available on KeyCare ) R390 R390 Salmeterol and Fluticasone Salmeterol and Fluticasone Foxair accuhaler 50/100; 50/250; 50/ dose Sereflo HFA 25/50; 25/125; 25/ dose R350 R350 Surgical item Inhaler device Dp haler device Spacer Glaxohaler R15 R15 Systemic Corticosteroids: Prednisone Prednisone Be-Tabs Prednisone 5mg Panafcort 5mg Trolic 5mg Bipolar mood disorder R110 R160 Anti-depressants: SSRI s Citalopram Adco-Talomil 20mg Arrow Citalopram 40mg Austell-Citalopram 20mg PAGE 5 OF 55

6 Bipolar mood disorder R110 R160 Anti-depressants: SSRI s Citalopram Bio Citalopram 20mg Escitalopram Accord Escitalopram 10mg; 20mg Escitalopram Be-Tabs 10mg Zitolex 10mg; 20mg Zytomil 10mg; 20mg Fluoxetine Deprozan 20mg Fluoxetine Actor Prolax Ranflocs 20mg 20mg 20mg Sertraline Dyna Sertraline 50mg; 100mg Serdep 50mg; 100mg Serlife 50mg R290 R385 Anti-epileptics: Carboxamide derivatives Carbamazepine Degranol 200mg Tegretol CR 200mg; 400mg Zeptol 200mg R490 R490 Anti-epileptics: Fatty acid derivatives Valproic acid Convulex 150mg Convulex syrup 250mg/5ml Epilim crushable Epilim sugar-free syrup Epilizine CR Eprolep CR Navalpro CR Valeptic CR 100mg 200mg/5ml 200mg; 300mg; 500mg 200mg; 300mg; 500mg 200mg; 300mg; 500mg 300mg; 500mg PAGE 6 OF 55

7 Bipolar mood disorder R310 R410 Anti-epileptics: Other agents Lamotrigine Dyna-Lamotrigine 25mg; 50mg; 100mg; 200mg Epitec 25mg; 50mg; 100mg; 200mg Lamidus Lamitor 50mg 25mg; 50mg; 100mg; 200mg R615 R945 Anti-psychotics: Clozapine R345 R345 Anti-psychotics: Lithium R590 R590 Anti-psychotics: Olanzapine Clozapine Aspen Clozapine 25mg; 100mg Cloment 25mg; 100mg Lithium Camcolit 250mg; 400mg Quilonum retard 450mg Olanzapine Olawin Olawin oradispersible Olexar Prexolan Prexolan odt Zylena 10mg R400 R400 Anti-psychotics: Phenothiazines with aliphatic sidechain Chlorpromazine Largactil 25mg; 100mg R335 R335 Anti-psychotics: Quetiapine Quetiapine Dopaquel 25mg; 100mg; 200mg; 300mg Kizofrin 25mg; 100mg; 200mg; 300mg Mylan Quetiapine 25mg; 100mg; 200mg; 300mg Psyquet 25mg; 100mg; 200mg; 300mg Quetiapine Biotech 25mg; 100mg; 200mg; 300mg Quetoser Serez Sizonorm Spec Quetiapine 25mg; 100mg; 200mg; 300mg 25mg; 100mg; 200mg; 300mg 25mg; 100mg; 200mg; 300mg 25mg; 100mg; 200mg; 300mg PAGE 7 OF 55

8 Bipolar mood disorder R515 R650 Anti-psychotics: Thioxanthene derivatives Flupenthixol Fluanxol 0.5mg; 1mg Fluanxol depot 1ml 20mg Fluanxol depot 2ml 40mg Zuclopenthixol Clopixol 2mg; 10mg Clopixol depot 200mg R585 R640 Other antipsychotics Risperidone Perizal 0.5mg; 1mg; 2mg; 3mg Risnia 0.5mg; 1mg; 2mg; 3mg Rispacor Rispevon Risponz Schizorol Zoxadon 0.5mg; 1mg; 2mg; 3mg 3mg; 4mg 1mg; 2mg; 3mg; 4mg 0.5mg 0.5mg; 1mg; 2mg Bronchiectasis R35 R35 Adrenergics: Short acting - Salbutamol R230 R230 Inhaled anticholinergics: Ipratropium bromide Salbutamol Asthavent ecohaler 200 dose 100mcg Venteze CFC free 200 dose 100mcg Ipratropium bromide Atrovent HFA 200 dose 20mcg Ipvent HFA 200 dose 40mcg/1dose R15 R15 Systemic Corticosteroids: Prednisone Prednisone Be-Tabs Prednisone 5mg Panafcort 5mg Trolic 5mg Cardiac failure R100 R125 ACE inhibitors and Enalapril and Enap co 20/12.5mg Pharmapress co 20/12.5mg Lisinopril and Adco-Zetomax co 10/12.5mg; 20/12.5mg Lisoretic 10/12.5mg; 20/12.5mg Lisozide 10/12.5mg; 20/12.5mg PAGE 8 OF 55

9 Cardiac failure R100 R125 ACE inhibitors and Lisinopril and Zestoretic 10/12.5mg; 20/12.5mg Perindopril and Bioprexum Plus 10/2.5mg Ciplasyl Plus 4/1.25mg Pearinda Plus 4/1.25mg Perindopril co Unicorn 4/1.25mg Prexum Plus 5/1.25mg R85 R120 ACE inhibitors: Plain Captopril Adco-Captomax 25mg; 50mg Bio-Captopril 25mg Mylan Captopril 25mg; 50mg Enalapril Alapren ; 20mg Enalapril Unicorn (Not available on KeyCare ) Envas (Not available on KeyCare ) 10mg; 20mg Lisinopril Austell-Lisinopril 10mg; 20mg Sinopren ; 20mg Perindopril Ciplasyl 4mg (Not available on KeyCare ) Ciplasyl 8mg Pearinda 4mg; 8mg Perindopril Unicorn 4mg Peristar 4mg; 8mg Prexum 5mg PAGE 9 OF 55

10 Cardiac failure R85 R120 ACE inhibitors: Plain Perindopril Ran-Perindopril 4mg Spec-Perindopril 4mg; 8mg Quinapril Accumax 10mg; 20mg R225 R255 Alpha and Beta blocking agents Carvedilol Carloc 6.25mg; 12.5mg; 25mg Carvedilol Unicorn 6.25mg; 12.5mg; 25mg Carvetrend Vediblok 6.25mg; 12.5mg; 25mg 6.25mg; 12.5mg; 25mg R120 R120 Angiotensin II antagonists: Combinations Losartan and Hytenza co 50/12.5mg Losaar Plus 50/12.5mg; 100/25mg Losacar co Losartan co Unicorn Netrasol co 50/12.5mg 50/12.5mg; 100/25mg 50/12.5mg; 100/25mg Zartan co 50/12.5mg Zartan co 100/25mg Valsartan and Dynaval co 80/12.5mg; 160/12.5mg; 160/25mg R85 R130 Angiotensin II antagonists: Plain Irbesartan Dynarb 150mg; 300mg Losartan Austell Losartan 100mg Ciplazar 100mg Losartan Unicorn 100mg Spec-Losartan 100mg Zartan 100mg PAGE 10 OF 55

11 Cardiac failure R95 R95 Arteriolar smooth muscle Hydrazinophthalazine derivatives Hydralazine Hyperphen 10mg; 50mg Sandoz Hydralazine 25mg R75 R80 Beta blocking Selective Bisoprolol Adco-Bisocor Bilocor Bislo Bisoprolol Unicorn Bisoprolol Zydus Mylan Bisoprolol Retocar Ziapro R25 R25 Cardiac glycosides: Digoxin R20 R40 High-ceiling Digoxin Lanoxin mg; 0.25mg Lanoxin paed syrup 0.05mg/1ml Furosemide Dino-Retic 40mg Diuresix 40mg Furobe Mylan Furosemide 40mg 40mg R15 R15 Low-ceiling : Thiazides, plain R20 R20 Low-ceiling : excluding Thiazides R110 R110 Potassium sparing agents Hydrochlorothiazide Hexazide 25mg Ridaq 12.5mg Indapamide Cipla-Indapamide 2.5mg Daptril 2.5mg Mylan Indapamide 2.5mg Spironolactone Aldactone 25mg Sandoz Spironolactone 25mg Spiractin (Not available on KeyCare ) 25mg R95 R95 Potassium supplements Potassium chloride Plenish K 600mg PAGE 11 OF 55

