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Mhrs_restrictive formulary jan12.xls

Restrictive Formulary
RESTRICTIVE PMB FORMULARY
Effective 1 Jan 2012
Products included on this chronic medicines formulary wil not attract a co-payment if authorised by Chronic Medicine Management for a disease on the CDL and obtained from the Designated Service Provider. Reimbursement will
however be subject to the Chronic Medicine Management clinical guidelines and protocols and the Medicine Price List (MPL).
KEY to Chronic Medicine Management Reimbursement Criteria:
Quantity/dosage and duration of authorisation may vary - depending on the requested drug.
Accepted Treatment - wil be authorised without requesting additional clinical information (unless specific concerns e.g. unusual dose requests).
Clinical Review - wil be authorised if the drug history or co-morbidity clearly indicates that use of the drug is indicated in the specific patient.
Clinical Motivation - specific clinical information required before reimbursement is considered
Specialist Script - wil require a relevant specialist's prescription before reimbursement is considered
Specialist Motivation - wil require a relevant specialist motivation before reimbursement is considered
Special Investigations (SI) - results of recent relevant tests required before reimbursement is considered
Drug Name
Active Ingredient
Strength
Chronic Medicine Management Reimbursement Criteria for
formulary drugs
Asthma
Inhaled B2 agonists
AIROMIR INHALER
Long acting B2 agonists
FO
Inhaled corticosteroids
BECEZE INHALER COMPLETE
Restrictive Formulary
Oral Xanthines
PULMOPHYLLIN SR 200
Oral Corticosteroids
ADCO PREDNISOLONE
Addison's disease
Oral Corticosteroids
COVOCORT
Bipolar Mood Disorder
Mood Stabilisers
ARROW LAMOTRIGINE
Restrictive Formulary
Restrictive Formulary
Antipsychotic agents
ASPEN RISPERIDONE
Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Restrictive Formulary
Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Antidepressants
ARROW CITALOPRAM
Restrictive Formulary
Bronchiectasis
Antibiotic therapy wil be evaluated on an individual basis Chronic Obstructive Pulmonary Disease
Inhaled B2 agonists
AIROMIR INHALER
Inhaled corticosteroids
Restrictive Formulary
Anticholinergic inhalers (short acting)
ATROVENT 40 MAC COMPL 300 DOSE
Oral Xanthines
PULMOPHYLLIN SR 200
Oral Corticosteroids
CAPSOID
Restrictive Formulary
Cardiac failure/ Cardiomyopathy
Anticoagulants
WARFARIN
Diuretics
ADCO-RETIC
Hydrochlorothiazide and potassium-sparing agents Hydrochlorothiazide and potassium-sparing agents Hydrochlorothiazide and potassium-sparing agents Hydrochlorothiazide and potassium-sparing agents Hydrochlorothiazide and potassium-sparing agents Hydrochlorothiazide and potassium-sparing agents Hydrochlorothiazide and potassium-sparing agents Hydrochlorothiazide and potassium-sparing agents Hydrochlorothiazide and potassium-sparing agents Hydrochlorothiazide and potassium-sparing agents Hydrochlorothiazide and potassium-sparing agents Hydrochlorothiazide and potassium-sparing agents Potassium supplementation
PLENISH K
ACE inhibitors
ACCUMAX
Restrictive Formulary
Restrictive Formulary
ACE inhibitor and diuretic combinations
AURO-LISINOPRIL CO
Restrictive Formulary
Angiotensin Receptor Blockers
COZAAR
Angiotensin Receptor Blockers and diuretic combinations
COZAAR COMP
Beta-blockers
ADCO-ATENOLOL
Restrictive Formulary
Alpha-beta blockers
ASPEN CARVEDILOL
Beta-blocker and diuretic combinations
ADCO-LOTEN
Cardiac glycosides
LANOXIN
Restrictive Formulary
Chronic Renal Disease
For diuretics and antihypertensives, refer to "Hypertension"
Calcium
TITRALAC
Vitamin D
CALCIFEROL
Oral Iron and Folic Acid supplementation
AHA FERROUS SULPHATE
Parenteral Iron Preparations
COSMOFER AMPOULE 2ML
Erythropoietin
ARANESP PREFILLED SYRINGE 0.3ML
Restrictive Formulary
Coronary Artery Disease
Aspirin
ASPIRIN (WHITE)
Nitrates
ANGISED
Restrictive Formulary
Beta-blockers
ADCO-ATENOLOL
Calcium channel antagonists
ADALAT XL
Restrictive Formulary
Restrictive Formulary
Crohn's Disease
Aminosalicylic acid preparations
SALAZOPYRIN
Immunosuppressants
AZAMUN
Methotrexate
ABITREXATE-20ML
Steroid preparations (oral)
CAPSOID
