CareCross Chronic Medicine Formulary 2013 Chronic application forms must accompany all first-time applications. All applications MUST include valid ICD10 codes. Risk Equalisation Fund criteria must be met. If the prescriber or patient insists on a non-formulary Product, where a therapeutic equivalent is available on the formulary, a co-pay will be levied at the point of dispensing. Reference pricing is applied. If a product is prescribed that is more expensive than the reference price, the patient will need to pay the difference in price at the point of dispensing. The examples below serve as a guide to the prescriber. Other generic products not specifically listed will be reimbursed in full if the price falls within the reference price range for that group. A clinically relevant motivation is required when prescribing any product which does not appear on this list. The formulary is subject to regular review. CareCross Health reserves the right to update and change the formulary when new information becomes available, prices change or when new medicines are released While every effort has been made to ensure that products listed are available on the market, it is possible that some products may be discontinued by the manufacturers during the course of the year. Ingredient Nappi Product Name Strength Form Restriction ADDISON'S DISEASE PRESCRIBED MINIMUM BENEFIT CHRONIC CONDITIONS The PMB is applicable to primary Addisons disease only. Please provide Practice number and name of diagnosing specialist Fludrocortisone 726540 FLORINEF ACETATE 0,1MG Hydrocortisone 716693 COVOCORT 10MG Prednisolone 800155 LENISOLONE 5MG Prednisolone 814407 CAPSOID 5MG Prednisone 818267 TROLIC 5MG Prednisone 752304 PANAFCORT 5MG Prednisone 788783 BE-S PREDNISONE 5MG
ASTHMA 402042 MASK BABY CIPLA ZZZ 454299 SPACER ZEROSTAT VT ZZZ 577802 DP HALER DEVICE ZZZ Prednisone 752304 PANAFCORT 5MG Only for severe persistent asthma (motivation required) Prednisone 788783 BE-S PREDNISONE 5MG Only for severe persistent asthma (motivation required) Prednisone 818267 TROLIC 5MG Only for severe persistent asthma (motivation required) Formoterol 704175 FORATEC DP-CAPS 12MCG CPS Will only be approved if prescribed together with an inhaled steroid Formoterol 710307 FORATEC HFA 120DOSE 12MCG/1DOSE INH Will only be approved if prescribed together with an inhaled steroid Salbutamol 700715 ASTHAVENT ECOHALER CFC-FREE 300DOSE Salbutamol 711213 VENTEZE CFC FREE 200 DOSE Salbutamol 849332 ASTHAVENT ECOHALER 200DOSE Fenoterol/ Ipratropium 707882 DUOVENT HFA 200DOSE INH Salmeterol/ Fluticasone 715189 SEREFLO 25/50 HFA 120 DOSE Beclometasone 819611 BECLATE 200DOSE 50MCG INH Beclometasone 819638 BECLATE 200DOSE 100MCG INH Beclometasone 820083 BECLATE 200DOSE 200MCG INH Budesonide 897462 BUDEFLAM HFA 300DOSE 100MCG INH Limited to 3 inhalers per year if no inhaled steroid 100MCG INH Limited to 3 inhalers per year if no inhaled steroid 100MCG INH Limited to 3 inhalers per year if no inhaled steroid 100MCG INH INH Only for Paediatric use for moderate & severe persistent asthma (motivation required)
Budesonide 897469 BUDEFLAM HFA 300DOSE 200MCG Budesonide 704176 BUDEFLAM DP-CAPS 200MCG CPS Salbutamol 775452 VENTEZE 2MG/5ML SYR only for children under 5 years Salbutamol 824186 ASTHAVENT 2MG/5ML SYR only for children under 5 years Theophylline Theophylline 788368 SANDOZ THEOPHYLLINE ANHYDROUS 788376 SANDOZ THEOPHYLLINE ANHYDROUS 200MG 300MG Theophylline 701750 ALCOPHYLLIN 26,67MG/5ML SYR BIPOLAR MOOD DISORDER Carbamazepine INH SRT SRT Please provide a report from a psychiatrist that confirms the diagnosis, based on DSM lv Diagnostic Criteria 712523 SANDOZ CARBAMAZEPINE 200MG Valproic acid 715980 CONVULEX 150MG CAP Valproic acid 715999 CONVULEX 300MG CAP Valproic acid 781568 CONVULEX 500MG CAP Valproic acid 818666 EPILIM CR 200MG SRT Valproic acid 818674 EPILIM CR 300MG SRT Valproic acid 818682 EPILIM CR 500MG SRT Lamotrigine 710887 LAMIDUS 100MG Lamotrigine 704379 EPITEC 25MG Lamotrigine 704488 LAMITOR 100MG Lamotrigine 705251 SANDOZ LAMOTRIGINE 25MG Lamotrigine 710387 DYNA-LAMOTRIGINE 25MG Lamotrigine 710388 DYNA-LAMOTRIGINE 50MG Lamotrigine 710389 DYNA-LAMOTRIGINE 100MG
Lamotrigine 710390 DYNA-LAMOTRIGINE 200MG Lamotrigine 710885 LAMIDUS 50MG Haloperidol 730327 SANDOZ HALOPERIDOL 5MG Haloperidol 730335 SANDOZ HALOPERIDOL 1,5MG Haloperidol 763411 SERENACE 0,5MG CAP Clozapine 700176 CLOMENT 25MG WCC required 6 monthly Clozapine 700178 CLOMENT 100MG WCC required 6 monthly Quetiapine 716637 QUETOSER 200MG Treatment to be initiated by a psychiatrist Quetiapine 716638 QUETOSER 300MG Treatment to be initiated by a psychiatrist Quetiapine 716051 DOPAQUEL 100MG Treatment to be initiated by a psychiatrist Quetiapine 716670 MYLAN QUETIAPINE 100MG Treatment to be initiated by a psychiatrist Quetiapine 716052 DOPAQUEL 200MG Treatment to be initiated by a psychiatrist Quetiapine 716671 MYLAN QUETIAPINE 200MG Treatment to be initiated by a psychiatrist Quetiapine 716050 DOPAQUEL 25MG Treatment to be initiated by a psychiatrist Quetiapine 716668 MYLAN QUETIAPINE 25MG Treatment to be initiated by a psychiatrist Quetiapine 716053 DOPAQUEL 300MG Treatment to be initiated by a psychiatrist Lithium 758833 QUILONUM RETARD 450MG Treatment to be initiated by a psychiatrist Lithium 712078 CAMCOLIT 250MG Treatment to be initiated by a psychiatrist Lithium 712086 CAMCOLIT 400MG Treatment to be initiated by a psychiatrist Risperidone 711511 ZOXADON 0,5MG Treatment to be initiated by a psychiatrist Risperidone 711512 ZOXADON 1MG Treatment to be initiated by a psychiatrist Risperidone 715736 SCHIZOROL 0,5MG Treatment to be initiated by a psychiatrist Risperidone 715737 SCHIZOROL 1MG Treatment to be initiated by a psychiatrist Risperidone 715738 SCHIZOROL 2MG Treatment to be initiated by a psychiatrist Risperidone 710793 RISPERIDONE HEXAL 3MG Treatment to be initiated by a psychiatrist Risperidone 711513 ZOXADON 2MG Treatment to be initiated by a psychiatrist
