motohealth custom chronic formulary 2019...salbutamol 711213 venteze cfc free 200 dose 100mcg inh...

Ingredient Nappi Product Name Strength Form Restriction

ADDISON'S DISEASE

The PMB is applicable to primary Addisons disease only. Please provide Practice number and name of diagnosing specialistFludrocortisone 726540 FLORINEF ACETATE 0,1MG TAB Hydrocortisone 716693 COVOCORT 10MG TAB Prednisolone 800155 LENISOLONE 5MG TAB Prednisone 818267 TROLIC 5MG TAB Prednisone 752304 PANAFCORT 5MG TAB Prednisone 788783 BE-TABS PREDNISONE 5MG TAB

ASTHMA

402042 MASK BABY CIPLA ZZZ

454299 SPACER ZEROSTAT VT ZZZ

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

(motivation required)

Prednisone 752304 PANAFCORT 5MG TAB Only for severe persistent asthma


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.

Motohealth Custom Chronic Medicine Formulary

2019

Prednisone 818267 TROLIC 5MG TAB Only for severe persistent asthma


Salbutamol 711213 VENTEZE CFC FREE 200 DOSE 100MCG INH Limited to 3 inhalers per year if no

inhaled steroid

Salbutamol 700715 ASTHAVENT ECOHALER CFC-FREE 300DOSE100MCG INH Limited to 3 inhalers per year if no

inhaled steroid

Salbutamol 849332 ASTHAVENT ECOHALER 200DOSE 100MCG INH Limited to 3 inhalers per year if no

inhaled steroid

Budesonide/ Formoterol 720218 VANNAIR 80/4.5 120 DOSE INH Only for moderate & severe

persistent asthma (motivation

required)

Budesonide/ Formoterol 720219 VANNAIR 160/4.5 120 DOSE INH Only for moderate & severe


required)

Salmeterol/ fluticasone 715190 SEREFLO 25/125 HFA 120 DOSE INH Only for moderate & severe


required)Salmeterol/ fluticasone 715191 SEREFLO 25/250 HFA 120 DOSE INH Only for moderate & severe


required)

Salmeterol/ fluticasone 715189 SEREFLO 25/50 HFA 120 DOSE INH Only for moderate & severe


required)

Salbutamol/ Ipratropium 718698 DUOLIN HFA 200DOSE INH

Beclometasone 827061 BECEZE 50 200DOSE 50MCG INH

Beclometasone 827088 BECEZE 100 CFC FREE 200DOSE 100MCG INH

Beclometasone 819611 BECLATE 200DOSE 50MCG INH



Budesonide 791423 PULMICORT TURBUHALER 200DOSE 100MCG TBH

Budesonide 791431 PULMICORT TURBUHALER 200DOSE 200MCG TBH

Budesonide 897462 BUDEFLAM HFA 300DOSE 100MCG INH

Budesonide 897469 BUDEFLAM HFA 300DOSE 200MCG INH

Salbutamol 775452 VENTEZE 2MG/5ML SYR

Salbutamol 824186 ASTHAVENT 2MG/5ML SYR

Theophylline 788368 SANDOZ THEOPHYLLINE ANHYDROUS 200MG SRT


BRONCHIECTASIS Please provide a sensitivity report if a different antibiotic is required

Doxycycline 809667 DOXYCYL 100MG CAP Doxycycline 716944 CYCLIDOX 100MG CAP Doxycycline 893402 A-LENNON DOXYCYCLINE HCL 100MG CAP Amoxicillin 705637 AUSTELL-AMOXICILLIN 500MG CAP Amoxicillin 788546 BETAMOX 500MG CAP Amoxicillin 744689 MOXYPEN 250MG CAP Amoxicillin 744697 MOXYPEN 500MG CAP

CARDIAC DYSRHYTHMIAS

Please provide a specific diagnosis and /or the relevant ICD10 code

Warfarin 709905 CIPLA-WARFARIN 5MG TAB Warfarin 709906 CIPLA-WARFARIN 1MG TAB Digoxin 735752 LANOXIN 0,25MG TAB Digoxin 758280 PURGOXIN 0,25MG TAB Quinidine 758868 QUINIDINE SULPH 200MG TAB Amiodarone 863157 HEXARONE 100MG TAB Amiodarone 863165 HEXARONE 200MG TAB Amiodarone 703513 ARYCOR 200MG TAB Amiodarone 703515 ARYCOR 100MG TAB Atenolol 826898 BIO-ATENOLOL (WAS IVAX-ATENOLOL) 50MG TAB Atenolol 786187 TEN-BLOKA 50MG TAB Atenolol 786195 TEN-BLOKA 100MG TAB Atenolol 704651 B-BLOCK 100MG TAB Atenolol 704653 B-BLOCK 50MG TAB Atenolol 705872 TENOPRESS 25MG TAB Atenolol 787892 SANDOZ ATENOLOL 50MG TAB Atenolol 806889 HEXA-BLOK 50MG TAB Bisoprolol 715276 ZIAPRO 10MG TAB Bisoprolol 715274 ZIAPRO 5MG TAB Bisoprolol 704372 BILOCOR 5MG TAB Bisoprolol 704373 BILOCOR 10MG TAB Verapamil 700071 VERAHEXAL 240 SR 240MG SRT

Verapamil 774944 VASOMIL 40MG TAB Verapamil 774952 VASOMIL 80MG TAB Diltiazem 824364 ADCO-ZILDEM 90MG TAB Diltiazem 839183 ADCO-ZILDEM SR 180MG SRC Diltiazem 839191 ADCO-ZILDEM SR 240MG SRC Acetylsalicylic acid 720577 DISPRIN 300MG EFT

