Sizwe Medical Fund: CDL Formulary - All · PDF fileSizwe Medical Fund: CDL Formulary - All Options This formulary is a summary of treatment covered on the Chronic Disease List (CDL)

Sizwe Medical Fund: CDL Formulary - All Options

This formulary is a summary of treatment covered on the Chronic Disease List (CDL) Formulary.

Applications for approval on the Chronic Medication Benefit (Excluding HIV) can be faxed or e-mailed:

Fax: 011 353 0352 / 011 353 0076

Email: [email protected].

Pharmacists or doctors can register telephonically by calling 011 353 0030. Pharmacists or doctors can register telephonically by calling 011 353 0030.

Please contact the Wellcare Management Team at 0860 10 34 54 for all HIV/Aids queries. Applications for approval on the HIV Programme, can be faxed to 011 221 5235.

The 26 listed conditions below are covered in full in terms of the scheme rules if

services are rendered according to the scheme's benefits, careplans, policies and protocols.

These conditions are covered on all the options, but benefits will be more or less

restrictive depending on the option the member has chosen.

The dispensing pharmacy may select a different generic equivalent to assist members to avoid co-payments. Sizwe rates apply for generic equivalents.

Stepwise therapy will apply according to state algorithms and latest applicable funding

guidelines (First Line, Second Line etc).

Disclaimer: Policies and formularies are updated by the Clinical Review Committee on a regular basis to comply with the latest industry norms, legislation, efficacy and safety.

PLEASE NOTE: Claims will not be paid as a PMB without the correct and specific ICD10 codes on prescriptions and claims.

mailto:[email protected]

1. ADDISONS DISEASE

Drug Class Full Budget Affordable Primary Care Special

Requirements

Steroid therapy

H02AA02 Florinef Acetate Florinef Acetate Florinef Acetate REF Entry Criteria

H02AB07 Be-tabs Prednisone,

Capsoid, Pulmison,

Panafcort, Lenisolone

Be-tabs Prednisone, Capsoid,

Pulmison, Panafcort,

Lenisolone



Lenisolone

REF Entry Criteria

H02AB09 Covocort Covocort Covocort REF Entry Criteria

2. ASTHMA


Requirements

Selective Beta adrenoreceptor agonists

R03AC02 Asthavent, Venteze Asthavent, Venteze Asthavent, Venteze REF Entry Criteria

R03AC04 Berotec - - REF Entry Criteria

R03AC12 Serevent Serevent - REF Entry Criteria

R03AC13 Foratec, Oxis Foratec,Oxis Foratec REF Entry Criteria

Corticoid steroid inhalers

R03BA01 Beclate Beclate Beclate REF Entry Criteria

R03BA02 Budeflam, Inflammide Budeflam, Inflammide Budeflam, Inflammide REF Entry Criteria

R03BA05 Flixotide - - REF Entry Criteria

R03BA07 Asmanex Asmanex - REF Entry Criteria

R03BA08 Alvesco - - REF Entry Criteria

Adrenergics and combinations Inhalers

R03AK03 Duovent Duovent Duovent Step 3 & up -Stepwise

therapy

R03AK06 Foxair, Sereflo Foxair, Sereflo Foxair, Sereflo Step 3 & up -Stepwise

therapy

R03AK07 Symbicord - - Step 3 & up -Stepwise

therapy

Anticholinergics Inhalers

R03BB01 Ipvent Ipvent Ipvent Step 4 & up Stepwise

therapy

Xanthines

R03DA04 EuphyllinR, Norstan

Theophyllin, Nuelin,

Sandoz Theophylline,

Uniphyl,Theoplus

EuphyllinR, Norstan

Theophyllin, Nuelin, Sandoz

Theophylline, Uniphyl,Theoplus

EuphyllinR, Norstan


Theophylline,

Uniphyl,Theoplus

Step 5,6 -Stepwise

therapy

Not approved as

Monotherapy

Leukotriene modifier (strictly according to policy)

R03DC03

Lumont, Min Air, Monte

Air, Topraz

Lumont, Min Air, Monte Air,

Topraz

Lumont, Min Air, Monte Air,

Topraz

Strictly according to

policy

3. BIPOLAR MOOD DISORDER

Drug Class Full Budget Affordable Primary Care Special Requirements

Moodstabilisers

N05AN01 Camcolit, Quilonum Camcolit, Quilonum Camcolit, Quilonum REF Entry Criteria

N03AA02 Lethyl Lethyl Lethyl REF Entry Criteria

N03AF01 Degranol; Sandoz

Carbamazepine; Tegretol

Syrup

Degranol; Sandoz

Carbamazepine; Tegretol Syrup

Degranol; Sandoz


Syrup

REF Entry Criteria

N03AG01 Convulex, Epilim Convulex, Epilim Convulex, Epilim REF Entry Criteria

N03AX09 Aspen Lamotrigine, Dyna

Lamotrigine, Epitec,

Lamidus, Lamitor, Sandoz

Lamotrigine

Aspen Lamotrigine, Dyna

Lamotrigine, Epitec, Lamidus,

Lamitor, Sandoz Lamotrigine



Lamidus, Lamitor, Sandoz

Lamotrigine

REF Entry Criteria

Antipsychotics: - Phenothiazines

N05AA01 Largactil Largactil Largactil REF Entry Criteria

N05AB02 Modecate Modecate Modecate REF Entry Criteria

N05AB06 Stelazine Stelazine Stelazine REF Entry Criteria

Butyrophenones

N05AD01 Sandoz Haloperidol Sandoz Haloperidol Sandoz Haloperidol REF Entry Criteria

N05AF01 Fluanxol Depot, Fluanxol

Tablets

Fluanxol Depot Fluanxol Depot REF Entry Criteria

N05AF05 Clopixol Clopixol Clopixol REF Entry Criteria

N05AH02 Aspen Clozapine Aspen Clozapine Aspen Clozapine REF Entry Criteria

N05AH03 Oleanz, Olexar,Redilanz Oleanz, Olexar,Redilanz Oleanz, Olexar,Redilanz REF Entry Criteria

