chronic medicine formulary - pnpms.co.za

1

This formulary applies to Pick n Pay Primary Option The following terms and conditions as set out below apply:

1. Chronic medication application forms must accompany all first-time applications. All applications must include valid ICD-10 codes. 2. Clinical criteria apply. 3. If the prescriber or patient requests a non-formulary product and a therapeutic equivalent for the non-formulary product is available

on the formulary, a co-payment will be charged at the point of dispensing. 4. 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. 5. The NAPPI code list serves as a guide to the prescriber. Other generic products that are not specifically listed will be reimbursed in full

if the price falls within the reference price range for that group. 6. A clinically relevant motivation is required when prescribing any product that does not appear on this list. 7. The formulary is subject to regular review. MMI Health reserves the right to update and change the formulary when new information

becomes available, prices change or when new medicines are released. 8. While every effort has been made to ensure that the products that are listed are available on the market, it is possible that some

products may be discontinued by the manufacturers during the course of the year. 9. The formularies are set out to include a list of carve-out medicines, as set out below. PRESCRIBED MINIMUM BENEFIT (PMB) CHRONIC DISEASE LIST (CDL) CONDITIONS

NAPPI CODE

INGREDIENT PRODUCT NAME STRENGTH FORM COMMENT

ADDISON'S DISEASE

The PMB is applicable to primary Addison’s disease only. Practice number and name of diagnosing specialist is required

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

454299 SPACER ZEROSTAT VT ZZZ

577802 DP HALER DEVICE ZZZ

402042 MASK BABY CIPLA ZZZ

788783 Prednisone BE-TABS PREDNISONE 5MG TAB Only for severe persistent asthma

(motivation required)



710307 Formoterol FORATEC HFA 120DOSE 12MCG/1DOSE INH Will only be approved if

prescribed together with an inhaled

steroid

700715 Salbutamol ASTHAVENT ECOHALER CFC-FREE

300DOSE 100MCG INH

CARECROSS HEALTH

CHRONIC MEDICINE FORMULARY

2017

2

NAPPI CODE


711213 Salbutamol VENTEZE CFC FREE 200 DOSE 100MCG INH Limited to 3

inhalers per year if no inhaled steroid

849332 Salbutamol ASTHAVENT ECOHALER 200DOSE 100MCG INH

718698 Salbutamol/ Ipratropium

DUOLIN HFA 200DOSE INH

715189 Salmeterol/ Fluticasone

SEREFLO 25/50 HFA 120 DOSE INH Only for moderate & severe persistent asthma (motivation

required)


SEREFLO 25/125 HFA 120 DOSE INH


SEREFLO 25/250 HFA 120 DOSE INH

827061 Beclometasone BECEZE 50 200DOSE 50MCG INH

827088 Beclometasone BECEZE 100 CFC FREE 200DOSE 100MCG INH

819611 Beclometasone BECLATE 200DOSE 50MCG INH



791423 Budesonide PULMICORT TURBUHALER

200DOSE 100MCG TBH

791431 Budesonide PULMICORT TURBUHALER

200DOSE 200MCG TBH

704176 Budesonide BUDEFLAM DP-CAPS 200MCG CPS

897462 Budesonide BUDEFLAM HFA 300DOSE 100MCG INH


824186 Salbutamol ASTHAVENT 2MG/5ML SYR Only for children under 5 years 775452 Salbutamol VENTEZE 2MG/5ML SYR

701750 Theophylline ALCOPHYLLIN 26,67MG/5ML SYR

788368 Theophylline SANDOZ THEOPHYLLINE

ANHYDROUS 200MG SRT


ANHYDROUS 300MG SRT

717623 Montelukast MINAIR 4MG CHU

Only for children under 5 years

717624 Montelukast MINAIR 5MG CHU

718604 Montelukast SINTAIR 4MG CHU

718605 Montelukast SINTAIR 5MG CHU

717383 Montelukast LUMONT 4MG CHU

717384 Montelukast LUMONT 5MG CHU

719638 Montelukast MONTELUKAST CHEW BIOTECH 4MG CHU

BIPOLAR MOOD DISORDER

A report from a psychiatrist confirming the diagnosis, based on DSM lV diagnostic criteria is required