CARDIAC FAILURE AND CARDIOMYOPATHY

Potassium chloride 702947 SANDOZ K-600 600MG TAB For documented hypokalaemiaPotassium chloride 755753 PLENISH K 600MG TAB For documented hypokalaemiaWarfarin 709905 CIPLA-WARFARIN 5MG TAB Warfarin 709906 CIPLA-WARFARIN 1MG TAB Digoxin 735752 LANOXIN 0,25MG TAB Digoxin 758280 PURGOXIN 0,25MG TAB Isosorbide dinitrate 784206 SANDOZ ISOSORBIDE DINITRATE 10MG TAB Hydrochlorothiazide 890470 HEXAZIDE 25MG TAB Furosemide 731668 SANDOZ FUROSEMIDE 40MG TAB Furosemide 758272 PURESIS 40MG TAB Furosemide 857769 MYLAN FUROSEMIDE 40MG TAB Spironolactone 765910 SPIRACTIN 25MG TAB Spironolactone 769665 SANDOZ SPIRONOLACTONE 25MG TAB Bisoprolol 715274 ZIAPRO 5MG TAB Bisoprolol 715276 ZIAPRO 10MG TAB Bisoprolol 703914 ADCO-BISOCOR 10MG TAB Bisoprolol 703913 ADCO-BISOCOR 5MG TAB Bisoprolol 704372 BILOCOR 5MG TAB Bisoprolol 704373 BILOCOR 10MG TAB Carvedilol 704672 CARVETREND 25MG TAB Carvedilol 710340 ASPEN CARVEDILOL 25MG TAB Carvedilol 704670 CARVETREND 6,25MG TAB Carvedilol 704671 CARVETREND 12,5MG TAB Carvedilol 710338 ASPEN CARVEDILOL 6,25MG TAB Carvedilol 710339 ASPEN CARVEDILOL 12,5MG TAB Carvedilol 710958 VEDIBLOK 6,25MG TAB Carvedilol 710959 VEDIBLOK 12,5MG TAB Carvedilol 710960 VEDIBLOK 25MG TAB Atenolol and other diuretics 786217 TENCHLOR 100MG/25MG TAB

Atenolol and other diuretics 807591 TENCHLOR HS 50MG/12.5MG TAB Captopril 836451 ADCO-CAPTOMAX 25MG TAB Captopril 836478 ADCO-CAPTOMAX 50MG TAB Captopril 852619 MYLAN CAPTOPRIL 25MG TAB Captopril 899429 MYLAN CAPTOPRIL 50MG TAB Enalapril 868922 PHARMAPRESS 20MG TAB Enalapril 891280 ENAP 20MG TAB Enalapril 891272 ENAP 5MG TAB Enalapril 891279 ENAP 10MG TAB Enalapril 708109 PHARMAPRESS 5MG TAB Perindopril 720387 PREXUM 5MG TAB Perindopril 715649 ACESYL 4MG TAB Perindopril 710510 CIPLA-PERINDOPRIL 8MG TAB Perindopril 714527 PEARINDA 4MG TAB Perindopril 714528 PEARINDA 8MG TAB Perindopril and diuretics 720388 PREXUM PLUS 5MG/1.25MG TAB Losartan 717024 HYTENZA 50MG TAB Motivation required - please specify

previous treatments and reason for

treatment changeLosartan 709225 ZARTAN 50MG TAB Motivation required - please specify




treatment changeLosartan 717042 HYTENZA 100MG TAB Motivation required - please specify


treatment changeAcetylsalicylic acid 720577 DISPRIN 300MG EFTPneumococcus, purified polysaccharides antigen conjugated836699 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 SPACER ZEROSTAT VT ZZZ

Prednisone 752304 PANAFCORT 5MG TAB

Prednisone 788783 BE-TABS PREDNISONE 5MG TAB

Prednisone 818267 TROLIC 5MG TAB

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

Salbutamol 711213 VENTEZE CFC FREE 200 DOSE 100MCG INH

Salbutamol 700715 ASTHAVENT ECOHALER CFC-FREE

300DOSE100MCG INH

Salbutamol 849332 ASTHAVENT ECOHALER 200DOSE 100MCG INH

SALBUTAMOL AND IPRATROPIUM BROMIDE718698 DUOLIN HFA 200DOSE INH

Beclometasone 819611 BECLATE 200DOSE 50MCG INH Steroid inhalers are reserved for

patients who are experiencing

frequent exacerbations. Please

provide a clinical history









Budesonide 791423 PULMICORT TURBUHALER 200DOSE 100MCG TBH Steroid inhalers are reserved for




Budesonide 791431 PULMICORT TURBUHALER 200DOSE 200MCG TBH Steroid inhalers are reserved for




Budesonide 897462 BUDEFLAM HFA 300DOSE 100MCG INH Steroid inhalers are reserved for




Budesonide 897469 BUDEFLAM HFA 300DOSE 200MCG INH Steroid inhalers are reserved for




Budesonide/ Formoterol 720218 VANNAIR 80/4.5 120 DOSE INH Steroid inhalers are reserved for




Budesonide/ Formoterol 720219 VANNAIR 160/4.5 120 DOSE INH Steroid inhalers are reserved for




Salmeterol/ fluticasone 715190 SEREFLO 25/125 HFA 120 DOSE INH Steroid inhalers are reserved for












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



CHRONIC RENAL FAILURE Creatinine clearance required

Calcium carbonate 703359 ENO TUMS ASSORTED FRUIT FLAVOURS CHU Calcium carbonate 703361 ENO TUMS PEPPERMINT FLAVOUR CHU Calcium carbonate 703364 ENO TUMS ORANGE FLAVOUR CHU Potassium chloride 702947 SANDOZ K-600 600MG TAB For documented hypokalaemiaPotassium chloride 755753 PLENISH K 600MG TAB For documented hypokalaemiaFerrous fumarate 756571 PREGAMAL TAB Various combinations 897329 GULF FERROUS SULPHATE COMPOUND TAB Folic acid 810967 BE-TABS FOLIC ACID 5MG TAB Hydrochlorothiazide 890470 HEXAZIDE 25MG TAB Furosemide 731668 SANDOZ FUROSEMIDE 40MG TAB Furosemide 758272 PURESIS 40MG TAB

