carecross chronic medicine formulary · 2015-03-26 · 700715 salbutamol asthavent ecohaler...
TRANSCRIPT
Nappi Code Ingredient Product Name Strength Form Comment
ADDISON'S DISEASE
The PMB is applicable to primary Addisons disease only. Please provide Practice number and name of diagnosing specialist
726540 Fludrocortisone FLORINEF ACETATE 0,1MG TAB
716693 Hydrocortisone COVOCORT 10MG TAB
800155 Prednisolone LENISOLONE 5MG TAB
814407 Prednisolone CAPSOID 5MG TAB
818267 Prednisone TROLIC 5MG TAB
752304 Prednisone PANAFCORT 5MG TAB
788783 Prednisone BE-TABS PREDNISONE 5MG TAB
ASTHMA
402042 Device MASK BABY CIPLA ZZZ
454299 Device SPACER ZEROSTAT VT ZZZ
577802 Device DP HALER DEVICE ZZZ
752304 Prednisone PANAFCORT 5MG TAB
788783 Prednisone BE-TABS PREDNISONE 5MG TAB
818267 Prednisone TROLIC 5MG TAB
704175 Formoterol FORATEC DP-CAPS 12MCG CPS
710307 Formoterol FORATEC HFA 120DOSE 12MCG/1DOSE INH
Only for severe persistent
asthma (motivation required)
Will only be approved if
prescribed together with an
CareCross Chronic Medicine Formulary
2015
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.
PRESCRIBED MINIMUM BENEFIT CHRONIC CONDITIONS
700715 Salbutamol ASTHAVENT ECOHALER CFC-FREE 300DOSE100MCG INH
711213 Salbutamol VENTEZE CFC FREE 200 DOSE100MCG INH
849332 Salbutamol ASTHAVENT ECOHALER 200DOSE100MCG INH
718698 Salbutamol/
Ipratropium
DUOLIN HFA 200DOSE INH
715190 Salmeterol/
Fluticasone
SEREFLO 25/125 HFA 120 DOSE INH
715191 Salmeterol/
Fluticasone
SEREFLO 25/250 HFA 120 DOSE INH
715189 Salmeterol/
Fluticasone
SEREFLO 25/50 HFA 120 DOSE INH Only for Paediatric use for
moderate & severe persistent
asthma
819611 Beclometasone BECLATE 200DOSE 50MCG INH
819638 Beclometasone BECLATE 200DOSE 100MCG INH
820083 Beclometasone BECLATE 200DOSE 200MCG INH
897462 Budesonide BUDEFLAM HFA 300DOSE 100MCG INH
897469 Budesonide BUDEFLAM HFA 300DOSE 200MCG INH
704176 Budesonide BUDEFLAM DP-CAPS 200MCG CPS
775452 Salbutamol VENTEZE 2MG/5ML SYR only for children under 5 years
824186 Salbutamol ASTHAVENT 2MG/5ML SYR only for children under 5 years
788368 Theophylline SANDOZ THEOPHYLLINE ANHYDROUS200MG SRT
788376 Theophylline SANDOZ THEOPHYLLINE ANHYDROUS300MG SRT
701750 Theophylline ALCOPHYLLIN 26,67MG/5ML SYR
717383 Montelukast LUMONT 4MG CHU only for children under 5 years
717384 Montelukast LUMONT 5MG CHU only for children under 5 years
Limited to 3 inhalers per year
if no inhaled steroid
Only for moderate & severe
persistent asthma (motivation
required)
BIPOLAR MOOD DISORDER
Please provide a report from a psychiatrist that confirms the diagnosis, based on DSM lV Diagnostic Criteria
712493 Carbamazepine DEGRANOL 200MG TAB
712523 Carbamazepine SANDOZ CARBAMAZEPINE 200MG TAB
715980 Valproic acid CONVULEX 150MG CAP
715999 Valproic acid CONVULEX 300MG CAP
781568 Valproic acid CONVULEX 500MG CAP
718274 Valproic acid EPILIZINE CR 200MG SRT
718275 Valproic acid EPILIZINE CR 300MG SRT
718276 Valproic acid EPILIZINE CR 500MG SRT
718465 Valproic acid NAVALPRO CR 200MG SRT
718468 Valproic acid NAVALPRO CR 500MG SRT
704379 Lamotrigine EPITEC 25MG TAB
704488 Lamotrigine LAMITOR 100MG TAB
705251 Lamotrigine SANDOZ LAMOTRIGINE 25MG TAB
710387 Lamotrigine DYNA-LAMOTRIGINE 25MG TAB
710388 Lamotrigine DYNA-LAMOTRIGINE 50MG TAB
710389 Lamotrigine DYNA-LAMOTRIGINE 100MG TAB
710390 Lamotrigine DYNA-LAMOTRIGINE 200MG TAB
710887 Lamotrigine LAMIDUS 100MG TAB
710885 Lamotrigine LAMIDUS 50MG TAB
730327 Haloperidol SANDOZ HALOPERIDOL 5MG TAB
730335 Haloperidol SANDOZ HALOPERIDOL 1,5MG TAB
763411 Haloperidol SERENACE 0,5MG CAP
700176 Clozapine CLOMENT 25MG TAB Treatment to be initiated by a
psychiatrist
700178 Clozapine CLOMENT 100MG TAB Treatment to be initiated by a
psychiatrist
715657 Olanzapine OLEXAR 2,5MG TAB Treatment to be initiated by a
psychiatrist
715658 Olanzapine OLEXAR 5MG TAB Treatment to be initiated by a
psychiatrist
715659 Olanzapine OLEXAR 10MG TAB Treatment to be initiated by a
psychiatrist
715995 Olanzapine OLEANZ 5MG TAB Treatment to be initiated by a
psychiatrist
715996 Olanzapine OLEANZ 10MG TAB Treatment to be initiated by a
psychiatrist
716672 Quetiapine MYLAN QUETIAPINE 300MG TAB Treatment to be initiated by a
psychiatrist
716670 Quetiapine MYLAN QUETIAPINE 100MG TAB Treatment to be initiated by a
psychiatrist
716671 Quetiapine MYLAN QUETIAPINE 200MG TAB Treatment to be initiated by a
psychiatrist
716668 Quetiapine MYLAN QUETIAPINE 25MG TAB Treatment to be initiated by a
psychiatrist
716637 Quetiapine QUETOSER 200MG TAB Treatment to be initiated by a
psychiatrist
758833 Lithium QUILONUM RETARD 450MG TAB
712078 Lithium CAMCOLIT 250MG TAB
712086 Lithium CAMCOLIT 400MG TAB
715736 Risperidone SCHIZOROL 0,5MG TAB Treatment to be initiated by a
psychiatrist
715737 Risperidone SCHIZOROL 1MG TAB Treatment to be initiated by a
psychiatrist
715738 Risperidone SCHIZOROL 2MG TAB Treatment to be initiated by a
psychiatrist
711511 Risperidone ZOXADON 0,5MG TAB Treatment to be initiated by a
psychiatrist
711512 Risperidone ZOXADON 1MG TAB Treatment to be initiated by a
psychiatrist
711513 Risperidone ZOXADON 2MG TAB Treatment to be initiated by a
psychiatrist
711475 Risperidone ASPEN RISPERIDONE 4MG TAB Treatment to be initiated by a
psychiatrist
711474 Risperidone ASPEN RISPERIDONE 3MG TAB Treatment to be initiated by a
psychiatrist
784230 Amitriptyline SANDOZ AMITRIPTYLINE 25MG TAB
771996 Amitriptyline TREPILINE 25MG TAB
772003 Amitriptyline TREPILINE 10MG TAB
800198 Dosulepin THADEN 25MG CAP
800201 Dosulepin THADEN 75MG TAB
724661 Imipramine ETHIPRAMINE 10MG TAB
724688 Imipramine ETHIPRAMINE 25MG TAB
713584 Citalopram ARROW CITALOPRAM 40MG TAB
