carecross chronic medicine formulary · 2015-03-26 · 700715 salbutamol asthavent ecohaler...

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




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



897462 Budesonide BUDEFLAM HFA 300DOSE 100MCG 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


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



718274 Valproic acid EPILIZINE CR 200MG SRT



718465 Valproic acid NAVALPRO CR 200MG SRT


704379 Lamotrigine EPITEC 25MG TAB

704488 Lamotrigine LAMITOR 100MG TAB

705251 Lamotrigine SANDOZ LAMOTRIGINE 25MG TAB

710387 Lamotrigine DYNA-LAMOTRIGINE 25MG TAB




710887 Lamotrigine LAMIDUS 100MG 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


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


psychiatrist

715995 Olanzapine OLEANZ 5MG TAB Treatment to be initiated by a

psychiatrist


psychiatrist

716672 Quetiapine MYLAN QUETIAPINE 300MG TAB Treatment to be initiated by a

psychiatrist


psychiatrist


psychiatrist


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


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


psychiatrist

711475 Risperidone ASPEN RISPERIDONE 4MG TAB Treatment to be initiated by a

psychiatrist


psychiatrist

784230 Amitriptyline SANDOZ AMITRIPTYLINE 25MG TAB

771996 Amitriptyline TREPILINE 25MG TAB


800198 Dosulepin THADEN 25MG CAP

800201 Dosulepin THADEN 75MG TAB

724661 Imipramine ETHIPRAMINE 10MG TAB


713584 Citalopram ARROW CITALOPRAM 40MG 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


712092 Sertraline ARROW SERTRALINE 100MG 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


735752 Digoxin LANOXIN 0,25MG TAB

758280 Digoxin PURGOXIN 0,25MG TAB

758868 Quinidine QUINIDINE SULPH 200MG TAB

703513 Amiodarone ARYCOR 200MG TAB


863157 Amiodarone HEXARONE 100MG TAB


758140 Propranolol PURBLOKA 10MG TAB


806552 Propranolol INDOBLOK 10MG 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


704372 Bisoprolol BILOCOR 5MG TAB


715276 Bisoprolol ZIAPRO 10MG TAB


700071 Verapamil VERAHEXAL 240 SR 240MG SRT

774944 Verapamil VASOMIL 40MG TAB


824364 Diltiazem ADCO-ZILDEM 90MG TAB

839183 Diltiazem ADCO-ZILDEM SR 180MG 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





784206 Isosorbide dinitrate SANDOZ ISOSORBIDE DINITRATE10MG TAB


761400 Hydralazine SANDOZ HYDRALAZINE 25MG TAB


731714 Hydralazine HYPERPHEN 10MG 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


769665 Spironolactone SANDOZ SPIRONOLACTONE 25MG TAB

703914 Bisoprolol ADCO-BISOCOR 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



708109 Enalapril PHARMAPRESS 5MG TAB

891280 Enalapril ENAP 20MG TAB

712763 Enalapril ENVAS 10MG TAB




715649 Perindopril ACESYL 4MG TAB

715795 Perindopril CIPLASYL 8 8MG TAB

714527 Perindopril PEARINDA 4MG TAB



719209 Candesartan MYLACAND 8MG TAB


717024 Losartan HYTENZA 50MG TAB

709964 Losartan ZARTAN 100MG TAB



714249 Telmisartan PRITOR 40MG TAB


715555 Valsartan ZOMEVEK 80MG TAB


704696 Valsartan TAREG 160MG 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




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




704176 Budesonide BUDEFLAM DP-CAPS 200MCG CPS



715574 Ipratropium bromide IPVENT HFA 200 DOSE 40MCG/1DOSE INH



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




























712763 Enalapril ENVAS 10MG TAB



















treatment change









CORONARY ARTERY DISEASE Stress ECG report & details of history of previous cardiovascular events (if applicable) is required