12 Cardiac failure R95 R95 Potassium supplements Potassium chloride Potassium Chloride Unicorn 600mg Sandoz K mg Ultipot 600mg R180 R180 Vasodilators in cardiac disease: Organic nitrates Glyceryl trinitrate Angised 0.5mg Isosorbide dinitrate Isordil 30mg Sandoz Isosorbide dinitrate Isosorbide mononitrate Elantan Elantan LA 20mg 50mg Monicor SR 60mg R90 R90 Influenza vaccines Influenza, purified antigen Influvac 0.5ml Vaxigrip single dose 0.5ml pre-filled R165 R165 Pneumococcus vaccines Pneumococcus, purified polysaccharides antigen Imovax pneumo 23 Cardiomyopathy R100 R125 ACE inhibitors and Enalapril and Enap co 20/12.5mg Pharmapress co 20/12.5mg Lisinopril and Adco-Zetomax co 10/12.5mg; 20/12.5mg Lisoretic 10/12.5mg; 20/12.5mg Lisozide 10/12.5mg; 20/12.5mg Zestoretic 10/12.5mg; 20/12.5mg Perindopril and Bioprexum Plus 10/2.5mg Ciplasyl Plus 4/1.25mg Pearinda Plus 4/1.25mg PAGE 12 OF 55

13 Cardiomyopathy R100 R125 ACE inhibitors and Perindopril and Perindopril co Unicorn 4/1.25mg Prexum Plus 5/1.25mg R85 R120 ACE inhibitors: Plain Captopril Adco-Captomax 25mg; 50mg Bio-Captopril 25mg Mylan Captopril 25mg; 50mg Enalapril Alapren ; 20mg Enalapril Unicorn (Not available on KeyCare ) Envas (Not available on KeyCare ) 10mg; 20mg Lisinopril Austell-Lisinopril 10mg; 20mg Sinopren ; 20mg Perindopril Ciplasyl 4mg (Not available on KeyCare ) Ciplasyl 8mg Pearinda 4mg; 8mg Perindopril Unicorn 4mg Peristar 4mg; 8mg Prexum 5mg Ran-Perindopril 4mg Spec-Perindopril 4mg; 8mg Quinapril Accumax 10mg; 20mg R225 R255 Alpha and Beta blocking agents Carvedilol Carloc 6.25mg; 12.5mg; 25mg Carvedilol Unicorn 6.25mg; 12.5mg; 25mg PAGE 13 OF 55

14 Cardiomyopathy R225 R255 Alpha and Beta blocking agents Carvedilol Carvetrend 6.25mg; 12.5mg; 25mg Vediblok 6.25mg; 12.5mg; 25mg R120 R120 Angiotensin II antagonists: Combinations Losartan and Hytenza co 50/12.5mg Losaar Plus 50/12.5mg; 100/25mg Losacar co Losartan co Unicorn Netrasol co 50/12.5mg 50/12.5mg; 100/25mg 50/12.5mg; 100/25mg Zartan co 50/12.5mg Zartan co 100/25mg Valsartan and Dynaval co 80/12.5mg; 160/12.5mg; 160/25mg R85 R130 Angiotensin II antagonists: Plain Irbesartan Dynarb 150mg; 300mg Losartan Austell Losartan 100mg Ciplazar 100mg Losartan Unicorn 100mg Spec-Losartan 100mg Zartan 100mg R85 R85 Anti-thrombotic Vitamin K antagonists Warfarin Cipla-Warfarin 1mg; 5mg R95 R95 Arteriolar smooth muscle Hydrazinophthalazine derivatives Hydralazine Hyperphen 10mg; 50mg Sandoz Hydralazine 25mg PAGE 14 OF 55

15 Cardiomyopathy R30 R35 Aspirin Acetylsalicylic acid Myoprin 100mg R75 R80 Beta blocking Selective Bisoprolol Adco-Bisocor Bilocor Bislo Bisoprolol Unicorn Bisoprolol Zydus Mylan Bisoprolol Retocar Ziapro R25 R25 Cardiac glycosides: Digoxin R20 R40 High-ceiling Digoxin Lanoxin mg; 0.25mg Lanoxin paed syrup 0.05mg/1ml Furosemide Dino-Retic 40mg Diuresix 40mg Furobe Mylan Furosemide 40mg 40mg R15 R15 Low-ceiling : Thiazides, plain R20 R20 Low-ceiling : excluding Thiazides R110 R110 Potassium sparing agents Hydrochlorothiazide Hexazide 25mg Ridaq 12.5mg Indapamide Cipla-Indapamide 2.5mg Daptril 2.5mg Mylan Indapamide 2.5mg Spironolactone Aldactone 25mg Sandoz Spironolactone 25mg Spiractin (Not available on KeyCare ) 25mg R95 R95 Potassium supplements Potassium chloride Plenish K 600mg Potassium Chloride Unicorn 600mg Sandoz K mg PAGE 15 OF 55

16 Cardiomyopathy R95 R95 Potassium supplements Potassium chloride Ultipot 600mg R180 R180 Vasodilators in cardiac disease: Organic nitrates Glyceryl trinitrate Angised 0.5mg Isosorbide dinitrate Isordil 30mg Sandoz Isosorbide dinitrate Isosorbide mononitrate Elantan Elantan LA 20mg 50mg Monicor SR 60mg R90 R90 Influenza vaccines Influenza, purified antigen Influvac 0.5ml Vaxigrip single dose 0.5ml pre-filled R165 R165 Pneumococcus vaccines Pneumococcus, purified polysaccharides antigen Imovax pneumo 23 Chronic obstructive pulmonary disease (COPD) R170 R170 Adrenergics: Long acting - Formoterol R35 R35 Adrenergics: Short acting - Salbutamol Formoterol Foratec HFA 120 dose 12mcg/1dose Salbutamol Asthavent ecohaler 200 dose 100mcg Venteze CFC free 200 dose 100mcg R370 R370 Adrenergics: Ultra long acting - Indacaterol Indacaterol Onbrez breezhaler 150mcg R95 R140 Anti-asthmatics: Systemic xanthines Theophylline Sandoz Theophylline anhydrous 200mg; 300mg R415 R415 Formoterol and Budesonide Formoterol and Budesonide Symbicord turbohaler 60 dose 160/4.5mcg; 320/9mcg Symbicord turbohaler 120 dose 160/4.5mcg Vannair 120 dose 80/4.5mcg; 160/4.5mcg R230 R230 Inhaled anticholinergics: Ipratropium bromide Ipratropium bromide Atrovent HFA 200 dose 20mcg Ipvent HFA 200 dose 40mcg/1dose PAGE 16 OF 55

17 Chronic obstructive pulmonary disease (COPD) R185 R185 Salbutamol and Ipratropium bromide R390 R390 Salmeterol and Fluticasone Salbutamol and Ipratropium bromide Salmeterol and Fluticasone Duolin HFA 200 dose Foxair accuhaler 50/100; 50/250; 50/ dose Sereflo HFA 25/50; 25/125; 25/ dose R786 R786 Surgical item: Oxygen concentrator Oxygen Oxygen concentrator rental R15 R15 Systemic Corticosteroids: Prednisone Prednisone Be-Tabs Prednisone 5mg Panafcort 5mg Trolic 5mg R90 R90 Influenza vaccines Influenza, purified antigen Influvac 0.5ml Vaxigrip single dose 0.5ml pre-filled Chronic renal disease R100 R125 ACE inhibitors and Enalapril and Enap co 20/12.5mg Pharmapress co 20/12.5mg Lisinopril and Adco-Zetomax co 10/12.5mg; 20/12.5mg Lisoretic 10/12.5mg; 20/12.5mg Lisozide 10/12.5mg; 20/12.5mg Zestoretic 10/12.5mg; 20/12.5mg Perindopril and Bioprexum Plus 10/2.5mg Ciplasyl Plus 4/1.25mg Pearinda Plus 4/1.25mg Perindopril co Unicorn 4/1.25mg Prexum Plus 5/1.25mg PAGE 17 OF 55