713583 Citalopram ARROW CITALOPRAM 20MG TAB
715403 Escitalopram ZYTOMIL 20MG TAB
715402 Escitalopram ZYTOMIL 10MG TAB
Antidepressants will only be
approved if prescribed
together with a mood
stabiliser
703391 Fluoxetine A-LENNON FLUOXETINE 20MG CAP
700877 Fluoxetine LORIEN 20MG TAB
705064 Fluoxetine ZYDUS FLUOXETINE 20MG CAP
894303 Fluoxetine DEPROZAN 20MG CAP
715935 Sertraline SERDEP 100MG TAB
705420 Sertraline SERDEP 50MG TAB
712092 Sertraline ARROW SERTRALINE 100MG TAB
712093 Sertraline ARROW SERTRALINE 50MG TAB
BRONCHIECTASIS Please provide a sensitivity report if a different antibiotic is required
809667 Doxycycline DOXYCYL 100MG CAP
716944 Doxycycline CYCLIDOX 100MG CAP
893402 Doxycycline A-LENNON DOXYCYCLINE HCL 100MG CAP
884167 Oxytetracycline NUCOTET 250MG CAP
751987 Oxytetracycline OXYPAN 250MG CAP
787434 Oxytetracycline BE-OXYTET 250MG CAP
788546 Amoxicillin BETAMOX 500MG CAP
705637 Amoxicillin AUSTELL-AMOXICILLIN 500MG CAP
744689 Amoxicillin MOXYPEN 250MG CAP
744697 Amoxicillin MOXYPEN 500MG CAP
CARDIAC DYSRHYTHMIAS Please provide a specific diagnosis and /or the relevant ICD10 code
709905 Warfarin CIPLA-WARFARIN 5MG TAB
709906 Warfarin CIPLA-WARFARIN 1MG TAB
735752 Digoxin LANOXIN 0,25MG TAB
758280 Digoxin PURGOXIN 0,25MG TAB
758868 Quinidine QUINIDINE SULPH 200MG TAB
703513 Amiodarone ARYCOR 200MG TAB
703515 Amiodarone ARYCOR 100MG TAB
863157 Amiodarone HEXARONE 100MG TAB
863165 Amiodarone HEXARONE 200MG TAB
758140 Propranolol PURBLOKA 10MG TAB
758167 Propranolol PURBLOKA 40MG TAB
806552 Propranolol INDOBLOK 10MG TAB
806560 Propranolol INDOBLOK 40MG TAB
786195 Atenolol TEN-BLOKA 100MG TAB
806889 Atenolol HEXA-BLOK 50MG TAB
705872 Atenolol TENOPRESS 25MG TAB
826898 Atenolol BIO-ATENOLOL (WAS IVAX-ATENOLOL)50MG TAB
787892 Atenolol SANDOZ ATENOLOL 50MG TAB
Antidepressants will only be
approved if prescribed
together with a mood
stabiliser
786187 Atenolol TEN-BLOKA 50MG TAB
704372 Bisoprolol BILOCOR 5MG TAB
704373 Bisoprolol BILOCOR 10MG TAB
715276 Bisoprolol ZIAPRO 10MG TAB
715274 Bisoprolol ZIAPRO 5MG TAB
700071 Verapamil VERAHEXAL 240 SR 240MG SRT
774944 Verapamil VASOMIL 40MG TAB
774952 Verapamil VASOMIL 80MG TAB
824364 Diltiazem ADCO-ZILDEM 90MG TAB
839183 Diltiazem ADCO-ZILDEM SR 180MG SRC
839191 Diltiazem ADCO-ZILDEM SR 240MG SRC
700909 Acetylsalicylic acid GULF ASPIRIN 300MG TAB
CARDIAC FAILURE AND CARDIOMYOPATHY
702947 Potassium chloride SANDOZ K-600 600MG TAB For documented
hypokalaemia
755753 Potassium chloride PLENISH K 600MG TAB For documented
hypokalaemia
709905 Warfarin CIPLA-WARFARIN 5MG TAB
709906 Warfarin CIPLA-WARFARIN 1MG TAB
735752 Digoxin LANOXIN 0,25MG TAB
758280 Digoxin PURGOXIN 0,25MG TAB
784206 Isosorbide dinitrate SANDOZ ISOSORBIDE DINITRATE10MG TAB
784214 Isosorbide dinitrate SANDOZ ISOSORBIDE DINITRATE30MG TAB
761400 Hydralazine SANDOZ HYDRALAZINE 25MG TAB
761419 Hydralazine SANDOZ HYDRALAZINE 50MG TAB
731714 Hydralazine HYPERPHEN 10MG TAB
731722 Hydralazine HYPERPHEN 50MG TAB
890470 Hydrochlorothiazide HEXAZIDE 25MG TAB
731668 Furosemide SANDOZ FUROSEMIDE 40MG TAB
758272 Furosemide PURESIS 40MG TAB
857769 Furosemide MYLAN FUROSEMIDE 40MG TAB
898937 Spironolactone SPIRACTIN 100MG TAB
765910 Spironolactone SPIRACTIN 25MG TAB
769665 Spironolactone SANDOZ SPIRONOLACTONE 25MG TAB
703914 Bisoprolol ADCO-BISOCOR 10MG TAB
703913 Bisoprolol ADCO-BISOCOR 5MG TAB
715274 Bisoprolol ZIAPRO 5MG TAB
715276 Bisoprolol ZIAPRO 10MG TAB
704372 Bisoprolol BILOCOR 5MG TAB
704373 Bisoprolol BILOCOR 10MG TAB
704670 Carvedilol CARVETREND 6,25MG TAB
704671 Carvedilol CARVETREND 12,5MG TAB
710338 Carvedilol ASPEN CARVEDILOL 6,25MG TAB
710339 Carvedilol ASPEN CARVEDILOL 12,5MG TAB
710958 Carvedilol VEDIBLOK 6,25MG TAB
710959 Carvedilol VEDIBLOK 12,5MG TAB
710960 Carvedilol VEDIBLOK 25MG TAB
710340 Carvedilol ASPEN CARVEDILOL 25MG TAB
704672 Carvedilol CARVETREND 25MG TAB
836478 Captopril ADCO-CAPTOMAX 50MG TAB
852619 Captopril MYLAN CAPTOPRIL 25MG TAB
899429 Captopril MYLAN CAPTOPRIL 50MG TAB
836451 Captopril ADCO-CAPTOMAX 25MG TAB
708109 Enalapril PHARMAPRESS 5MG TAB
891280 Enalapril ENAP 20MG TAB
712763 Enalapril ENVAS 10MG TAB
868922 Enalapril PHARMAPRESS 20MG TAB
891272 Enalapril ENAP 5MG TAB
891279 Enalapril ENAP 10MG TAB
715649 Perindopril ACESYL 4MG TAB
715795 Perindopril CIPLASYL 8 8MG TAB
714527 Perindopril PEARINDA 4MG TAB
714528 Perindopril PEARINDA 8MG TAB
715786 Perindopril CIPLASYL 4 4MG TAB
719209 Candesartan MYLACAND 8MG TAB
719210 Candesartan MYLACAND 16MG TAB
717024 Losartan HYTENZA 50MG TAB
709964 Losartan ZARTAN 100MG TAB
717042 Losartan HYTENZA 100MG TAB
709225 Losartan ZARTAN 50MG TAB
714249 Telmisartan PRITOR 40MG TAB
714250 Telmisartan PRITOR 80MG TAB
715555 Valsartan ZOMEVEK 80MG TAB
715556 Valsartan ZOMEVEK 160MG TAB
704696 Valsartan TAREG 160MG TAB
705060 Valsartan TAREG 80MG TAB
700909 Acetylsalicylic acid GULF ASPIRIN 300MG TAB
Motivation required for ARB's -
please specify previous
treatments and reason for
treatment change
836699 Pneumococcal
vaccine
IMOVAX PNEUMO 23 VAC once only
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
Please attach a lung function test report (The REF Entry criteria are in line with the GOLD classification)
454299 Device SPACER ZEROSTAT VT ZZZ
577802 Device DP HALER DEVICE ZZZ
752304 Prednisone PANAFCORT 5MG TAB
788783 Prednisone BE-TABS PREDNISONE 5MG TAB
818267 Prednisone TROLIC 5MG TAB
704175 Formoterol FORATEC DP-CAPS 12MCG CPS
710307 Formoterol FORATEC HFA 120DOSE 12MCG/1DOSE INH
849332 Salbutamol ASTHAVENT ECOHALER 200DOSE100MCG INH
700715 Salbutamol ASTHAVENT ECOHALER CFC-FREE 300DOSE100MCG INH
711213 Salbutamol VENTEZE CFC FREE 200 DOSE100MCG INH