Amitriptyline 771996 TREPILINE 25MG Will only be approved if prescribed together with a mood stabiliser Amitriptyline 772003 TREPILINE 10MG Will only be approved if prescribed together with a mood stabiliser Amitriptyline 784230 SANDOZ AMITRIPTYLINE 25MG Will only be approved if prescribed together with a mood stabiliser Dothiepin 800198 THADEN 25MG CAP Will only be approved if prescribed together with a mood stabiliser Dothiepin 800201 THADEN 75MG Will only be approved if prescribed together with a mood stabiliser Dothiepin 816515 SANDOZ DOTHIEPIN HCL 75MG Will only be approved if prescribed together with a mood stabiliser Imipramine 724661 ETHIPRAMINE 10MG Will only be approved if prescribed together with a mood stabiliser Imipramine 724688 ETHIPRAMINE 25MG Will only be approved if prescribed together with a mood stabiliser Citalopram 705252 DEPRAMIL 40MG Will only be approved if prescribed together with a mood stabiliser Citalopram 709407 CITALOPRAM-WINTHROP 20MG Will only be approved if prescribed together with a mood stabiliser Citalopram 713583 ARROW CITALOPRAM 20MG Will only be approved if prescribed together with a mood stabiliser Escitalopram 715402 ZYTOMIL 10MG Will only be approved if prescribed together with a mood stabiliser Fluoxetine 700686 RANFLOCS 20MG CAP Will only be approved if prescribed together with a mood stabiliser Fluoxetine 703391 A-LENNON FLUOXETINE 20MG CAP Will only be approved if prescribed together with a mood stabiliser Sertraline 715935 SERDEP 100MG Will only be approved if prescribed together with a mood stabiliser
Sertraline 705420 SERDEP 50MG Will only be approved if prescribed together with a mood stabiliser BRONCHIECTASIS Doxycycline 716944 CYCLIDOX 100MG CAP Doxycycline 893402 A-LENNON DOXYCYCLINE HCL 100MG Oxytetracycline 884167 NUCOTET 250MG CAP Oxytetracycline 751987 OXYPAN 250MG CAP Oxytetracycline 787434 BE-OXYTET 250MG CAP Amoxicillin 788546 BETAMOX 500MG CAP Amoxicillin 705637 AUSTELL-AMOXICILLIN 500MG CAP CARDIAC FAILURE AND CARDIOMYOPATHY Potassium chloride 755753 PLENISH K 600MG For documented hypokalaemia Potassium chloride 702947 SANDOZ K-600 600MG For documented hypokalaemia Warfarin 709905 CIPLA-WARFARIN 5MG Warfarin 709906 CIPLA-WARFARIN 1MG Warfarin 712390 CIPLA-WARFARIN 3MG Digoxin 758280 PURGOXIN 0,25MG Digoxin 735752 LANOXIN 0,25MG Isosorbide dinitrate Isosorbide dinitrate 784206 SANDOZ ISOSORBIDE DINITRATE 784214 SANDOZ ISOSORBIDE DINITRATE 10MG 30MG Hydralazine 761400 SANDOZ HYDRALAZINE 25MG Hydralazine 761419 SANDOZ HYDRALAZINE 50MG Hydralazine 731714 HYPERPHEN 10MG CAP
Hydralazine 731722 HYPERPHEN 50MG Hydrochlorothiazide 890470 HEXAZIDE 25MG Furosemide 857769 MYLAN FUROSEMIDE 40MG Furosemide 731668 SANDOZ FUROSEMIDE 40MG Furosemide 758272 PURESIS 40MG Spironolactone 765910 SPIRACTIN 25MG Spironolactone 769665 SANDOZ SPIRONOLACTONE 25MG Bisoprolol 703914 ADCO-BISOCOR 10MG Bisoprolol 703913 ADCO-BISOCOR 5MG Bisoprolol 715274 ZIAPRO 5MG Bisoprolol 715276 ZIAPRO 10MG Carvedilol 710340 ASPEN CARVEDILOL 25MG Carvedilol 704672 CARVETREND 25MG Captopril 852619 MYLAN CAPTOPRIL 25MG Captopril 899429 MYLAN CAPTOPRIL 50MG Captopril 836451 ADCO-CAPTOMAX 25MG Captopril 836478 ADCO-CAPTOMAX 50MG Enalapril 867861 HR-ENALAPRIL 20MG Enalapril 868914 PHARMAPRESS 10MG Enalapril 881473 ALAPREN 5MG Enalapril 881481 ALAPREN 10MG Enalapril 881503 ALAPREN 20MG Enalapril 894316 CIPLATEC 5MG Enalapril 894324 CIPLATEC 10MG Enalapril 708109 PHARMAPRESS 5MG
Enalapril 701729 CIPLATEC 20MG Enalapril 712762 ENVAS 5MG Enalapril 712763 ENVAS 10MG Perindopril 715795 CIPLASYL 8 8MG Perindopril 715786 CIPLASYL 4 4MG Perindopril 714527 PEARINDA 4MG Perindopril 714528 PEARINDA 8MG Losartan 709964 ZARTAN 100MG Losartan 709225 ZARTAN 50MG Motivation required - please specify Losartan 709909 LOSARTAN-WINTHROP 50MG Motivation required - please specify Losartan 709924 LOS-ARB 50MG Motivation required - please specify Telmisartan 714249 PRITOR 40MG Motivation required - please specify Telmisartan 714250 PRITOR 80MG Motivation required - please specify Valsartan 715555 ZOMEVEK 80MG Motivation required - please specify Valsartan 715556 ZOMEVEK 160MG Motivation required - please specify Valsartan 704696 TAREG 160MG Motivation required - please specify
Valsartan 705060 TAREG 80MG Motivation required - please specify Pneumococcal vaccine 836699 IMOVAX PNEUMO 23 VAC Once only Acetylsalicylic acid 798533 BE-S ASPIRIN (WHITE) 300MG Acetylsalicylic acid 700909 GULF ASPIRIN 300MG Acetylsalicylic acid 808261 ASPIRIN JUNIOR 60MG CHRONIC OBSTRUCTIVE PULMONARY DISEASE Please attach a lung function test report (The REF Entry criteria are in line with the GOLD classification) 454299 SPACER ZEROSTAT VT ZZZ For use with Cipla Medpro Inhalers 577802 DP HALER DEVICE ZZZ For use with Cipla Medpro DP caps Prednisone 788783 BE-S PREDNISONE 5MG Prednisone 818267 TROLIC 5MG Prednisone 752304 PANAFCORT 5MG Formoterol 704175 FORATEC DP-CAPS 12MCG CPS Salbutamol 849332 ASTHAVENT ECOHALER 200DOSE Salbutamol 711213 VENTEZE CFC FREE 200 DOSE Salbutamol 700715 ASTHAVENT ECOHALER CFC-FREE 300DOSE 100MCG 100MCG 100MCG Fenoterol / Ipratropium 707882 DUOVENT HFA 200DOSE INH Beclometasone 819611 BECLATE 200DOSE 50MCG INH For Stage ll & lll COPD only Beclometasone 819638 BECLATE 200DOSE 100MCG INH For Stage ll & lll COPD only Beclometasone 820083 BECLATE 200DOSE 200MCG INH For Stage ll & lll COPD only INH INH INH
Budesonide 897462 BUDEFLAM HFA 300DOSE Budesonide 897469 BUDEFLAM HFA 300DOSE 100MCG INH For Stage ll & lll COPD only 200MCG INH For Stage ll & lll COPD only Budesonide 704176 BUDEFLAM DP-CAPS 200MCG CPS For Stage ll & lll COPD only Ipratropium bromide 715574 IPVENT HFA 200 DOSE 40MCG/1DOSE INH Theophylline 788368 SANDOZ THEOPHYLLINE ANHYDROUS 200MG Theophylline 788376 SANDOZ THEOPHYLLINE 300MG SRT CHRONIC RENAL FAILURE Creatinine clearance required Calcium carbonate 771066 TITRALAC Alfacalcidol 750654 ONE ALPHA 0,25MCG CAP Alfacalcidol 750662 ONE ALPHA 1MCG CAP Potassium chloride 755753 PLENISH K 600MG For documented hypokalaemia Potassium chloride 702947 SANDOZ K-600 600MG For documented hypokalaemia Saccharated iron oxide 873276 VENOFER 20MG/1ML INJ Motivation and Hb and iron studies required Ferrous fumarate 756571 PREGAMAL Various combinations 705853 AUTRIN CAP Various combinations 727024 FOLIGLOBIN Motivation and Hb and iron studies required Various combinations 897329 GULF FERROUS SULPHATE COMPOUND Folic acid 810967 BE-S FOLIC ACID 5MG Erythropoietin 820741 EPREX PREFILL 4000U/0,4ML INJ Motivation and Hb and iron studies required Erythropoietin 837318 EPREX PREFILL 2000U/0,5ML INJ Motivation and Hb and iron studies required SRT