N05AH04 Mylan Quetiapine,

Quetoser, Serez, Seroquel

xr,

Mylan Quetiapine, Quetoser,

Serez, Seroquel xr,


Serez, Seroquel xr,

REF Entry Criteria

N05AL05 Solian Solian - REF Entry Criteria

N05AX08 Aspen risperidone, Drl

risperidone, Perizal, Risnia

Rispacor, Risperdal Drops,

Risperidone Hexal,

Risperlet, Risponz,

Schizorol,Mylan

Risperidone, Zoxadon

Aspen risperidone, Drl



Risperidone Hexal,

Risperlet, Risponz,

Schizorol,Mylan Risperidone,

Zoxadon




Risperidone Hexal,

Risperlet, Risponz,


Zoxadon

REF Entry Criteria

Tricyclic antidepressants & Sulpiride

N05AL01

Bio Sulpiride, Espiride Bio Sulpiride, Espiride Bio Sulpiride, Espiride REF Entry Criteria

N06AA02 Ethipramine Ethipramine Ethipramine REF Entry Criteria

N06AA04 Edronax, Equinorm Equinorm 25mg Equinorm 25mg REF Entry Criteria

N06AA07 Emdalen - - REF Entry Criteria

N06AA10 Tydamine - - REF Entry Criteria

N06AA16 Thaden Thaden Thaden REF Entry Criteria

Selective Serotonin Re-uptake Inhibitors (SSIRs)

N06AB03 A-Lennon Fluoxetine,

Deprozan, Lorien, Nuzak,

Prohexal, Ranflocs, Rezak,

Sandoz fluoxetine, Trizac,

Zydus Fluoxetine

A-Lennon Fluoxetine,




Zydus Fluoxetine





Zydus Fluoxetine

REF Entry Criteria

N06AB04 Adco-Talomil, Arrow

Citalopram, Austell

citalopram, Bio citalopram,

Cilate, Cilift , Citalohexal,

Citalopram Winthrop,

Depramil, DRL

Citalopram, Simayla

Citalopram,Sandoz

Citalopram

Adco-Talomil, Austell

citalopram, Arrow Citalopram,

Bio citalopram, Cilate, Cilift ,

Citalohexal, Citalopram

Winthrop, Depramil, DRL

Citalopram, Simayla

Citalopram, Sandoz Citalopram


citalopram, Arrow

Citalopram, Bio citalopram,



Depramil, DRL Citalopram,

Simayla Citalopram, Sandoz

Citalopram

REF Entry Criteria

N06AB05 Adco-Paroxetine, Austell-

paroxetine, Deparoc,

Parax,Paroxetine unicorn,

Paxil,

Serrapress, Xet,

Paroxetine Unicorn

Adco-Paroxetine, Austell-


Paroxetine unicorn,

Parax,Paxil,

Serrapress, Xet, Paroxetine

Unicorn



Paroxetine unicorn, Paxil,

Parax,


Unicorn

REF Entry Criteria

N06AB06 Arrow sertraline, Austell

sertraline, Serdep, Serlife,

Sertraline-winthrop, Zylin

Arrow sertraline, Austell






REF Entry Criteria

N06AB08 Faverin, Fluvoxamine-

Hexal

- - REF Entry Criteria

N06AB10 Aspen Escitalopram,

Citraz, Lexamil, Mylan

Escitalopram, Zytomil

Aspen Escitalopram, Citraz,

Lexamil, Mylan Escitalopram,

Zytomil

- REF Entry Criteria

Mono-amine oxidase

N06AF04 Parnate Parnate Parnate

N06AG02 Depnil, Adco-

meclobemide

Depnil, Adco-meclobemide Depnil, Adco-meclobemide

Tetracyclics

N06AX03 Lantanon Lantanon Lantanon REF Entry Criteria

N06AX05 Aspen Trazodone, - - REF Entry Criteria

N06AX11 Adco-Mirteron, Aspen

Mitarzapine, Beron, Mylan

mirtazapine, Ramure,

Sandoz mirtazapine


Noadrenaline Re-uptake Inhibitors

N06AX12 Wellbutrin SR - - REF Entry Criteria

Serotonin & Noadrenaline Re-uptake Inhibitor

N06AX16 Efegen xr, Venlafaxine –

Adco, Odiven, Sandoz

venlafaxine xl, Venlor XR,

Venlafaxine-Unicon


N06AX21 Cymgen, Yelate - - REF Entry Criteria

Melatonergic Antidepressabt

N06AX22 Valdoxane - - REF Entry Criteria

4. BRONCHIECTASIS


Requirements

Selective Beta adrenoreceptor agonists

R03AC02 Asthavent, Venteze Asthavent, Venteze Asthavent, Venteze REF Entry Criteria

R03AC13 Foratec Foratec Foratec REF Entry Criteria

R03AC04 Berotec - - REF Entry Criteria

5. CARDIAC FAILURE & CARDIOMYOPATHY


Requirements

Potassium Chloride

A12BA51 Plenish K, Sandoz -K Plenish K, Sandoz -K Plenish K, Sandoz -K Not approved as

Monotherapy

Platelet aggregation inhibitors

B01AC06 Bayer Aspirin Cardio,

Myoprin, Lo-Aspirin,

Aspirirn Teva, Ecotrin

Bayer Aspirin Cardio, Myoprin,

Lo-Aspirin, Asprin Teva,

Ecotrin

Bayer Aspirin Cardio,

Myoprin, Lo-Aspirin, Aspirin

Teva, Ecotrin

REF Entry Criteria

Anticoagulants

B01A A03 Cipla-warfarin, Warfarin

5mg (Lennon)

Cipla-warfarin, Warfarin 5mg

(Lennon) Cipla-warfarin, Warfarin 5mg

(Lennon)

REF Entry Criteria

Digitalis

C01AA05 Lanoxin, Purgoxin Lanoxin, Purgoxin Lanoxin, Purgoxin REF Entry Criteria

Organic Nitrates

C01DA02 Angised Angised Angised REF Entry Criteria

C01DA08

Imdur, Sandoz-isosorbide

dinitrate, Isordil Tembid

Sandoz-isosorbide dinitrate,

Isordil Tembid

Sandoz-isosorbide dinitrate,

Isordil Tembid

REF Entry Criteria

C01DA14 Elantan, Monicor SR Elantan, Monicor SR Elantan, Monicor SR REF Entry Criteria