Furosemide 857769 MYLAN FUROSEMIDE 40MG TAB Atenolol 786195 TEN-BLOKA 100MG TAB Atenolol 705872 TENOPRESS 25MG TAB Atenolol 787892 SANDOZ ATENOLOL 50MG TAB Atenolol 806889 HEXA-BLOK 50MG TAB Atenolol 826898 BIO-ATENOLOL (WAS IVAX-ATENOLOL) 50MG TAB Atenolol 786187 TEN-BLOKA 50MG TAB Bisoprolol 715276 ZIAPRO 10MG TAB Bisoprolol 715274 ZIAPRO 5MG TAB Bisoprolol 703913 ADCO-BISOCOR 5MG TAB Bisoprolol 703914 ADCO-BISOCOR 10MG TAB Bisoprolol 704372 BILOCOR 5MG TAB Bisoprolol 704373 BILOCOR 10MG TAB Verapamil 700071 VERAHEXAL 240 SR 240MG SRT Verapamil 774944 VASOMIL 40MG TAB Captopril 852619 MYLAN CAPTOPRIL 25MG TAB Captopril 899429 MYLAN CAPTOPRIL 50MG TAB Enalapril 868922 PHARMAPRESS 20MG TAB Enalapril 891280 ENAP 20MG TAB Enalapril 891272 ENAP 5MG TAB Enalapril 891279 ENAP 10MG TAB Enalapril 708109 PHARMAPRESS 5MG TAB Perindopril 715649 ACESYL 4MG TAB Perindopril 715786 CIPLASYL 4 4MG TAB Perindopril 715795 CIPLASYL 8 8MG TAB Perindopril 720387 PREXUM 5MG TAB Perindopril 714527 PEARINDA 4MG TAB Perindopril 714528 PEARINDA 8MG TAB Losartan 717024 HYTENZA 50MG TAB Motivation required - please specify






treatment change

Losartan 717042 HYTENZA 100MG TAB Motivation required - please specify


treatment change

CORONARY ARTERY DISEASE

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

Warfarin 709905 CIPLA-WARFARIN 5MG TAB

Warfarin 709906 CIPLA-WARFARIN 1MG TAB

Isosorbide dinitrate 784192 SANDOZ ISOSORBIDE DINITRATE 5MG SLT

Isosorbide dinitrate 784206 SANDOZ ISOSORBIDE DINITRATE 10MG TAB

Atenolol 786195 TEN-BLOKA 100MG TAB

Atenolol 705872 TENOPRESS 25MG TAB

Atenolol 787892 SANDOZ ATENOLOL 50MG TAB

Atenolol 806889 HEXA-BLOK 50MG TAB

Atenolol 826898 BIO-ATENOLOL (WAS IVAX-ATENOLOL) 50MG TAB

Atenolol 786187 TEN-BLOKA 50MG TAB

Bisoprolol 715276 ZIAPRO 10MG TAB

Bisoprolol 715274 ZIAPRO 5MG TAB

Bisoprolol 704372 BILOCOR 5MG TAB

Bisoprolol 704373 BILOCOR 10MG TAB

Amlodipine 708051 AMLODAC 10MG TAB

Amlodipine 708050 AMLODAC 5MG TAB

Amlodipine 708190 NORCARD 5MG TAB

Amlodipine 710236 PHARMA DYNAMICS AMLODIPINE BESYLATE5MG TAB

Amlodipine 710238 PHARMA DYNAMICS AMLODIPINE BESYLATE10MG TAB

Amlodipine 708191 NORCARD 10MG TAB

Amlodipine 708141 ALMADIN 5MG TAB

Amlodipine 708142 ALMADIN 10MG TAB

Nifedipine 840963 ADCO-VASCARD 20 SR 20MG SRC

Nifedipine 711682 FEDALOC SR 30MG SRT

Verapamil 700071 VERAHEXAL 240 SR 240MG SRT

Verapamil 774944 VASOMIL 40MG TAB

Diltiazem 822213 ADCO-ZILDEM 60MG TAB

Diltiazem 824364 ADCO-ZILDEM 90MG TAB

Diltiazem 839183 ADCO-ZILDEM SR 180MG SRC

Diltiazem 839191 ADCO-ZILDEM SR 240MG SRC

Perindopril 720387 PREXUM 5MG TAB

Perindopril and diuretics 720388 PREXUM PLUS 5MG/1.25MG TAB

Acetylsalicylic acid 720577 DISPRIN 300MG EFT

CROHN'S DISEASE

Practice number and name of the diagnosing specialist (physician or gastroenterologist) required.

Sulfasalazine 762008 SALAZOPYRIN 500MG TAB Folic acid 810967 BE-TABS FOLIC ACID 5MG TAB Prednisone 752304 PANAFCORT 5MG TAB Prednisone 788783 BE-TABS PREDNISONE 5MG TAB Prednisone 818267 TROLIC 5MG TAB Ciprofloxacin 700518 DYNAFLOC 500MG TAB Ciprofloxacin 701210 ORPIC 500MG TAB Ciprofloxacin 704775 CIPROL 500MG TAB Ciprofloxacin 704777 CIPROL 250MG TAB Ciprofloxacin 701208 ORPIC 250MG TAB Ciprofloxacin 700284 CPL ALLIANCE CIPROFLOXACIN 250MG TAB Ciprofloxacin 700287 CPL ALLIANCE CIPROFLOXACIN 500MG TAB Ciprofloxacin 703045 CIPROGEN 500MG TAB Ciprofloxacin 700516 DYNAFLOC 250MG TAB Azathioprine 706108 AZAPRESS 50MG TAB Azathioprine 712609 AZATHIOPRINE PCH 50MG TAB Methotrexate 712504 ABITREXATE 2,5MG TAB Metronidazole 772216 TRICHAZOLE 200MG TAB Metronidazole 707241 BIO-METRONIDAZOLE 200MG TAB Metronidazole 707242 BIO-METRONIDAZOLE 400MG TAB Metronidazole 793159 METAZOL 200MG TAB Metronidazole 793167 METAZOL 400MG TAB Metronidazole 772224 TRICHAZOLE 400MG TAB Metronidazole 779822 METRAZOLE 400MG TAB