784192 Isosorbide dinitrate SANDOZ ISOSORBIDE DINITRATE5MG SLT









826898 Atenolol BIO-ATENOLOL 50MG TAB








708141 Amlodipine ALMADIN 5MG TAB

708190 Amlodipine NORCARD 5MG TAB


703917 Amlodipine AMLOC 10MG TAB

708050 Amlodipine AMLODAC 5MG TAB

710236 Amlodipine PHARMA DYNAMICS AMLODIPINE BESYLATE5MG TAB



711682 Nifedipine FEDALOC SR 30MG SRT





treatment change

715000 Nifedipine MACOREL SR 30MG SRT


829501 Nifedipine NIFEDALAT 20SR 20MG SRT

840963 Nifedipine ADCO-VASCARD 20 SR 20MG SRC








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





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


711636 Metformin METORED 500MG TAB

718231 Metformin METCHEK 500MG 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


705597 Carbamazepine SANDOZ CARBAMAZEPINE CR 200MG SRT

705602 Carbamazepine SANDOZ CARBAMAZEPINE CR 400MG SRT


717226 Oxcarbazepine MYLAN OXCARBAZEPINE 300MG TAB Motivation required

717227 Oxcarbazepine MYLAN OXCARBAZEPINE 600MG TAB Motivation required



780545 Valproic acid EPILIM SUGAR FREE 200MG/5ML SYR

781541 Valproic acid CONVULEX 250MG/5ML SYR







705441 Lamotrigine ASPEN LAMOTRIGINE 100MG 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



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



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






719185 Atorvastatin ASTOR 10MG TAB




703905 Lovastatin LOVACHOL 40MG TAB

703906 Lovastatin LOVACHOL 20MG TAB

710829 Simvastatin ZYSIM 80MG TAB

700519 Simvastatin SIMVACOR 10MG TAB


707089 Simvastatin ARROW SIMVASTATIN 10MG 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






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





769665 Spironolactone SANDOZ SPIRONOLACTONE 25MG 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











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


708141 Amlodipine ALMADIN 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)




840963 Nifedipine ADCO-VASCARD 20 SR 20MG SRC



864153 Nifedipine CIPALAT RETARD 20MG 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









Motivation required - please

specify previous treatments

and reason for treatment

change





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



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





865567 Baclofen BIO-BACLOFEN 10MG TAB

712607 Baclofen TEVA BACLOFEN 10MG TAB




Second Line - After adequate

trial with Tricyclic

Motivation required - please

specify previous treatments

and reason for treatment

change



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



706712 Selegiline PARKILYNE 5MG TAB

RHEUMATOID ARTHRITIS


762016 Sulfasalazine SALAZOPYRIN EN 500MG ECT





723274 Cyclophosphamide ENDOXAN 50MG TAB





834327 Diclofenac SANDOZ DICLOFENAC SODIUM 100 SIMPLE REG100MG SRT

853240 Diclofenac DICLOHEXAL 25MG TAB

893390 Diclofenac A-LENNON DICLOFENAC 25MG TAB


786012 Diclofenac MYLAN DICLOFENAC 25MG 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


700316 Ibuprofen IBUCINE (WAS IBUMAX) 200MG 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
















705441 Lamotrigine ASPEN LAMOTRIGINE 100MG TAB

720542 Orphenadrine DISIPAL 50MG TAB

735868 Chlorpromazine LARGACTIL 25MG 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


psychiatrist


psychiatrist

715657 Olanzapine OLEXAR 2,5MG TAB Treatment to be initiated by a

psychiatrist


psychiatrist


psychiatrist


psychiatrist


psychiatrist


psychiatrist


psychiatrist


psychiatrist


psychiatrist


psychiatrist


psychiatrist


psychiatrist


psychiatrist


psychiatrist

711511 Risperidone ZOXADON 0,5MG TAB Treatment to be initiated by a

psychiatrist


psychiatrist


psychiatrist

715736 Risperidone SCHIZOROL 0,5MG TAB Treatment to be initiated by a

psychiatrist


psychiatrist


psychiatrist


















SYSTEMIC LUPUS ERYTHEMATOSUS

Please provide a report from a rheumatologist or specialist physician, confirming the diagnosis.





723274 Cyclophosphamide ENDOXAN 50MG TAB
























700315 Ibuprofen IBUCINE (WAS IBUMAX) 100MG/5ML SUS



701975 Ibuprofen BETAPROFEN FC 400MG 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









MENOPAUSE

832448 Conjugated estrogens PREMARIN VCR

756725 Conjugated estrogens PREMARIN 0,3MG TAB



822477 Estradiol ESTRO-PAUSE 1MG TAB

822485 Estradiol ESTRO-PAUSE 2MG TAB

706049 Estradiol ESTRADOT 25MCG PTD

706052 Estradiol ESTRADOT 37,5MCG 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


estrogen

TRISEQUENS TAB


estrogen

ESTRO-PAUSE N TAB

825980 Norgestrel/ estrogen POSTOVAL TAB

818550 Cyproterone/ estrogen CLIMEN TAB

CARDIAC ARRYTHMIA (NON CDL)




PMB 270 DTP CONDITIONS


758868 Quinidine QUINIDINE SULPH 200MG 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


















GOUT

758329 Allopurinol PURICOS 300MG TAB

738778 Allopurinol SANDOZ ALLOPURINOL 100MG TAB

758310 Allopurinol PURICOS 100MG TAB

MIGRAINE (PROPHYLAXIS ONLY)










OSTEOARTHRITIS






















701975 Ibuprofen BETAPROFEN FC 400MG TAB




799629 Paracetamol PAINAMOL (GREEN) 500MG TAB

824992 Paracetamol GENCETAMOL TAB

carecross chronic medicine formulary · 2015-03-26 · 700715 salbutamol asthavent ecohaler...

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