Antihypertensives

Diuretics

C03AA03 Hexazide, Renezide, Ridaq Hexazide, Renezide, Ridaq Hexazide, Renezide, Ridaq REF Entry Criteria

C03AB03 Urirex K Urirex K Urirex K REF Entry Criteria

C03BA11

Adco-Dapamax, Cipla

indapamide, Dyna

indapamide sr, Mylan

Indapamide, Dapamax,

Hydroless, Sandoz-

indapamide, Daptril

Adco-Dapamax, Cipla

indapamide, Dyna indapamide

sr, Dapamax, Hydroless,

Sandoz-indapamide, Daptril,

Mylan Indapamide,

Adco-Dapamax, Cipla

indapamide, Dyna

indapamide sr, Dapamax,

Hydroless, Sandoz-

indapamide, Daptril, Mylan

Indapamide,

REF Entry Criteria

C03CA01

Austell Furosemide,

Beuresis, Lasix, Mylan-

Furosemide, Puresis, Sandoz-furosemide,

Furobe

Austell Furosemide, Beuresis,

Lasix, Mylan-Furosemide,

Puresis, Sandoz-furosemide,

Furobe

Austell Furosemide,

Beuresis, Lasix, Mylan-

Furosemide, Puresis, Sandoz-

furosemide, Furobe

REF Entry Criteria

C03CA02 Burinex - - REF Entry Criteria

C03CA04 Torahexal - - REF Entry Criteria

C03DA01 Sandoz-spironolactone,

Spiractin,

Sandoz-spironolactone,

Spiractin,


Spiractin,

REF Entry Criteria

C03DB01 Adco-retic, Amiloretic,

Betaretic

Adco-retic, Amiloretic,

Betaretic


Betaretic

REF Entry Criteria

ACE Inhibitors with or without combinations

C09AA01 Adco Captomax, Bio-

Captopril, Captohexal,

Mylan Captopril, Sandoz

Captopril, Zapto

Adco Captomax, Bio-

Captopril, Captohexal, Mylan

Captopril, Sandoz Captopril,

Zapto

Adco Captomax, Bio-



Zapto

REF Entry Criteria

C09AA02 Alapren, Ciplatec, Enap,

Envas, HR-Enalapril,

Alapren, Ciplatec, Enap, Envas,

HR-Enalapril, Pharmapress

Alapren, Ciplatec, Enap,


REF Entry Criteria

Pharmapress Pharmapress

C09AA03 Adco Zetomax,Auro

Lisinopril, Austell

Lisinopril, Diace,Hexal-

lisinopril, Simayla

Lisinopril,Lysin, Sinopren,

Zemax

Adco Zetomax,, Austell

Lisinopril, Hexal-lisinopril,

Simayla Lisinopril,Lysin,

Sinopren, Zemax

Adco Zetomax,, Austell


Simayla Lisinopril,Lysin,

Sinopren, Zemax

REF Entry Criteria

C09AA04 Acesyl, Bindace, Cipla-

perindopril, Ciplasyl,

Coversyl 10mg, Pearinda,

Prexum, Ran-perindopril,

Spec Perindopril, Simayla

Lisinopril,Vectoryl

Acesyl, Bindace, Cipla-

perindopril, Ciplasyl, Coversyl

10mg, Pearinda, Prexum, Ran-

perindopril, Spec Perindopril,

Simayla Lisinopril,Vectoryl






Lisinopril,Vectoryl

REF Entry Criteria

C09AA05 Austell-Ramipril; Ramipril

– Hexal; Ramiwin; Rampil;

Ran-ramipril; Retace;

Simayla Ramipril

Austell-Ramipril; Ramipril –

Hexal; Ramiwin; Rampil; Ran-

ramipril; Retace; Simayla

Ramipril




Ramipril

REF Entry Criteria

C09AA06 Accumax; Quinaspen; Accumax; Quinaspen; Accumax; Quinaspen; REF Entry Criteria

C09AA10 Mavik Mavik Mavik REF Entry Criteria

C09BA01 Zapto-co Zapto-co Zapto-co REF Entry Criteria

C09BA02 Enap co; Pharmapress co Enap co; Pharmapress co Enap co; Pharmapress co REF Entry Criteria

C09BA03 Adco Zetomax, Diace co,

Hexal-lisinopril co,

Lisoretic, Lisozide,

Lisinopril , Co-Unicorm

Adco Zetomax, Diace co,

Hexal-lisinopril co, Lisoretic,

Lisozide, Lisinopril Co-

Unicorm

Adco Zetomax, Diace Co,


Lisozide, Lisinopril, Co-

Unicorm

REF Entry Criteria

C09BA04 Acesyl co, Prexum Plus,

Spec Perindopril plus,

Vectoryl Plus

Acesyl co, Prexum Plus, Spec

Perindopril plus, Vectoryl Plus


Perindopril plus, Vectoryl

Plus

REF Entry Criteria

C09BA06 Accumax Co, Adco-

Quinaretic

Accumax Co, Adco-

Quinaretic

Accumax Co, Adco-

Quinaretic

REF Entry Criteria

Angiotensin Receptor Blockers (ARBs) & combinations

C09CA01 Cipla Losartan, Ciplazar,

Cozaar, Losaar plus,

Losartan Winthrop,

Netrasol co, Sartoc,

Zartan, Spec Losartan

Cipla Losartan, Ciplazar,

Cozaar, Lohype Plus, Losaar

plus, Losartan Winthrop,

Netrasol co, Sartoc, Zartan,

Spec Losartan,

Cipla Losartan, Ciplazar,

Cozaar, Lohype Plus, Losaar

plus, Losartan Winthrop,


Spec Losartan

REF Entry Criteria

C09CA03 Migroben, Tareg,

Zomevek


C09CA04 Irbewin ,Dynarb - - REF Entry Criteria

C09CA07 Pritor - - REF Entry Criteria

C09DA01 Ciplazar, Ciplazar co,

Cozaar Comp, Fortzaar,

Lohype Forte Plus, Lozaan

co, Zartan co,Lozacar co,

Losaan co,Netrasol co

Ciplazar, Ciplazar co, Cozaar

Comp, Fortzaar, Lohype Forte

Plus, Lozaan co, Zartan

co,Lozacar co, Losaan

co,Netrasol co


Comp, Fortzaar, Lohype

Forte Plus, Lozaan co, Zartan

co,Lozacar co, Losaan

co,Netrasol co

REF Entry Criteria

C09DA03 Co Tareg, Zomevak co - - REF Entry Criteria

C09DA04 Co Irbewin - - REF Entry Criteria

C09DA07 Co Pritor - - REF Entry Criteria

C09DB01 Exforge, Co exforge - - REF Entry Criteria

Beta Blockers

C07AB03

Adco-Atenolol; Sandoz-

atenolol; Tenbloka; Adco-

atenolol, B-Block, Bio-

Atenolol, Hexablok

Prodorol; Purbloka; Sandoz-


atenolol, B-Block, Bio-Atenolol,

Hexablok




Atenolol, Hexablok

REF Entry Criteria

C07AA05 Prodorol; Purbloka; Prodorol; Purbloka Prodorol; Purbloka; REF Entry Criteria