Erythropoietin 704630 RECORMON 6000 IU/0. PRE-FILLED SYRIN Erythropoietin Erythropoietin 704772 RECORMON 2000 PRE- FILLED SYRINGE 704631 RECORMON 4000 IU/0. PREFILLED SYRINGE Hydrochlorothiazide 890470 HEXAZIDE 25MG Furosemide 857769 MYLAN FUROSEMIDE 40MG Furosemide 731668 SANDOZ FUROSEMIDE 40MG Furosemide 758272 PURESIS 40MG 6000IU INJ Motivation and Hb and iron studies required 2000UNIT INJ Motivation and Hb and iron studies required 4000U/0, INJ Motivation and Hb and iron studies required Propranolol 758140 PURBLOKA 10MG Fourth line agents for hypertension as per SA Hypertension Guidelines 2006 Propranolol 758167 PURBLOKA 40MG Fourth line agents for hypertension as per SA Hypertension Guidelines 2006 Propranolol 806552 INDOBLOK 10MG Fourth line agents for hypertension as per SA Hypertension Guidelines 2006 Propranolol 806560 INDOBLOK 40MG Fourth line agents for hypertension as per SA Hypertension Guidelines 2006 Atenolol 806889 HEXA-BLOK 50MG Fourth line agents for hypertension as per SA Hypertension Guidelines 2006 Atenolol 787892 SANDOZ ATENOLOL 50MG Fourth line agents for hypertension as per SA Hypertension Guidelines 2006 Atenolol 787914 SANDOZ ATENOLOL 100MG Fourth line agents for hypertension as per SA Hypertension Guidelines 2006 Atenolol 826898 BIO-ATENOLOL (WAS IVAX-ATENOLOL) 50MG Fourth line agents for hypertension as per SA Hypertension Guidelines 2006 Atenolol 705872 TENOPRESS 25MG Fourth line agents for hypertension as per SA Hypertension Guidelines 2006 Atenolol 705873 TENOPRESS 100MG Fourth line agents for hypertension as per SA Hypertension Guidelines 2006
Bisoprolol 703913 ADCO-BISOCOR 5MG Fourth line agents for hypertension as per SA Hypertension Guidelines 2006 Bisoprolol 703914 ADCO-BISOCOR 10MG Fourth line agents for hypertension as per SA Hypertension Guidelines 2006 Bisoprolol 715276 ZIAPRO 10MG Fourth line agents for hypertension as per SA Hypertension Guidelines 2006 Bisoprolol 715274 ZIAPRO 5MG Fourth line agents for hypertension as per SA Hypertension Guidelines 2006 Verapamil 700071 VERAHEXAL 240 SR 240MG SRT Captopril 836478 ADCO-CAPTOMAX 50MG Captopril 836451 ADCO-CAPTOMAX 25MG Captopril 852619 MYLAN CAPTOPRIL 25MG Captopril 899429 MYLAN CAPTOPRIL 50MG Enalapril 881473 ALAPREN 5MG Enalapril 881481 ALAPREN 10MG Enalapril 881503 ALAPREN 20MG Enalapril 867861 HR-ENALAPRIL 20MG Enalapril 868914 PHARMAPRESS 10MG Enalapril 894316 CIPLATEC 5MG Enalapril 894324 CIPLATEC 10MG Enalapril 701729 CIPLATEC 20MG Enalapril 708109 PHARMAPRESS 5MG Enalapril 712762 ENVAS 5MG Enalapril 712763 ENVAS 10MG Perindopril 715786 CIPLASYL 4 4MG Perindopril 715795 CIPLASYL 8 8MG Perindopril 714527 PEARINDA 4MG
Perindopril 714528 PEARINDA 8MG Losartan 709225 ZARTAN 50MG Motivation required - please specify Losartan 709909 LOSARTAN-WINTHROP 50MG Motivation required - please specify Losartan 709924 LOS-ARB 50MG Motivation required - please specify Losartan 709964 ZARTAN 100MG Motivation required - please specify Telmisartan 714249 PRITOR 40MG Motivation required - please specify Telmisartan 714250 PRITOR 80MG Motivation required - please specify Valsartan 715555 ZOMEVEK 80MG Motivation required - please specify Valsartan 715556 ZOMEVEK 160MG Motivation required - please specify Valsartan 704696 TAREG 160MG Motivation required - please specify Valsartan 705060 TAREG 80MG Motivation required - please specify
CORONARY ARTERY DISEASE Stress ECG report & details of history of previous cardiovascular events (if applicable) is required Warfarin 709905 CIPLA-WARFARIN 5MG Warfarin 709906 CIPLA-WARFARIN 1MG Warfarin 712390 CIPLA-WARFARIN 3MG Isosorbide dinitrate Isosorbide dinitrate Isosorbide dinitrate 784192 SANDOZ ISOSORBIDE DINITRATE 784206 SANDOZ ISOSORBIDE DINITRATE 784214 SANDOZ ISOSORBIDE DINITRATE 5MG 10MG 30MG Propranolol 758140 PURBLOKA 10MG Propranolol 758167 PURBLOKA 40MG Propranolol 806552 INDOBLOK 10MG Propranolol 806560 INDOBLOK 40MG Atenolol 806889 HEXA-BLOK 50MG Atenolol 826898 BIO-ATENOLOL (WAS IVAX-ATENOLOL) 50MG Atenolol 787892 SANDOZ ATENOLOL 50MG Atenolol 787914 SANDOZ ATENOLOL 100MG Atenolol 705872 TENOPRESS 25MG Atenolol 705873 TENOPRESS 100MG Bisoprolol 703913 ADCO-BISOCOR 5MG Bisoprolol 703914 ADCO-BISOCOR 10MG Bisoprolol 715276 ZIAPRO 10MG Bisoprolol 715274 ZIAPRO 5MG Amlodipine 708141 ALMADIN 5MG SLT
Amlodipine 708142 ALMADIN 10MG Amlodipine 707979 PENDINE 5MG Amlodipine 707980 PENDINE 10MG Nifedipine 711682 FEDALOC SR 30MG SRT Nifedipine 711714 FEDALOC SR 60MG SRT Nifedipine 715000 MACOREL SR 30MG SRT Nifedipine 715001 MACOREL SR 60MG SRT Nifedipine 829501 NIFEDALAT 20SR 20MG SRT Nifedipine 864153 CIPALAT RETARD 20MG Verapamil 700071 VERAHEXAL 240 SR 240MG SRT Diltiazem 839183 ADCO-ZILDEM SR 180MG SRC Diltiazem 839191 ADCO-ZILDEM SR 240MG SRC Diltiazem 822213 ADCO-ZILDEM 60MG Diltiazem 824364 ADCO-ZILDEM 90MG Acetylsalicylic acid 808261 ASPIRIN JUNIOR 60MG Acetylsalicylic acid 700909 GULF ASPIRIN 300MG Acetylsalicylic acid 798533 BE-S ASPIRIN 300MG CROHN'S DISEASE Practice number and name of the diagnosing specialist (physician or gastroenterologist) required. Mesalazine 783668 ASACOL 400MG Treatment to be initiated by a specialist Mesalazine 824135 ASACOL 500MG SUP Treatment to be initiated by a specialist Mesalazine 890775 PENTASA 500MG Treatment to be initiated by a specialist Olsalazine 792519 DIPENTUM 250MG CAP Treatment to be initiated by a specialist Sulfasalazine 762008 SALAZOPYRIN 500MG Treatment to be initiated by a specialist Folic acid 810967 BE-S FOLIC ACID 5MG Treatment to be initiated by a specialist Prednisone 752304 PANAFCORT 5MG Treatment to be initiated by a specialist