718698 Salbutamol/
Ipratropium
DUOLIN HFA 200DOSE INH
819611 Beclometasone BECLATE 200DOSE 50MCG INH
819638 Beclometasone BECLATE 200DOSE 100MCG INH
820083 Beclometasone BECLATE 200DOSE 200MCG INH
704176 Budesonide BUDEFLAM DP-CAPS 200MCG CPS
897462 Budesonide BUDEFLAM HFA 300DOSE 100MCG INH
897469 Budesonide BUDEFLAM HFA 300DOSE 200MCG INH
715574 Ipratropium bromide IPVENT HFA 200 DOSE 40MCG/1DOSE INH
788368 Theophylline SANDOZ THEOPHYLLINE ANHYDROUS200MG SRT
788376 Theophylline SANDOZ THEOPHYLLINE ANHYDROUS300MG SRT
CHRONIC RENAL FAILURE Creatinine clearance required
703359 Calcium carbonate ENO TUMS ASSORTED FRUIT FLAVOURS CHU
703361 Calcium carbonate ENO TUMS PEPPERMINT FLAVOUR CHU
703364 Calcium carbonate ENO TUMS ORANGE FLAVOUR CHU
750654 Alfacalcidol ONE ALPHA 0,25MCG CAP
750662 Alfacalcidol ONE ALPHA 1MCG CAP
755753 Potassium chloride PLENISH K 600MG TAB
702947 Potassium chloride SANDOZ K-600 600MG TAB
873276 Saccharated iron oxide VENOFER 20MG/1ML INJ
756571 Ferrous fumarate PREGAMAL TAB
727024 Iron supplement FOLIGLOBIN TAB
Hb and iron studies required
Steroid inhalers are reserved
for patients who are
experiencing frequent
exacerbations. Please
provide a clinical history
For documented
hypokalaemia
705853 Iron supplement AUTRIN CAP
897329 Iron supplement GULF FERROUS SULPHATE COMPOUND TAB
810967 Folic acid BE-TABS FOLIC ACID 5MG TAB
820741 Erythropoietin EPREX PREFILL 4000U/0,4ML INJ
837318 Erythropoietin EPREX PREFILL 2000U/0,5ML INJ
704630 Erythropoietin RECORMON 6000 IU/0.3ML PRE-FILLED SYRIN6000IU INJ
704772 Erythropoietin RECORMON 2000 PRE-FILLED SYRINGE2000UNIT/0,3ML INJ
704631 Erythropoietin RECORMON 4000 IU/0.3ML PREFILLED SYRINGE4000U/0,3ML INJ
890470 Hydrochlorothiazide HEXAZIDE 25MG TAB
857769 Furosemide MYLAN FUROSEMIDE 40MG TAB
758272 Furosemide PURESIS 40MG TAB
731668 Furosemide SANDOZ FUROSEMIDE 40MG TAB
758140 Propranolol PURBLOKA 10MG TAB
758167 Propranolol PURBLOKA 40MG TAB
806552 Propranolol INDOBLOK 10MG TAB
806560 Propranolol INDOBLOK 40MG TAB
786195 Atenolol TEN-BLOKA 100MG TAB
786187 Atenolol TEN-BLOKA 50MG TAB
806889 Atenolol HEXA-BLOK 50MG TAB
787892 Atenolol SANDOZ ATENOLOL 50MG TAB
826898 Atenolol BIO-ATENOLOL (WAS IVAX-ATENOLOL)50MG TAB
705872 Atenolol TENOPRESS 25MG TAB
703913 Bisoprolol ADCO-BISOCOR 5MG TAB
703914 Bisoprolol ADCO-BISOCOR 10MG TAB
704372 Bisoprolol BILOCOR 5MG TAB
704373 Bisoprolol BILOCOR 10MG TAB
715276 Bisoprolol ZIAPRO 10MG TAB
715274 Bisoprolol ZIAPRO 5MG TAB
774944 Verapamil VASOMIL 40MG TAB
700071 Verapamil VERAHEXAL 240 SR 240MG SRT
836451 Captopril ADCO-CAPTOMAX 25MG TAB
852619 Captopril MYLAN CAPTOPRIL 25MG TAB
899429 Captopril MYLAN CAPTOPRIL 50MG TAB
836478 Captopril ADCO-CAPTOMAX 50MG TAB
708109 Enalapril PHARMAPRESS 5MG TAB
712763 Enalapril ENVAS 10MG TAB
891279 Enalapril ENAP 10MG TAB
891272 Enalapril ENAP 5MG TAB
868922 Enalapril PHARMAPRESS 20MG TAB
891280 Enalapril ENAP 20MG TAB
Hb and iron studies required
Hb and iron studies required
715649 Perindopril ACESYL 4MG TAB
715786 Perindopril CIPLASYL 4 4MG TAB
715795 Perindopril CIPLASYL 8 8MG TAB
714527 Perindopril PEARINDA 4MG TAB
714528 Perindopril PEARINDA 8MG TAB
719209 Candesartan MYLACAND 8MG TAB
719210 Candesartan MYLACAND 16MG TAB
717024 Losartan HYTENZA 50MG TAB
709964 Losartan ZARTAN 100MG TAB
Motivation required for ARB's -
please specify previous
treatments and reason for
treatment change
717042 Losartan HYTENZA 100MG TAB
709225 Losartan ZARTAN 50MG TAB
714249 Telmisartan PRITOR 40MG TAB
714250 Telmisartan PRITOR 80MG TAB
704696 Valsartan TAREG 160MG TAB
705060 Valsartan TAREG 80MG TAB
715555 Valsartan ZOMEVEK 80MG TAB
715556 Valsartan ZOMEVEK 160MG TAB
CORONARY ARTERY DISEASE Stress ECG report & details of history of previous cardiovascular events (if applicable) is required
709905 Warfarin CIPLA-WARFARIN 5MG TAB
709906 Warfarin CIPLA-WARFARIN 1MG TAB
784192 Isosorbide dinitrate SANDOZ ISOSORBIDE DINITRATE5MG SLT
784206 Isosorbide dinitrate SANDOZ ISOSORBIDE DINITRATE10MG TAB
784214 Isosorbide dinitrate SANDOZ ISOSORBIDE DINITRATE30MG TAB
758140 Propranolol PURBLOKA 10MG TAB
758167 Propranolol PURBLOKA 40MG TAB
806552 Propranolol INDOBLOK 10MG TAB
806560 Propranolol INDOBLOK 40MG TAB
786195 Atenolol TEN-BLOKA 100MG TAB
806889 Atenolol HEXA-BLOK 50MG TAB
826898 Atenolol BIO-ATENOLOL 50MG TAB
787892 Atenolol SANDOZ ATENOLOL 50MG TAB
705872 Atenolol TENOPRESS 25MG TAB
786187 Atenolol TEN-BLOKA 50MG TAB
715276 Bisoprolol ZIAPRO 10MG TAB
715274 Bisoprolol ZIAPRO 5MG TAB
704372 Bisoprolol BILOCOR 5MG TAB
704373 Bisoprolol BILOCOR 10MG TAB
708141 Amlodipine ALMADIN 5MG TAB
708190 Amlodipine NORCARD 5MG TAB
708191 Amlodipine NORCARD 10MG TAB
703917 Amlodipine AMLOC 10MG TAB
708050 Amlodipine AMLODAC 5MG TAB
710236 Amlodipine PHARMA DYNAMICS AMLODIPINE BESYLATE5MG TAB
710238 Amlodipine PHARMA DYNAMICS AMLODIPINE BESYLATE10MG TAB
708051 Amlodipine AMLODAC 10MG TAB
711682 Nifedipine FEDALOC SR 30MG SRT
711714 Nifedipine FEDALOC SR 60MG SRT
Motivation required for ARB's -
please specify previous
treatments and reason for
treatment change
715000 Nifedipine MACOREL SR 30MG SRT
715001 Nifedipine MACOREL SR 60MG SRT
829501 Nifedipine NIFEDALAT 20SR 20MG SRT
840963 Nifedipine ADCO-VASCARD 20 SR 20MG SRC
700071 Verapamil VERAHEXAL 240 SR 240MG SRT
774944 Verapamil VASOMIL 40MG TAB
839183 Diltiazem ADCO-ZILDEM SR 180MG SRC
839191 Diltiazem ADCO-ZILDEM SR 240MG SRC
822213 Diltiazem ADCO-ZILDEM 60MG TAB
824364 Diltiazem ADCO-ZILDEM 90MG TAB
700909 Acetylsalicylic acid GULF ASPIRIN 300MG TAB
CROHN'S DISEASE Practice number and name of the diagnosing specialist (physician or gastroenterologist) required.