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

3

NAPPI CODE





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


715657 Olanzapine OLEXAR 2,5MG TAB

715658 Olanzapine OLEXAR 5MG TAB


715995 Olanzapine OLEANZ 5MG TAB


716672 Quetiapine MYLAN QUETIAPINE 300MG TAB




716637 Quetiapine QUETOSER 200MG TAB

758833 Lithium QUILONUM RETARD 450MG TAB

712078 Lithium CAMCOLIT 250MG TAB

712086 Lithium CAMCOLIT 400MG TAB

715736 Risperidone SCHIZOROL 0,5MG TAB


715737 Risperidone SCHIZOROL 1MG TAB


711511 Risperidone ZOXADON 0,5MG TAB

711512 Risperidone ZOXADON 1MG TAB


711475 Risperidone ASPEN RISPERIDONE 4MG TAB


784230 Amitriptyline SANDOZ AMITRIPTYLINE 25MG TAB

Antidepressants will only be approved if prescribed together

with a mood stabiliser

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

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


4

NAPPI CODE


712092 Sertraline ARROW SERTRALINE 100MG TAB


BRONCHIECTASIS

A sensitivity report must be included with a request for an alternative antibiotic

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

A specific diagnosis and/or the relevant ICD-10 code is required

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


758167 Propranolol PURBLOKA 40MG TAB

806552 Propranolol INDOBLOK 10MG TAB



826898 Atenolol BIO-ATENOLOL (WAS IVAX-

ATENOLOL) 50MG TAB

786187 Atenolol TEN-BLOKA 50MG TAB


704651 Atenolol B-BLOCK 100MG TAB


705872 Atenolol TENOPRESS 25MG TAB

787892 Atenolol SANDOZ ATENOLOL 50MG TAB

806889 Atenolol HEXA-BLOK 50MG TAB

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

5

NAPPI CODE


CARDIAC FAILURE AND CARDIOMYOPATHY

702947 Potassium chloride SANDOZ K-600 600MG TAB For documented hypokalaemia 755753 Potassium chloride PLENISH K 600MG TAB





784206 Isosorbide dinitrate SANDOZ ISOSORBIDE DINITRATE 10MG TAB

731714 Hydralazine HYPERPHEN 10MG TAB


761400 Hydralazine SANDOZ HYDRALAZINE 25MG TAB


890470 Hydrochlorothiazid

e HEXAZIDE 25MG TAB

731668 Furosemide SANDOZ FUROSEMIDE 40MG TAB

758272 Furosemide PURESIS 40MG TAB

857769 Furosemide MYLAN FUROSEMIDE 40MG TAB

765910 Spironolactone SPIRACTIN 25MG TAB

769665 Spironolactone SANDOZ SPIRONOLACTONE 25MG TAB



703914 Bisoprolol ADCO-BISOCOR 10MG TAB




704672 Carvedilol CARVETREND 25MG TAB

710340 Carvedilol ASPEN CARVEDILOL 25MG 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

852619 Captopril MYLAN CAPTOPRIL 25MG TAB


836451 Captopril ADCO-CAPTOMAX 25MG TAB


868922 Enalapril PHARMAPRESS 20MG TAB

891280 Enalapril ENAP 20MG TAB



712763 Enalapril ENVAS 10MG TAB


714527 Perindopril PEARINDA 4MG TAB


715786 Perindopril CIPLASYL 4 4MG TAB


6

NAPPI CODE


720387 Perindopril PREXUM 5MG TAB

715649 Perindopril ACESYL 4MG TAB

720388 Perindopril and

diuretics PREXUM PLUS 5MG/1.25MG

TAB

717024 Losartan HYTENZA 50MG TAB

Motivation required – please specify

previous treatments and reason for

treatment change

709225 Losartan ZARTAN 50MG TAB



719851 Valsartan VALANT 160MG TAB


704696 Valsartan TAREG 160MG TAB


715555 Valsartan ZOMEVEK 80MG TAB



836699

Pneumococcus, purified

polysaccharides antigen conjugated

IMOVAX PNEUMO 23

VAC Once only

CHRONIC OBSTRUCTIVE PULMONARY DISEASE

A lung function test report is required (the REF entry criteria are in line with the GOLD classification)

454299 Device SPACER ZEROSTAT VT

ZZZ

577802 Device DP HALER DEVICE

ZZZ




710307 Formoterol FORATEC HFA 120DOSE 12MCG/1DOSE INH

849332 Salbutamol ASTHAVENT ECOHALER 200DOSE 100MCG INH

700715 Salbutamol ASTHAVENT ECOHALER CFC-FREE

300DOSE 100MCG INH

711213 Salbutamol VENTEZE CFC FREE 200 DOSE 100MCG INH

718698 Salbutamol/ Ipratropium

DUOLIN HFA 200DOSE

INH


Steroid inhalers are reserved for

patients who are experiencing

frequent exacerbations.