C07AB04 Butobloc, Sectral - - REF Entry Criteria

C07AB07 Adco-Bisocor,

Betacor,Bilocor, Bisohexal,

Cardicor, Bisoprolol

Unicorn

Adco-Bisocor, Betacor,Bilocor,

Bisohexal, Cardicor, Bisoprolol

Unicorn

Adco-Bisocor,


Cardicor, Bisoprolol Unicorn

REF Entry Criteria

C07AB07 Bisoprolol

Hydrochlorothiazide


C07BB03 Tenchlor, Sandoz Co

Tenidone

Tenchlor, Sandoz Co Tenidone Tenchlor, Sandoz Co

Tenidone

REF Entry Criteria

Calcium Channel Blockers (CCBs)

C08CA01 Almadin, Amlate, Amloc,

Amlodac, Amlosyn,

Austell-amlodipine,

Calbloc, Ciplavasc,

Klodip,Lomanor, Norcard,

Pharma Dynamics

Amlodipine Besylate,

Almadin, Amlate, Amloc,

Amlodac, Amlosyn, Austell-

amlodipine, Calbloc, Ciplavasc,


Pharma Dynamics Amlodipine

Besylate,



amlodipine, Calbloc,

Ciplavasc, Klodip,Lomanor,

Norcard, Pharma Dynamics

Amlodipine Besylate,,

REF Entry Criteria

C08CA02 Felodipine Hexal, Fedaloc Felodipine Hexal,Fedaloc Felodipine Hexal, Fedaloc REF Entry Criteria

C08CA03 Dynacirc SRO - - REF Entry Criteria

C08CA05 Adco-Vascard, Cipalat

Retard, Fedaloc, Macorel

sr, Nifedalat SR, Spec

nifedipine SR

Adco-Vascard, Cipalat Retard,

Fedaloc, Macorel sr, Nifedalat

SR, Spec nifedipine SR

Adco-Vascard, Cipalat

Retard, Fedaloc, Macorel sr,

Nifedalat SR, Spec nifedipine

SR

REF Entry Criteria

C08CA13 Zanidip - - REF Entry Criteria

C08DA01 Calcicard SR, Ravamil SR,

Vasomil, Verahexal,

Calcicard SR, Ravamil SR,

Vasomil, Verahexal,


Vasomil, Verahexal,

REF Entry Criteria

C08DB01 Adco-Zildem Adco-Zildem Adco-Zildem REF Entry Criteria

Alpha & Beta Receptor Blockers

C02CA01 Pratsiol - - REF Entry Criteria

C02CA04 Cardura XL, Adco-

Doxazosin, Cardugen,

Carzin

Adco-Doxazosin, Cardugen,

Carzin


Carzin

REF Entry Criteria

C07AG02 Aspen Carvedilol, Carloc,

Carvetrend, Vediblok,

Aspen Carvedilol, Carloc,




REF Entry Criteria

Vasodilators

C02DB02 Hyperphen, Sandoz

Hydralazine

Hyperphen, Sandoz

Hydralazine

Hyperphen, Sandoz

Hydralazine

REF Entry Criteria

Antiadrenergic agents, centrally acting

C02LB01 Hypotone, Sandoz

Methyldopa, Mylan

Methyldopa

Hypotone, Sandoz Methyldopa,

Mylan Methyldopa

Hypotone, Sandoz

Methyldopa, Mylan

Methyldopa

REF Entry Criteria

Sympathetic Nervous Blockers

C02AA02 Reserpine Reserpine Reserpine REF Entry Criteria

Antihypertensive Combinations with Statins

C10BX03 Caduet - - Motivation rqd

6. CHRONIC OBSTRUCTIVE AIRWAYS DISEASE

Drug Class Full Budget Affordable Primary Care Other Special

Requirements

Oral corticosteroids are no longer recommended for maintenance treatment of COPD-SPECIALIST REFERRAL REQUIRED.

R03AC02 Asthavent, Venteze Asthavent, Venteze Asthavent, Venteze Step 1 and up

R03AC04 Berotec - - Step 1 and up

R03AC12 Serevent Serevent - Step 2 and up

R03AC13 Foratec, Oxis Foratec,Oxis Foratec Step 2 and up

Anticholinergics

R03BB02 Atrovent, Ipvent Atrovent, Ipvent Atrovent, Ipvent Step 2 and up

R03BB04 Forvent Strictly according to policy Strictly according to policy Step 2 and up

Corticoid steroid inhalers

R03BA01 Beclate Beclate Beclate Step 2 and up

R03BA02 Budeflam, Inflammide Budeflam, Inflammide Budeflam, Inflammide Step 2 and up

R03BA05 Flixotide - - Step 2 and up

R03BA08 Alvesco - - Step 2 and up

Adrenergics and combinations for Obstructive Airways Disease

R03AK03 Duovent Duovent Duovent Step 2 and up

R03AK06 Foxair, Sereflo Foxair, Sereflo Foxair, Sereflo Step 2 and up

R03AK07 Symbicord - - Step 2 and up

Xanthines

R03DA04 EuphyllinR, Norstan

Theophyllin, Nuelin,

Sandoz Theophylline,

EuphyllinR, Norstan


EuphyllinR, Norstan


Theophylline,

Not approved as

Monotherapy

Uniphyl,Theoplus Theophylline,

Uniphyl,Theoplus

Uniphyl,Theoplus

7. CHRONIC RENAL FAILURE


Requirements

Vitamin D analogues and supplements

A11CC03 One Alpha One Alpha One Alpha REF Entry Criteria

A12AA B-Cal B-Cal B-Cal REF Entry Criteria

B03AB02 Venofer, Cosmofer Venofer, Cosmofer Venofer, Cosmofer REF Entry Criteria

Potassium Chloride

A12BA51 Plenish K, Sandoz -K Plenish K, Sandoz -K Plenish K, Sandoz -K

Haematopoietic Agents

B03XA01 Eprex; Recormon; Repotin Eprex; Recormon; Repotin Eprex; Recormon; Repotin REF Entry Criteria