783668 Mesalazine ASACOL 400MG TAB
824135 Mesalazine ASACOL 500MG SUP
890775 Mesalazine PENTASA 500MG TAB
792519 Olsalazine DIPENTUM 250MG CAP
762008 Sulfasalazine SALAZOPYRIN 500MG TAB
810967 Folic acid BE-TABS FOLIC ACID 5MG TAB
818267 Prednisone TROLIC 5MG TAB
788783 Prednisone BE-TABS PREDNISONE 5MG TAB
752304 Prednisone PANAFCORT 5MG TAB
700516 Ciprofloxacin DYNAFLOC 250MG TAB
703045 Ciprofloxacin CIPROGEN 500MG TAB
700284 Ciprofloxacin CPL ALLIANCE CIPROFLOXACIN250MG TAB
700287 Ciprofloxacin CPL ALLIANCE CIPROFLOXACIN500MG TAB
701210 Ciprofloxacin ORPIC 500MG TAB
700518 Ciprofloxacin DYNAFLOC 500MG TAB
704775 Ciprofloxacin CIPROL 500MG TAB
704777 Ciprofloxacin CIPROL 250MG TAB
701208 Ciprofloxacin ORPIC 250MG TAB
706108 Azathioprine AZAPRESS 50MG TAB
712609 Azathioprine AZATHIOPRINE PCH 50MG TAB
700777 Azathioprine ZAPRINE 50MG TAB
712504 Methotrexate ABITREXATE 2,5MG TAB
772224 Metronidazole TRICHAZOLE 400MG TAB
779822 Metronidazole METRAZOLE 400MG TAB
792284 Metronidazole ACUZOLE 200MG TAB
792292 Metronidazole ACUZOLE 400MG TAB
707241 Metronidazole BIO-METRONIDAZOLE 200MG TAB
707242 Metronidazole BIO-METRONIDAZOLE 400MG TAB
793159 Metronidazole METAZOL 200MG TAB
793167 Metronidazole METAZOL 400MG TAB
772216 Metronidazole TRICHAZOLE 200MG TAB
DIABETES INSIPIDUS
Please provide the practice number and name of the diagnosing specialist (physician, paediatrician or endocrinologist)
703639 Desmopressin DDAVP 0,2MG TAB
717746 Desmopressin DDAVP 2.5ML NOD
837555 Desmopressin DDAVP NASAL SPRAY 5ML 0,1MG/1ML NSS
837563 Desmopressin DDAVP 0,1MG TAB
DIABETES MELLITUS TYPE 1
491915 CONTOUR TS GLUCOSE TEST STRIPS STR
605351 GLUCOCHECK LANCETS ZZZ
667990 GLUCOCHECK STRIPS 50S ZZZ
712767 Insulin (human) BIOSULIN R CARTRIDGE 3ML 100U/1ML INJ
863564 Insulin (human) HUMULIN R CARTRIDGE 3ML 100U/1ML INJ
897767 Insulin aspart NOVORAPID FLEXPEN PENSET 3ML100U/1ML INJ
897775 Insulin aspart NOVORAPID PENFILL 3ML 100U/1ML INJ
709861 Insulin glulisine APIDRA SOLOSTAR DISPOSABLE PENS 3ML100U/1ML INJ
862355 Insulin lispro HUMALOG CARTRIDGE 3ML 100U/1ML INJ
863556 Insulin (human) HUMULIN N CARTRIDGE 3ML 100U/1ML INJ
700183 Insulin (human) PROTAPHANE FLEXPEN 3ML 100U/1ML INJ
712768 Insulin (human) BIOSULIN N CARTRIDGE 3ML 100U/1ML INJ
712769 Insulin (human) BIOSULIN L CARTRIDGE 3ML 100U/1ML INJ
712770 Insulin (human) BIOSULIN 30-70 CARTRIDGE 3ML100U/1ML INJ
863572 Insulin (human) HUMULIN 30/70 CARTRIDGE 3ML100U/1ML INJ
710299 Insulin (human) INSUMAN COMB 30/70 CARTRIDGE 3ML100U/1ML INJ
714977 Insulin (human) ACTRAPHANE HM (GE) FLEXPEN 3ML100U/1ML INJ
702086 Insulin aspart NOVOMIX 30 FLEXPEN 3ML 100U/1ML INJ
702089 Insulin aspart NOVOMIX 30 PENFILL 3ML 100U/1ML INJ
861782 Insulin lispro HUMALOG MIX 25 CARTRIDGE 3ML100U/1ML INJ
DIABETES MELLITUS TYPE 2
605351 GLUCOCHECK LANCETS ZZZ
667990 GLUCOCHECK STRIPS 50S ZZZ
491915 CONTOUR TS GLUCOSE TEST STRIPS STR
863564 Insulin (human) HUMULIN R CARTRIDGE 3ML 100U/1ML INJ
712767 Insulin (human) BIOSULIN R CARTRIDGE 3ML 100U/1ML INJ
897767 Insulin aspart NOVORAPID FLEXPEN PENSET 3ML100U/1ML INJ
897775 Insulin aspart NOVORAPID PENFILL 3ML 100U/1ML INJ
709861 Insulin glulisine APIDRA SOLOSTAR DISPOSABLE PENS 3ML100U/1ML INJ
862355 Insulin lispro HUMALOG CARTRIDGE 3ML 100U/1ML INJ
700183 Insulin (human) PROTAPHANE FLEXPEN 3ML 100U/1ML INJ
863556 Insulin (human) HUMULIN N CARTRIDGE 3ML 100U/1ML INJ
712769 Insulin (human) BIOSULIN L CARTRIDGE 3ML 100U/1ML INJ
712768 Insulin (human) BIOSULIN N CARTRIDGE 3ML 100U/1ML INJ
712770 Insulin (human) BIOSULIN 30-70 CARTRIDGE 3ML100U/1ML INJ
710299 Insulin (human) INSUMAN COMB 30/70 CARTRIDGE 3ML100U/1ML INJ
714977 Insulin (human) ACTRAPHANE HM (GE) FLEXPEN 3ML100U/1ML INJ
863572 Insulin (human) HUMULIN 30/70 CARTRIDGE 3ML100U/1ML INJ
702086 Insulin aspart NOVOMIX 30 FLEXPEN 3ML 100U/1ML INJ
702089 Insulin aspart NOVOMIX 30 PENFILL 3ML 100U/1ML INJ
861782 Insulin lispro HUMALOG MIX 25 CARTRIDGE 3ML100U/1ML INJ
897957 Metformin MYLAN METFORMIN 500MG TAB
897961 Metformin MYLAN METFORMIN 850MG TAB
706672 Metformin ARROW METFORMIN 500MG TAB
709172 Metformin BIGSENS 1000MG TAB
708281 Metformin BIGSENS 500MG TAB
711636 Metformin METORED 500MG TAB
718231 Metformin METCHEK 500MG TAB
708282 Metformin BIGSENS 850MG TAB
711638 Metformin METORED 850MG TAB
718232 Metformin METCHEK 850MG TAB
706673 Metformin ARROW METFORMIN 850MG TAB
711773 Metformin METORED 1000MG TAB Fasting glucose results will be
requested if metformin is
prescribed as a single agent
729361 Glibenclamide GLYCOMIN 5MG TAB
827053 Glibenclamide BIO-GLIBENCLAMIDE 5MG TAB
716953 Gliclazide DYNA GLICLAZIDE SR 30MG SRT
709538 Gliclazide ARROW GLICLAZIDE 80MG TAB
838209 Gliclazide GLYCRON 80MG TAB
EPILEPSY
737844 Phenobarbital LETHYL 30MG TAB
723525 Phenytoin EPANUTIN 100MG CAP
Fasting glucose results will be
requested if metformin is
prescribed as a single agent
754870 Phenytoin PHENYTOIN SOD 100MG TAB
779105 Ethosuximide ZARONTIN 250MG/5ML SYR
761079 Clonazepam RIVOTRIL 0,5MG TAB
761087 Clonazepam RIVOTRIL 2MG TAB
712523 Carbamazepine SANDOZ CARBAMAZEPINE 200MG TAB
705597 Carbamazepine SANDOZ CARBAMAZEPINE CR 200MG SRT
705602 Carbamazepine SANDOZ CARBAMAZEPINE CR 400MG SRT
712493 Carbamazepine DEGRANOL 200MG TAB
717226 Oxcarbazepine MYLAN OXCARBAZEPINE 300MG TAB Motivation required
717227 Oxcarbazepine MYLAN OXCARBAZEPINE 600MG TAB Motivation required
715980 Valproic acid CONVULEX 150MG CAP
715999 Valproic acid CONVULEX 300MG CAP
780545 Valproic acid EPILIM SUGAR FREE 200MG/5ML SYR
781541 Valproic acid CONVULEX 250MG/5ML SYR