Please provide a clinical history



704176 Budesonide BUDEFLAM DP-CAPS 200MCG CPS



791423 Budesonide PULMICORT TURBUHALER 100MCG TBH

791431 Budesonide PULMICORT TURBUHALER 200MCG TBH

715574 Ipratropium

bromide IPVENT HFA 200 DOSE 40MCG/1DOSE INH


ANHYDROUS 200MG SRT


ANHYDROUS 300MG SRT

CHRONIC RENAL FAILURE

Creatinine clearance is required

703359 Calcium carbonate ENO TUMS ASSORTED FRUIT

FLAVOURS CHU

703361 Calcium carbonate ENO TUMS PEPPERMINT

FLAVOUR CHU

7

NAPPI CODE


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 For documented hypokalaemia 702947 Potassium chloride SANDOZ K-600 600MG TAB

873276 Saccharated iron

oxide VENOFER 20MG/1ML INJ

Hb and iron studies required

756571 Ferrous fumarate PREGAMAL

TAB

727024 Iron supplement FOLIGLOBIN

TAB

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

Hb and iron studies required

837318 Erythropoietin EPREX PREFILL 2000U/0,5ML INJ

704630 Erythropoietin RECORMON 6000 IU/0.3ML PRE-

FILLED SYRIN 6000IU INJ

704772 Erythropoietin RECORMON 2000 PRE-FILLED

SYRINGE 2000UNIT/0,3ML INJ

704631 Erythropoietin RECORMON 4000 IU/0.3ML

PREFILLED SYRINGE 4000U/0,3ML INJ


e HEXAZIDE 25MG TAB













ATENOLOL) 50MG TAB















712763 Enalapril ENVAS 10MG TAB


8

NAPPI CODE










720387 Perindopril arginine PREXUM 5MG TAB

719209 Candesartan MYLACAND 8MG TAB

Motivation required for ARB's - please specify previous treatments and

reason for treatment change










CORONARY ARTERY DISEASE

Stress ECG report and details of history of previous cardiovascular events (if applicable) is required



784192 Isosorbide dinitrate SANDOZ ISOSORBIDE DINITRATE 5MG SLT

784206 Isosorbide dinitrate SANDOZ ISOSORBIDE DINITRATE 10MG TAB










ATENOLOL) 50MG TAB






708141 Amlodipine ALMADIN 5MG TAB


708191 Amlodipine NORCARD 10MG TAB


703917 Amlodipine AMLOC 10MG TAB

708050 Amlodipine AMLODAC 5MG TAB

710236 Amlodipine PHARMA DYNAMICS AMLODIPINE

BESYLATE 5MG TAB


9

NAPPI CODE



BESYLATE 10MG TAB

711682 Nifedipine FEDALOC SR 30MG SRT


715000 Nifedipine MACOREL SR 30MG SRT


840963 Nifedipine ADCO-VASCARD 20 SR 20MG SRC










TAB


CROHN'S DISEASE

The practice number and name of the diagnosing specialist (physician or gastroenterologist) is 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