DIABETES INSIPIDUS

Please provide the practice number and name of the diagnosing specialist (physician, paediatrician or endocrinologist)Desmopressin 717746 DDAVP 2.5ML NOD Desmopressin 837555 DDAVP NASAL SPRAY 5ML 0,1MG/1ML NSS Desmopressin 837563 DDAVP 0,1MG TAB Desmopressin 703639 DDAVP 0,2MG TAB

DIABETES MELLITUS TYPE 1

161552 ACCU-CHEK ACTIVE STRIPS STR 616102 SOFTCLIX LANCETS ZZZ

Insulin (human) 712767 BIOSULIN R CARTRIDGE 3ML 100U/1ML INJ Insulin (human) 863564 HUMULIN R CARTRIDGE 3ML 100U/1ML INJ Insulin aspart 897767 NOVORAPID FLEXPEN PENSET 3ML 100U/1ML INJ Insulin aspart 897775 NOVORAPID PENFILL 3ML 100U/1ML INJ Insulin glulisine 709861 APIDRA SOLOSTAR DISPOSABLE PENS 3ML100U/1ML INJ Insulin lispro 862355 HUMALOG CARTRIDGE 3ML 100U/1ML INJ Insulin (human) 700183 PROTAPHANE FLEXPEN 3ML 100U/1ML INJ Insulin (human) 863556 HUMULIN N CARTRIDGE 3ML 100U/1ML INJ Insulin (human) 712768 BIOSULIN N CARTRIDGE 3ML 100U/1ML INJ Insulin (human) 712769 BIOSULIN L CARTRIDGE 3ML 100U/1ML INJ Insulin (human) 712770 BIOSULIN 30-70 CARTRIDGE 3ML 100U/1ML INJ Insulin (human) 863572 HUMULIN 30/70 CARTRIDGE 3ML 100U/1ML INJ Insulin (human) 710299 INSUMAN COMB 30/70 CARTRIDGE 3ML 100U/1ML INJ Insulin (human) 714977 ACTRAPHANE HM (GE) FLEXPEN 3ML 100U/1ML INJ Insulin aspart 702086 NOVOMIX 30 FLEXPEN 3ML 100U/1ML INJ Insulin aspart 702089 NOVOMIX 30 PENFILL 3ML 100U/1ML INJ Insulin lispro 861782 HUMALOG MIX 25 CARTRIDGE 3ML 100U/1ML INJ

DIABETES MELLITUS TYPE 2

161552 ACCU-CHEK ACTIVE STRIPS STR 616102 SOFTCLIX LANCETS ZZZ

Insulin (human) 863564 HUMULIN R CARTRIDGE 3ML 100U/1ML INJ Insulin (human) 712767 BIOSULIN R CARTRIDGE 3ML 100U/1ML INJ Insulin aspart 897767 NOVORAPID FLEXPEN PENSET 3ML 100U/1ML INJ Insulin aspart 897775 NOVORAPID PENFILL 3ML 100U/1ML INJ Insulin glulisine 709861 APIDRA SOLOSTAR DISPOSABLE PENS 3ML100U/1ML INJ Insulin lispro 862355 HUMALOG CARTRIDGE 3ML 100U/1ML INJ Insulin (human) 712769 BIOSULIN L CARTRIDGE 3ML 100U/1ML INJ Insulin (human) 712768 BIOSULIN N CARTRIDGE 3ML 100U/1ML INJ Insulin (human) 700183 PROTAPHANE FLEXPEN 3ML 100U/1ML INJ Insulin (human) 863556 HUMULIN N CARTRIDGE 3ML 100U/1ML INJ Insulin (human) 863572 HUMULIN 30/70 CARTRIDGE 3ML 100U/1ML INJ Insulin (human) 712770 BIOSULIN 30-70 CARTRIDGE 3ML 100U/1ML INJ Insulin (human) 710299 INSUMAN COMB 30/70 CARTRIDGE 3ML 100U/1ML INJ

Insulin (human) 714977 ACTRAPHANE HM (GE) FLEXPEN 3ML 100U/1ML INJ Insulin aspart 702086 NOVOMIX 30 FLEXPEN 3ML 100U/1ML INJ Insulin aspart 702089 NOVOMIX 30 PENFILL 3ML 100U/1ML INJ Insulin lispro 861782 HUMALOG MIX 25 CARTRIDGE 3ML 100U/1ML INJ Metformin 714427 ACCORD METFORMIN 500MG TAB Fasting glucose results may be

requested if prescribed as a single

agentMetformin 714426 ACCORD METFORMIN 850MG TAB Fasting glucose results may be


agentMetformin 706672 ARROW METFORMIN 500MG TAB Fasting glucose results may be


agentMetformin 706673 ARROW METFORMIN 850MG TAB Fasting glucose results may be


agentMetformin 709172 BIGSENS 1000MG TAB Fasting glucose results may be






agentMetformin 719786 DIAPHAGE 1000MG TAB Fasting glucose results may be






agentMetformin 714525 GLUCONORM 500MG TAB Fasting glucose results may be


agent

Metformin 714526 GLUCONORM 850MG TAB Fasting glucose results may be


agentMetformin 718231 METCHEK 500MG TAB Fasting glucose results may be


agentMetformin 718232 METCHEK 850MG TAB Fasting glucose results may be


agentMetformin 711773 METORED 1000MG TAB Fasting glucose results may be






agentMetformin 897957 MYLAN METFORMIN 500MG TAB Fasting glucose results may be


agentMetformin 897961 MYLAN METFORMIN 850MG TAB Fasting glucose results may be


agentGlibenclamide 729361 GLYCOMIN 5MG TAB Glibenclamide 827053 BIO-GLIBENCLAMIDE 5MG TAB Gliclazide 838209 GLYCRON 80MG TAB Gliclazide 716953 DYNA GLICLAZIDE SR 30MG SRT Pioglitazone 718148 ACCORD PIOGLITAZONE 15MG TAB Motivation RequiredPioglitazone 718150 ACCORD PIOGLITAZONE 30MG TAB Motivation Required

EPILEPSY

Phenobarbital 737844 LETHYL 30MG TAB Phenytoin 754870 PHENYTOIN SOD 100MG TAB Phenytoin 723525 EPANUTIN 100MG CAP