781568 Valproic acid CONVULEX 500MG CAP
718465 Valproic acid NAVALPRO CR 200MG SRT
718466 Valproic acid NAVALPRO CR 300MG SRT
718468 Valproic acid NAVALPRO CR 500MG SRT
710389 Lamotrigine DYNA-LAMOTRIGINE 100MG TAB
710885 Lamotrigine LAMIDUS 50MG TAB
705441 Lamotrigine ASPEN LAMOTRIGINE 100MG TAB
710387 Lamotrigine DYNA-LAMOTRIGINE 25MG TAB
710388 Lamotrigine DYNA-LAMOTRIGINE 50MG TAB
710390 Lamotrigine DYNA-LAMOTRIGINE 200MG TAB
704379 Lamotrigine EPITEC 25MG TAB
710901 Topiramate EPITOZ 100MG TAB
708392 Topiramate TOPLEP 200MG TAB
710240 Topiramate ADCO-TOPIRAMATE 25MG TAB
710900 Topiramate EPITOZ 50MG TAB
708390 Topiramate TOPLEP 50MG TAB
GLAUCOMA
709410 Brimonidine ALPHAGAN PURITE 5ML 1,5MG/1ML OPD
734179 Pilocarpine ISOPTO CARPINE 2% 15ML 2% OPD
734195 Pilocarpine ISOPTO CARPINE 4% 15ML 4% OPD
734284 Pilocarpine ISOPTO CARPINE 1% 15ML 1% OPD
789771 Acetazolamide AZOMID 250MG TAB
701523 Brinzolamide AZOPTIC 5ML EYE SUSPENSION1% OPD
819832 Dorzolamide TRUSOPT 5ML OWI 2% OPD
708445 Betaxolol BETOPTIC 5ML OPD
Severe and uncontrolled
epilepsy only, not responding
to first-line agents. Motivation
Required
Severe and uncontrolled
epilepsy only, not responding
to first-line agents. Motivation
834335 Carteolol TEOPTIC 5ML 2% OPD
781134 Levobunolol BETAGAN 7.5ML 0,5% OPD
816728 Metipranolol BETA-OPHTIOLE 5ML 0,3% OPD
816736 Metipranolol BETA-OPHTIOLE 5ML 0,6% OPD
821624 Timolol GLAUCOSAN 5ML 0,5% OPD
770833 Timolol TIMOPTOL 5ML 0,25% OPD
819824 Timolol TIMOPTOL-XE 2.5ML 0,5% OPD
860379 Timolol, combinations COSOPT 5ML 0,5% OPD
709863 Timolol, combinations COMBIGAN 2MG/5MG 5ML OPD
702983 Timolol, combinations XALACOM 2.5ML OPD
717260 Timolol, combinations AZARGA 5ML OPD
703666 Bimatoprost LUMIGAN 3ML 0,03% OPD
715961 Latanoprost OCUPROST 3ML 50MCG/1ML OPD
702534 Travoprost TRAVATAN 2,5ML 0,004% OPD
HAEMOPHILIA
Please provide laboratory reports confirming the diagnosis. Treatment to be initiated by Specialist Haematologist
714722 Tranexamic acid TRANEXAMIC ACID MEDWICH 500MG TAB
716276 Tranexamic acid TRANIC 500MG TAB
800767 Coagulation factor IX, HAEMOSOLVEX IX 500U INJ
813648 Coagulation factor VIII HAEMOSOLVATE VIII 2X10ML 1000U INJ
841560 Coagulation factor VIII HAEMOSOLVATE VIII 300U INJ
800759 Coagulation factor VIII HAEMOSOLVATE VIII 10ML 500U INJ
717754 Desmopressin DDAVP 1ML INJ
HYPERLIPIDAEMIA
718218 Atorvastatin DYNATOR 10MG TAB
708121 Atorvastatin ASPAVOR 10MG TAB
718073 Atorvastatin ADCO ATORVASTATIN 10MG TAB
718219 Atorvastatin DYNATOR 20MG TAB
708122 Atorvastatin ASPAVOR 20MG TAB
Treatment 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
718074 Atorvastatin ADCO ATORVASTATIN 20MG TAB
718221 Atorvastatin DYNATOR 80MG TAB
718075 Atorvastatin ADCO ATORVASTATIN 40MG TAB
718220 Atorvastatin DYNATOR 40MG TAB
710912 Atorvastatin ASPAVOR 40MG TAB
719185 Atorvastatin ASTOR 10MG TAB
719189 Atorvastatin ASTOR 80MG TAB
719186 Atorvastatin ASTOR 20MG TAB
719187 Atorvastatin ASTOR 40MG TAB
703905 Lovastatin LOVACHOL 40MG TAB
703906 Lovastatin LOVACHOL 20MG TAB
710829 Simvastatin ZYSIM 80MG TAB
700519 Simvastatin SIMVACOR 10MG TAB
710826 Simvastatin ZYSIM 10MG TAB
707089 Simvastatin ARROW SIMVASTATIN 10MG TAB
707090 Simvastatin ARROW SIMVASTATIN 20MG TAB
707091 Simvastatin ARROW SIMVASTATIN 40MG TAB
700520 Simvastatin SIMVACOR 20MG TAB
710827 Simvastatin ZYSIM 20MG TAB
708463 Simvastatin SIMVACOR 40MG TAB
710828 Simvastatin ZYSIM 40MG TAB
710122 Bezafibrate DYNA-BEZAFIBRATE SR 400MG SRT
HYPERTENSION Please provide current blood pressure and bp at time of diagnosis
702947 Potassium chloride SANDOZ K-600 600MG TAB
755753 Potassium chloride PLENISH K 600MG TAB
760048 Reserpine RESERPINE 0,25MG TAB
764116 Methyldopa SANDOZ METHYLDOPA 250MG TAB
732052 Methyldopa HYPOTONE 250MG TAB
785962 Methyldopa MYLAN METHYLDOPA 250MG TAB
701425 Doxazosin CARDUGEN 1MG TAB
701426 Doxazosin CARDUGEN 4MG TAB
714292 Doxazosin CARZIN XL 4MG FCR
782122 Prazosin PRATSIOL 1MG TAB
782130 Prazosin PRATSIOL 2MG TAB
731714 Hydralazine HYPERPHEN 10MG TAB
731722 Hydralazine HYPERPHEN 50MG TAB
761400 Hydralazine SANDOZ HYDRALAZINE 25MG TAB
761419 Hydralazine SANDOZ HYDRALAZINE 50MG TAB
890470 Hydrochlorothiazide HEXAZIDE 25MG TAB
For use in pregnancy only
For documented
hypokalaemia
774057 Hydrochlorothiazide
and potassium
URIREX-K 50MG/300MG 50MG;300MG TAB
833045 Indapamide DAPTRIL 2,5MG TAB
703329 Indapamide MYLAN INDAPAMIDE 2,5MG TAB
710313 Indapamide CIPLA-INDAPAMIDE 2,5MG TAB
857769 Furosemide MYLAN FUROSEMIDE 40MG TAB
758272 Furosemide PURESIS 40MG TAB
731668 Furosemide SANDOZ FUROSEMIDE 40MG TAB
765910 Spironolactone SPIRACTIN 25MG TAB
769665 Spironolactone SANDOZ SPIRONOLACTONE 25MG TAB
898937 Spironolactone SPIRACTIN 100MG TAB
780618 Amiloride Co ADCO-RETIC 50MG/5MG 50MG;5MG TAB
808695 Amiloride Co BETARETIC 50MG/5MG 50MG;5MG TAB
702803 Amiloride Co AMILORETIC 50MG/5MG 50MG;5MG TAB
705872 Atenolol TENOPRESS 25MG TAB
826898 Atenolol BIO-ATENOLOL (WAS IVAX-ATENOLOL)50MG TAB
787892 Atenolol SANDOZ ATENOLOL 50MG TAB
806889 Atenolol HEXA-BLOK 50MG TAB
786195 Atenolol TEN-BLOKA 100MG TAB
786187 Atenolol TEN-BLOKA 50MG TAB
704373 Bisoprolol BILOCOR 10MG TAB
704372 Bisoprolol BILOCOR 5MG TAB
715276 Bisoprolol ZIAPRO 10MG TAB
715274 Bisoprolol ZIAPRO 5MG TAB
718082 Bisoprolol/ HCTZ BISOPROLOL HYDROCHLOROTHIAZIDE ZYDUS 2.5TAB
718086 Bisoprolol/ HCTZ BISOPROLOL HYDROCHLOROTHIAZIDE ZYDUS 5MGTAB
718087 Bisoprolol/ HCTZ BISOPROLOL HYDROCHLOROTHIAZIDE ZYDUS 10MTAB
719200 Bisoprolol/ HCTZ BILOCOR CO 2.5MG/6.25MG TAB
719201 Bisoprolol/ HCTZ BILOCOR CO 5MG/6.25MG TAB
719202 Bisoprolol/ HCTZ BILOCOR CO 10MG/6.25MG TAB