18 Chronic renal disease R85 R120 ACE inhibitors: Plain Captopril Adco-Captomax 25mg; 50mg Bio-Captopril 25mg Mylan Captopril 25mg; 50mg Enalapril Alapren ; 20mg Enalapril Unicorn (Not available on KeyCare ) Envas (Not available on KeyCare ) 10mg; 20mg Lisinopril Austell-Lisinopril 10mg; 20mg Sinopren ; 20mg Perindopril Ciplasyl 4mg (Not available on KeyCare ) Ciplasyl 8mg Pearinda 4mg; 8mg Perindopril Unicorn 4mg Peristar 4mg; 8mg Prexum 5mg Ran-Perindopril 4mg Spec-Perindopril 4mg; 8mg Quinapril Accumax 10mg; 20mg R120 R120 Angiotensin II antagonists: Combinations Losartan and Hytenza co 50/12.5mg Losaar Plus 50/12.5mg; 100/25mg Losacar co Losartan co Unicorn 50/12.5mg 50/12.5mg; 100/25mg PAGE 18 OF 55

19 Chronic renal disease R120 R120 Angiotensin II antagonists: Combinations Losartan and Netrasol co 50/12.5mg; 100/25mg Zartan co 50/12.5mg Zartan co 100/25mg Valsartan and Dynaval co 80/12.5mg; 160/12.5mg; 160/25mg R85 R130 Angiotensin II antagonists: Plain Irbesartan Dynarb 150mg; 300mg Losartan Austell Losartan 100mg Ciplazar 100mg Losartan Unicorn 100mg Spec-Losartan 100mg R215 R215 Calcium supplements Calcium carbonate Zartan 100mg B-cal R5 R5 Folic acid and derivatives Folic acid Be-Tabs Folic acid 5mg Folic acid 0.5mg R40 R40 Iron in combination with folic acid Ferrous fumarate Pregamal R525 R525 Iron, parenteral preparations Iron, parenteral preparations Cosmofer ampoule 2ml Rautevene ampoule 5ml 50mg/1ml 100mg/5ml Sucrofer 5ml 20mg/1ml Zypiron vial 5ml 20mg/1ml R3 670 R3 670 Other antianaemic preparations Darbepoetin Alfa Aranesp pre-filled syringe 0.4ml 10mcg/0.4ml Aranesp pre-filled syringe 0.5ml 20mcg/0.5ml Aranesp pre-filled syringe 0.3ml Aranesp pre-filled syringe 0.4ml 30mcg/0.3ml 40mcg/0.4ml PAGE 19 OF 55

20 Chronic renal disease R3 670 R3 670 Other antianaemic preparations Darbepoetin Alfa Aranesp pre-filled syringe 0.5ml 50mcg/0.5ml Aranesp pre-filled syringe 0.3ml 60mcg/0.3ml Erythropoietin Eprex pre-fill 2000U/0.5ml 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 2000U Repotin 1ml 4000U Methoxy polyethylene-glycolepoetin beta Mircera pre-filled syringe 0.3ml Mircera pre-filled syringe 0.3ml 30mcg/0.3ml 50mcg/0.3ml 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 R385 R385 Vitamin D and analogues Alfacalcidol One alpha 0.25mcg; 1mcg Coronary artery disease R30 R35 Aspirin Acetylsalicylic acid Myoprin 100mg R85 R200 Beta blocking Non-selective Propranolol Inderal 10mg Purbloka 10mg; 40mg R75 R80 Beta blocking Selective Atenolol B-Block 100mg Bio-Atenolol 50mg; 100mg Gulf Atenolol 50mg Gulf Atenolol 100mg Tenopress 50mg; 100mg PAGE 20 OF 55

21 Coronary artery disease R75 R80 Beta blocking Selective Atenolol Zetenol 50mg; 100mg R215 R295 Selective calcium channel blockers with direct cardiac effects Diltiazem Adco-Zildem 60mg Adco-Zildem SR 180mg; 240mg Verapamil Vasomil 40mg; 80mg Verahexal SR 240mg R100 R130 Selective calcium channel blockers with mainly vascular effects Amlodipine Amtas 5mg Amtas 10mg Austell-Amlodipine Ciplavasc 5mg Ciplavasc 10mg Gulf Amlodipine Lomanor Pendine Pharma Dynamics Amlodipine besylate Felodipine Felodipine-Hexal 10mg Plendil 2.5mg; 5mg Nifedipine Adco-Vascard SR 20mg Cipalat Retard 20mg R180 R180 Vasodilators in cardiac disease: Organic nitrates Glyceryl trinitrate Angised 0.5mg Isosorbide dinitrate Isordil 30mg Sandoz Isosorbide dinitrate Isosorbide mononitrate Elantan 20mg PAGE 21 OF 55

22 Coronary artery disease R180 R180 Vasodilators in cardiac disease: Organic nitrates Isosorbide mononitrate Elantan LA Monicor SR 50mg 60mg Crohn s disease R5 R5 Folic acid and derivatives R810 R810 Intestinal antiinflammatories: Aminosalicylic acid and similar agents Folic acid Be-Tabs Folic acid 5mg Folic acid 0.5mg Mesalazine Asacol 400mg; 500mg; 800mg Mezavant 1200mg Pentasa 500mg; 1000mg Salofalk 1000mg Olsalazine Dipentum 250mg Sulfasalazine Salazopyrin 500mg Salazopyrin EN 500mg R1 940 R1 940 Intestinal antiinflammatories: Corticosteroids Budesonide Entocord enema R690 R690 Other immunosuppressive Azathioprine Azathioprine Azamun 50mg Azathioprine PCH 50mg R250 R250 Other immunosuppressive Methotrexate Methotrexate Abitrexate 2.5mg Methotrexate 2.5mg R15 R15 Systemic Corticosteroids: Prednisone Prednisone Be-Tabs Prednisone 5mg Panafcort 5mg Trolic 5mg Diabetes insipidus R1 450 R1 700 Posterior pituitary hormones: Vasopressin and analogues Desmopressin Ddavp 0.1mg; 0.2mg Ddavp nasal spray 5ml 0.1mg/1ml PAGE 22 OF 55

23 ***Please note that an overall monthly limit applies to Insulins across the different Insulin classes*** The overall monthly limit for Priority, is R700. The overall monthly limit for is R720. Diabetes mellitus Type 1 R460 R530 Anti-diabetic Fast acting Insulins Insulin Human Biosulin r - cartridge 3ml Humulin r - cartridge 3ml; vial 10ml Insulin Lispro Humalog - cartridge 3ml; kwikpen 3ml; vial 10ml R700 R720 Anti-diabetic Intermediate or long acting combined with fast acting Insulins (Biphasic) Insulin Aspart Insulin Human Novomix 30 - flexpen 3ml Actraphane hm(ge) vial 10ml Biosulin cartridge 3ml Humulin 30/70 - cartridge 3ml; kwikpen 3ml; vial 10ml Insuman comb 30/70 - cartridge 3ml Insulin Lispro Humalog mix 25 - cartridge 3ml; vial 10ml Humalog mix 25 - kwikpen 3ml Humalog mix 50 - cartridge 3ml Humalog mix 50 - kwikpen 3ml R435 R465 Anti-diabetic Intermediate acting Insulins Insulin Human Biosulin l - cartridge 3ml Biosulin n - cartridge 3ml Humulin n - cartridge 3ml; kwikpen 3ml; vial 10ml R460 R555 Anti-diabetic Long acting Insulins Insulin Glargine Basaglar cartridge 3ml (Not available on KeyCare ) Basaglar pre-filled pen 3ml PAGE 23 OF 55

24 Diabetes mellitus Type 1 R30 R35 Aspirin Acetylsalicylic acid Myoprin 100mg R200 R280 Blood glucose monitoring agents Glucose strips Accu-chek active strips (Not available on KeyCare ) Caresens n glucose test strips 29g Fora diamond blood glucose strips Freestyle optium glucose test strips (Not available on KeyCare ) Glucocheck strips 50 s (Not available on KeyCare ) Glucoplus (Not available on KeyCare ) Glucoplus provider strips (Not available on KeyCare ) Glucose test strips easymax (Not available on KeyCare ) On-call plus ez strips Onetouch select test strips (Not available on KeyCare ) Test strips onetouch select plus (Not available on KeyCare ) R350 R350 Surgical item Lancets Lancets 50's Lancets blood collection needles loris Lancets solus v2 Needles BD microfine pen needle tw 32g 4mm BD microfine pen needle 31g 5mm BD microfine pen needle 30g 8mm Droplet pen needle 12mm x 29g Droplet pen needle 10mm x 29g Droplet pen needle 8mm x 31g Droplet pen needle 6mm x 31g Droplet pen needle 6mm x 32g PAGE 24 OF 55