Prednisone 788783 BE-S PREDNISONE 5MG Treatment to be initiated by a specialist Prednisone 818267 TROLIC 5MG Treatment to be initiated by a specialist Ciprofloxacin Ciprofloxacin Ciprofloxacin Ciprofloxacin 704351 AUSTELL CIPROFLOXACIN 704353 AUSTELL CIPROFLOXACIN 700284 CPL ALLIANCE CIPROFLOXACIN 700287 CPL ALLIANCE CIPROFLOXACIN 500MG Treatment to be initiated by a specialist 250MG Treatment to be initiated by a specialist 250MG Treatment to be initiated by a specialist 500MG Treatment to be initiated by a specialist Azathioprine 712609 AZATHIOPRINE PCH 50MG Treatment to be initiated by a specialist Azathioprine 700777 ZAPRINE 50MG Treatment to be initiated by a specialist Methotrexate 712504 ABITREXATE (WAS EMTHEXATE) 2,5MG Treatment to be initiated by a specialist Methotrexate 742465 METHOTREXATE 2,5MG Treatment to be initiated by a specialist Metronidazole 707241 BIO-METRONIDAZOLE 200MG Treatment to be initiated by a specialist Metronidazole 707242 BIO-METRONIDAZOLE 400MG Treatment to be initiated by a specialist Metronidazole 793159 METAZOL 200MG Treatment to be initiated by a specialist Metronidazole 793167 METAZOL 400MG Treatment to be initiated by a specialist DIABETES INSIPIDUS Please provide the practice number and name of the diagnosing specialist (physician, paediatrician or endocrinologist) Desmopressin 703639 DDAVP 0,2MG Treatment to be initiated by a specialist Desmopressin 717746 DDAVP 2.5ML NOD Treatment to be initiated by a specialist Desmopressin 837555 DDAVP NASAL SPRAY 5ML 0,1MG/1ML NSS Treatment to be initiated by a specialist Desmopressin 837563 DDAVP 0,1MG Treatment to be initiated by a specialist
DIABETES MELLITUS TYPE 1 Test strips 491915 CONTOUR TS GLUCOSE TEST STRIPS Lancets 605351 GLUCOCHECK LANCETS ZZZ Test strips 667990 GLUCOCHECK STRIPS 50S Insulin (human) 712767 BIOSULIN R CARTRIDGE 100U/1ML INJ Insulin aspart 897767 NOVORAPID FLEXPEN PENSET 100U/1ML Insulin aspart 897775 NOVORAPID PENFILL 100U/1ML INJ Insulin glulisine 709861 APIDRA SOLOSTAR DISPOSABLE PENS 100U/1ML Insulin lispro 853445 HUMALOG PENSET 100U/1ML INJ Insulin lispro 862355 HUMALOG CARTRIDGE 100U/1ML INJ Insulin (human) 853453 HUMULIN N KWICKPEN 100U/1ML INJ Insulin (human) 700183 PROTAPHANE FLEXPEN 100U/1ML INJ Insulin (human) 712768 BIOSULIN N CARTRIDGE 100U/1ML INJ Insulin (human) 712769 BIOSULIN L CARTRIDGE 100U/1ML INJ Insulin (human) 863556 HUMULIN N CARTRIDGE 100U/1ML INJ Insulin (human) 704456 HUMULIN 30/70 KWIKPEN Insulin (human) 710299 INSUMAN COMB 30/70 CARTRIDGE Insulin (human) Insulin (human) 714977 ACTRAPHANE HM (GE) FLEXPEN 816213 ACTRAPHANE HM(GE) PENSET 3.0ML 100U/1ML 100U/1ML 100U/1ML 100U/1ML Insulin (human) 712770 BIOSULIN 30-70 100U/1ML INJ STR ZZZ INJ INJ INJ INJ INJ INJ
CARTRIDGE Insulin (human) 863572 HUMULIN 30/70 CARTRIDGE 100U/1ML Insulin aspart 702086 NOVOMIX 30 FLEXPEN 100U/1ML INJ Insulin aspart 702089 NOVOMIX 30 PENFILL 100U/1ML INJ Insulin lispro 853461 HUMALOG MIX 25 PENSET Insulin lispro 861782 HUMALOG MIX 25 CARTRIDGE DIABETES MELLITUS TYPE 2 100U/1ML 100U/1ML INJ INJ INJ Insulin only for patients who are uncontrolled on oral agents Lancets 605351 GLUCOCHECK LANCETS ZZZ Test strips Test strips 667990 GLUCOCHECK STRIPS 50S 491915 CONTOUR TS GLUCOSE TEST STRIPS Insulin (human) 712767 BIOSULIN R CARTRIDGE 100U/1ML INJ Insulin aspart 897767 NOVORAPID FLEXPEN PENSET 100U/1ML Insulin aspart 897775 NOVORAPID PENFILL 100U/1ML INJ Insulin glulisine 709861 APIDRA SOLOSTAR DISPOSABLE PENS 100U/1ML Insulin lispro 853445 HUMALOG PENSET 100U/1ML INJ Insulin lispro 862355 HUMALOG CARTRIDGE 100U/1ML INJ Insulin (human) 853453 HUMULIN N KWICKPEN 100U/1ML INJ Insulin (human) 863556 HUMULIN N CARTRIDGE 100U/1ML INJ Insulin (human) 700183 PROTAPHANE FLEXPEN 100U/1ML INJ Insulin (human) 712769 BIOSULIN L CARTRIDGE 100U/1ML INJ Insulin (human) 712768 BIOSULIN N CARTRIDGE 100U/1ML INJ ZZZ STR INJ INJ
Insulin (human) 712770 BIOSULIN 30-70 CARTRIDGE Insulin (human) 704456 HUMULIN 30/70 KWIKPEN Insulin (human) 863572 HUMULIN 30/70 CARTRIDGE Insulin (human) 816213 ACTRAPHANE HM(GE) PENSET 3.0ML Insulin (human) 710299 INSUMAN COMB 30/70 CARTRIDGE Insulin (human) 714977 ACTRAPHANE HM (GE) FLEXPEN 100U/1ML 100U/1ML 100U/1ML 100U/1ML 100U/1ML 100U/1ML Insulin aspart 702086 NOVOMIX 30 FLEXPEN 100U/1ML INJ Insulin aspart 702089 NOVOMIX 30 PENFILL 100U/1ML INJ Insulin lispro 853461 HUMALOG MIX 25 PENSET Insulin lispro 861782 HUMALOG MIX 25 CARTRIDGE 100U/1ML 100U/1ML Metformin 709246 METPHAGE 500MG Fasting glucose results may be requested if prescribed as a single agent Metformin 709247 METPHAGE 850MG Fasting glucose results may be requested if prescribed as a single agent Metformin 897957 MYLAN METFORMIN 500MG Fasting glucose results may be requested if prescribed as a single agent Metformin 897961 MYLAN METFORMIN 850MG Fasting glucose results may be requested if prescribed as a single agent Glibenclamide 781258 SANDOZ GLIBENCLAMIDE Glibenclamide 894502 DIACARE 5MG Gliclazide 834599 ADCO-GLUCOMED 80MG 5MG INJ INJ INJ INJ INJ INJ INJ INJ
Gliclazide 834866 SANDOZ GLICLAZIDE 80MG Gliclazide 868906 DIAGLUCIDE 80MG Gliclazide 700717 GLYGARD 80MG Gliclazide 716953 DYNA GLICLAZIDE SR 30MG SRT Pioglitazone 707974 CIPLA-PIOGLITAZONE 15MG Motivation Required Pioglitazone 707981 CIPLA-PIOGLITAZONE 30MG Motivation Required CARDIAC DYSRHYTHMIAS Please provide a specific diagnosis and /or the relevant ICD10 code Warfarin 709905 CIPLA-WARFARIN 5MG Warfarin 709906 CIPLA-WARFARIN 1MG Warfarin 712390 CIPLA-WARFARIN 3MG Digoxin 735752 LANOXIN 0,25MG Digoxin 758280 PURGOXIN 0,25MG Quinidine 758868 QUINIDINE SULPH 200MG Amiodarone 703513 ARYCOR 200MG Amiodarone 703515 ARYCOR 100MG Amiodarone 863157 HEXARONE 100MG Amiodarone 863165 HEXARONE 200MG Propranolol 806552 INDOBLOK 10MG Propranolol 806560 INDOBLOK 40MG Propranolol 758140 PURBLOKA 10MG Propranolol 758167 PURBLOKA 40MG Atenolol 705872 TENOPRESS 25MG Atenolol 705873 TENOPRESS 100MG Atenolol 806889 HEXA-BLOK 50MG Atenolol 787892 SANDOZ ATENOLOL 50MG
Atenolol 787914 SANDOZ ATENOLOL 100MG Atenolol EPILEPSY 826898 BIO-ATENOLOL (WAS IVAX-ATENOLOL) 50MG Bisoprolol 703913 ADCO-BISOCOR 5MG Bisoprolol 703914 ADCO-BISOCOR 10MG Bisoprolol 715276 ZIAPRO 10MG Bisoprolol 715274 ZIAPRO 5MG Verapamil 700071 VERAHEXAL 240 SR 240MG SRT Verapamil 774944 VASOMIL 40MG Verapamil 774952 VASOMIL 80MG Diltiazem 839183 ADCO-ZILDEM SR 180MG SRC Diltiazem 839191 ADCO-ZILDEM SR 240MG SRC Diltiazem 824364 ADCO-ZILDEM 90MG Acetylsalicylic acid 700909 GULF ASPIRIN 300MG Acetylsalicylic acid 798533 BE-S ASPIRIN (WHITE) 300MG Acetylsalicylic acid 808261 ASPIRIN JUNIOR 60MG Phenobarbital 737844 LETHYL 30MG Phenytoin 723525 EPANUTIN 100MG CAP Phenytoin 754870 PHENYTOIN SOD 100MG Ethosuximide 779105 ZARONTIN 250MG/5ML SYR Severe and uncontrolled epilepsy only, not responding to first-line agents. Motivation Required Clonazepam 761079 RIVOTRIL 0,5MG Severe and uncontrolled epilepsy only, not responding to first-line agents. Clonazepam 761087 RIVOTRIL 2MG Severe and uncontrolled epilepsy only,