700518 Ciprofloxacin DYNAFLOC 500MG TAB

701210 Ciprofloxacin ORPIC 500MG TAB

700284 Ciprofloxacin CPL ALLIANCE CIPROFLOXACIN 250MG TAB

700287 Ciprofloxacin CPL ALLIANCE CIPROFLOXACIN 500MG TAB

704775 Ciprofloxacin CIPROL 500MG TAB

704777 Ciprofloxacin CIPROL 250MG TAB

701208 Ciprofloxacin ORPIC 250MG TAB

700516 Ciprofloxacin DYNAFLOC 250MG TAB

703045 Ciprofloxacin CIPROGEN 500MG TAB

706108 Azathioprine AZAPRESS 50MG TAB

700777 Azathioprine ZAPRINE 50MG TAB

712609 Azathioprine AZATHIOPRINE PCH 50MG TAB

712504 Methotrexate ABITREXATE 2,5MG TAB

772216 Metronidazole TRICHAZOLE 200MG TAB

707241 Metronidazole BIO-METRONIDAZOLE 200MG TAB

707242 Metronidazole BIO-METRONIDAZOLE 400MG TAB

793159 Metronidazole METAZOL 200MG TAB

793167 Metronidazole METAZOL 400MG TAB

772224 Metronidazole TRICHAZOLE 400MG TAB

779822

Metronidazole

METRAZOLE

400MG

TAB

10

NAPPI CODE


DIABETES INSIPIDUS

The practice number and name of the diagnosing specialist (physician, paediatrician or endocrinologist) is required

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

161552

ACCU-CHEK ACTIVE STRIPS

STR

616102

SOFTCLIX LANCETS

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

3ML 100U/1ML INJ

897775 Insulin aspart NOVORAPID PENFILL 3ML 100U/1ML INJ

709861 Insulin glulisine APIDRA SOLOSTAR DISPOSABLE

PENS 3ML 100U/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 3ML 100U/1ML INJ