Clonazepam 761079 RIVOTRIL 0,5MG TAB Severe and uncontrolled epilepsy

only, not responding to first-line

agents. Motivation Required

Clonazepam 761087 RIVOTRIL 2MG TAB Severe and uncontrolled epilepsy

only, not responding to first-line

agents. Motivation Required

Carbamazepine 712493 DEGRANOL 200MG TAB Valproic acid 720762 EPROLEP CR 300 300MG SRT Valproic acid 721055 EPROLEP CR 500 500MG SRT Valproic acid 718465 NAVALPRO CR 200MG SRT Valproic acid 718466 NAVALPRO CR 300MG SRT Valproic acid 718468 NAVALPRO CR 500MG SRT Valproic acid 715980 CONVULEX 150MG CAP Valproic acid 715999 CONVULEX 300MG CAP Valproic acid 780545 EPILIM SUGAR FREE 200MG/5ML SYR Valproic acid 781541 CONVULEX 250MG/5ML SYR Valproic acid 781568 CONVULEX 500MG CAP Lamotrigine 710885 LAMIDUS 50MG TAB Lamotrigine 704379 EPITEC 25MG TAB Lamotrigine 705441 ASPEN LAMOTRIGINE 100MG TAB Lamotrigine 710387 DYNA-LAMOTRIGINE 25MG TAB Lamotrigine 710388 DYNA-LAMOTRIGINE 50MG TAB Lamotrigine 710390 DYNA-LAMOTRIGINE 200MG TAB Lamotrigine 710389 DYNA-LAMOTRIGINE 100MG TAB

GLAUCOMA Please provide the name and practice of the diagnosisng ophthalmologist

Brimonidine 709410 ALPHAGAN PURITE 5ML 1,5MG/1ML OPD Pilocarpine 734179 ISOPTO CARPINE 2% 15ML 2% OPD Pilocarpine 734195 ISOPTO CARPINE 4% 15ML 4% OPD Pilocarpine 734284 ISOPTO CARPINE 1% 15ML 1% OPD Acetazolamide 789771 AZOMID 250MG TAB Brinzolamide 701523 AZOPTIC 5ML EYE SUSPENSION 1% OPD Dorzolamide 819832 TRUSOPT 5ML OWI 2% OPD Betaxolol 708445 BETOPTIC 5ML OPD Levobunolol 781134 BETAGAN 7.5ML 0,5% OPD Timolol 770833 TIMOPTOL 5ML 0,25% OPD Timolol 819824 TIMOPTOL-XE 2.5ML 0,5% OPD

Timolol 821624 GLAUCOSAN 5ML 0,5% OPD Timolol, combinations 717260 AZARGA 5ML OPD Timolol, combinations 722712 CO-ATANA 2.5ML OPD Timolol, combinations 709863 COMBIGAN 2MG/5MG 5ML OPD Timolol, combinations 721902 GLAUMIDE-CO 0,5% OPD Bimatoprost 703666 LUMIGAN 3ML 0,03% OPD

Latanoprost 720971 ATANA 2.5ML 50MCG/1ML OPD Travoprost 702534 TRAVATAN 2,5ML 0,004% OPD

HYPERLIPIDAEMIA

Atorvastatin 718073 ADCO ATORVASTATIN 10MG TAB Atorvastatin 718074 ADCO ATORVASTATIN 20MG TAB Atorvastatin 718075 ADCO ATORVASTATIN 40MG TAB Atorvastatin 708121 ASPAVOR 10MG TAB Atorvastatin 708122 ASPAVOR 20MG TAB Atorvastatin 710912 ASPAVOR 40MG TAB Atorvastatin 719185 ASTOR 10MG TAB Atorvastatin 719186 ASTOR 20MG TAB Atorvastatin 719187 ASTOR 40MG TAB Atorvastatin 719189 ASTOR 80MG TAB Atorvastatin 711621 ATORVASTATIN UNICORN 10MG TAB Atorvastatin 712170 ATORVASTATIN UNICORN 20MG TAB Atorvastatin 713522 ATORVASTATIN UNICORN 40MG TAB Atorvastatin 718218 DYNATOR 10MG TAB Atorvastatin 718219 DYNATOR 20MG TAB Atorvastatin 718220 DYNATOR 40MG TAB Atorvastatin 718221 DYNATOR 80MG TAB Simvastatin 707089 ARROW SIMVASTATIN 10MG TAB Simvastatin 707090 ARROW SIMVASTATIN 20MG TAB Simvastatin 707091 ARROW SIMVASTATIN 40MG TAB Simvastatin 714705 CHOLESTE 20MG TAB Simvastatin 714706 CHOLESTE 40MG TAB Simvastatin 700519 SIMVACOR 10MG TAB Simvastatin 700520 SIMVACOR 20MG TAB Simvastatin 708463 SIMVACOR 40MG TAB

Treatment subject to criteria for Lipid Lowering Therapy being met. (For Primary prevention - Framingham 2012 score > 15%) .Assessment

Simvastatin 710826 ZYSIM 10MG TAB Simvastatin 710827 ZYSIM 20MG TAB Simvastatin 710828 ZYSIM 40MG TAB Bezafibrate 710122 DYNA-BEZAFIBRATE SR 400MG SRT