Antihypertensives

Diuretics



C03BA11 Natrilix SR , Adco-

Dapamax, Cipla

indapamide, Dyna

indapamide sr, Hydroless,

Sandoz-indapamide

Adco-Dapamax, Cipla

indapamide, Dyna indapamide

sr, Hydroless, Sandoz-

indapamide

Adco-Dapamax, Cipla

indapamide, Dyna


Sandoz-indapamide

REF Entry Criteria

C03CA01 A lennon Furosemide,

Austell Furosemide,

Beuresis, Lasix, Lasix Soln,

Mylan-Furosemide, Puresis, Sandoz-furosemide,

Furobe

A lennon Furosemide, Austell

Furosemide, Beuresis, Lasix,

Lasix Soln, Mylan-Furosemide,


Furobe

A lennon Furosemide,

Austell Furosemide,


Mylan-Furosemide, Puresis, Sandoz-furosemide, Furobe




Spiractin,


Spiractin,


Spiractin,

REF Entry Criteria


Betaretic


Betaretic


Betaretic

REF Entry Criteria

ACE Inhibitors and combinations




Captopril, Zapto,

Adco Captomax, Bio-



Zapto,

Adco Captomax, Bio-



Captopril, Zapto,

REF Entry Criteria

C09AA02 Alapren, Ciplatec, Enap,


Pharmapress,

Alapren, Ciplatec, Enap, Envas,

HR-Enalapril, Pharmapress,



Pharmapress,

REF Entry Criteria

C09AA03 Adco Zetomax, Austell


Simayla Lisinopril,

Sinopren, Zemax,

Zestozide

Adco Zetomax, Austell


Simayla Lisinopril, Sinopren,

Zemax, Zestozide



Simayla Lisinopril,

Sinopren, Zemax,

Zestozide

REF Entry Criteria






Lisinopril,Vectoryl











Lisinopril,Vectoryl

REF Entry Criteria

C09AA05 Austell-Ramipril; Ramipril



Simayla Ramipril




Ramipril

Austell-Ramipril; Ramipril



Simayla Ramipril

REF Entry Criteria

C09AA06 Accumax; Quinaspen; Accumax; Quinaspen; Accumax; Quinaspen; REF Entry Criteria




C09BA03 Adco Zetomax, Diace co,



Lisinopril Co-Unicorm




Unicorm





REF Entry Criteria

C09BA04 Acesyl co, Prexum Plus,


Vectoryl Plus



Acesyl co, Prexum Plus,


Vectoryl Plus

REF Entry Criteria

C09BA06 Accumax co, Adco-

Quinaretic

Accumax co, Adco-Quinaretic Accumax Co, Adco-

Quinaretic

REF Entry Criteria

Angiotensin Receptor Blockers & combinations

C09CA01 Cipla Losartan, Cozaar,

Lohype Plus, Losaar plus,

Losartan Winthprop,


Zartan,

Cipla Losartan, Cozaar, Lohype

Plus, Losaar plus, Losartan

Winthprop, Netrasol co,

Sartoc, Zartan,

Cipla Losartan, Cozaar,


Losartan Winthprop,


Zartan,

REF Entry Criteria

C09CA03 Co Tareg, Diovan, Co-

migroben, Co-zomevek,

Migroben, Sartoc, Tareg,

Zomevek

Co Tareg, Diovan, Sartoc,

Tareg,

Co Tareg, Diovan, Sartoc, Tareg,

REF Entry Criteria

C09CA04 Irbewin, Dynarb - - REF Entry Criteria


C09DA01 Ciplazar, Ciplazar co,





Plus, Lozaan co, Zartan co

Ciplazar, Ciplazar co,



REF Entry Criteria

co, Zartan co co, Zartan co

C09DA03 Co Tareg - - REF Entry Criteria




Beta Blockers & combinations

C07AB03




Atenolol, Hexablok




Hexablok




Atenolol, Hexablok

REF Entry Criteria






Unicorn



Unicorn

Adco-Bisocor,



Unicorn

REF Entry Criteria

C07AB57 Bisoprolol

Hydrochlorothiazide



Tenidone


Tenidone

REF Entry Criteria



Amlodac, Amlosyn,

Austell-amlodipine,

Calbloc, Ciplavasc,


Pharma Dynamics







Besylate,


Amlodac, Amlosyn,

Austell-amlodipine,

Calbloc, Ciplavasc,


Pharma Dynamics


REF Entry Criteria






nifedipine SR







nifedipine SR

REF Entry Criteria



Vasomil, Verahexal,


Vasomil, Verahexal,


Vasomil, Verahexal,

REF Entry Criteria


Alpha & Beta Receptor Blockers




Carzin


Carzin

Adco-Doxazosin,

Cardugen, Carzin

REF Entry Criteria







REF Entry Criteria

Vasodilators


Hydralazine

Hyperphen, Sandoz

Hydralazine

Hyperphen, Sandoz

Hydralazine

REF Entry Criteria

C02DC01 Loniten Loniten Loniten REF Entry Criteria

Centrally Acting Sympathetic NS Inhibitors


Methyldopa, Mylan

Methyldopa


Mylan Methyldopa

Hypotone, Sandoz

Methyldopa, Mylan

Methyldopa

REF Entry Criteria



Methyldopa, Mylan

Methyldopa


Mylan Methyldopa

Hypotone, Sandoz

Methyldopa, Mylan

Methyldopa

REF Entry Criteria


C10BX03 Caduet - - Full Lipogram (Refer to

Hyperlipidaemia)