Carbamazepine Carbamazepine Carbamazepine 712523 SANDOZ CARBAMAZEPINE 705597 SANDOZ CARBAMAZEPINE CR 705602 SANDOZ CARBAMAZEPINE CR 200MG 200MG 400MG SRT SRT not responding to first-line agents. Oxcarbazepine 717226 MYLAN OXCARBAZEPINE 300MG Severe and uncontrolled epilepsy only, not responding to first-line agents. Motivation Required Oxcarbazepine 717227 MYLAN OXCARBAZEPINE 600MG Severe and uncontrolled epilepsy only, not responding to first-line agents. Motivation Required Valproic acid 715980 CONVULEX 150MG CAP Valproic acid 715999 CONVULEX 300MG CAP Valproic acid 780545 EPILIM SUGAR FREE 200MG/5ML SYR Valproic acid 781541 CONVULEX 250MG/5ML SYR Valproic acid 781568 CONVULEX 500MG CAP Valproic acid 818666 EPILIM CR 200MG SRT Valproic acid 818674 EPILIM CR 300MG SRT Valproic acid 818682 EPILIM CR 500MG SRT Lamotrigine 710387 DYNA-LAMOTRIGINE 25MG Lamotrigine 710388 DYNA-LAMOTRIGINE 50MG Lamotrigine 710390 DYNA-LAMOTRIGINE 200MG Lamotrigine 704379 EPITEC 25MG Lamotrigine 704488 LAMITOR 100MG Lamotrigine 705251 SANDOZ LAMOTRIGINE 25MG Lamotrigine 705441 ASPEN LAMOTRIGINE 100MG
GLAUCOMA Topiramate 710901 EPITOZ 100MG Severe and uncontrolled epilepsy only, not responding to first-line agents. Motivation Required Topiramate 708392 TOPLEP 200MG Severe and uncontrolled epilepsy only, not responding to first-line agents. Motivation Required Topiramate 710240 ADCO-TOPIRAMATE 25MG Severe and uncontrolled epilepsy only, not responding to first-line agents. Motivation Required Topiramate 710900 EPITOZ 50MG Severe and uncontrolled epilepsy only, not responding to first-line agents. Motivation Required Topiramate 708390 TOPLEP 50MG Severe and uncontrolled epilepsy only, not responding to first-line agents. Motivation Required Brimonidine 709410 ALPHAGAN PURITE 5ML 1,5MG/1ML OPD Pilocarpine 734179 ISOPTO CARPINE 2% 15ML Pilocarpine 734195 ISOPTO CARPINE 4% 15ML Pilocarpine 734284 ISOPTO CARPINE 1% 15ML 2% OPD 4% OPD 1% OPD Acetazolamide 789771 AZOMID 250MG Brinzolamide 701523 AZOPTIC 5ML EYE SUSPENSION 1% OPD Dorzolamide 819832 TRUSOPT 5ML OWI 2% OPD Betaxolol 708445 BETOPTIC 5ML OPD Carteolol 834335 TEOPTIC 5ML 2% OPD Levobunolol 781134 BETAGAN 7.5ML 0,5% OPD
Metipranolol 816728 BETA-OPHTIOLE 5ML 0,3% OPD Metipranolol 816736 BETA-OPHTIOLE 5ML 0,6% OPD Timolol 821624 GLAUCOSAN 5ML 0,5% OPD Timolol 819824 TIMOPTOL-XE 2.5ML 0,5% OPD Timolol 770833 TIMOPTOL 5ML 0,25% OPD Timolol, combinations 860379 COSOPT 5ML 0,5% OPD Timolol, combinations 709863 COMBIGAN 2MG/5MG 5ML Timolol, combinations 702983 XALACOM 2.5ML OPD Bimatoprost 703666 LUMIGAN 0,03% OPD Latanoprost 715961 OCUPROST 50MCG/1ML OPD Travoprost 702534 TRAVATAN 2,5ML 0,004% OPD HAEMOPHILLIA Tranexamic acid OPD Please provide laboratory reports confirming the diagnosis. Treatment to be initiated by Specialist Haematologist 714722 TRANEXAMIC ACID MEDWICH 500MG Treatment to be initiated by Specialist Haematologist Tranexamic acid 716276 TRANIC 500MG Treatment to be initiated by Specialist Haematologist Coagulation factor IX, II, VII and X in combination Coagulation factor VIII 800767 HAEMOSOLVEX IX 500U INJ Treatment to be initiated by Specialist Haematologist 813648 HAEMOSOLVATE VIII 2X10ML 1000U INJ Treatment to be initiated by Specialist Haematologist Coagulation factor VIII 841560 HAEMOSOLVATE VIII 300U INJ Treatment to be initiated by Specialist Haematologist Coagulation factor VIII 800759 HAEMOSOLVATE VIII 10ML 500U INJ Treatment to be initiated by Specialist Haematologist Desmopressin 717754 DDAVP 1ML INJ Treatment to be initiated by Specialist Haematologist
HYPERLIPIDAEMIA Treatment approval subject to criteria for Lipid Lowering Therapy being met. (For Primary prevention - Framingham score > 20%). Assessment requires completed Risk Evaluation Report as well as diagnostic & latest Lipograms Atorvastatin 716617 ATORVASTATIN WINTHROP 40MG Motivation required - please specify Atorvastatin 714373 ATOLIP 80MG Motivation required - please specify Atorvastatin Atorvastatin 716616 ATORVASTATIN WINTHROP 716615 ATORVASTATIN WINTHROP Lovastatin 703905 LOVACHOL 40MG Lovastatin 703906 LOVACHOL 20MG Simvastatin 708307 CIPLA-SIMVASTATIN 10MG Simvastatin 708308 CIPLA-SIMVASTATIN 20MG Simvastatin 701279 ADCO-SIMVASTATIN 20MG Simvastatin 701281 ADCO-SIMVASTATIN 40MG Simvastatin 710511 CIPLA-SIMVASTATIN 40MG Bezafibrate 828300 SANDOZ BEZAFIBRATE 400MG SRT Bezafibrate 710122 DYNA-BEZAFIBRATE SR 400MG SRT HYPERTENSION 20MG Motivation required - please specify 10MG Motivation required - please specify Please provide current blood pressure and blood pressure at time of diagnosis Potassium chloride 755753 PLENISH K 600MG for documented hypokalaemia only Potassium chloride 702947 SANDOZ K-600 600MG for documented hypokalaemia only Reserpine 760048 RESERPINE 0,25MG
Methyldopa 764116 SANDOZ METHYLDOPA 250MG For use in pregnancy only Methyldopa 785962 MYLAN METHYLDOPA 250MG For use in pregnancy only Methyldopa 732052 HYPOTONE 250MG For use in pregnancy only Doxazosin 714292 CARZIN XL 4MG FCR Doxazosin Doxazosin 701425 CARDUGEN (WAS MERCK-DOXAZOSIN) 701426 CARDUGEN (WAS MERCK-DOXAZOSIN) Prazosin 782122 PRATSIOL 1MG Prazosin 782130 PRATSIOL 2MG Prazosin 782149 PRATSIOL 5MG Hydralazine 731714 HYPERPHEN 10MG Hydralazine 731722 HYPERPHEN 50MG Hydralazine 761400 SANDOZ HYDRALAZINE 25MG Hydralazine 761419 SANDOZ HYDRALAZINE 50MG Hydrochlorothiazide 890470 HEXAZIDE 25MG Hydrochlorothiazide and potassium 1MG 4MG 774057 URIREX-K 50MG/300MG 50MG;300MG Indapamide 833045 DAPTRIL 2,5MG Indapamide 703329 MERCK-INDAPAMIDE 2,5MG Indapamide 710313 CIPLA-INDAPAMIDE 2,5MG Furosemide 731668 SANDOZ FUROSEMIDE 40MG Furosemide 857769 MYLAN FUROSEMIDE 40MG Furosemide 758272 PURESIS 40MG Spironolactone 765910 SPIRACTIN 25MG Spironolactone 769665 SANDOZ SPIRONOLACTONE 25MG