863572 Insulin (human) HUMULIN 30/70 CARTRIDGE 3ML 100U/1ML INJ

710299 Insulin (human) INSUMAN COMB 30/70

CARTRIDGE 3ML 100U/1ML INJ

714977 Insulin (human) ACTRAPHANE HM (GE) FLEXPEN

3ML 100U/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

3ML 100U/1ML INJ

DIABETES MELLITUS TYPE 2

161552

ACCU-CHEK ACTIVE STRIPS

STR

616102

SOFTCLIX LANCETS

ZZZ

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

3ML 100U/1ML INJ

897775 Insulin aspart NOVORAPID PENFILL 3ML 100U/1ML INJ

709861 Insulin glulisine APIDRA SOLOSTAR DISPOSABLE

PENS 3ML 100U/1ML INJ

862355 Insulin lispro HUMALOG 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

700183 Insulin (human) PROTAPHANE FLEXPEN 3ML 100U/1ML INJ

863556 Insulin (human) HUMULIN N CARTRIDGE 3ML 100U/1ML INJ

863572 Insulin (human) HUMULIN 30/70 CARTRIDGE 3ML 100U/1ML INJ

712770 Insulin (human) BIOSULIN 30-70 CARTRIDGE 3ML 100U/1ML INJ

710299 Insulin (human) INSUMAN COMB 30/70

CARTRIDGE 3ML 100U/1ML INJ

714977 Insulin (human) ACTRAPHANE HM (GE) FLEXPEN

3ML 100U/1ML INJ

11

NAPPI CODE


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

3ML 100U/1ML INJ

714427 Metformin ACCORD METFORMIN 500MG TAB

Fasting glucose results may be

requested if prescribed as a

single agent

714426 Metformin ACCORD METFORMIN 850MG TAB

706672 Metformin ARROW METFORMIN 500MG TAB

706673 Metformin ARROW METFORMIN 850MG TAB

709172 Metformin BIGSENS 1000MG TAB



719786 Metformin DIAPHAGE 1000MG TAB



714525 Metformin GLUCONORM 500MG TAB

714526 Metformin GLUCONORM 850MG TAB

718231 Metformin METCHEK 500MG TAB

718232 Metformin METCHEK 850MG TAB

711773 Metformin METORED 1000MG TAB



897957 Metformin MYLAN METFORMIN 500MG TAB

897961 Metformin MYLAN METFORMIN 850MG TAB

729361 Glibenclamide GLYCOMIN 5MG TAB

827053 Glibenclamide BIO-GLIBENCLAMIDE 5MG TAB

838209 Gliclazide GLYCRON 80MG TAB

716953 Gliclazide DYNA GLICLAZIDE SR 30MG SRT

718247 Gliclazide DIAGLUCIDE MR 60MG 60MG SRT

718148 Pioglitazone ACCORD PIOGLITAZONE 15MG TAB Motivation required

718150 Pioglitazone ACCORD PIOGLITAZONE 30MG TAB

EPILEPSY


705597 Carbamazepine SANDOZ CARBAMAZEPINE CR 200MG SRT

705602 Carbamazepine SANDOZ CARBAMAZEPINE CR 400MG SRT

761079 Clonazepam RIVOTRIL 0,5MG TAB Severe and uncontrolled

epilepsy only, not responding to first-

line agents

761087 Clonazepam RIVOTRIL 2MG TAB

779105 Ethosuximide ZARONTIN 250MG/5ML SYR

705441 Lamotrigine ASPEN LAMOTRIGINE 100MG TAB





704379 Lamotrigine EPITEC 25MG TAB


12

NAPPI CODE


717226 Oxcarbazepine MYLAN OXCARBAZEPINE 300MG TAB Severe and uncontrolled


line agents; motivation required

717227 Oxcarbazepine MYLAN OXCARBAZEPINE 600MG TAB

737844 Phenobarbital LETHYL 30MG TAB

723525 Phenytoin EPANUTIN 100MG CAP

754870 Phenytoin PHENYTOIN SOD 100MG TAB

710240 Topiramate ADCO-TOPIRAMATE 25MG TAB Severe and uncontrolled


line agents; motivation required

710901 Topiramate EPITOZ 100MG TAB

710900 Topiramate EPITOZ 50MG TAB

708392 Topiramate TOPLEP 200MG TAB

708390 Topiramate TOPLEP 50MG TAB


781541 Valproic acid CONVULEX 250MG/5ML SYR



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

720762 Valproic acid EPROLEP CR 300 300MG SRT

721055 Valproic acid EPROLEP CR 500 500MG SRT




GLAUCOMA

The practice number and name of the diagnosing ophthalmologist is required

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 SUSPENSION 1% OPD

819832 Dorzolamide TRUSOPT 5ML OWI 2% OPD

708445 Betaxolol BETOPTIC 5ML

OPD

781134 Levobunolol BETAGAN 7.5ML 0,5% OPD

770833 Timolol TIMOPTOL 5ML 0,25% OPD

819824 Timolol TIMOPTOL-XE 2.5ML 0,5% OPD

821624 Timolol GLAUCOSAN 5ML 0,5% OPD

717260 Timolol,

combinations AZARGA 5ML

OPD

702983 Timolol,

combinations XALACOM 2.5ML

OPD

709863 Timolol,

combinations COMBIGAN 2MG/5MG 5ML

OPD

860379 Timolol,

combinations COSOPT 5ML 0,5% OPD

703666 Bimatoprost LUMIGAN 3ML 0,03% OPD

715961 Latanoprost OCUPROST 3ML 50MCG/1ML OPD

702534 Travoprost TRAVATAN 2,5ML 0,004% OPD

HAEMOPHILIA

The laboratory reports confirming the diagnosis and the treatment to be initiated by specialist haematologist is required

714722 Tranexamic acid TRANEXAMIC ACID MEDWICH 500MG TAB

13

NAPPI CODE


716276 Tranexamic acid TRANIC 500MG TAB

800767 Coagulation factor

IX, HAEMOSOLVEX IX 500U INJ


VIII HAEMOSOLVATE VIII 2X10ML 1000U INJ


VIII HAEMOSOLVATE VIII 300U INJ


VIII HAEMOSOLVATE VIII 10ML 500U INJ

717754 Desmopressin DDAVP 1ML

INJ

HYPERLIPIDAEMIA

Treatment subject to criteria for lipid lowering therapy being met (for primary prevention – Framingham 2012 score > 15%); assessment requires completed risk evaluation report, as well as diagnostic and latest lipograms