Steroid preparations (enemas)
ENTOCORD ENEMAS
Diabetes Mellitus Type 1
Insulin
INSU ACTRAPH HMGE 10ML VIAL
Restrictive Formulary
INSU APIDRA SOLOSTAR DISPOSABLE PENS 3ML Applicances
Diabetic strips, needles and lancets
Diabetes Mellitus Type 2
Biguanides
ACCORD METFORMIN
Restrictive Formulary
Sulphonylureas
ALEMBIC GLICLAZIDE
Thiazolidines
ACTOS 15MG
Insulin
INSU ACTRAPH HMGE 10ML VIAL
Restrictive Formulary
INSU APIDRA SOLOSTAR DISPOSABLE PENS 3ML Applicances
Diabetic strips, needles and lancets
Diabetes Insipidus
Desmopressin
DDAVP
Dysrhythmias
Anticoagulants
WARFARIN
Antiplatelet agents
ASPIRIN (WHITE)
Restrictive Formulary
Beta-blockers
ADCO-ATENOLOL
Restrictive Formulary
Cardiac glycosides
LANOXIN
Calcium channel antagonists
CALCICARD SR
Anti-arrhythmics
ARYCOR
Epilepsy
ADCO-PHENOBARB VITALET ELIXIR
Restrictive Formulary
Restrictive Formulary
Restrictive Formulary
Glaucoma
Sympathomimetics
ALPHAGAN
Parasympathomimetics
ISOPTO CARPINE 15ML
Carbonic anhydrase inhibitor
AZOPTIC EYE DROP
Beta-blockers
GLAUCOSAN 0.25% 5ML
Combination products
COMBIGAN 2MG/5MG 5ML
Prostaglandin derivatives
LUMIGAN 3ML
Acetazolamide
AZOMID
Haemophilia
Tranexamic Acid
CYKLOKAPRON
Desmopressin
DDAVP
Analgesics
ACTAMOL
Restrictive Formulary
Restrictive Formulary
Hyperlipidaemia
Statins
ADCO-SIMVASTATIN
Restrictive Formulary
Fibrates
BEZACHOLE SR
Nicotinic Acid
NICOTINIC ACID
Hypertension
Sympathetic Nervous System Blockers
RESERPINE
Alpha-aderenergic blockers
ADCO-DOXAZASIN
Arterial Vasodilators
APRESOLINE
Diuretics
ADCO-RETIC
Hydrochlorothiazide and potassium-sparing agents Restrictive Formulary
Hydrochlorothiazide and potassium-sparing agents Hydrochlorothiazide and potassium-sparing agents Hydrochlorothiazide and potassium-sparing agents Hydrochlorothiazide and potassium-sparing agents Hydrochlorothiazide and potassium-sparing agents Hydrochlorothiazide and potassium-sparing agents Hydrochlorothiazide and potassium-sparing agents Hydrochlorothiazide and potassium-sparing agents Hydrochlorothiazide and potassium-sparing agents Hydrochlorothiazide and potassium-sparing agents Hydrochlorothiazide and potassium-sparing agents Beta-blockers
ADCO-ATENOLOL
Restrictive Formulary
Beta-blocker and diuretic combinations
AD
Calcium channel antagonists
ADALAT XL
Restrictive Formulary
ACE inhibitors
ACCUMAX
Restrictive Formulary
Restrictive Formulary
Angiotensin Receptor Blockers
Restrictive Formulary
Angiotensin Receptor Blockers and diuretic combinations
COZAAR COMP
Hypothyroidism
ELTROXIN
Multiple sclerosis
Anticholinergics
DITROPAN
Immunosuppressants
ABITREXATE-20ML
Restrictive Formulary
Muscle relaxants
LIORESAL
Tricyclic Antidepressants
ETHIPRAMINE
Carbamazepine
DEGRANOL
Analgesics
ANTALGIC 500
Restrictive Formulary
Acetylsalicylic acid comb. excl. psycholeptics Non-steroidal anti-inflammatories
AD
Restrictive Formulary
Restrictive Formulary
Parkinson's Disease
Levodopa combinations
CARBILEV
Dopamine agonists and other
AKINETON
Restrictive Formulary
Rheumatoid arthritis
Disease modifying agents
ABITREXATE-20ML
Immunosuppressants
AZAMUN
Alkylating agents
EN
Non-steroidal anti-inflammatories
ADCO-DICLOFENAC
Restrictive Formulary
Restrictive Formulary
Oral Corticosteroids
ADCO PREDNISOLONE
Schizophrenia
Antipsychotic agents
ASPEN RISPERIDONE
Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Restrictive Formulary
Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Restrictive Formulary
Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Accepted treatment (clinical motivation for low-cost options) Antidepressants
ETHIPRAMINE
Mood Stabilisers
ARROW LAMOTRIGINE
Restrictive Formulary
Systemic Lupus Erythematosus
Non-steroidal anti-inflammatories
ADCO-DICLOFENAC
Restrictive Formulary
Restrictive Formulary
Oral Corticosteroids
CAP
Anticoagulants
ASPIRIN (WHITE)
Disease modifying agents
Restrictive Formulary
Immunosuppressants
AZAMUN
Alkylating agents
ENDOXAN
Ulcerative colitis
Aminosalicylic acid preparations
SALAZOPYRIN
Immunosuppressants
AZAMUN
Steroid preparations (oral)
CAPSOID
Steroid preparations (enemas)
ENTOCORD ENEMAS

Source: http://www.ungererhealth.co.za/docs/bonitas/Restrictive%20Formulary%20Jan%202012.pdf

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