25 Diabetes mellitus Type 1 R350 R350 Surgical item Needles Needle novofine Syringes BD microfine 0.3ml insulin syringe 30g 8mm BD microfine 1ml insulin syringe 30g 8mm BD microfine 1ml insulin syringe 29g 12mm Needle accufine insulin pen 8 x 30g Syringe insulin 1.0ml with 27g needle Diabetes mellitus Type 2 R65 R65 Anti-diabetic Biguanides Metformin Accord Metformin 500mg; 850mg Apex-Metformin 500mg Arrow Metformin Austell-Metformin Bigsens Diaformin Diaformin forte Diamin Diaphage Gluconorm Mengen Metchek Metforal Metformin Alkem Metored Metphage Mylan Metformin Romidab Sandoz Metformin Sandoz Metformin FCT 500mg; 850mg 500mg; 850mg 500mg; 850mg; 1000mg 500mg 850mg 500mg; 850mg 500mg; 850mg; 1000mg 500mg; 850mg 500mg; 850mg; 1000mg 500mg; 850mg 500mg; 850mg 500mg; 850mg 500mg; 850mg; 1000mg 500mg; 850mg 500mg; 850mg 500mg; 850mg; 1000mg 500mg 500mg; 850mg PAGE 25 OF 55

26 ***Please note that an overall monthly limit applies to Insulins across the different Insulin classes*** The overall monthly limit for Priority, is R700. The overall monthly limit for is R720. Diabetes mellitus Type 2 R460 R530 Anti-diabetic Fast acting Insulins Insulin Human Biosulin r - cartridge 3ml Humulin r - cartridge 3ml; vial 10ml Insulin Lispro Humalog - cartridge 3ml; kwikpen 3ml; vial 10ml R700 R720 Anti-diabetic Intermediate or long acting combined with fast acting Insulins (Biphasic) Insulin Aspart Insulin Human Novomix 30 - flexpen 3ml Actraphane hm(ge) vial 10ml Biosulin cartridge 3ml Humulin 30/70 - cartridge 3ml; kwikpen 3ml; vial 10ml Insuman comb 30/70 - cartridge 3ml Insulin Lispro Humalog mix 25 - cartridge 3ml; vial 10ml Humalog mix 25 - kwikpen 3ml Humalog mix 50 - cartridge 3ml Humalog mix 50 - kwikpen 3ml R435 R465 Anti-diabetic Intermediate acting Insulins Insulin Human Biosulin l - cartridge 3ml Biosulin n - cartridge 3ml Humulin n - cartridge 3ml; kwikpen 3ml; vial 10ml R460 R555 Anti-diabetic Long acting Insulins Insulin Glargine Basaglar cartridge 3ml (Not available on KeyCare ) Basaglar pre-filled pen 3ml PAGE 26 OF 55

27 Diabetes mellitus Type 2 R130 R130 Anti-diabetic Sulfonamides, urea derivatives Glibenclamide Bio-Glibenclamide 5mg Diacare 5mg Glycomin 5mg Sandoz Glibenclamide 5mg Gliclazide Adco-Glucomed 80mg Austell-Gliclazide Diaglucide Diaglucide MR (Not available on KeyCare ) Diaran MR Dyna Gliclazide SR Gliclazide Unicorn MR Glycron Glygard Mylan Gliclazide Sandoz Gliclazide 80mg 80mg 60mg 30mg 30mg 30mg 80mg 80mg 80mg 80mg R185 R215 Anti-diabetic Thiazolidinediones Pioglitazone Accord Pioglitazone 15mg; 30mg; 45mg Cipla-Pioglitazone 15mg; 30mg R30 R35 Aspirin Acetylsalicylic acid Myoprin 100mg R200 R280 Blood glucose monitoring agents Glucose strips Accu-chek active strips (Not available on KeyCare ) Caresens n glucose test strips 29g Fora diamond blood glucose strips Freestyle optium glucose test strips (Not available on KeyCare ) Glucocheck strips 50 s (Not available on KeyCare ) Glucoplus (Not available on KeyCare ) PAGE 27 OF 55

28 Diabetes mellitus Type 2 R200 R280 Blood glucose monitoring agents Glucose strips Glucoplus provider strips (Not available on KeyCare ) Glucose test strips easymax (Not available on KeyCare ) On-call plus ez strips Onetouch select test strips (Not available on KeyCare ) Test strips onetouch select plus (Not available on KeyCare ) R350 R350 Surgical item Lancets Lancets 50's Lancets blood collection needles loris Lancets solus v2 Needles BD microfine pen needle tw 32g 4mm BD microfine pen needle 31g 5mm BD microfine pen needle 30g 8mm Droplet pen needle 12mm x 29g Droplet pen needle 10mm x 29g Droplet pen needle 8mm x 31g Droplet pen needle 6mm x 31g Droplet pen needle 6mm x 32g Needle novofine Syringes BD microfine 0.3ml insulin syringe 30g 8mm BD microfine 1ml insulin syringe 30g 8mm BD microfine 1ml insulin syringe 29g 12mm Needle accufine insulin pen 8 x 30g Syringe insulin 1.0ml with 27g needle Dysrhythmia R620 R680 Anti-arrhythmics: class Ic Flecainide Tambocor 100mg Tambocor CR 100mg; 200mg Propafenone Rythmol 150mg; 300mg (Not available on KeyCare ) PAGE 28 OF 55

29 Dysrhythmia R445 R445 Anti-arrhythmics: class III - Amiodarone Amiodarone Arycor 100mg; 200mg Bio-Amiodarone 200mg Hexarone 100mg; 200mg R85 R85 Anti-thrombotic Vitamin K antagonists Warfarin Cipla-Warfarin 1mg; 5mg R30 R35 Aspirin Acetylsalicylic acid Myoprin 100mg R85 R200 Beta blocking Non-selective Propranolol Inderal 10mg Purbloka 10mg; 40mg Sotalol Sotahexal 80mg; 160mg R75 R80 Beta blocking Selective Atenolol B-Block 100mg Bio-Atenolol 50mg; 100mg Gulf Atenolol 50mg Gulf Atenolol 100mg Tenopress Zetenol 50mg; 100mg 50mg; 100mg R25 R25 Cardiac glycosides: Digoxin R215 R295 Selective calcium channel blockers with direct cardiac effects Digoxin Lanoxin mg; 0.25mg Lanoxin paed syrup 0.05mg/1ml Verapamil Vasomil 40mg; 80mg Verahexal SR 240mg Epilepsy R185 R285 Anti-epileptics: Benzodiazepine derivatives R290 R385 Anti-epileptics: Carboxamide derivatives Clonazepam Clonam 0.5mg; 2mg Rivotril 0.5mg; 2mg Carbamazepine Degranol 200mg Tegretol CR 200mg; 400mg Zeptol 200mg R490 R490 Anti-epileptics: Fatty acid derivatives Valproic acid Convulex 150mg Convulex syrup 250mg/5ml PAGE 29 OF 55

30 Epilepsy R490 R490 Anti-epileptics: Fatty acid derivatives Valproic acid Epilim crushable 100mg Epilim sugar-free syrup 200mg/5ml Epilizine CR Eprolep CR Navalpro CR Valeptic CR 200mg; 300mg; 500mg 200mg; 300mg; 500mg 200mg; 300mg; 500mg 300mg; 500mg R70 R70 Anti-epileptics: Hydantoin derivatives Phenytoin Phenytoin sod 100mg R310 R410 Anti-epileptics: Other agents Lamotrigine Dyna-Lamotrigine 25mg; 50mg; 100mg; 200mg Epitec 25mg; 50mg; 100mg; 200mg Lamidus Lamitor 50mg 25mg; 50mg; 100mg; 200mg Topiramate Epitoz 25mg; 50mg; 100mg R30 R30 Anti-epileptics: Barbiturates and derivatives R5 R5 Folic acid and derivatives Glaucoma R165 R205 Anti-glaucoma Carbonic anhydrase inhibitors R220 R230 Anti-glaucoma Prostaglandin analogues Phenobarbital Lethyl 30mg Sedabarb 30mg Folic acid Be-Tabs Folic acid 5mg Folic acid 0.5mg Dorzolamide Glaucopress 5ml 2% Trusopt 5ml owi 2% Bimatoprost Lumigan 0.01% Latanoprost Atana 2.5ml 50mcg/1ml Ocuprost 3ml 50mcg/1ml Xalatan 2.5ml 50mcg/1ml Travoprost Travatan 2.5ml 0.004% PAGE 30 OF 55