8. CORONARY ARTERY DISEASE


Requirements



Disprin CV, Myoprin, Lo-

Aspirin, Aspirin Teva,

Ecotrin

Bayer Aspirin Cardio, Disprin

CV, Myoprin, Lo-Aspirin,

Aspirin Teva, Ecotrin




Ecotrin

REF Entry Criteria

Organic Nitrates

C01DA02 Angised Angised Angised REF Entry Criteria

C01DA08 Imdur, Sandoz-isosorbide

dinitrate,

Sandoz-isosorbide dinitrate, Sandoz-isosorbide

dinitrate

REF Entry Criteria

C01DA14 Elantan, Monicor SR Elantan, Monicor SR Elantan, Monicor SR REF Entry Criteria

C01DA58 Isordil Tembid Isordil Tembid Isordil Tembid REF Entry Criteria

Antihypertensives

Beta Blockers

C07AB03




Atenolol, Hexablok




Hexablok




Atenolol, Hexablok

REF Entry Criteria






Unicorn



Unicorn

Adco-Bisocor,



Unicorn

REF Entry Criteria

C07AB07 Bisoprolol

Hydrochlorothiazide



Tenidone


Tenidone

REF Entry Criteria

Alpha & Beta Blockers




Carzin


Carzin

Adco-Doxazosin,

Cardugen, Carzin

REF Entry Criteria







REF Entry Criteria



Amlodac, Amlosyn,

Austell-amlodipine,

Calbloc, Ciplavasc,


Pharma Dynamics







Besylate,


Amlodac, Amlosyn,

Austell-amlodipine,

Calbloc, Ciplavasc,


Pharma Dynamics


REF Entry Criteria






nifedipine SR







nifedipine SR

REF Entry Criteria



Vasomil, Verahexal,


Vasomil, Verahexal,


Vasomil, Verahexal,

REF Entry Criteria


9. CROHN’S DISEASE


Steroids

H02AB07 Be-tabs Prednisone,

Capsoid, Pulmison,




Lenisolone

Be-tabs Prednisone,

Capsoid, Pulmison,


REF Entry Criteria

A07EA06 Entocord Entocord Entocord REF Entry Criteria

5 - ASA Agents

A07EC01 Salazopyrin; Salazopyrin

EN,

Salazopyrin; Salazopyrin EN, Salazopyrin; Salazopyrin

EN,

REF Entry Criteria

A07EC01 Pentasa, Pentasa supp,

Dipentum, Asacol

Pentasa, Pentasa supp,

Dipentum, Asacol


Dipentum, Asacol

REF Entry Criteria

Immunosuppressants

Folic Acid analogues

L01BA01 Abitrexate , Methotrexate-

Lederle, Methotrexate

(Wyeth)

Abitrexate , Methotrexate-


(Wyeth)



(Wyeth)

REF Entry Criteria

Folic Acid Supplements

B03BB01 Betabs Folic Acid Betabs Folic Acid Betabs Folic Acid Only approved in

combination therapy

Other immunosuppressants

L04AX01 Azathioprine, Azapress,

Zaprine

Azathioprine, Azapress,

Zaprine


Zaprine

REF Entry Criteria

Anti-TNF therapy and Biologics

Strictly according to policy Strictly according to policy Not Covered

10. DIABETES INSIPIDUS


Vasopressin Analogue

H01BA02 DDAVP DDAVP DDAVP REF Entry Criteria incl

Motivation

11. DIABETES MELLITIS Type 1


Insulins Fast Acting

A10AB01 Biosulin R; Humalog,

Humulin R, Novorapid

Biosulin R; Humalog, Humulin

R, Novorapid

Biosulin R; Humalog,


REF Entry Criteria

Analogues - Fast Acting

A10AB06 Apidra Apidra Apidra REF Entry Criteria

Insulins -Intermediate Acting

A10AC01 Biosulin N Biosulin N Biosulin N REF Entry Criteria

Insulins -Intermediate Acting combined with Fast Acting

A10AD01 Biosulin 30/70, Humulin

30/70 Humalog Mix 25,

Humalog Mix50

Actraphane, Novomix,

Insuman Comb

Biosulin 30/70, Humulin 30/70 Humalog Mix 25, Humalog

Mix50 Actraphane, Novomix,

Insuman Comb

Biosulin 30/70, Humulin


Humalog Mix50


Insuman Comb

REF Entry Criteria

Insulins- long Acting

A10AE01 Biosulin L, Humulin N,

Protaphane

Biosulin L, Humulin N,

Protaphane


Protaphane

REF Entry Criteria

Analogues- long Acting

A10AE04 Lantus; Levemir Lantus; Levemir Lantus; Levemir Strictly according to

clinical criteria & protocol

(motivation rqd)

12. DIABETES MELLITIS Type 2


Biguanides

A10BA02 Accord Metformin;

Arrow-Metformin, Austell-

Metformin, Bigsens,

Forminal, Gluconorm,

Glucophage, Glucophage

XR, Metchek,Metforal,

Metored, Metphage, Mylan

Metformin, Sandoz-

metformin

Accord Metformin; Arrow-

Metformin, Austell-Metformin,

Bigsens, Forminal, Gluconorm,

Glucophage, Glucophage XR,

Metchek,Metforal, Metored,

Metphage, Mylan Metformin,

Sandoz-metformin

Accord Metformin;