711621 Atorvastatin ATORVASTATIN UNICORN 10MG TAB



718221 Atorvastatin DYNATOR 80MG TAB

718075 Atorvastatin ADCO ATORVASTATIN 40MG TAB



719185 Atorvastatin ASTOR 10MG TAB




710912 Atorvastatin ASPAVOR 40MG TAB






703905 Lovastatin LOVACHOL 40MG TAB

703906 Lovastatin LOVACHOL 20MG TAB

714705 Simvastatin CHOLESTE 20MG TAB

714706 Simvastatin CHOLESTE 40MG TAB

707089 Simvastatin ARROW SIMVASTATIN 10MG TAB



700520 Simvastatin SIMVACOR 20MG TAB

710827 Simvastatin ZYSIM 20MG TAB





710122 Bezafibrate DYNA-BEZAFIBRATE SR 400MG SRT For hypertriglyceri-

demia

HYPERTENSION

Current blood pressure and BP at time of diagnosis is required

702947 Potassium chloride SANDOZ K-600 600MG TAB

755753 Potassium chloride PLENISH K 600MG TAB

760048 Reserpine RESERPINE 0,25MG TAB

14

NAPPI CODE


732052 Methyldopa HYPOTONE 250MG TAB For use in pregnancy

only 764116 Methyldopa SANDOZ METHYLDOPA 250MG TAB

785962 Methyldopa MYLAN METHYLDOPA 250MG TAB

701425 Doxazosin CARDUGEN (WAS MERCK-

DOXAZOSIN) 1MG TAB

701426 Doxazosin CARDUGEN (WAS MERCK-

DOXAZOSIN) 4MG TAB

714292 Doxazosin CARZIN XL 4MG FCR

782122 Prazosin PRATSIOL 1MG TAB

782130 Prazosin PRATSIOL 2MG TAB






e HEXAZIDE 25MG TAB


e/ potassium URIREX-K 50MG/300MG 50MG;300MG TAB

710313 Indapamide CIPLA-INDAPAMIDE 2,5MG TAB

703329 Indapamide MYLAN INDAPAMIDE 2,5MG TAB

833045 Indapamide DAPTRIL 2,5MG TAB




765910 Spironolactone SPIRACTIN 25MG TAB

769665 Spironolactone SANDOZ SPIRONOLACTONE 25MG TAB

702803 Amiloride Co AMILORETIC 50MG/5MG 50MG;5MG TAB

780618 Amiloride Co ADCO-RETIC 50MG/5MG 50MG;5MG TAB


ATENOLOL) 50MG TAB










716166 Bisoprolol BISOPROLOL UNICORN 10MG TAB

716167 Bisoprolol BISOPROLOL UNICORN 5MG TAB



718082 Bisoprolol/ HCTZ BISOPROLOL

HYDROCHLOROTHIAZIDE ZYDUS 2.5

2.5MG/6.25MG TAB


HYDROCHLOROTHIAZIDE ZYDUS 5MG

5MG/6.25MG TAB


HYDROCHLOROTHIAZIDE ZYDUS 10M

10MG/6.25MG TAB

719200 Bisoprolol/ HCTZ BILOCOR CO 2.5MG/6.25MG

TAB

15

NAPPI CODE


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


713971 Amlodipine AMTAS 5MG TAB

713972 Amlodipine AMTAS 10MG TAB

708039 Amlodipine CALBLOC 5MG TAB

708040 Amlodipine CALBLOC 10MG TAB


BESYLATE 5MG TAB



BESYLATE 10MG TAB



708150 Amlodipine CIPLAVASC 5MG TAB








864153 Nifedipine CIPALAT RETARD 20MG TAB

840963 Nifedipine ADCO-VASCARD 20 SR 20MG SRC










886843 Enalapril ENALAPRIL UNICORN 10MG TAB

886851 Enalapril ENALAPRIL UNICORN 20MG TAB



700691 Lisinopril SINOPREN 5MG TAB



708189 Lisinopril AUSTELL-LISINOPRIL 20MG TAB

712598 Lisinopril AUSTELL-LISINOPRIL 10MG TAB



717783 Perindopril PERINDOPRIL UNICORN 4MG TAB


16

NAPPI CODE





839795 Captopril and

diuretics ZAPTO-CO 50MG/25MG 50MG;25MG TAB

885019 Enalapril and

diuretics PHARMAPRESS CO

20MG/12.5MG TAB

891287 Enalapril and

diuretics ENAP CO 20MG/12.5MG 20MG;12,5MG TAB

707292 Lisinopril and

diuretics LISOZIDE 10MG/12.5MG

TAB


diuretics ZESTORETIC 10MG/12.5MG 10MG;12,5MG TAB


diuretics LISOZIDE 20MG/12.5MG

TAB


diuretics ZESTORETIC 20MG/12.5MG 20MG;12,5MG TAB


diuretics BIOPREXUM PLUS 10MG/2.5MG

TAB


diuretics PERINDOPRIL CO UNICORN

4MG/1.25MG TAB



TAB


diuretics ACESYL CO 4MG/1.25MG

TAB


diuretics PEARINDA PLUS 4MG/1.25MG

TAB


diuretics ARIPREL PLUS 4MG/1.25MG

TAB


amlodipine COVERAM 5/10

TAB



TAB



TAB



TAB


Motivation required – please specify

previous treatments and reason for