Amiloride Co 702803 AMILORETIC 50MG/5MG 50MG;5MG Amiloride Co 780618 ADCO-RETIC 50MG/5MG 50MG;5MG Amiloride Co 808695 BETARETIC 50MG/5MG 50MG;5MG Atenolol 705872 TENOPRESS 25MG Certain beta-blockers (e.g. atenolol) are no longer considered as routine step 1 to 3 treatment, unless there are compelling indications for their use (refer to SA Hypertension Guidelines 2006) Atenolol 705873 TENOPRESS 100MG Certain beta-blockers (e.g. atenolol) are no longer considered as routine step 1 to 3 treatment, unless there are compelling indications for their use (refer to SA Hypertension Guidelines 2006) Atenolol 826898 BIO-ATENOLOL (WAS IVAX-ATENOLOL) 50MG Certain beta-blockers (e.g. atenolol) are no longer considered as routine step 1 to 3 treatment, unless there are compelling indications for their use (refer to SA Hypertension Guidelines 2006) Atenolol 787892 SANDOZ ATENOLOL 50MG Certain beta-blockers (e.g. atenolol) are no longer considered as routine step 1 to 3 treatment, unless there are compelling indications for their use (refer to SA Hypertension Guidelines 2006) Atenolol 787914 SANDOZ ATENOLOL 100MG Certain beta-blockers (e.g. atenolol) are no longer considered as routine step 1 to 3 treatment, unless there are compelling indications for their use (refer to SA Hypertension Guidelines 2006) Atenolol 806889 HEXA-BLOK 50MG Certain beta-blockers (e.g. atenolol) are no longer considered as routine step 1 to 3 treatment, unless there are compelling indications for their use (refer to SA Hypertension Guidelines 2006)
Bisoprolol 703913 ADCO-BISOCOR 5MG Bisoprolol 703914 ADCO-BISOCOR 10MG Bisoprolol 715276 ZIAPRO 10MG Bisoprolol 715274 ZIAPRO 5MG Bisoprolol and thiazides 840300 ZIAK 2.5MG/6.25MG 2,5MG/6,25MG Motivation Required Bisoprolol and thiazides 840319 ZIAK 5MG/6.25MG 5MG;6,25MG Motivation Required Bisoprolol and thiazides 852929 ZIAK 10MG/6.25MG 10MG;6,25MG Motivation Required Atenolol and other diuretics Atenolol and other diuretics 789607 SANDOZ CO-TENIDONE 50MG/12.5MG 789615 SANDOZ CO- TENIDONE100MG/25MG Amlodipine 707979 PENDINE 5MG Amlodipine 707980 PENDINE 10MG Amlodipine 708141 ALMADIN 5MG Amlodipine 708142 ALMADIN 10MG Nifedipine 711682 FEDALOC SR 30MG SRT Nifedipine 711714 FEDALOC SR 60MG SRT Nifedipine 715000 MACOREL SR 30MG SRT Nifedipine 715001 MACOREL SR 60MG SRT Beta-blocker comb with thiazide diuretic not recommended, esp in patients with abdominal obesity and hypertension, both classes of drugs have adverse metabolic effects and increase incidence of new diabetes (ref SA Hypertension Guideline 2006) Beta-blocker comb with thiazide diuretic not recommended, esp in patients with abdominal obesity and hypertension, both classes of drugs have adverse metabolic effects and increase incidence of new diabetes (ref SA Hypertension Guideline 2006)
Nifedipine 829501 NIFEDALAT 20SR 20MG SRT Nifedipine 864153 CIPALAT RETARD 20MG Verapamil 700071 VERAHEXAL 240 SR 240MG SRT Captopril 836451 ADCO-CAPTOMAX 25MG Captopril 836478 ADCO-CAPTOMAX 50MG Captopril 852619 MYLAN CAPTOPRIL 25MG Captopril 899429 MYLAN CAPTOPRIL 50MG Enalapril 894316 CIPLATEC 5MG Enalapril 894324 CIPLATEC 10MG Enalapril 867861 HR-ENALAPRIL 20MG Enalapril 868914 PHARMAPRESS 10MG Enalapril 881473 ALAPREN 5MG Enalapril 881481 ALAPREN 10MG Enalapril 881503 ALAPREN 20MG Enalapril 701729 CIPLATEC 20MG Enalapril 708109 PHARMAPRESS 5MG Enalapril 712762 ENVAS 5MG Enalapril 712763 ENVAS 10MG Perindopril 715786 CIPLASYL 4 4MG Perindopril 715795 CIPLASYL 8 8MG Perindopril 710510 CIPLA-PERINDOPRIL 8MG Perindopril 714527 PEARINDA 4MG Perindopril 714528 PEARINDA 8MG Captopril and diuretics 839795 ZAPTO-CO 50MG/25MG 50MG;25MG Enalapril and diuretics 885019 PHARMAPRESS CO 20MG/12.5MG
Perindopril and diuretics 717782 PERINDOPRIL CO UNICORN 4MG/1.25MG Perindopril and diuretics 714952 PEARINDA PLUS 4MG/1.25MG Losartan 709225 ZARTAN 50MG Motivation required - please specify Losartan 709964 ZARTAN 100MG Motivation required - please specify Telmisartan 714249 PRITOR 40MG Motivation required - please specify Telmisartan 714250 PRITOR 80MG Motivation required - please specify Valsartan 715555 ZOMEVEK 80MG Motivation required - please specify Valsartan 715556 ZOMEVEK 160MG Motivation required - please specify Valsartan 705060 TAREG 80MG Motivation required - please specify Valsartan 704696 TAREG 160MG Motivation required - please specify Losartan and diuretics 716515 SARTOC 100MG/25MG Motivation required - please specify Losartan and diuretics 716216 ZARTAN CO Motivation required - please specify
Losartan and diuretics 50MG/12.5MG 716217 ZARTAN CO 100MG/25MG Motivation required - please specify Telmisartan and diuretics 714251 CO-PRITOR 40/12.5 MG Motivation required - please specify Telmisartan and diuretics 714252 CO-PRITOR 80/12.5MG Motivation required - please specify Valsartan and diuretics 705068 CO-TAREG 80MG/12.5MG Motivation required - please specify Valsartan and diuretics Valsartan and diuretics Valsartan and diuretics Valsartan and diuretics Valsartan and diuretics 715558 CO-ZOMEVEK 80MG/12.5MG 715559 CO-ZOMEVEK 160MG/12.5MG 715571 CO-MIGROBEN 160MG/12.5MG 715672 CO-TAREG 160MG/12.5MG 715673 CO-TAREG PLUS 160MG/25MG Motivation required - please specify Motivation required - please specify Motivation required - please specify 160/12.5MG Motivation required - please specify Motivation required - please specify HYPOTHYROIDISM
Combinations of levothyroxine and liothyronine 720224 DIOTROXIN Levothyroxine sodium 713172 EUTHYROX 25MCG Levothyroxine sodium 722944 ELTROXIN 0,05MG Levothyroxine sodium 722952 ELTROXIN 0,1MG Levothyroxine sodium 713168 EUTHYROX 50MCG Levothyroxine sodium 713169 EUTHYROX 100MCG MULTIPLE SCLEROSIS Please provide the practice number and name of the diagnosing neurologist Oxybutynin 872253 LENDITRO 5MG Second Line - After adequate trial with Tricyclic Antidepressants Azathioprine 700777 ZAPRINE 50MG Treatment to be initiated by specialist Azathioprine 712609 AZATHIOPRINE PCH 50MG Treatment to be initiated by specialist Methotrexate 712504 ABITREXATE (WAS EMTHEXATE) 2,5MG Treatment to be initiated by specialist Methotrexate 742465 METHOTREXATE 2,5MG Treatment to be initiated by specialist Baclofen 865567 BIO-BACLOFEN (WAS NORTON-BACLOFEN) 10MG Treatment to be initiated by specialist Baclofen 712607 TEVA BACLOFEN 10MG Treatment to be initiated by specialist Carbamazepine 712523 SANDOZ CARBAMAZEPINE 200MG Treatment to be initiated by specialist Amitriptyline 771996 TREPILINE 25MG Treatment to be initiated by specialist Amitriptyline 772003 TREPILINE 10MG Treatment to be initiated by specialist Amitriptyline 784230 SANDOZ AMITRIPTYLINE 25MG Treatment to be initiated by specialist PARKINSON'S DISEASE