Arrow-Metformin, Austell-

Metformin, Bigsens,

Forminal, Gluconorm,

Glucophage, Glucophage

XR, Metchek,Metforal,

Metored, Metphage, Mylan

Metformin, Sandoz-

metformin

REF Entry Criteria

Sulfonamides,urea derivatives

A10BB01 Bio-Glibenclamide,

Glycomin, Sandoz-

glibenclamide

Bio-Glibenclamide, Glycomin,

Sandoz-glibenclamide Bio-Glibenclamide,

Glycomin, Sandoz-

glibenclamide

REF Entry Criteria

A10BB02 Hypomide Hypomide Hypomide REF Entry Criteria

A10BB09 Adco Glucomed, Arrow

gliclazide, Austell

Adco Glucomed, Arrow

gliclazide, Austell Gliclazide,

Adco Glucomed, Arrow

gliclazide, Austell Gliclazide,

REF Entry Criteria

Gliclazide, Diaglucide,

Diaran, Dyna gliclazide sr,

Glycron, Glygard, Mylan

Gliclazide, Sandoz

Gliclazide

Diaglucide, Diaran, Dyna

gliclazide sr, Glycron, Glygard,

Mylan Gliclazide, Sandoz

Gliclazide

Diaglucide, Diaran, Dyna

gliclazide sr, Glycron,

Glygard, Mylan Gliclazide,

Sandoz Gliclazide

A10BB12 Aspen glimepiride, Euglim,

Glamaryl, Mylan

Glimepiride, Sandoz-

Glimepiride, ,Sulphonur

Aspen glimepiride, Euglim,

Glamaryl, Mylan Glimepiride,

Sandoz-Glimepiride, Sulphonur

Aspen glimepiride, Euglim,

Glamaryl, Mylan Glimepiride,

Sandoz-Glimepiride,

Sulphonur

REF Entry Criteria

Alpha glucosidase inhibitors

A10BFD01 Glucobay - - REF Entry Criteria

Thiazolidinediones

A10BG03 Cipla- Pioglitazone Cipla- Pioglitazone Cipla- Pioglitazone REF Entry Criteria

Combination :Sulfonamides and Biguanides

A10BA02 Glucovance - - REF Entry Criteria

Dipeptidyl peptidase-4 inhibitors

A10BH01

Januvia Januvia - Strictly on Motivation

A10BH02 Galvus Galvus - Strictly on Motivation

A10BH03 Onglyza Onglyza - Strictly on Motivation

Dipeptidyl peptidase-4 inhibitors combinations

A10BH01

Janumet Janumet - Strictly on Motivation

A10BH02 Galvus Met Galvus Met - Strictly on Motivation

GLP-1 AGONIST

A10BX04 Byetta - - Strictly on Motivation

A10BX07 Victoza - - Strictly on Motivation

Insulins Fast Acting

A10AB01 Biosulin R; Humalog,


Biosulin R; Humalog, Humulin

R, Novorapid

Biosulin R; Humalog,


REF Entry Criteria

Analogues - Fast Acting

A10AB06 Apidra Apidra Apidra REF Entry Criteria

Insulins -Intermediate Acting

A10AC01 Biosulin N Biosulin N Biosulin N REF Entry Criteria

Insulins -Intermediate Acting combined with Fast Acting

A10AD01 Biosulin 30/70, Humulin


Biosulin 30/70, Humulin 30/70 Humalog Mix 25, Humalog

Biosulin 30/70, Humulin


REF Entry Criteria

Humalog Mix50


Insuman Comb

Mix50 Actraphane, Novomix,

Insuman Comb Humalog Mix50 Actraphane,

Novomix, Insuman Comb

Insulins- long Acting

A10AE01 Biosulin L, Humulin N,

Protaphane


Protaphane


Protaphane

REF Entry Criteria

Analogues- long Acting

A10AE04 Lantus; Levemir Lantus; Levemir Lantus; Levemir Strictly on Motivation

13. DYSRHYTHMIAS


Requirements

Platelet Aggregation inhibitors




Ecotrin







Ecotrin

REF Entry Criteria

Anticoagulants

B01A A03 Cipla-warfarin, Warfarin

5mg (Lennon)

Cipla-warfarin, Warfarin 5mg

(Lennon) Cipla-warfarin, Warfarin 5mg

(Lennon)

REF Entry Criteria

Digitalis

C01AA05 Lanoxin, Purgoxin Lanoxin, Purgoxin Lanoxin, Purgoxin REF Entry Criteria

Antiarrythmics

C01BA03 Rythmodan, Rythmol - - REF Entry Criteria

C01BD01 Arycor, Bio-Amiodarone,

Hexarone

Arycor, Bio-Amiodarone,

Hexarone

Arycor, Bio-Amiodarone,

Hexarone

REF Entry Criteria

Antihypertensives

Betablockers

C07AA05 Prodorol; Purbloka;

Sandoz-atenolol; Tenbloka;