HYPERTENSION Please provide current blood pressure and bp at time of diagnosis

Potassium chloride 702947 SANDOZ K-600 600MG TAB For documented hypokalaemiaPotassium chloride 755753 PLENISH K 600MG TAB Reserpine 760048 RESERPINE 0,25MG TAB Methyldopa (levorotatory) 732052 HYPOTONE 250MG TAB Methyldopa (levorotatory) 764116 SANDOZ METHYLDOPA 250MG TAB Methyldopa (levorotatory) 785962 MYLAN METHYLDOPA 250MG TAB Doxazosin 701425 CARDUGEN (WAS MERCK-DOXAZOSIN) 1MG TAB Doxazosin 701426 CARDUGEN (WAS MERCK-DOXAZOSIN) 4MG TAB Doxazosin 714292 CARZIN XL 4MG FCR Prazosin 782122 PRATSIOL 1MG TAB Prazosin 782130 PRATSIOL 2MG TAB Hydrochlorothiazide 890470 HEXAZIDE 25MG TAB Hydrochlorothiazide and potassium774057 URIREX-K 50MG/300MG 50MG;300MG TAB Indapamide 710313 CIPLA-INDAPAMIDE 2,5MG TAB Indapamide 833045 DAPTRIL 2,5MG TAB Indapamide 703329 MYLAN INDAPAMIDE 2,5MG TAB Furosemide 731668 SANDOZ FUROSEMIDE 40MG TAB Furosemide 758272 PURESIS 40MG TAB Furosemide 857769 MYLAN FUROSEMIDE 40MG TAB Spironolactone 765910 SPIRACTIN 25MG TAB Spironolactone 769665 SANDOZ SPIRONOLACTONE 25MG TAB Hydrochlorothiazide and potassium-sparing agents702803 AMILORETIC 50MG/5MG 50MG;5MG TAB Hydrochlorothiazide and potassium-sparing agents780618 ADCO-RETIC 50MG/5MG 50MG;5MG TAB Atenolol 786195 TEN-BLOKA 100MG TAB Atenolol 704651 B-BLOCK 100MG TAB Atenolol 704653 B-BLOCK 50MG TAB Atenolol 705872 TENOPRESS 25MG TAB Atenolol 787892 SANDOZ ATENOLOL 50MG TAB Atenolol 806889 HEXA-BLOK 50MG TAB Atenolol 826898 BIO-ATENOLOL (WAS IVAX-ATENOLOL) 50MG TAB Atenolol 786187 TEN-BLOKA 50MG TAB

Bisoprolol 715276 ZIAPRO 10MG TAB Bisoprolol 715274 ZIAPRO 5MG TAB Bisoprolol 716166 BISOPROLOL UNICORN 10MG TAB Bisoprolol 716167 BISOPROLOL UNICORN 5MG TAB Bisoprolol 704373 BILOCOR 10MG TAB Bisoprolol 704372 BILOCOR 5MG TAB Atenolol and other diuretics 786217 TENCHLOR 100MG/25MG TAB Atenolol and other diuretics 807591 TENCHLOR HS 50MG/12.5MG TAB Amlodipine 708039 CALBLOC 5MG TAB Amlodipine 708040 CALBLOC 10MG TAB Amlodipine 708141 ALMADIN 5MG TAB Amlodipine 710236 PHARMA DYNAMICS AMLODIPINE BESYLATE5MG TAB Amlodipine 710238 PHARMA DYNAMICS AMLODIPINE BESYLATE10MG TAB Amlodipine 708050 AMLODAC 5MG TAB Amlodipine 708051 AMLODAC 10MG TAB Amlodipine 708150 CIPLAVASC 5MG TAB Amlodipine 713971 AMTAS 5MG TAB Amlodipine 713972 AMTAS 10MG TAB Amlodipine 708190 NORCARD 5MG TAB Amlodipine 708191 NORCARD 10MG TAB Nifedipine 840963 ADCO-VASCARD 20 SR 20MG SRC Nifedipine 864153 CIPALAT RETARD 20MG TAB Nifedipine 711682 FEDALOC SR 30MG SRT Verapamil 700071 VERAHEXAL 240 SR 240MG SRT Verapamil 774944 VASOMIL 40MG TAB Captopril 852619 MYLAN CAPTOPRIL 25MG TAB Captopril 899429 MYLAN CAPTOPRIL 50MG TAB Enalapril 886843 ENALAPRIL UNICORN 10MG TAB Enalapril 886851 ENALAPRIL UNICORN 20MG TAB Enalapril 708109 PHARMAPRESS 5MG TAB Enalapril 868922 PHARMAPRESS 20MG TAB Enalapril 891280 ENAP 20MG TAB Enalapril 891272 ENAP 5MG TAB Enalapril 891279 ENAP 10MG TAB Lisinopril 700691 SINOPREN 5MG TAB Lisinopril 700692 SINOPREN 10MG TAB Lisinopril 700694 SINOPREN 20MG TAB

Lisinopril 708189 AUSTELL-LISINOPRIL 20MG TAB Lisinopril 712598 AUSTELL-LISINOPRIL 10MG TAB Perindopril 717783 PERINDOPRIL UNICORN 4MG TAB Perindopril 720387 PREXUM 5MG TAB Perindopril 715649 ACESYL 4MG TAB Perindopril 714527 PEARINDA 4MG TAB Perindopril 714528 PEARINDA 8MG TAB Captopril and diuretics 839795 ZAPTO-CO 50MG/25MG 50MG;25MG TAB Enalapril and diuretics 885019 PHARMAPRESS CO 20MG/12.5MG TAB Enalapril and diuretics 891287 ENAP CO 20MG/12.5MG 20MG;12,5MG TAB Lisinopril and diuretics 707292 LISOZIDE 10MG/12.5MG TAB Lisinopril and diuretics 817848 ZESTORETIC 10MG/12.5MG 10MG;12,5MG TAB Lisinopril and diuretics 707291 LISOZIDE 20MG/12.5MG TAB Lisinopril and diuretics 797685 ZESTORETIC 20MG/12.5MG 20MG;12,5MG TAB Perindopril and diuretics 717782 PERINDOPRIL CO UNICORN 4MG/1.25MG TAB Perindopril and diuretics 720388 PREXUM PLUS 5MG/1.25MG TAB Perindopril and diuretics 715651 ACESYL CO 4MG/1.25MG TAB Perindopril and diuretics 714952 PEARINDA PLUS 4MG/1.25MG TAB Perindopril and diuretics 717795 ARIPREL PLUS 4MG/1.25MG TAB Perindopril and amlodipine 719852 COVERAM 5/10 TAB Perindopril and amlodipine 719853 COVERAM 10/10 TAB Perindopril and amlodipine 719854 COVERAM 10/5 TAB Perindopril and amlodipine 719855 COVERAM 5/5 TAB Losartan