treatment change


720583 Irbesartan ANTOSART 300MG TAB

717793 Irbesartan DYNARB 150MG TAB

717794 Irbesartan DYNARB 300MG TAB

720582 Irbesartan ANTOSART 150MG TAB







718363 Valsartan VALSARTAN UNICORN 80MG TAB

718364 Valsartan VALSARTAN UNICORN 160MG TAB


719506 Candesartan and

diuretics MYLACAND PLUS 16MG/12.5MG

TAB

716476 Losartan and

diuretics HYTENZA CO 50MG/12.5MG

TAB

717084 Losartan and

diuretics HYTENZA CO 100MG/25MG

TAB

17

NAPPI CODE


716515 Losartan and

diuretics SARTOC-CO 100MG/25MG

TAB

716217 Losartan and

diuretics ZARTAN CO 100MG/25MG

TAB

716216 Losartan and

diuretics ZARTAN CO 50MG/12.5MG

TAB

715856 Losartan and

diuretics LOSAAR PLUS 50MG/12.5MG

TAB

715857 Losartan and

diuretics LOSAAR PLUS 100MG/25MG

TAB

718367 Losartan and

diuretics LOSARTAN CO UNICORN

50MG/12.5MG TAB

718368 Losartan and

diuretics LOSARTAN CO UNICORN

100MG/25MG TAB

705068 Valsartan and

diuretics CO-TAREG 80MG/12.5MG

TAB


diuretics CO-ZOMEVEK 80MG/12.5MG

TAB


diuretics CO-ZOMEVEK 160MG/12.5MG

TAB


diuretics CO-MIGROBEN 160MG/12.5MG

TAB


diuretics CO-TAREG 160MG/12.5MG 160/12.5MG TAB


diuretics CO-TAREG PLUS 160MG/25MG

TAB


diuretics DYNAVAL CO 80MG/12.5MG

TAB


diuretics DYNAVAL CO 160MG/12.5MG

TAB


diuretics DYNAVAL CO 160MG/25MG

TAB

HYPOTHYROIDISM

720224 Levothyroxine/

liothyronine DIOTROXIN

TAB

713172 Levothyroxine

sodium EUTHYROX 25MCG TAB





MULTIPLE SCLEROSIS

The practice number and name of the diagnosing neurologist and the treatment to be initiated by specialist are required

701893 Oxybutynin MYLAN OXYBUTYNIN 5MG TAB Second Line – after adequate trial with

tricyclic antidepressants

872253 Oxybutynin LENDITRO 5MG TAB





865567 Baclofen BIO-BACLOFEN 10MG TAB

712607 Baclofen TEVA BACLOFEN 10MG TAB





PARKINSON'S DISEASE

700500 Amantadine SYMADIN 100MG CAP

18

NAPPI CODE


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

700652 Ropinirole REQUIP 1MG TAB



706712 Selegiline PARKILYNE 5MG TAB

RHEUMATOID ARTHRITIS

The name and practice number of the diagnosing specialist is required

PMBs only cover rheumatoid arthritis and excludes other closely related conditions. Copies of the relevant blood tests, reports and supportive clinical history confirming the diagnosis of rheumatoid arthritis are required


762016 Sulfasalazine SALAZOPYRIN EN 500MG ECT





723274 Cyclophosphamide ENDOXAN 50MG TAB





853240 Diclofenac DICLOHEXAL 25MG TAB

893390 Diclofenac A-LENNON DICLOFENAC 25MG TAB


786012 Diclofenac MYLAN DICLOFENAC 25MG TAB


834327 Diclofenac SANDOZ DICLOFENAC SODIUM

100 SIMPLE REG 100MG SRT

704725 Indometacin ARTHREXIN 25MG CAP

704776 Indometacin SANDOZ INDOMETHACIN 25MG CAP

711324 Meloxicam ARROW MELOXICAM 7,5MG TAB

704829 Meloxicam FLEXOCAM 7,5MG TAB

705375 Meloxicam ADCO-MELOXICAM 7,5MG TAB

701520 Meloxicam LOXIFLAM 7,5MG TAB

716168 Meloxicam MELOXICAM UNICORN 7,5MG TAB

705176 Meloxicam M-CAM 7,5MG TAB

705229 Meloxicam ZYDUS-MELOXICAM 7,5MG TAB

701072 Piroxicam ROXIFEN 20MG CAP

797030 Piroxicam XYCAM 20MG CAP

799432 Piroxicam PYROCAPS 20MG CAP

782807 Ibuprofen SANDOZ IBUPROFEN 600MG TAB

733741 Ibuprofen INZA 200MG TAB

19

NAPPI CODE


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

747297 Chloroquine NIVAQUINE 200MG TAB

SCHIZOPHRENIA

A report from a psychiatrist confirming the diagnosis, based on DSM lV diagnostic criteria is required