31 Glaucoma R235 R270 Anti-glaucoma Sympathomimetics R90 R90 Anti-glaucoma Beta blocking Timolol Brimonidine Alphagan purite 5ml 1.5mg/1ml Brimoct 5ml 2mg/1ml Timolol Glaucosan 5ml 0.5% Occumol 5ml 0.5% R265 R280 Anti-glaucoma Beta blocking Timolol, combinations Timolol, combinations Azarga 5ml Combigan 5ml 2mg/5mg Cosopt 5ml 0.5% Duotrav 2.5ml Ganfort 3ml Glaumide-co 5ml Xalacom 2.5ml Haemophilia R5 R5 Analgesics: Paracetamol Paracetamol Adco-Napamol 500mg Adco-Prolief 500mg Cetapon Painogesic 500mg 500mg R220 R220 Anti-fibrinolytics: Amino acids Tranexamic acid Tranexamic Acid Medwich 500mg R R Blood coagulation factors R1 450 R1 700 Posterior pituitary hormones: Vasopressin and analogues Coagulation factor IX Haemosolvex IX 500U Coagulation factor VIII Haemosolvate VIII 300U; 500U; 1000U Desmopressin Ddavp 0.1mg; 0.2mg Ddavp nasal spray 5ml 0.1mg/1ml Hyperlipidaemia R270 R270 Lipid modifying Fibrates R45 R55 Lipid modifying Statins Bezafibrate Dyna-Bezafibrate SR 400mg Sandoz Bezafibrate 400mg Atorvastatin Adco Atorvastatin 10mg; 20mg; 40mg Aspavor 10mg; 20mg; 40mg (Not available on KeyCare ) PAGE 31 OF 55

32 Hyperlipidaemia R45 R55 Lipid modifying Statins Atorvastatin Aspavor 80mg Astor 40mg (Not available on KeyCare ) Astor Atolip 80mg 10mg; 20mg; 40mg; 80mg Atorvastatin Unicorn 10mg; 20mg; 40mg (Not available on KeyCare ) Dynator (Not available on KeyCare ) Dynator 40mg 80mg Lestavor 10mg; 20mg; 40mg; 80mg Simvastatin Adco-Simvastatin 10mg; 20mg; 40mg Aspen Simvastatin Austell-Simvastatin Choleste Cipla-Simvastatin Simvacor Zysim 10mg; 20mg; 40mg 10mg; 20mg; 40mg 20mg; 40mg 10mg; 20mg; 40mg 40mg 10mg; 20mg; 40mg Hypertension R190 R190 ACE inhibitors and calcium channel blockers Perindopril and Amlodipine Coveram 5/5mg; 10/5mg; 5/10mg; 10/10mg R100 R125 ACE inhibitors and Enalapril and Enap co 20/12.5mg Pharmapress co 20/12.5mg Lisinopril and Adco-Zetomax co 10/12.5mg; 20/12.5mg Lisoretic 10/12.5mg; 20/12.5mg Lisozide 10/12.5mg; 20/12.5mg PAGE 32 OF 55

33 Hypertension R100 R125 ACE inhibitors and Lisinopril and Zestoretic 10/12.5mg; 20/12.5mg Perindopril and Bioprexum Plus 10/2.5mg Ciplasyl Plus 4/1.25mg Pearinda Plus 4/1.25mg Perindopril co Unicorn 4/1.25mg Prexum Plus 5/1.25mg R85 R120 ACE inhibitors: Plain Captopril Adco-Captomax 25mg; 50mg Bio-Captopril 25mg Mylan Captopril 25mg; 50mg Enalapril Alapren ; 20mg Enalapril Unicorn (Not available on KeyCare ) Envas (Not available on KeyCare ) 10mg; 20mg Lisinopril Austell-Lisinopril 10mg; 20mg Sinopren ; 20mg Perindopril Ciplasyl 4mg (Not available on KeyCare ) Ciplasyl 8mg Pearinda 4mg; 8mg Perindopril Unicorn 4mg Peristar 4mg; 8mg Prexum 5mg PAGE 33 OF 55

34 Hypertension R85 R120 ACE inhibitors: Plain Perindopril Ran-Perindopril 4mg Spec-Perindopril 4mg; 8mg Quinapril Accumax 10mg; 20mg R225 R255 Alpha and Beta blocking agents Carvedilol Carloc 6.25mg; 12.5mg; 25mg Carvedilol Unicorn 6.25mg; 12.5mg; 25mg Carvetrend Vediblok 6.25mg; 12.5mg; 25mg 6.25mg; 12.5mg; 25mg R120 R120 Angiotensin II antagonists: Combinations Losartan and Hytenza co 50/12.5mg Losaar Plus 50/12.5mg; 100/25mg Losacar co Losartan co Unicorn Netrasol co 50/12.5mg 50/12.5mg; 100/25mg 50/12.5mg; 100/25mg Zartan co 50/12.5mg Zartan co 100/25mg Valsartan and Dynaval co 80/12.5mg; 160/12.5mg; 160/25mg R85 R130 Angiotensin II antagonists: Plain Irbesartan Dynarb 150mg; 300mg Losartan Austell Losartan 100mg Ciplazar 100mg Losartan Unicorn 100mg Spec-Losartan 100mg Zartan 100mg PAGE 34 OF 55

35 Hypertension R155 R155 Anti-adrenergic Alphaadrenoreceptor antagonists Doxazosin Cardugen 1mg; 4mg R150 R150 Anti-adrenergic Methyldopa Methyldopa Hypotone 250mg Mylan Methyldopa 250mg Sandoz Methyldopa 250mg R30 R30 Anti-adrenergic Rauwolfia alkaloids Reserpine Reserpine 0.25mg R95 R95 Arteriolar smooth muscle Hydrazinophthalazine derivatives Hydralazine Hyperphen 10mg; 50mg Sandoz Hydralazine 25mg R85 R200 Beta blocking Non-selective R75 R80 Beta blocking Selective Propranolol Inderal 10mg Purbloka 10mg; 40mg Atenolol B-Block 100mg Bio-Atenolol 50mg; 100mg Gulf Atenolol 50mg Gulf Atenolol 100mg Tenopress Zetenol 50mg; 100mg 50mg; 100mg R20 R40 High-ceiling Furosemide Dino-Retic 40mg Diuresix 40mg Furobe Mylan Furosemide 40mg 40mg R15 R15 Low-ceiling : Thiazides, plain Hydrochlorothiazide Hexazide 25mg Ridaq 12.5mg PAGE 35 OF 55

36 Hypertension R20 R20 Low-ceiling : excluding Thiazides R110 R110 Potassium sparing agents Indapamide Cipla-Indapamide 2.5mg Daptril 2.5mg Mylan Indapamide 2.5mg Spironolactone Aldactone 25mg Sandoz Spironolactone 25mg Spiractin (Not available on KeyCare ) 25mg R95 R95 Potassium supplements Potassium chloride Plenish K 600mg Potassium Chloride Unicorn 600mg Sandoz K-600 Ultipot 600mg 600mg R215 R295 Selective calcium channel blockers with direct cardiac effects Diltiazem Adco-Zildem 60mg Adco-Zildem SR 180mg; 240mg Verapamil Vasomil 40mg; 80mg Verahexal SR 240mg R100 R130 Selective calcium channel blockers with mainly vascular effects Amlodipine Amtas 5mg Amtas 10mg Austell-Amlodipine Ciplavasc 5mg Ciplavasc 10mg Gulf Amlodipine Lomanor Pendine Pharma Dynamics Amlodipine besylate Felodipine Felodipine-Hexal 10mg PAGE 36 OF 55

37 Hypertension R100 R130 Selective calcium channel blockers with mainly vascular effects Felodipine Plendil 2.5mg; 5mg Nifedipine Adco-Vascard SR 20mg Cipalat Retard 20mg Hypothyroidism R45 R45 Thyroid hormones Levothyroxine sodium Euthyrox 25mcg; 50mcg; 100mcg Multiple sclerosis R80 R80 Anti-depressants: Tricyclics Amitriptyline Gulf Amitriptyline 25mg Sandoz Amitriptyline 25mg Trepiline 10mg R210 R265 Drugs for urinary frequency and incontinence Oxybutynin Lenditro 5mg Mylan Oxybutynin 5mg R R Interferons Interferon beta-1a Avonex pre-filled syringe 0.5ml 30mcg/0.5ml 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 215 R1 215 Muscle relaxants: Other centrally acting agents R15 R15 Systemic Corticosteroids: Prednisone Baclofen Bio-Baclofen 10mg Teva Baclofen 10mg Prednisone Be-Tabs Prednisone 5mg Panafcort 5mg Trolic 5mg Parkinson's disease R350 R350 Anticholinergic Tertiary amines Biperiden Akineton 2mg Lennon-Biperiden 2mg R725 R725 Dopamine agonists Pramipexole Oxpola 0.125mg; 0.25mg; 1mg PAGE 37 OF 55