717024

HYTENZA 50MG TAB Motivation required - please specify


treatment changeLosartan

709964

ZARTAN 100MG TAB Motivation required - please specify



709225

ZARTAN 50MG TAB Motivation required - please specify



717042

HYTENZA 100MG TAB Motivation required - please specify


treatment change

Losartan and diuretics

716476

HYTENZA CO 50MG/12.5MG TAB Motivation required - please specify


treatment changeLosartan and diuretics

717084

HYTENZA CO 100MG/25MG TAB Motivation required - please specify



716515

SARTOC-CO 100MG/25MG TAB Motivation required - please specify



716217

ZARTAN CO 100MG/25MG TAB Motivation required - please specify



716216

ZARTAN CO 50MG/12.5MG TAB Motivation required - please specify



715856

LOSAAR PLUS 50MG/12.5MG TAB Motivation required - please specify



715857

LOSAAR PLUS 100MG/25MG TAB Motivation required - please specify



718367

LOSARTAN CO UNICORN 50MG/12.5MG TAB Motivation required - please specify



718368

LOSARTAN CO UNICORN 100MG/25MG TAB Motivation required - please specify


treatment changeAmlodiopine/ losartan 3000130 AMZAAR 5/50MG TAB Motivation required - please specify previous

treatments and reason for treatment change

Amlodiopine/ losartan 3000161 AMZAAR 5/100MG TAB Motivation required - please specify previous

treatments and reason for treatment change

HYPOTHYROIDISM

Combinations of levothyroxine and liothyronine720224 DIOTROXIN TAB

Levothyroxine sodium 713172 EUTHYROX 25MCG TAB Levothyroxine sodium 713168 EUTHYROX 50MCG TAB Levothyroxine sodium 713169 EUTHYROX 100MCG TAB

MULTIPLE SCLEROSIS

Please provide the practice number and name of the diagnosing neurologist. Treatment to be initiated by specialist

Oxybutynin 872253 LENDITRO 5MG TAB Second Line - After adequate trial

with Tricyclic Antidepressants

Oxybutynin 701893 MYLAN OXYBUTYNIN 5MG TAB Azathioprine 706108 AZAPRESS 50MG TAB Azathioprine 712609 AZATHIOPRINE PCH 50MG TAB Methotrexate 712504 ABITREXATE 2,5MG TAB Baclofen 712607 TEVA BACLOFEN 10MG TAB Carbamazepine 712493 DEGRANOL 200MG TAB Amitriptyline 771996 TREPILINE 25MG TAB Amitriptyline 772003 TREPILINE 10MG TAB Amitriptyline 784230 SANDOZ AMITRIPTYLINE 25MG TAB

PARKINSON'S DISEASE

Orphenadrine (chloride) 720542 DISIPAL 50MG TAB Levodopa and decarboxylase inhibitor710468 TEVA CARBI-LEVO 25/250 TAB

Levodopa and decarboxylase inhibitor710286 TEVA CARBI-LEVO 25/100 TAB Amantadine 700500 SYMADIN (WAS FLU-STOP) 100MG CAP

RHEUMATOID ARTHRITIS Please provide the name and practice number of the diagnosisng specilaist

Sulfasalazine 762008 SALAZOPYRIN 500MG TAB Sulfasalazine 762016 SALAZOPYRIN EN 500MG ECT Folic acid 810967 BE-TABS FOLIC ACID 5MG TAB Prednisone 752304 PANAFCORT 5MG TAB Prednisone 788783 BE-TABS PREDNISONE 5MG TAB Prednisone 818267 TROLIC 5MG TAB Azathioprine 706108 AZAPRESS 50MG TAB Azathioprine 712609 AZATHIOPRINE PCH 50MG TAB

The PMB chronic benefit only covers rheumatoid arthritis and excludes other closely related conditions. We

Methotrexate 712504 ABITREXATE 2,5MG TAB Diclofenac 853240 DICLOHEXAL 25MG TAB Diclofenac 893390 A-LENNON DICLOFENAC 25MG TAB Diclofenac 893391 A-LENNON DICLOFENAC 50MG TAB Diclofenac 786012 MYLAN DICLOFENAC 25MG TAB Diclofenac 786020 MYLAN DICLOFENAC 50MG TAB Diclofenac 834327 SANDOZ DICLOFENAC SODIUM 100 SIMPLE REG100MG SRT Indometacin 704725 ARTHREXIN 25MG CAP Indometacin 704776 SANDOZ INDOMETHACIN 25MG CAP Meloxicam 701520 LOXIFLAM 7,5MG TAB Meloxicam 704829 FLEXOCAM 7,5MG TAB Meloxicam 705375 ADCO-MELOXICAM 7,5MG TAB Meloxicam 705176 M-CAM 7,5MG TAB Meloxicam 705229 ZYDUS-MELOXICAM 7,5MG TAB Meloxicam 711324 ARROW MELOXICAM 7,5MG TAB Piroxicam 701072 ROXIFEN 20MG CAP Piroxicam 797030 XYCAM 20MG CAP Piroxicam 799432 PYROCAPS 20MG CAP Ibuprofen 782807 SANDOZ IBUPROFEN 600MG TAB Ibuprofen 733741 INZA 200MG TAB Ibuprofen 700316 IBUCINE (WAS IBUMAX) 200MG TAB Ibuprofen 700318 IBUCINE (WAS IBUMAX) 400MG TAB Ibuprofen 733768 INZA 400MG TAB Naproxen 805238 NAPROSCRIPT 250MG TAB Naproxen 810185 MYLAN NAPROXEN 250MG TAB Paracetamol 799629 PAINAMOL (GREEN) 500MG TAB Paracetamol 824992 GENCETAMOL TAB Chloroquine 747297 NIVAQUINE 200MG TAB

SCHIZOPHRENIA

Please provide a report from a psychiatrist that confirms the diagnosis, based on DSM lV Diagnostic Criteria