Orphenadrine (chloride) 720542 DISIPAL 50MG Levodopa and decarboxylase inhibitor Levodopa and decarboxylase inhibitor 710286 TEVA CARBI-LEVO 25/100 710468 TEVA CARBI-LEVO 25/250 Ropinirole 700647 REQUIP 0,25MG Motivation Required Ropinirole 700650 REQUIP 0,5MG Motivation Required Ropinirole 700652 REQUIP 1MG Motivation Required Ropinirole 700655 REQUIP 2MG Motivation Required Ropinirole 700658 REQUIP 5MG Motivation Required Selegiline 706712 PARKILYNE 5MG RHEUMATOID ARTHRITIS The PMB chronic benefit only covers rheumatoid arthritis and excludes other closely related conditions. We therefore require copies of the relevant blood tests, reports and supportive clinical history confirming the diagnosis of rheumatoid arthritis. Sulfasalazine 762008 SALAZOPYRIN 500MG Sulfasalazine 762016 SALAZOPYRIN EN 500MG ECT Folic acid 810967 BE-S FOLIC ACID 5MG Prednisone 788783 BE-S PREDNISONE 5MG Prednisone 752304 PANAFCORT 5MG Prednisone 818267 TROLIC 5MG Cyclophosphamide 723274 ENDOXAN 50MG Treatment to be initiated by a specialist Azathioprine 700777 ZAPRINE 50MG Treatment to be initiated by a specialist Azathioprine 712609 AZATHIOPRINE PCH 50MG Treatment to be initiated by a specialist Methotrexate 742465 METHOTREXATE 2,5MG Treatment to be initiated by a specialist Methotrexate 712504 ABITREXATE (WAS EMTHEXATE) 2,5MG Treatment to be initiated by a specialist Diclofenac 786012 MYLAN DICLOFENAC 25MG Will only be approved if prescribed with a DMARD
Diclofenac 786020 MYLAN DICLOFENAC 50MG Will only be approved if prescribed with a DMARD Diclofenac 834327 SANDOZ DICLOFENAC SODIUM 100 SIMPLE REG 100MG SRT Will only be approved if prescribed with a DMARD Diclofenac 853240 DICLOHEXAL 25MG Will only be approved if prescribed with a DMARD Diclofenac 893390 A-LENNON DICLOFENAC 25MG Will only be approved if prescribed with a DMARD Diclofenac 893391 A-LENNON DICLOFENAC 50MG Will only be approved if prescribed with a DMARD Indometacin 704725 ARTHREXIN 25MG CAP Will only be approved if prescribed with a DMARD Indometacin 704776 SANDOZ INDOMETHACIN 25MG CAP Will only be approved if prescribed with a DMARD Indometacin 701106 ADCO-INDOMETHACIN 25MG CAP Will only be approved if prescribed with a DMARD Meloxicam 704829 FLEXOCAM 7,5MG Will only be approved if prescribed with a DMARD Meloxicam 705375 ADCO-MELOXICAM 7,5MG Will only be approved if prescribed with a DMARD Piroxicam 701072 ROXIFEN 20MG CAP Will only be approved if prescribed with a DMARD Piroxicam 797030 XYCAM 20MG CAP Will only be approved if prescribed with a DMARD Piroxicam 799432 PYROCAPS 20MG CAP Will only be approved if prescribed with a DMARD Ibuprofen 733741 INZA 200MG Will only be approved if prescribed with a DMARD Ibuprofen 701654 RANFEN 400MG Will only be approved if prescribed with a DMARD
Ibuprofen 701975 BETAPROFEN FC 400MG Will only be approved if prescribed with a DMARD Ibuprofen 782807 SANDOZ IBUPROFEN 600MG Will only be approved if prescribed with a DMARD Ibuprofen 868221 IBUNATE 200MG Will only be approved if prescribed with a DMARD Ibuprofen 787426 BETAPROFEN 200MG Will only be approved if prescribed with a DMARD Naproxen 805238 NAPROSCRIPT 250MG Will only be approved if prescribed with a DMARD Naproxen 810185 MYLAN NAPROXEN 250MG Will only be approved if prescribed with a DMARD Paracetamol 824992 GENCETAMOL Paracetamol 799629 PAINAMOL (GREEN) 500MG Chloroquine 747297 NIVAQUINE 200MG Treatment to be initiated by a specialist SCHIZOPHRENIA Carbamazepine Please provide a report from a psychiatrist that confirms the diagnosis, based on DSM lv Diagnostic Criteria. Treatment to be initiated by a psychiatrist 712523 SANDOZ CARBAMAZEPINE 200MG Valproic acid 715980 CONVULEX 150MG CAP Valproic acid 715999 CONVULEX 300MG CAP Valproic acid 781568 CONVULEX 500MG CAP Valproic acid 818666 EPILIM CR 200MG SRT Valproic acid 818674 EPILIM CR 300MG SRT Valproic acid 818682 EPILIM CR 500MG SRT Lamotrigine 710387 DYNA-LAMOTRIGINE 25MG Lamotrigine 710388 DYNA-LAMOTRIGINE 50MG
Lamotrigine 710389 DYNA-LAMOTRIGINE 100MG Lamotrigine 710390 DYNA-LAMOTRIGINE 200MG Lamotrigine 705441 ASPEN LAMOTRIGINE 100MG Orphenadrine (chloride) 720542 DISIPAL 50MG Chlorpromazine 735868 LARGACTIL 25MG Chlorpromazine 735876 LARGACTIL 50MG Chlorpromazine 735884 LARGACTIL 100MG Fluphenazine 744301 MODECATE 1ML 25MG/1ML INJ Haloperidol 763411 SERENACE 0,5MG CAP Haloperidol 730327 SANDOZ HALOPERIDOL 5MG Haloperidol 730335 SANDOZ HALOPERIDOL 1,5MG Flupentixol 726672 FLUANXOL DEPOT 1ML 20MG INJ Depot Preparations Only - 2nd Line Zuclopenthixol 714852 CLOPIXOL DEPOT 200MG INJ Depot Preparations Only - 2nd Line Clozapine 700176 CLOMENT 25MG WCC required 6 monthly Clozapine 700178 CLOMENT 100MG WCC required 6 monthly Olanzapine 715685 REDILANZ 10MG Olanzapine 715683 REDILANZ 2,5MG Olanzapine 715684 REDILANZ 5MG Risperidone 715736 SCHIZOROL 0,5MG Risperidone 715737 SCHIZOROL 1MG Risperidone 715738 SCHIZOROL 2MG Risperidone 710793 RISPERIDONE HEXAL 3MG Risperidone 711511 ZOXADON 0,5MG Risperidone 711512 ZOXADON 1MG Risperidone 711513 ZOXADON 2MG Amitriptyline 771996 TREPILINE 25MG
Amitriptyline 772003 TREPILINE 10MG Amitriptyline 784230 SANDOZ AMITRIPTYLINE 25MG Dothiepin 800198 THADEN 25MG CAP Dothiepin 800201 THADEN 75MG Dothiepin 816515 SANDOZ DOTHIEPIN HCL 75MG Imipramine 724661 ETHIPRAMINE 10MG Imipramine 724688 ETHIPRAMINE 25MG Citalopram 704331 CITALOHEXAL 20MG Citalopram 705252 DEPRAMIL 40MG Citalopram 709407 CITALOPRAM-WINTHROP 20MG Fluoxetine 700686 RANFLOCS 20MG CAP Fluoxetine 703391 A-LENNON FLUOXETINE 20MG CAP Sertraline 715935 SERDEP 100MG Sertraline 705420 SERDEP 50MG SYSTEMIC LUPUS ERYTHEMATOSUS Please provide a report from a rheumatologist or specialist physician, confirming the diagnosis. Folic acid 810967 BE-S FOLIC ACID 5MG Prednisone 818267 TROLIC 5MG Prednisone 752304 PANAFCORT 5MG Prednisone 788783 BE-S PREDNISONE 5MG Cyclophosphamide 723274 ENDOXAN 50MG Treatment to be initiated by a specialist Azathioprine 700777 ZAPRINE 50MG Treatment to be initiated by a specialist Azathioprine 712609 AZATHIOPRINE PCH 50MG Treatment to be initiated by a specialist Methotrexate 712504 ABITREXATE (WAS EMTHEXATE) 2,5MG Treatment to be initiated by a specialist Methotrexate 742465 METHOTREXATE 2,5MG Treatment to be initiated by a specialist