38 Parkinson's disease R725 R725 Dopamine agonists Pramipexole Pramex 0.125mg; 0.25mg; 1mg Ropinirole Accord Ropinirole 0.25mg; 0.5mg; 1mg; 2mg; 5mg Requip 0.25mg; 0.5mg; 1mg; 2mg; 5mg R280 R280 Dopaminergic Adamantane derivatives Amantadine Symadin 100mg R505 R635 Levodopa and decarboxylase inhibitor Levodopa and decarboxylase inhibitor Sinemet 25/100mg; 25/250mg (Not available on KeyCare ) Teva Carbi-Levo 25/100mg; 25/250mg Rheumatoid arthritis R55 R55 Anti-inflammatory Acetic acid derivatives and related substances Diclofenac Adco-Diclofenac 50mg A-Lennon Diclofenac 25mg; 50mg Diclofenac Biotech 25mg Mylan Diclofenac Panamor AT 25mg; 50mg 50mg Indomethacin Betacin 25mg Gulf Indomethacin Methocaps 25mg 25mg R75 R95 Anti-inflammatory Oxicams Meloxicam Adco-Meloxicam 15mg Arrow Meloxicam 7.5mg (Not available on KeyCare ) Coxflam 7.5mg Flamaryx 7.5mg Flexocam Medoxicam Zydus-Meloxicam (Not available on KeyCare ) 7.5mg 7.5mg 7.5mg Piroxicam Pyrocaps 20mg Roxifen 20mg PAGE 38 OF 55

39 Rheumatoid arthritis R30 R30 Anti-inflammatory Propionic acid derivatives Ibuprofen Betaprofen 200mg Betaprofen FC 400mg Bren 400mg Ibu Ibucine Ibunate Ranfen 200mg 200mg; 400mg 200mg 400mg Naproxen Mylan Naproxen 250mg Naproscript 250mg R95 R95 Anti-rheumatic Chloroquine Chloroquine Plasmoquine 200mg R5 R5 Folic acid and derivatives R810 R810 Intestinal antiinflammatories: Aminosalicylic acid and similar agents Folic acid Be-Tabs Folic acid 5mg Folic acid 0.5mg Sulfasalazine Salazopyrin 500mg Salazopyrin EN 500mg R690 R690 Other immunosuppressive Azathioprine Azathioprine Azamun 50mg Azathioprine PCH 50mg R250 R250 Other immunosuppressive Methotrexate Methotrexate Abitrexate 2.5mg Methotrexate 2.5mg R15 R15 Systemic Corticosteroids: Prednisone Prednisone Be-Tabs Prednisone 5mg Panafcort 5mg Trolic 5mg Schizophrenia R110 R160 Anti-depressants: SSRI s Citalopram Adco-Talomil 20mg Arrow Citalopram 40mg Austell-Citalopram Bio Citalopram 20mg 20mg PAGE 39 OF 55

40 Schizophrenia R110 R160 Anti-depressants: SSRI s Escitalopram Accord Escitalopram 10mg; 20mg Escitalopram Be-Tabs 10mg Zitolex 10mg; 20mg Zytomil 10mg; 20mg Fluoxetine Deprozan 20mg Fluoxetine Actor Prolax Ranflocs 20mg 20mg 20mg Sertraline Dyna Sertraline 50mg; 100mg Serdep 50mg; 100mg Serlife 50mg R290 R385 Anti-epileptics: Carboxamide derivatives Carbamazepine Degranol 200mg Tegretol CR 200mg; 400mg Zeptol 200mg R615 R945 Anti-psychotics: Clozapine R590 R590 Anti-psychotics: Olanzapine Clozapine Aspen Clozapine 25mg; 100mg Cloment 25mg; 100mg Olanzapine Olawin Olawin oradispersible Olexar Prexolan Prexolan odt Zylena 10mg PAGE 40 OF 55

41 Schizophrenia R400 R400 Anti-psychotics: Phenothiazines with aliphatic sidechain Chlorpromazine Largactil 25mg; 100mg R335 R335 Anti-psychotics: Quetiapine Quetiapine Dopaquel 25mg; 100mg; 200mg; 300mg Kizofrin 25mg; 100mg; 200mg; 300mg Mylan Quetiapine 25mg; 100mg; 200mg; 300mg Psyquet 25mg; 100mg; 200mg; 300mg Quetiapine Biotech 25mg; 100mg; 200mg; 300mg Quetoser Serez Sizonorm Spec Quetiapine 25mg; 100mg; 200mg; 300mg 25mg; 100mg; 200mg; 300mg 25mg; 100mg; 200mg; 300mg 25mg; 100mg; 200mg; 300mg R515 R650 Anti-psychotics: Thioxanthene derivatives Flupenthixol Fluanxol 0.5mg; 1mg Fluanxol depot 1ml 20mg Fluanxol depot 2ml 40mg Zuclopenthixol Clopixol 2mg; 10mg Clopixol depot 200mg R585 R640 Other antipsychotics Risperidone Perizal 0.5mg; 1mg; 2mg; 3mg Risnia 0.5mg; 1mg; 2mg; 3mg Rispacor Rispevon Risponz Schizorol Zoxadon 0.5mg; 1mg; 2mg; 3mg 3mg; 4mg 1mg; 2mg; 3mg; 4mg 0.5mg 0.5mg; 1mg; 2mg Systemic lupus erythematosus (SLE) R55 R55 Anti-inflammatory Acetic acid derivatives and related substances Diclofenac Adco-Diclofenac 50mg A-Lennon Diclofenac 25mg; 50mg PAGE 41 OF 55

42 Systemic lupus erythematosus (SLE) R55 R55 Anti-inflammatory Acetic acid derivatives and related substances Diclofenac Diclofenac Biotech 25mg Mylan Diclofenac 25mg; 50mg Panamor AT 50mg Indomethacin Betacin 25mg Gulf Indomethacin Methocaps 25mg 25mg R75 R95 Anti-inflammatory Oxicams Meloxicam Adco-Meloxicam 15mg Arrow Meloxicam 7.5mg (Not available on KeyCare ) Coxflam 7.5mg Flamaryx 7.5mg Flexocam Medoxicam Zydus-Meloxicam (Not available on KeyCare ) 7.5mg 7.5mg 7.5mg Piroxicam Pyrocaps 20mg Roxifen 20mg R30 R30 Anti-inflammatory Propionic acid derivatives Ibuprofen Betaprofen 200mg Betaprofen FC 400mg Bren 400mg Ibu Ibucine Ibunate Ranfen 200mg 200mg; 400mg 200mg 400mg Naproxen Mylan Naproxen 250mg Naproscript 250mg PAGE 42 OF 55

43 Systemic lupus erythematosus (SLE) R95 R95 Anti-rheumatic Chloroquine Chloroquine Plasmoquine 200mg R85 R85 Anti-thrombotic Vitamin K antagonists Warfarin Cipla-Warfarin 1mg; 5mg R30 R35 Aspirin Acetylsalicylic acid Myoprin 100mg R25 R25 Emolients and protectives: Zinc products Zinc products Zinc ointment bp R5 R5 Folic acid and derivatives R690 R690 Other immunosuppressive Azathioprine Folic acid Be-Tabs Folic acid 5mg Folic acid 0.5mg Azathioprine Azamun 50mg Azathioprine PCH 50mg R250 R250 Other immunosuppressive Methotrexate Methotrexate Abitrexate 2.5mg Methotrexate 2.5mg R15 R15 Systemic Corticosteroids: Prednisone Prednisone Be-Tabs Prednisone 5mg Panafcort 5mg Trolic 5mg R25 R25 Topical Corticosteroids: Group III Betamethasone Repivate cream 0.1% Topivate cream 0.1% Vari-Betamethasone cream 0.1% Ulcerative colitis R5 R5 Folic acid and derivatives R810 R810 Intestinal antiinflammatories: Aminosalicylic acid and similar agents Folic acid Be-Tabs Folic acid 5mg Folic acid 0.5mg Mesalazine Asacol 400mg; 500mg; 800mg Mezavant 1200mg Pentasa 500mg; 1000mg Salofalk 1000mg PAGE 43 OF 55