786217 Atenolol/
chlorthalidone
TENCHLOR 100MG/25MG TAB
807591 Atenolol/
chlorthalidone
TENCHLOR HS 50MG/12.5MG TAB
710238 Amlodipine PHARMA DYNAMICS AMLODIPINE BESYLATE10MG TAB
708141 Amlodipine ALMADIN 5MG TAB
710236 Amlodipine PHARMA DYNAMICS AMLODIPINE BESYLATE5MG TAB
708050 Amlodipine AMLODAC 5MG TAB
703917 Amlodipine AMLOC 10MG TAB
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)
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)
708190 Amlodipine NORCARD 5MG TAB
708191 Amlodipine NORCARD 10MG TAB
708051 Amlodipine AMLODAC 10MG TAB
840963 Nifedipine ADCO-VASCARD 20 SR 20MG SRC
711682 Nifedipine FEDALOC SR 30MG SRT
711714 Nifedipine FEDALOC SR 60MG SRT
864153 Nifedipine CIPALAT RETARD 20MG TAB
715000 Nifedipine MACOREL SR 30MG SRT
715001 Nifedipine MACOREL SR 60MG SRT
774944 Verapamil VASOMIL 40MG TAB
700071 Verapamil VERAHEXAL 240 SR 240MG SRT
836478 Captopril ADCO-CAPTOMAX 50MG TAB
899429 Captopril MYLAN CAPTOPRIL 50MG TAB
852619 Captopril MYLAN CAPTOPRIL 25MG TAB
836451 Captopril ADCO-CAPTOMAX 25MG TAB
708109 Enalapril PHARMAPRESS 5MG TAB
891279 Enalapril ENAP 10MG TAB
891280 Enalapril ENAP 20MG TAB
868922 Enalapril PHARMAPRESS 20MG TAB
891272 Enalapril ENAP 5MG TAB
715649 Perindopril ACESYL 4MG TAB
715786 Perindopril CIPLASYL 4 4MG TAB
715795 Perindopril CIPLASYL 8 8MG TAB
714527 Perindopril PEARINDA 4MG TAB
714528 Perindopril PEARINDA 8MG TAB
839795 Captopril/ HCTZ ZAPTO-CO 50MG/25MG 50MG;25MG TAB
891287 Enalapril/ HCTZ ENAP CO 20MG/12.5MG 20MG;12,5MG TAB
885019 Enalapril/ HCTZ PHARMAPRESS CO 20MG/12.5MG TAB
715651 Perindopril Co ACESYL CO 4MG/ 12.5MG 4MG/12.5MG TAB
714952 Perindopril Co PEARINDA PLUS 4MG/1.25MG TAB
717782 Perindopril Co PERINDOPRIL CO UNICORN 4MG/1.25MG TAB
717795 Perindopril Co ARIPREL PLUS 4MG/1.25MG TAB
719209 Candesartan MYLACAND 8MG TAB
719210 Candesartan MYLACAND 16MG TAB
717024 Losartan HYTENZA 50MG TAB
717042 Losartan HYTENZA 100MG TAB
709964 Losartan ZARTAN 100MG TAB
709225 Losartan ZARTAN 50MG TAB
714249 Telmisartan PRITOR 40MG TAB
714250 Telmisartan PRITOR 80MG TAB
Motivation required - please
specify previous treatments
and reason for treatment
change
705060 Valsartan TAREG 80MG TAB
704696 Valsartan TAREG 160MG TAB
715555 Valsartan ZOMEVEK 80MG TAB
715556 Valsartan ZOMEVEK 160MG TAB
719506 Candesartan/ HCTZ MYLACAND PLUS 16MG/12.5MG
717084 Losartan / HCTZ HYTENZA CO 100MG/25MG TAB
716476 Losartan / HCTZ HYTENZA CO 50MG/12.5MG TAB
716217 Losartan / HCTZ ZARTAN CO 100MG/25MG TAB
716515 Losartan / HCTZ SARTOC-CO 100MG/25MG TAB
714251 Telmisartan / HCTZ CO-PRITOR 40/12.5 MG TAB
714252 Telmisartan / HCTZ CO-PRITOR 80/12.5MG TAB
719205 Valsartan/ HCTZ DYNAVAL CO 160MG/12.5MG TAB
719206 Valsartan/ HCTZ DYNAVAL CO 160MG/25MG TAB
719204 Valsartan/ HCTZ DYNAVAL CO 80MG/12.5MG TAB
715672 Valsartan / HCTZ CO-TAREG 160MG/12.5MG 160/12.5MG TAB
715673 Valsartan / HCTZ CO-TAREG PLUS 160MG/25MG TAB
715558 Valsartan / HCTZ CO-ZOMEVEK 80MG/12.5MG TAB
715559 Valsartan / HCTZ CO-ZOMEVEK 160MG/12.5MG TAB
715571 Valsartan / HCTZ CO-MIGROBEN 160MG/12.5MG TAB
705068 Valsartan / HCTZ CO-TAREG 80MG/12.5MG TAB
HYPOTHYROIDISM
720224 Levothyroxine/ liothyronineDIOTROXIN TAB
713172 Levothyroxine sodium EUTHYROX 25MCG TAB
713168 Levothyroxine sodium EUTHYROX 50MCG TAB
713169 Levothyroxine sodium EUTHYROX 100MCG TAB
MULTIPLE SCLEROSIS
Please provide the practice number and name of the diagnosing neurologist. Treatment to be initiated by specialist
701893 Oxybutynin MYLAN OXYBUTYNIN 5MG TAB
872253 Oxybutynin LENDITRO 5MG TAB
706108 Azathioprine AZAPRESS 50MG TAB
700777 Azathioprine ZAPRINE 50MG TAB
712609 Azathioprine AZATHIOPRINE PCH 50MG TAB
712504 Methotrexate ABITREXATE 2,5MG TAB
865567 Baclofen BIO-BACLOFEN 10MG TAB
712607 Baclofen TEVA BACLOFEN 10MG TAB
712493 Carbamazepine DEGRANOL 200MG TAB
712523 Carbamazepine SANDOZ CARBAMAZEPINE 200MG TAB
771996 Amitriptyline TREPILINE 25MG TAB
Second Line - After adequate
trial with Tricyclic
Motivation required - please
specify previous treatments
and reason for treatment
change
772003 Amitriptyline TREPILINE 10MG TAB
784230 Amitriptyline SANDOZ AMITRIPTYLINE 25MG TAB
PARKINSON'S DISEASE
700500 Amantadine SYMADIN 100MG CAP
720542 Orphenadrine DISIPAL 50MG TAB
710468 Levodopa/ carbidopa TEVA CARBI-LEVO 25/250 TAB
710286 Levodopa/ carbidopa TEVA CARBI-LEVO 25/100 TAB
719843 Pramipexole PRAMEX 0,25MG TAB
719844 Pramipexole PRAMEX 0,125MG TAB
719845 Pramipexole PRAMEX 1MG TAB
700647 Ropinirole REQUIP 0,25MG TAB Motivation Required
700650 Ropinirole REQUIP 0,5MG TAB Motivation Required
700652 Ropinirole REQUIP 1MG TAB Motivation Required
700655 Ropinirole REQUIP 2MG TAB Motivation Required
700658 Ropinirole REQUIP 5MG TAB Motivation Required
706712 Selegiline PARKILYNE 5MG TAB
RHEUMATOID ARTHRITIS
762008 Sulfasalazine SALAZOPYRIN 500MG TAB
762016 Sulfasalazine SALAZOPYRIN EN 500MG ECT
810967 Folic acid BE-TABS FOLIC ACID 5MG TAB
752304 Prednisone PANAFCORT 5MG TAB
818267 Prednisone TROLIC 5MG TAB
788783 Prednisone BE-TABS PREDNISONE 5MG TAB
723274 Cyclophosphamide ENDOXAN 50MG TAB
700777 Azathioprine ZAPRINE 50MG TAB
706108 Azathioprine AZAPRESS 50MG TAB
712609 Azathioprine AZATHIOPRINE PCH 50MG TAB
712504 Methotrexate ABITREXATE 2,5MG TAB
834327 Diclofenac SANDOZ DICLOFENAC SODIUM 100 SIMPLE REG100MG SRT
853240 Diclofenac DICLOHEXAL 25MG TAB
893390 Diclofenac A-LENNON DICLOFENAC 25MG TAB
893391 Diclofenac A-LENNON DICLOFENAC 50MG TAB
786012 Diclofenac MYLAN DICLOFENAC 25MG TAB
786020 Diclofenac MYLAN DICLOFENAC 50MG TAB
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.