Diclofenac 786012 MYLAN DICLOFENAC 25MG Diclofenac 786020 MYLAN DICLOFENAC 50MG Diclofenac 834327 SANDOZ DICLOFENAC SODIUM 100 SIMPLE REG 100MG Diclofenac 853240 DICLOHEXAL 25MG Diclofenac 893390 A-LENNON DICLOFENAC 25MG Diclofenac 893391 A-LENNON DICLOFENAC 50MG Indometacin 704725 ARTHREXIN 25MG CAP Indometacin 704776 SANDOZ INDOMETHACIN 25MG CAP Indometacin 701106 ADCO-INDOMETHACIN 25MG CAP Meloxicam 704829 FLEXOCAM 7,5MG Meloxicam 705375 ADCO-MELOXICAM 7,5MG Piroxicam 797030 XYCAM 20MG CAP Piroxicam 799432 PYROCAPS 20MG CAP Piroxicam 701072 ROXIFEN 20MG CAP Ibuprofen 787426 BETAPROFEN 200MG Ibuprofen 782807 SANDOZ IBUPROFEN 600MG Ibuprofen 733741 INZA 200MG Ibuprofen 701654 RANFEN 400MG Ibuprofen 701975 BETAPROFEN FC 400MG Naproxen 805238 NAPROSCRIPT 250MG Naproxen 810185 MYLAN NAPROXEN 250MG Acetylsalicylic acid 798533 BE-S ASPIRIN (WHITE) 300MG Acetylsalicylic acid 808261 ASPIRIN JUNIOR 60MG Acetylsalicylic acid 700909 GULF ASPIRIN 300MG SRT
Chloroquine 747297 NIVAQUINE 200MG Treatment to be initiated by a specialist ULCERATIVE COLITIS Please provide a report from a specialist physician or gastroenterologist that confirms the diagnosis Budesonide 824593 ENTOCORD ENE Treatment to be initiated by a specialist Mesalazine 783668 ASACOL 400MG Treatment to be initiated by a specialist Mesalazine 890775 PENTASA 500MG Treatment to be initiated by a specialist Mesalazine 824135 ASACOL 500MG SUP Treatment to be initiated by a specialist Olsalazine 792519 DIPENTUM 250MG CAP Treatment to be initiated by a specialist Sulfasalazine 762008 SALAZOPYRIN 500MG Treatment to be initiated by a specialist Prednisone 788783 BE-S PREDNISONE 5MG Prednisone 752304 PANAFCORT 5MG Prednisone 818267 TROLIC 5MG Azathioprine 700777 ZAPRINE 50MG Treatment to be initiated by a specialist Azathioprine 712609 AZATHIOPRINE PCH 50MG Treatment to be initiated by a specialist Methotrexate MENOPAUSE 712504 ABITREXATE (WAS EMTHEXATE) 2,5MG Treatment to be initiated by a specialist Methotrexate 742465 METHOTREXATE 2,5MG Treatment to be initiated by a specialist OTHER CHRONIC DISEASES Conjugated estrogens 832448 PREMARIN VCR Conjugated estrogens 756725 PREMARIN 0,3MG Conjugated estrogens 756733 PREMARIN 0,625MG Conjugated estrogens 756741 PREMARIN 1,25MG Estradiol 822477 ESTRO-PAUSE 1MG Estradiol 822485 ESTRO-PAUSE 2MG Estradiol 824631 CLIMARA 50 PTD
ACNE Estradiol 824658 CLIMARA 100 PTD Estradiol Estradiol 834920 ESTRADERM TTS 100MCG/DAY 834939 ESTRADERM TTS 25MCG/DAY Estriol 827452 SYNAPAUSE-E3 2MG Medroxyprogesterone 706704 HEXAL-MPA 5MG Norethisterone and estrogen Medroxyprogesterone and estrogen Norethisterone and estrogen Norethisterone and estrogen PTD PTD 881112 ACTIVELLE 853429 PREMELLE-CYCLE 5 825913 TRISEQUENS 822493 ESTRO-PAUSE N Norgestrel and estrogen 825980 POSTOVAL Cyproterone and estrogen Doxycycline 818550 CLIMEN OTHER CHRONIC DISEASES - NOT APPLICABLE TO LIBERTY BONAPLUS, MOTOHEALTH and TOPMED 893402 A-LENNON DOXYCYCLINE HCL 100MG CAP Maximum 30 per month Doxycycline 716944 CYCLIDOX 100MG CAP Maximum 30 per month Oxytetracycline 884167 NUCOTET 250MG CAP Maximum 60 per month Oxytetracycline 787434 BE-OXYTET 250MG CAP Maximum 60 per month Oxytetracycline 812072 TETRACEM 250MG CAP Maximum 60 per month Oxytetracycline 751987 OXYPAN 250MG CAP Maximum 60 per month
Erythromycin 758388 PURMYCIN 250MG CAP Maximum 60 per month Erythromycin 765651 SPECTRASONE 250MG CAP Maximum 60 per month Erythromycin 824682 XERAMEL 250MG CAP Maximum 60 per month ALLERGIC RHINITIS Beclometasone Beclometasone 820709 BECLATE AQUANASE 150DOSE 897937 CLENIL AQUEOUS 200DOSE 50MCG 50MCG Fluticasone 714595 FLONASE 120 DOSE 50MCG AQS second line Fluticasone 704383 FLOMIST 120DOSE 50MCG AQS second line Cetirizine 712764 ZETOP 10MG Clinical motivation required if used with inhaled steroid CARDIAC ARRYTHMIA -non PMB Warfarin 709905 CIPLA-WARFARIN 5MG Warfarin 709906 CIPLA-WARFARIN 1MG Warfarin 712390 CIPLA-WARFARIN 3MG Digoxin 735752 LANOXIN 0,25MG Digoxin 758280 PURGOXIN 0,25MG Quinidine 758868 QUINIDINE SULPH 200MG Amiodarone 863157 HEXARONE 100MG Amiodarone 863165 HEXARONE 200MG Amiodarone 703513 ARYCOR 200MG Amiodarone 703515 ARYCOR 100MG Propranolol 758140 PURBLOKA 10MG Propranolol 758167 PURBLOKA 40MG Propranolol 806552 INDOBLOK 10MG AQS AQS
Propranolol 806560 INDOBLOK 40MG Atenolol 806889 HEXA-BLOK 50MG Atenolol 787892 SANDOZ ATENOLOL 50MG Atenolol 787914 SANDOZ ATENOLOL 100MG Atenolol 826898 BIO-ATENOLOL (WAS IVAX-ATENOLOL) 50MG Atenolol 705872 TENOPRESS 25MG Atenolol 705873 TENOPRESS 100MG Bisoprolol 703913 ADCO-BISOCOR 5MG Bisoprolol 703914 ADCO-BISOCOR 10MG Bisoprolol 715276 ZIAPRO 10MG Bisoprolol 715274 ZIAPRO 5MG Verapamil 700071 VERAHEXAL 240 SR 240MG SRT Verapamil 774944 VASOMIL 40MG Verapamil 774952 VASOMIL 80MG Diltiazem 839183 ADCO-ZILDEM SR 180MG SRC Diltiazem 839191 ADCO-ZILDEM SR 240MG SRC Diltiazem 822213 ADCO-ZILDEM 60MG Diltiazem 824364 ADCO-ZILDEM 90MG Acetylsalicylic acid 700909 GULF ASPIRIN 300MG Acetylsalicylic acid 808261 ASPIRIN JUNIOR 60MG Acetylsalicylic acid DEPRESSION, MAJOR 798533 BE-S ASPIRIN (WHITE) 300MG Amitriptyline 771996 TREPILINE 25MG Amitriptyline 772003 TREPILINE 10MG
Amitriptyline 784230 SANDOZ AMITRIPTYLINE 25MG Dothiepin 800198 THADEN 25MG CAP Dothiepin 800201 THADEN 75MG Dothiepin 816515 SANDOZ DOTHIEPIN HCL 75MG Imipramine 724661 ETHIPRAMINE 10MG Imipramine 724688 ETHIPRAMINE 25MG Citalopram 705252 DEPRAMIL 40MG Citalopram 709407 CITALOPRAM-WINTHROP 20MG Citalopram 713583 ARROW CITALOPRAM 20MG Fluoxetine 700686 RANFLOCS 20MG CAP Fluoxetine 703391 A-LENNON FLUOXETINE 20MG CAP Sertraline 715935 SERDEP 100MG Sertraline 705420 SERDEP 50MG GOUT Allopurinol 811432 LONOL 300MG Allopurinol 738778 SANDOZ ALLOPURINOL 100MG Allopurinol 738786 SANDOZ ALLOPURINOL 300MG Allopurinol 758310 PURICOS 100MG MIGRAINE (PROPHYLAXIS ONLY) Propranolol 758140 PURBLOKA 10MG Propranolol 758167 PURBLOKA 40MG Propranolol 806552 INDOBLOK 10MG Propranolol 806560 INDOBLOK 40MG Amitriptyline 771996 TREPILINE 25MG Amitriptyline 772003 TREPILINE 10MG