44 Ulcerative colitis R810 R810 Intestinal antiinflammatories: Aminosalicylic acid and similar agents Olsalazine Dipentum 250mg Sulfasalazine Salazopyrin 500mg Salazopyrin EN 500mg R1 940 R1 940 Intestinal antiinflammatories: Corticosteroids Budesonide Entocord enema R690 R690 Other immunosuppressive Azathioprine Azathioprine Azamun 50mg Azathioprine PCH 50mg R250 R250 Other immunosuppressive Methotrexate Methotrexate Abitrexate 2.5mg Methotrexate 2.5mg R15 R15 Systemic Corticosteroids: Prednisone Prednisone Be-Tabs Prednisone 5mg Panafcort 5mg Trolic 5mg PAGE 44 OF 55

45 Chronic Drug Amounts for the The Chronic Drug Amounts below apply to the Executive Plan and for non-cdl s. Non-CDL Chronic Drug Amount Medicine class or medicine Ankylosing spondylitis R250 Other immunosuppressive agents - Methotrexate R95 R245 R55 R40 R335 R300 R75 R95 R30 R690 R810 R4 200 R5 Potassium supplements Systemic Corticosteroids - Betamethasone Anti-inflammatory agents - Acetic acid derivatives 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 derivatives Other immunosuppressive agents - Azathioprine Intestinal anti-inflammatories - Aminosalicylic acid and similar agents Selective immunosuppressive agents Folic acid and derivatives Behcet's disease R95 Potassium supplements R325 R245 R690 R4 200 Alkylating agents - Nitrogen mustard analogues Systemic Corticosteroids - Betamethasone Other immunosuppressive agents - Azathioprine Selective immunosuppressive agents PAGE 45 OF 55

46 Non-CDL Chronic Drug Amount Medicine class or medicine Cystic fibrosis R35 Adrenergics - Short acting - Salbutamol R95 R110 R100 R245 R300 R415 R385 R440 R650 R500 R435 R6 500 Potassium supplements Other plain vitamin preparations Sodium Chloride for nebulisation Systemic Corticosteroids - Betamethasone Drugs for constipation Mucolytics Vitamin D and analogues Adrenergics - Long acting - Salmeterol Nutritional supplements Anti-fungal agents, Systemic Anti-bacterial agents, Systemic Digestive enzymes Delusional disorder R350 Anticholinergic agents - Tertiary amines R160 R80 R640 R620 R530 R455 R425 R460 R460 Anti-depressants - SSRI's Anti-depressants - Tricyclics Anti-depressants - MAOI's - Non-selective Other anti-depressants - Noradrenergic and specific serotonergic agents - Mianserin Other anti-depressants - Augmenters - Trazodone Other anti-depressants - Noradrenergic and specific serotonergic agents - Mirtazapine Other anti-depressants - Norepinephrine-Dopamine re-uptake inhibitors - Bupropion Other anti-depressants - Serotonin-Norepinephrine re-uptake inhibitors - Venlafaxine Other anti-depressants - Serotonin-Norepinephrine re-uptake inhibitors - Desvenlafaxine R575 Other anti-depressants - Norepinephrine re-uptake inhibitors - Reboxetine PAGE 46 OF 55

47 Non-CDL Chronic Drug Amount Medicine class or medicine Delusional disorder R285 Other anti-depressants - Serotonin-Norepinephrine re-uptake inhibitors - Duloxetine R455 R400 Other anti-depressants - Vortioxetine Anti-psychotics - Phenothiazines with aliphatic side-chain Dermatopolymyositis R95 Anti-rheumatic agents - Chloroquine R250 R95 R245 R690 R4 200 R5 Other immunosuppressive agents - Methotrexate Potassium supplements Systemic Corticosteroids - Betamethasone Other immunosuppressive agents - Azathioprine Selective immunosuppressive agents Folic acid and derivatives Generalised anxiety disorder R160 Anti-depressants - SSRI's R80 R640 R620 R530 R455 R425 R460 R460 Anti-depressants - Tricyclics Anti-depressants - MAOI's - Non-selective Other anti-depressants - Noradrenergic and specific serotonergic agents - Mianserin Other anti-depressants - Augmenters - Trazodone Other anti-depressants - Noradrenergic and specific serotonergic agents - Mirtazapine Other anti-depressants - Norepinephrine-Dopamine re-uptake inhibitors - Bupropion Other anti-depressants - Serotonin-Norepinephrine re-uptake inhibitors - Venlafaxine Other anti-depressants - Serotonin-Norepinephrine re-uptake inhibitors - Desvenlafaxine R575 Other anti-depressants - Norepinephrine re-uptake inhibitors - Reboxetine R285 R455 Other anti-depressants - Serotonin-Norepinephrine re-uptake inhibitors - Duloxetine Other anti-depressants - Vortioxetine PAGE 47 OF 55

48 Non-CDL Chronic Drug Amount Medicine class or medicine Huntington's disease R285 Anti-epileptics - Benzodiazepine derivatives R70 R160 R345 R80 R385 R490 R640 R620 R620 R530 R455 R425 R460 R460 Anti-epileptics - Hydantoin derivatives Anti-depressants - SSRI's Anti-psychotics - Lithium Anti-depressants - Tricyclics Anti-epileptics - Carboxamide derivatives Anti-epileptics - Fatty acid derivatives Anti-depressants - MAOI's - Non-selective Anti-epileptics - Succinimide derivatives Other anti-depressants - Noradrenergic and specific serotonergic agents - Mianserin Other anti-depressants - Augmenters - Trazodone Other anti-depressants - Noradrenergic and specific serotonergic agents - Mirtazapine Other anti-depressants - Norepinephrine-Dopamine re-uptake inhibitors - Bupropion Other anti-depressants - Serotonin-Norepinephrine re-uptake inhibitors - Venlafaxine Other anti-depressants - Serotonin-Norepinephrine re-uptake inhibitors - Desvenlafaxine R575 Other anti-depressants - Norepinephrine re-uptake inhibitors - Reboxetine R285 Other anti-depressants - Serotonin-Norepinephrine re-uptake inhibitors - Duloxetine R455 Other anti-depressants - Vortioxetine R410 Anti-epileptics - Other agents R400 Anti-psychotics - Phenothiazines with aliphatic side-chain Isolated growth hormone deficiency in children under 18 years R9 800 Anterior Pituitary Hormones - Somatropin and somatropin agonists Major depression R350 Anticholinergic agents - Tertiary amines R70 Anti-epileptics - Hydantoin derivatives PAGE 48 OF 55

49 Non-CDL Chronic Drug Amount Medicine class or medicine Major depression R160 Anti-depressants - SSRI's R345 R800 R650 R80 R385 R490 R640 R620 R620 R530 R455 R425 R460 R460 Anti-psychotics - Lithium Anti-psychotics - Benzamides Anti-psychotics - Thioxanthene derivatives Anti-depressants - Tricyclics Anti-epileptics - Carboxamide derivatives Anti-epileptics - Fatty acid derivatives Anti-depressants - MAOI's - Non-selective Anti-epileptics - Succinimide derivatives Other anti-depressants - Noradrenergic and specific serotonergic agents - Mianserin Other anti-depressants - Augmenters - Trazodone Other anti-depressants - Noradrenergic and specific serotonergic agents - Mirtazapine Other anti-depressants - Norepinephrine-Dopamine re-uptake inhibitors - Bupropion Other anti-depressants - Serotonin-Norepinephrine re-uptake inhibitors - Venlafaxine Other anti-depressants - Serotonin-Norepinephrine re-uptake inhibitors - Desvenlafaxine R575 Other anti-depressants - Norepinephrine re-uptake inhibitors - Reboxetine R285 R460 R455 R410 Other anti-depressants - Serotonin-Norepinephrine re-uptake inhibitors - Duloxetine Other anti-depressants Melatonergic Agents - Agomelatine Other anti-depressants - Vortioxetine Anti-epileptics - Other agents Motor neurone disease R285 Anti-epileptics - Benzodiazepine derivatives R80 R625 R5 370 Anti-depressants - Tricyclics Muscle relaxants - Carbamic acid esters Other nervous system drugs PAGE 49 OF 55