701106 Indometacin ADCO-INDOMETHACIN 25MG CAP
704725 Indometacin ARTHREXIN 25MG CAP
704776 Indometacin SANDOZ INDOMETHACIN 25MG CAP
704829 Meloxicam FLEXOCAM 7,5MG TAB
705375 Meloxicam ADCO-MELOXICAM 7,5MG TAB
705176 Meloxicam M-CAM 7,5MG TAB
705229 Meloxicam ZYDUS-MELOXICAM 7,5MG TAB
711324 Meloxicam ARROW MELOXICAM 7,5MG TAB
797030 Piroxicam XYCAM 20MG CAP
799432 Piroxicam PYROCAPS 20MG CAP
701072 Piroxicam ROXIFEN 20MG CAP
733768 Ibuprofen INZA 400MG TAB
782807 Ibuprofen SANDOZ IBUPROFEN 600MG TAB
733741 Ibuprofen INZA 200MG TAB
700316 Ibuprofen IBUCINE (WAS IBUMAX) 200MG TAB
700318 Ibuprofen IBUCINE (WAS IBUMAX) 400MG TAB
805238 Naproxen NAPROSCRIPT 250MG TAB
810185 Naproxen MYLAN NAPROXEN 250MG TAB
824992 Paracetamol GENCETAMOL TAB
799629 Paracetamol PAINAMOL (GREEN) 500MG TAB
747297 Chloroquine NIVAQUINE 200MG TAB
SCHIZOPHRENIA
Please provide a report from a psychiatrist that confirms the diagnosis, based on DSM lV Diagnostic Criteria
712523 Carbamazepine SANDOZ CARBAMAZEPINE 200MG TAB
712493 Carbamazepine DEGRANOL 200MG TAB
715980 Valproic acid CONVULEX 150MG CAP
715999 Valproic acid CONVULEX 300MG CAP
781568 Valproic acid CONVULEX 500MG CAP
718274 Valproic acid EPILIZINE CR 200MG SRT
718275 Valproic acid EPILIZINE CR 300MG SRT
718276 Valproic acid EPILIZINE CR 500MG SRT
718465 Valproic acid NAVALPRO CR 200MG SRT
718466 Valproic acid NAVALPRO CR 300MG SRT
718468 Valproic acid NAVALPRO CR 500MG SRT
710387 Lamotrigine DYNA-LAMOTRIGINE 25MG TAB
710388 Lamotrigine DYNA-LAMOTRIGINE 50MG TAB
710389 Lamotrigine DYNA-LAMOTRIGINE 100MG TAB
710390 Lamotrigine DYNA-LAMOTRIGINE 200MG TAB
705441 Lamotrigine ASPEN LAMOTRIGINE 100MG TAB
720542 Orphenadrine DISIPAL 50MG TAB
735868 Chlorpromazine LARGACTIL 25MG TAB
735876 Chlorpromazine LARGACTIL 50MG TAB
735884 Chlorpromazine LARGACTIL 100MG TAB
744301 Fluphenazine MODECATE 1ML 25MG/1ML INJ
763411 Haloperidol SERENACE 0,5MG CAP
730327 Haloperidol SANDOZ HALOPERIDOL 5MG TAB
730335 Haloperidol SANDOZ HALOPERIDOL 1,5MG TAB
726672 Flupentixol FLUANXOL DEPOT 1ML 20MG INJ
714852 Zuclopenthixol CLOPIXOL DEPOT 200MG INJ
700176 Clozapine CLOMENT 25MG TAB Treatment to be initiated by a
psychiatrist
700178 Clozapine CLOMENT 100MG TAB Treatment to be initiated by a
psychiatrist
715657 Olanzapine OLEXAR 2,5MG TAB Treatment to be initiated by a
psychiatrist
715658 Olanzapine OLEXAR 5MG TAB Treatment to be initiated by a
psychiatrist
715659 Olanzapine OLEXAR 10MG TAB Treatment to be initiated by a
psychiatrist
715995 Olanzapine OLEANZ 5MG TAB Treatment to be initiated by a
psychiatrist
715996 Olanzapine OLEANZ 10MG TAB Treatment to be initiated by a
psychiatrist
716672 Quetiapine MYLAN QUETIAPINE 300MG TAB Treatment to be initiated by a
psychiatrist
716668 Quetiapine MYLAN QUETIAPINE 25MG TAB Treatment to be initiated by a
psychiatrist
716670 Quetiapine MYLAN QUETIAPINE 100MG TAB Treatment to be initiated by a
psychiatrist
716671 Quetiapine MYLAN QUETIAPINE 200MG TAB Treatment to be initiated by a
psychiatrist
716636 Quetiapine QUETOSER 100MG TAB Treatment to be initiated by a
psychiatrist
716637 Quetiapine QUETOSER 200MG TAB Treatment to be initiated by a
psychiatrist
716635 Quetiapine QUETOSER 25MG TAB Treatment to be initiated by a
psychiatrist
711475 Risperidone ASPEN RISPERIDONE 4MG TAB Treatment to be initiated by a
psychiatrist
711474 Risperidone ASPEN RISPERIDONE 3MG TAB Treatment to be initiated by a
psychiatrist
711511 Risperidone ZOXADON 0,5MG TAB Treatment to be initiated by a
psychiatrist
711512 Risperidone ZOXADON 1MG TAB Treatment to be initiated by a
psychiatrist
711513 Risperidone ZOXADON 2MG TAB Treatment to be initiated by a
psychiatrist
715736 Risperidone SCHIZOROL 0,5MG TAB Treatment to be initiated by a
psychiatrist
715737 Risperidone SCHIZOROL 1MG TAB Treatment to be initiated by a
psychiatrist
715738 Risperidone SCHIZOROL 2MG TAB Treatment to be initiated by a
psychiatrist
771996 Amitriptyline TREPILINE 25MG TAB
772003 Amitriptyline TREPILINE 10MG TAB
784230 Amitriptyline SANDOZ AMITRIPTYLINE 25MG TAB
800198 Dosulepin THADEN 25MG CAP
800201 Dosulepin THADEN 75MG TAB
724661 Imipramine ETHIPRAMINE 10MG TAB
724688 Imipramine ETHIPRAMINE 25MG TAB
713584 Citalopram ARROW CITALOPRAM 40MG TAB
713583 Citalopram ARROW CITALOPRAM 20MG TAB
703391 Fluoxetine A-LENNON FLUOXETINE 20MG CAP
705064 Fluoxetine ZYDUS FLUOXETINE 20MG CAP
894303 Fluoxetine DEPROZAN 20MG CAP
700877 Fluoxetine LORIEN 20MG TAB
715935 Sertraline SERDEP 100MG TAB
712093 Sertraline ARROW SERTRALINE 50MG TAB
705420 Sertraline SERDEP 50MG TAB
712092 Sertraline ARROW SERTRALINE 100MG TAB
SYSTEMIC LUPUS ERYTHEMATOSUS
Please provide a report from a rheumatologist or specialist physician, confirming the diagnosis.
810967 Folic acid BE-TABS FOLIC ACID 5MG TAB
818267 Prednisone TROLIC 5MG TAB
788783 Prednisone BE-TABS PREDNISONE 5MG TAB
752304 Prednisone PANAFCORT 5MG TAB
723274 Cyclophosphamide ENDOXAN 50MG TAB
706108 Azathioprine AZAPRESS 50MG TAB
712609 Azathioprine AZATHIOPRINE PCH 50MG TAB
700777 Azathioprine ZAPRINE 50MG TAB
712504 Methotrexate ABITREXATE 2,5MG TAB
834327 Diclofenac SANDOZ DICLOFENAC SODIUM 100 SIMPLE REG100MG SRT
853240 Diclofenac DICLOHEXAL 25MG TAB
893390 Diclofenac A-LENNON DICLOFENAC 25MG TAB
893391 Diclofenac A-LENNON DICLOFENAC 50MG TAB
786012 Diclofenac MYLAN DICLOFENAC 25MG TAB
786020 Diclofenac MYLAN DICLOFENAC 50MG TAB
704725 Indometacin ARTHREXIN 25MG CAP
704776 Indometacin SANDOZ INDOMETHACIN 25MG CAP
701106 Indometacin ADCO-INDOMETHACIN 25MG CAP
704829 Meloxicam FLEXOCAM 7,5MG TAB
705375 Meloxicam ADCO-MELOXICAM 7,5MG TAB
705176 Meloxicam M-CAM 7,5MG TAB
705229 Meloxicam ZYDUS-MELOXICAM 7,5MG TAB
711324 Meloxicam ARROW MELOXICAM 7,5MG TAB
797030 Piroxicam XYCAM 20MG CAP
799432 Piroxicam PYROCAPS 20MG CAP
701072 Piroxicam ROXIFEN 20MG CAP
733768 Ibuprofen INZA 400MG TAB
782807 Ibuprofen SANDOZ IBUPROFEN 600MG TAB
700315 Ibuprofen IBUCINE (WAS IBUMAX) 100MG/5ML SUS
700316 Ibuprofen IBUCINE (WAS IBUMAX) 200MG TAB
733741 Ibuprofen INZA 200MG TAB
701975 Ibuprofen BETAPROFEN FC 400MG TAB
700318 Ibuprofen IBUCINE (WAS IBUMAX) 400MG TAB
805238 Naproxen NAPROSCRIPT 250MG TAB
810185 Naproxen MYLAN NAPROXEN 250MG TAB
700909 Acetylsalicylic acid GULF ASPIRIN 300MG TAB
747297 Chloroquine NIVAQUINE 200MG TAB
ULCERATIVE COLITIS
Please provide a report from a specialist physician or gastroenterologist that confirms the diagnosis