712523 Carbamazepine SANDOZ CARBAMAZEPINE 200MG TAB















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




715657 Olanzapine OLEXAR 2,5MG TAB










20

NAPPI CODE






711511 Risperidone ZOXADON 0,5MG TAB



715736 Risperidone SCHIZOROL 0,5MG TAB




















SYSTEMIC LUPUS ERYTHEMATOSUS

A report from a rheumatologist or specialist physician confirming the diagnosis is required





723274 Cyclophosphamide ENDOXAN 50MG TAB














701106 Indometacin ADCO-INDOMETHACIN 25MG CAP


21

NAPPI CODE











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



701975 Ibuprofen BETAPROFEN FC 400MG TAB





747297 Chloroquine NIVAQUINE 200MG TAB

ULCERATIVE COLITIS

A report from a specialist physician or gastroenterologist that confirms the diagnosis is required

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









NON-CDL CONDITIONS

ACNE

Treatment limited to a maximum of six months

893402 Doxycycline A-LENNON DOXYCYCLINE HCL 100MG CAP

716944 Doxycycline CYCLIDOX 100MG CAP

809667 Doxycycline DOXYCYL 100MG CAP

758388 Erythromycin PURMYCIN 250MG CAP

765651 Erythromycin SPECTRASONE 250MG CAP

824682 Erythromycin XERAMEL 250MG CAP

ALLERGIC RHINITIS

820709 Beclometasone BECLATE AQUANASE 150DOSE 50MCG AQS

897937 Beclometasone CLENIL AQUEOUS 200DOSE 50MCG AQS

714595 Fluticasone FLONASE 120 DOSE 50MCG AQS

22

NAPPI CODE


704383 Fluticasone FLOMIST 120DOSE 50MCG AQS

712890 Cetirizine ACUZYRT 10MG TAB

Clinical motivation required if an

antihistamine is prescribed with inhaled steroid

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

CARDIAC ARRYTHMIA (NON CDL)





758868 Quinidine QUINIDINE SULPH 200MG TAB










ATENOLOL) 50MG TAB



















GOUT

758329 Allopurinol PURICOS 300MG TAB

738778 Allopurinol SANDOZ ALLOPURINOL 100MG TAB

758310 Allopurinol PURICOS 100MG TAB

23

NAPPI CODE


MAJOR DEPRESSION










717094 Citalopram BIO CITALOPRAM 20MG TAB









MENOPAUSE

832448 Conjugated estrogens

PREMARIN

VCR


PREMARIN 0,3MG TAB


PREMARIN 0,625MG TAB


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




824631 Estradiol CLIMARA 50

PTD

824658 Estradiol CLIMARA 100

PTD

827452 Estriol SYNAPAUSE-E3 2MG TAB

706704 Medroxyprogestero

ne HEXAL-MPA 5MG TAB

881112 Norethisterone/

estrogen ACTIVELLE

TAB

853429 Medroxyprogestero

ne/ estrogen PREMELLE-CYCLE 5

TAB


estrogen TRISEQUENS

TAB


estrogen ESTRO-PAUSE N

TAB

825980 Norgestrel/

estrogen POSTOVAL

TAB

818550 Cyproterone/

estrogen CLIMEN

TAB

24

NAPPI CODE


MIGRAINE (PROPHYLAXIS ONLY)










OSTEOARTHRITIS











716168 Meloxicam MELOXICAM UNICORN 7,5MG TAB



701520 Meloxicam LOXIFLAM 7,5MG TAB







701975 Ibuprofen BETAPROFEN FC 400MG TAB







799629 Paracetamol PAINAMOL (GREEN) 500MG TAB

824992 Paracetamol GENCETAMOL

TAB

chronic medicine formulary - pnpms.co.za

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