50 Non-CDL Chronic Drug Amount Medicine class or medicine Muscular dystrophy and other inherited myopathies R95 R245 Potassium supplements Systemic Corticosteroids - Betamethasone R285 Anti-epileptics - Benzodiazepine derivatives R625 Muscle relaxants - Carbamic acid esters Myasthenia gravis R250 Other immunosuppressive agents - Methotrexate R95 R325 R245 R690 R1 725 R4 200 R5 Potassium supplements Alkylating agents - Nitrogen mustard analogues Systemic Corticosteroids - Betamethasone Other immunosuppressive agents - Azathioprine Parasympathomimetics - Anticholinesterases Selective immunosuppressive agents Folic acid and derivatives Obsessive compulsive disorder R350 Anticholinergic agents - Tertiary amines R70 R160 R345 R80 R385 R490 R640 R620 R620 R530 Anti-epileptics - Hydantoin derivatives Anti-depressants SSRI s Anti-psychotics - Lithium Anti-depressants - Tricyclics Anti-epileptics - Carboxamide derivatives Anti-epileptics - Fatty acid derivatives Anti-depressants MAOI s - Non-selective Anti-epileptics - Succinimide derivatives Other anti-depressants - Noradrenergic and specific serotonergic agents - Mianserin Other anti-depressants - Augmenters - Trazodone R455 R425 R460 Other anti-depressants - Noradrenergic and specific serotonergic agents - Mirtazapine Other anti-depressants - Norepinephrine-Dopamine re-uptake inhibitors - Bupropion Other anti-depressants - Serotonin-Norepinephrine re-uptake inhibitors - Venlafaxine PAGE 50 OF 55

51 Non-CDL Chronic Drug Amount Medicine class or medicine Obsessive compulsive disorder R460 Other anti-depressants - Serotonin-Norepinephrine re-uptake inhibitors - Desvenlafaxine R575 Other anti-depressants - Norepinephrine re-uptake inhibitors - Reboxetine R285 R455 R410 Other anti-depressants - Serotonin-Norepinephrine re-uptake inhibitors - Duloxetine Other anti-depressants - Vortioxetine Anti-epileptics - Other agents Osteoporosis R310 Drugs treating bone disorders - Bisphosphonates R575 R605 R310 Anti-parathyroid agents - Calcitonin preparations Selective estrogen receptor modulators Other drugs treating bone disorders Paget's disease R310 Drugs treating bone disorders - Bisphosphonates Panic disorder R160 Anti-depressants SSRI s R80 R640 R620 R530 R455 R425 R460 R460 Anti-depressants - Tricyclics Anti-depressants - MAOI s - Non-selective Other anti-depressants - Noradrenergic and specific serotonergic agents - Mianserin Other anti-depressants - Augmenters - Trazodone Other anti-depressants - Noradrenergic and specific serotonergic agents - Mirtazapine Other anti-depressants - Norepinephrine-Dopamine re-uptake inhibitors - Bupropion Other anti-depressants - Serotonin-Norepinephrine re-uptake inhibitors - Venlafaxine Other anti-depressants - Serotonin-Norepinephrine re-uptake inhibitors - Desvenlafaxine R575 Other anti-depressants - Norepinephrine re-uptake inhibitors - Reboxetine R285 R455 Other anti-depressants - Serotonin-Norepinephrine re-uptake inhibitors - Duloxetine Other anti-depressants - Vortioxetine PAGE 51 OF 55

52 Non-CDL Chronic Drug Amount Medicine class or medicine Polyarteritis nodosa R95 Anti-rheumatic agents - Chloroquine R250 R95 R245 R690 R810 R5 Other immunosuppressive agents - Methotrexate Potassium supplements Systemic Corticosteroids - Betamethasone Other immunosuppressive agents - Azathioprine Intestinal anti-inflammatories - Aminosalicylic acid and similar agents Folic acid and derivatives Post traumatic stress disorder R160 Anti-depressants - SSRI's R80 R640 R620 R530 R455 R425 R460 R460 Anti-depressants - Tricyclics Anti-depressants - MAOI's - Non-selective Other anti-depressants - Noradrenergic and specific serotonergic agents - Mianserin Other anti-depressants - Augmenters - Trazodone Other anti-depressants - Noradrenergic and specific serotonergic agents - Mirtazapine Other anti-depressants - Norepinephrine-Dopamine re-uptake inhibitors - Bupropion Other anti-depressants - Serotonin-Norepinephrine re-uptake inhibitors - Venlafaxine Other anti-depressants - Serotonin-Norepinephrine re-uptake inhibitors - Desvenlafaxine R575 Other anti-depressants - Norepinephrine re-uptake inhibitors - Reboxetine R285 R455 Other anti-depressants - Serotonin-Norepinephrine re-uptake inhibitors - Duloxetine Other anti-depressants - Vortioxetine Psoriatic arthritis R95 Anti-rheumatic agents - Chloroquine R250 R95 R245 Other immunosuppressive agents - Methotrexate Potassium supplements Systemic Corticosteroids - Betamethasone PAGE 52 OF 55

53 Non-CDL Chronic Drug Amount Medicine class or medicine Psoriatic arthritis R55 Anti-inflammatory agents - Acetic acid derivatives and related substances R40 R335 R300 R75 R95 R30 R690 R810 R5 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 derivatives Other immunosuppressive agents - Azathioprine Intestinal anti-inflammatories - Aminosalicylic acid and similar agents Folic acid and derivatives Pulmonary interstitial fibrosis R35 Adrenergics - Short acting - Salbutamol R95 R250 R95 R325 R245 R370 R440 R230 R690 R810 R5 Anti-rheumatic agents - Chloroquine Other immunosuppressive agents - Methotrexate Potassium supplements Alkylating agents - Nitrogen mustard analogues Systemic Corticosteroids - Betamethasone Inhaled Glucocorticoids Adrenergics - Long acting - Salmeterol Inhaled anticholinergics - Ipratropium bromide Other immunosuppressive agents - Azathioprine Intestinal anti-inflammatories - Aminosalicylic acid and similar agents Folic acid and derivatives Sjogren s syndrome R55 Anti-inflammatory agents - Acetic acid derivatives and related substances R40 R335 R300 Anti-inflammatory agents - Butylpyrazolidines Anti-inflammatory agents - Coxibs Anti-inflammatory agents - Fenamates PAGE 53 OF 55

54 Non-CDL Chronic Drug Amount Medicine class or medicine Sjogren s syndrome R75 Anti-inflammatory agents - Other anti-inflammatory and antirheumatic agents, non-steroids R95 R30 R95 R250 R245 R100 Anti-inflammatory agents - Oxicams Anti-inflammatory agents - Propionic acid derivatives Anti-rheumatic agents - Chloroquine Other immunosuppressive agents - Methotrexate Systemic Corticosteroids - Betamethasone Other urologicals Systemic sclerosis R95 Anti-rheumatic agents - Chloroquine R250 R95 R130 R325 R245 R205 R55 R40 R335 R300 R75 R95 R30 R690 R1 300 R1 945 R5 Other immunosuppressive agents - Methotrexate Potassium supplements Selective calcium channel blockers with mainly vascular effects Alkylating agents - Nitrogen mustard analogues Systemic Corticosteroids - Betamethasone Proton pump inhibitors Anti-inflammatory agents - Acetic acid derivatives 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 derivatives Other immunosuppressive agents - Azathioprine Anti-rheumatic agents - Penicillamine and similar agents Anti-metabolites - Purine analogues Folic acid and derivatives PAGE 54 OF 55

55 Non-CDL Chronic Drug Amount Medicine class or medicine Wegener's granulomatosis R250 Other immunosuppressive agents - Methotrexate R95 R245 R690 R5 Potassium supplements Systemic Corticosteroids - Betamethasone Other immunosuppressive agents - Azathioprine Folic acid and derivatives Contact us You can call us on or visit for more information. Complaints process We explain the complaints and dispute process on the website You may lodge a query or complaint with Discovery Health Medical Scheme by calling , ing healthinfo@discovery.co.za or by completing an online complaints form. If you are not satisfied with how your complaint was resolved, please use the website to address your complaint to the Principal Officer. If you have received a final decision from us and want to challenge it, you may lodge a formal dispute by following the disputes process detailed on the website. Discovery Health Medical Scheme is regulated by the Council for Medical Schemes. You may contact the Council at any stage of the complaints process, but we encourage you to first follow the steps above to resolve your complaint before contacting the Council. Contact details for the Council for Medical Schemes: Council for Medical Schemes Complaints Unit, Block A, Eco Glades 2 Office Park, 420 Witch- Hazel Avenue, Eco Park, Centurion 0157 complaints@medicalschemes.com PAGE 55 OF 55