824593 Budesonide ENTOCORD ENE Motivation required
783668 Mesalazine ASACOL 400MG TAB
890775 Mesalazine PENTASA 500MG TAB
824135 Mesalazine ASACOL 500MG SUP
792519 Olsalazine DIPENTUM 250MG CAP
762008 Sulfasalazine SALAZOPYRIN 500MG TAB
752304 Prednisone PANAFCORT 5MG TAB
818267 Prednisone TROLIC 5MG TAB
788783 Prednisone BE-TABS PREDNISONE 5MG TAB
706108 Azathioprine AZAPRESS 50MG TAB
700777 Azathioprine ZAPRINE 50MG TAB
712609 Azathioprine AZATHIOPRINE PCH 50MG TAB
712504 Methotrexate ABITREXATE 2,5MG TAB
MENOPAUSE
832448 Conjugated estrogens PREMARIN VCR
756725 Conjugated estrogens PREMARIN 0,3MG TAB
756733 Conjugated estrogens PREMARIN 0,625MG TAB
756741 Conjugated estrogens PREMARIN 1,25MG TAB
822477 Estradiol ESTRO-PAUSE 1MG TAB
822485 Estradiol ESTRO-PAUSE 2MG TAB
706049 Estradiol ESTRADOT 25MCG PTD
706052 Estradiol ESTRADOT 37,5MCG PTD
706053 Estradiol ESTRADOT 50MCG PTD
706054 Estradiol ESTRADOT 75MCG PTD
706055 Estradiol ESTRADOT 100MCG PTD
824631 Estradiol CLIMARA 50 PTD
824658 Estradiol CLIMARA 100 PTD
827452 Estriol SYNAPAUSE-E3 2MG TAB
706704 Medroxyprogesterone HEXAL-MPA 5MG TAB
881112 Norethisterone/
estrogen
ACTIVELLE TAB
853429 Medroxyprogesterone/
estrogen
PREMELLE-CYCLE 5 TAB
825913 Norethisterone/
estrogen
TRISEQUENS TAB
822493 Norethisterone/
estrogen
ESTRO-PAUSE N TAB
825980 Norgestrel/ estrogen POSTOVAL TAB
818550 Cyproterone/ estrogen CLIMEN TAB
CARDIAC ARRYTHMIA (NON CDL)
709905 Warfarin CIPLA-WARFARIN 5MG TAB
709906 Warfarin CIPLA-WARFARIN 1MG TAB
735752 Digoxin LANOXIN 0,25MG TAB
PMB 270 DTP CONDITIONS
758280 Digoxin PURGOXIN 0,25MG TAB
758868 Quinidine QUINIDINE SULPH 200MG TAB
703513 Amiodarone ARYCOR 200MG TAB
703515 Amiodarone ARYCOR 100MG TAB
863157 Amiodarone HEXARONE 100MG TAB
863165 Amiodarone HEXARONE 200MG TAB
806552 Propranolol INDOBLOK 10MG TAB
806560 Propranolol INDOBLOK 40MG TAB
758140 Propranolol PURBLOKA 10MG TAB
758167 Propranolol PURBLOKA 40MG TAB
786195 Atenolol TEN-BLOKA 100MG TAB
786187 Atenolol TEN-BLOKA 50MG TAB
705872 Atenolol TENOPRESS 25MG TAB
787892 Atenolol SANDOZ ATENOLOL 50MG TAB
806889 Atenolol HEXA-BLOK 50MG TAB
826898 Atenolol BIO-ATENOLOL (WAS IVAX-ATENOLOL)50MG TAB
715276 Bisoprolol ZIAPRO 10MG TAB
715274 Bisoprolol ZIAPRO 5MG TAB
703913 Bisoprolol ADCO-BISOCOR 5MG TAB
703914 Bisoprolol ADCO-BISOCOR 10MG TAB
704373 Bisoprolol BILOCOR 10MG TAB
704372 Bisoprolol BILOCOR 5MG TAB
774944 Verapamil VASOMIL 40MG TAB
774952 Verapamil VASOMIL 80MG TAB
700071 Verapamil VERAHEXAL 240 SR 240MG SRT
839183 Diltiazem ADCO-ZILDEM SR 180MG SRC
839191 Diltiazem ADCO-ZILDEM SR 240MG SRC
822213 Diltiazem ADCO-ZILDEM 60MG TAB
824364 Diltiazem ADCO-ZILDEM 90MG TAB
700909 Acetylsalicylic acid GULF ASPIRIN 300MG TAB
ACNE
893402 Doxycycline A-LENNON DOXYCYCLINE HCL 100MG CAP
716944 Doxycycline CYCLIDOX 100MG CAP
809667 Doxycycline DOXYCYL 100MG CAP
884167 Oxytetracycline NUCOTET 250MG CAP
787434 Oxytetracycline BE-OXYTET 250MG CAP
812072 Oxytetracycline TETRACEM 250MG CAP
751987 Oxytetracycline OXYPAN 250MG CAP
758396 Erythromycin PURMYCIN 125MG/5ML SUS
758418 Erythromycin PURMYCIN 250MG/5ML SUS
758388 Erythromycin PURMYCIN 250MG CAP
765651 Erythromycin SPECTRASONE 250MG CAP
824682 Erythromycin XERAMEL 250MG CAP
ALLERGIC RHINITIS
820709 Beclometasone BECLATE AQUANASE 150DOSE50MCG AQS
897937 Beclometasone CLENIL AQUEOUS 200DOSE 50MCG AQS
714595 Fluticasone FLONASE 120 DOSE 50MCG AQS
704383 Fluticasone FLOMIST 120DOSE 50MCG AQS
712890 Cetirizine ACUZYRT 10MG TAB
703821 Cetirizine ALLERMINE 10MG TAB
704188 Cetirizine ASPEN CETIRIZINE 10MG TAB
710672 Cetirizine TEXA 5MG/5ML SYR
712889 Cetirizine ACUZYRT 5MG/5ML SYR
713231 Cetirizine ASPEN CETIRIZINE 5MG/5ML SYR
703314 Cetirizine TEXA 10MG TAB
704659 Cetirizine ZYNCET 10MG TAB
712764 Cetirizine ZETOP 10MG TAB
OTHER CHRONIC DISEASES NOT APPLICABLE TO ALL
Clinical motivation required if
an antihistamine is prescribed
with inhaled steroid
Not applicable for Bankmed PMB option, Liberty and Topmed
MAJOR DEPRESSION
771996 Amitriptyline TREPILINE 25MG TAB
772003 Amitriptyline TREPILINE 10MG TAB
784230 Amitriptyline SANDOZ AMITRIPTYLINE 25MG TAB
800198 Dosulepin THADEN 25MG CAP
800201 Dosulepin THADEN 75MG TAB
724661 Imipramine ETHIPRAMINE 10MG TAB
724688 Imipramine ETHIPRAMINE 25MG TAB
713584 Citalopram ARROW CITALOPRAM 40MG TAB
713583 Citalopram ARROW CITALOPRAM 20MG TAB
700877 Fluoxetine LORIEN 20MG TAB
705064 Fluoxetine ZYDUS FLUOXETINE 20MG CAP
894303 Fluoxetine DEPROZAN 20MG CAP
703391 Fluoxetine A-LENNON FLUOXETINE 20MG CAP
715935 Sertraline SERDEP 100MG TAB
705420 Sertraline SERDEP 50MG TAB
712092 Sertraline ARROW SERTRALINE 100MG TAB
712093 Sertraline ARROW SERTRALINE 50MG TAB
GOUT
758329 Allopurinol PURICOS 300MG TAB
738778 Allopurinol SANDOZ ALLOPURINOL 100MG TAB
758310 Allopurinol PURICOS 100MG TAB
MIGRAINE (PROPHYLAXIS ONLY)
758140 Propranolol PURBLOKA 10MG TAB
758167 Propranolol PURBLOKA 40MG TAB
806552 Propranolol INDOBLOK 10MG TAB
806560 Propranolol INDOBLOK 40MG TAB
771996 Amitriptyline TREPILINE 25MG TAB
772003 Amitriptyline TREPILINE 10MG TAB
784230 Amitriptyline SANDOZ AMITRIPTYLINE 25MG TAB
724661 Imipramine ETHIPRAMINE 10MG TAB
724688 Imipramine ETHIPRAMINE 25MG TAB
OSTEOARTHRITIS
786012 Diclofenac MYLAN DICLOFENAC 25MG TAB
786020 Diclofenac MYLAN DICLOFENAC 50MG TAB
834327 Diclofenac SANDOZ DICLOFENAC SODIUM 100 SIMPLE REG100MG SRT
853240 Diclofenac DICLOHEXAL 25MG TAB
893390 Diclofenac A-LENNON DICLOFENAC 25MG TAB
893391 Diclofenac A-LENNON DICLOFENAC 50MG TAB
701106 Indometacin ADCO-INDOMETHACIN 25MG CAP
704725 Indometacin ARTHREXIN 25MG CAP
704776 Indometacin SANDOZ INDOMETHACIN 25MG CAP
705176 Meloxicam M-CAM 7,5MG TAB
711324 Meloxicam ARROW MELOXICAM 7,5MG TAB
705229 Meloxicam ZYDUS-MELOXICAM 7,5MG TAB
704829 Meloxicam FLEXOCAM 7,5MG TAB
705375 Meloxicam ADCO-MELOXICAM 7,5MG TAB
797030 Piroxicam XYCAM 20MG CAP
799432 Piroxicam PYROCAPS 20MG CAP
701072 Piroxicam ROXIFEN 20MG CAP
733768 Ibuprofen INZA 400MG TAB
782807 Ibuprofen SANDOZ IBUPROFEN 600MG TAB
700318 Ibuprofen IBUCINE (WAS IBUMAX) 400MG TAB
733741 Ibuprofen INZA 200MG TAB
701975 Ibuprofen BETAPROFEN FC 400MG TAB
700316 Ibuprofen IBUCINE (WAS IBUMAX) 200MG TAB
805238 Naproxen NAPROSCRIPT 250MG TAB
810185 Naproxen MYLAN NAPROXEN 250MG TAB
799629 Paracetamol PAINAMOL (GREEN) 500MG TAB
824992 Paracetamol GENCETAMOL TAB