Valproic acid 718274 EPILIZINE CR 200MG SRT



Valproic acid 718465 NAVALPRO CR 200MG SRT



Lamotrigine 705441 ASPEN LAMOTRIGINE 100MG TAB

Lamotrigine 710387 DYNA-LAMOTRIGINE 25MG TAB




Orphenadrine (chloride) 720542 DISIPAL 50MG TAB

Chlorpromazine 735868 LARGACTIL 25MG TAB



Fluphenazine 744301 MODECATE 1ML 25MG/1ML INJ

Haloperidol 763411 SERENACE 0,5MG CAP

Flupentixol 726672 FLUANXOL DEPOT 1ML 20MG INJ

Zuclopenthixol 714852 CLOPIXOL DEPOT 200MG INJ

Amitriptyline 771996 TREPILINE 25MG TAB


Amitriptyline 784230 SANDOZ AMITRIPTYLINE 25MG TAB

Dosulepin 800198 THADEN 25MG CAP

Dosulepin 800201 THADEN 75MG TAB

Imipramine 724661 ETHIPRAMINE 10MG TAB


Citalopram 713584 ARROW CITALOPRAM 40MG TAB


Fluoxetine 705064 ZYDUS FLUOXETINE 20MG CAP

Fluoxetine 894303 DEPROZAN 20MG CAP

Fluoxetine 703391 A-LENNON FLUOXETINE 20MG CAP

Fluoxetine 700877 LORIEN 20MG TAB

SYSTEMIC LUPUS ERYTHEMATOSUS

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

Folic acid 810967 BE-TABS FOLIC ACID 5MG TAB



Azathioprine 706108 AZAPRESS 50MG TAB

Azathioprine 712609 AZATHIOPRINE PCH 50MG TAB

Methotrexate 712504 ABITREXATE 2,5MG TAB

Diclofenac 786012 MYLAN DICLOFENAC 25MG TAB

Diclofenac 786020 MYLAN DICLOFENAC 50MG TAB

Diclofenac 834327 SANDOZ DICLOFENAC SODIUM 100 SIMPLE REG100MG SRT

Diclofenac 853240 DICLOHEXAL 25MG TAB

Diclofenac 893390 A-LENNON DICLOFENAC 25MG TAB

Diclofenac 893391 A-LENNON DICLOFENAC 50MG TAB

Indometacin 704725 ARTHREXIN 25MG CAP

Indometacin 704776 SANDOZ INDOMETHACIN 25MG CAP

Meloxicam 704829 FLEXOCAM 7,5MG TAB

Meloxicam 705375 ADCO-MELOXICAM 7,5MG TAB

Meloxicam 705176 M-CAM 7,5MG TAB

Meloxicam 705229 ZYDUS-MELOXICAM 7,5MG TAB

Meloxicam 711324 ARROW MELOXICAM 7,5MG TAB

Piroxicam 701072 ROXIFEN 20MG CAP

Piroxicam 797030 XYCAM 20MG CAP

Piroxicam 799432 PYROCAPS 20MG CAP

Ibuprofen 782807 SANDOZ IBUPROFEN 600MG TAB

Ibuprofen 700318 IBUCINE (WAS IBUMAX) 400MG TAB

Ibuprofen 733768 INZA 400MG TAB

Ibuprofen 787426 BETAPROFEN 200MG TAB

Ibuprofen 701654 RANFEN 400MG TAB

Ibuprofen 701975 BETAPROFEN FC 400MG TAB

Ibuprofen 733741 INZA 200MG TAB

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

Ibuprofen 700316 IBUCINE (WAS IBUMAX) 200MG TAB

Naproxen 805238 NAPROSCRIPT 250MG TAB

Naproxen 810185 MYLAN NAPROXEN 250MG TAB

Acetylsalicylic acid 720577 DISPRIN 300MG EFT

Chloroquine 747297 NIVAQUINE 200MG TAB

ULCERATIVE COLITIS

Please provide a report from a specialist physician or gastroenterologist that confirms the diagnosis

Sulfasalazine 762008 SALAZOPYRIN 500MG TAB



Prednisone 818267 TROLIC 5MG TAB

Azathioprine 712609 AZATHIOPRINE PCH 50MG TAB

Azathioprine 706108 AZAPRESS 50MG TAB

Azathioprine 700777 ZAPRINE 50MG TAB

Methotrexate 712504 ABITREXATE 2,5MG TAB

DEPRESSION, MAJOR



Amitriptyline 784230 SANDOZ AMITRIPTYLINE 25MG TAB

Dosulepin 800198 THADEN 25MG CAP

Dosulepin 800201 THADEN 75MG TAB




Citalopram 717094 BIO CITALOPRAM 20MG TAB


Fluoxetine 705064 ZYDUS FLUOXETINE 20MG CAP

Fluoxetine 894303 DEPROZAN 20MG CAP

Fluoxetine 703391 A-LENNON FLUOXETINE 20MG CAP

Fluoxetine 700877 LORIEN 20MG TAB

Sertraline 715935 SERDEP 100MG TAB

Sertraline 705420 SERDEP 50MG TAB

Sertraline 712092 ARROW SERTRALINE 100MG TAB

Sertraline 712093 ARROW SERTRALINE 50MG TAB

MENOPAUSE

Conjugated estrogens 832448 PREMARIN VCR

Conjugated estrogens 756725 PREMARIN 0,3MG TAB



Estradiol 822477 ESTRO-PAUSE 1MG TAB

Estradiol 822485 ESTRO-PAUSE 2MG TAB

Estradiol 824631 CLIMARA 50 PTD

Estradiol 824658 CLIMARA 100 PTD

Estradiol 706052 ESTRADOT 37,5MCG PTD

Estradiol 706053 ESTRADOT 50MCG PTD




Estriol 827452 SYNAPAUSE-E3 2MG TAB

Medroxyprogesterone 706704 HEXAL-MPA 5MG TAB

Norethisterone and estrogen881112 ACTIVELLE TAB

Medroxyprogesterone and estrogen853429 PREMELLE-CYCLE 5 TAB

Norethisterone and estrogen825913 TRISEQUENS TAB

Norethisterone and estrogen822493 ESTRO-PAUSE N TAB

Norgestrel and estrogen 825980 POSTOVAL TAB

motohealth custom chronic formulary 2019...salbutamol 711213 venteze cfc free 200 dose 100mcg inh...

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