Adco-atenolol, B-Block,

Bio-Atenolol, Hexablok




Hexablok




Atenolol, Hexablok

REF Entry Criteria





Unicorn



Unicorn

Adco-Bisocor,



REF Entry Criteria







REF Entry Criteria

Calcium Channel Blockers


Vasomil, Verahexal


Vasomil, Verahexal


Vasomil, Verahexal

REF Entry Criteria

14. EPILEPSY


Requirements

Antiepeleptics

N03AA02 Lethyl Lethyl Lethyl REF Entry Criteria

N03AB02 Epanutin Caps, Epanutin

Syrup, Phenytoin Sodium

Epanutin Caps, Epanutin Syrup,

Phenytoin Sodium Epanutin Caps, Epanutin

Syrup, Phenytoin Sodium

REF Entry Criteria

N03AD01 Zarontin Zarontin Zarontin REF Entry Criteria

N03AE01 Rivotril Rivotril Rivotril REF Entry Criteria ,

Combination use only

N03AF01 Degranol, Sandoz-

Carbamazepine CR,

Sandoz-Carbamazepine,

CPL Carbamazepine

Tegretol CR, Tegretol

Syrup

Degranol, Sandoz-

Carbamazepine CR, Sandoz-

Carbamazepine, CPL

Carbamazepine Tegretol CR,

Tegretol Syrup

Degranol, Sandoz-


Carbamazepine, CPL


Tegretol Syrup

REF Entry Criteria

N03AF02 Trileptal Trileptal Trileptal REF Entry Criteria

N03AG01 Convulex, Epilim CR,

Epilim Crushable, Epilim

Syrup

Convulex, Epilim CR, Epilim

Crushable, Epilim Syrup

Convulex, Epilim CR, Epilim

Crushable, Epilim Syrup

REF Entry Criteria

NO3AX09 Aspen lamotrigine, DYNA-


Lamidus, Lamitor, Sandoz-

Lamotrigine

Aspen lamotrigine, DYNA-


Lamitor, Sandoz-Lamotrigine

Aspen lamotrigine, DYNA-


Lamitor, Sandoz-Lamotrigine

REF Entry Criteria

NO3AX11 Epitoz, Sandoz

Topiramate,

Topalex,Toplep

Epitoz, Sandoz Topiramate,

Topalex,Toplep

Epitoz, Sandoz Topiramate,

Topalex,Toplep

REF Entry Criteria

NO3AX12 Epleptin, Neurexal, Ran

Gabapentin

Epleptin, Neurexal, Ran

Gabapentin

Epleptin, Neurexal, Ran

Gabapentin

REF Entry Criteria

NO3AX14 Redilev Redilev Redilev REF Entry Criteria

15. GLAUCOMA


Requirements

Beta Blockers

S01ED01 Glaucosan, Nyogel,

Timoptol, Timoptol XE

Glaucosan, Nyogel, Timoptol, Timoptol XE

Glaucosan, Nyogel,

Timoptol, Timoptol XE

REF Entry Criteria

S01ED01 Nyogel Nyogel Nyogel REF Entry Criteria

S01ED02 Betoptic S, Betoptic - - REF Entry Criteria

S01ED03 Betagan - - REF Entry Criteria

Parasympathomimetics

S01EB01 Isopto-carpine Isopto-carpine Isopto-carpine REF Entry Criteria

Sympathomimetics

S01EA05 Alphagan Alphagan Alphagan REF Entry Criteria

Carbonic anhydrase inhibitors

S01EC03 Trusopt Trusopt Trusopt REF Entry Criteria

S01EC04 Azoptic Azoptic Azoptic REF Entry Criteria

Prostaglandin analogues

S01EE01 Xalatan, Ocuprost Xalatan, Ocuprost Xalatan, Ocuprost REF Entry Criteria

S01EE03 Lumigan Lumigan Lumigan REF Entry Criteria

S01EE04 Travatan Travatan Travatan REF Entry Criteria

Beta Blocker Combinations

S01EE01 Xalacom Xalacom Xalacom REF Entry Criteria

S01ED51 Combigan Combigan Combigan REF Entry Criteria

S01ED51 Azarga Azarga Azarga REF Entry Criteria

S01EC03 Cosopt Cosopt Cosopt REF Entry Criteria

S01EE04 Duotrav Duotrav Duotrav REF Entry Criteria

16. HAEMOPHILIA


Requirements

Analgesics and Antipyretics

N02BE01 Panado, Feverpain,

Gencetamol, Adco

Paracetamol, Antalgic,

Austell Paracetamol,

Napamol, Painamol, Betab

Panado, Feverpain,

Gencetamol, Adco

Paracetamol, Antalgic, Austell

Paracetamol, Napamol,

Painamol, Betab

Panado, Feverpain,

Gencetamol, Adco




REF Entry Criteria

Paracetamol,Prolief,

Varipan

Paracetamol,Prolief, Varipan Paracetamol,Prolief, Varipan

Antifibrinolytics

B02AA02 Cyklokapron Cyklokapron Cyklokapron REF Entry Criteria

Blood Coagulation Factors

B02BD02 Haemosolvate Haemosolvate Haemosolvate REF Entry Criteria

17. HIV

Disease: Special Requirements

Registration with Wellcare at 0860 10 34 54 is required


Requirements

Analgesics and Antipyretics Nucleoside Reverse Transcriptase Inhibitors (NRTIs)

J05AF01

Adco-Zidovudine, Aspen

Zidovudine, Auro-

Zidovudine, Cipla-

Zidovudine, Retrovir,

Dozra, Sonke-Zidovudine,

Zidomat,


Zidovudine, Auro-Zidovudine,

Cipla-Zidovudine, Retrovir,

Dozra, Sonke-Zidovudine,

Zidomat,


Zidovudine, Auro-

Zidovudine, Cipla-

Zidovudine, Retrovir, Dozra,

Sonke-Zidovudine, Zidomat,

J05AF02 Aspen Didanosine,

Deladex, Sonke-

Didanosine, Deladex,

Videx

Aspen Didanosine, Deladex,

Sonke-Didanosine, Deladex,

Videx

Aspen Didanosine, Deladex,

Sonke-Didanosine, Deladex,

Videx

J05AF04 Aspen Stavudine, Auro

Stavudine, Sonke-

Stavudine, Stavir, Vari-

Stavudine, Zerit,

Aspen Stavudine, Auro

Stavudine, Sonke-Stavudine,

Stavir, Vari-Stavudine, Zerit,

Aspen Stavudine, Auro

Stavudine, Sonke-Stavudine,

Stavir, Vari-Stavudine, Zerit,

J05AF05

Adco-lamivudine, Aspen

lamivudine, 3TC, Cipla-

lamivudine, Sonke-

lamivudine, Lazena,

Legram,



lamivudine, Sonke-lamivudine,

Lazena, Legram,



lamivudine, Sonke-

lamivudine, Lazena, Legram,

J05AF06 Adco-Abacavir, Auro-

Abacavir, Cipla-Abacavir,

Sonke-Abacavir, Kavimun

Adco-Abacavir, Auro-Abacavir,

Cipla-Abacavir, Sonke-Abacavir,

Kavimun

Adco-Abacavir, Auro-

Abacavir, Cipla-Abacavir,

Sonke-Abacavir, Kavimun

Subject to clinical

Criteria & protocols

J05AF07

Adco Tenofovir, Aspen

Tenofovir, Cipla-tenofovir,

Ricovir, Sonke- Tenofovir,

Tenofovir Winthrop,

Viread, Zefin




Tenofovir Winthrop, Viread,

Zefin




Tenofovir Winthrop, Viread,

Zefin

Subject to clinical


Non-Nucleoside Reverse Transcriptase Inhibitors (NNTIs)

J05AG01

Adco-Nevirapine, Acriptaz,

Aspen Nevirapine, Cipla

Nevirapine, Auro-

Nevirapine, Sonke-

Nevirapine, Nevivir, Vari-

Nevirapine, Viramune,



Nevirapine, Auro-Nevirapine,

Sonke-Nevirapine, Nevivir,

Vari-Nevirapine, Viramune,

Viropon



Nevirapine, Auro-

Nevirapine, Sonke-

Nevirapine, Nevivir, Vari-

Nevirapine, Viramune,

Viropon Viropon

J05AG03

Adco-efavirenz, Arrow-

efavirenz, Auro-efavirenz,

Cipla-Efavirenz, Efavirenz

Winthrop, Efrin, Erige,

Hevaz, Sonke-Efavirenz,

Stocrin,




Winthrop, Efrin, Erige, Hevaz, Sonke-Efavirenz, Stocrin,




Winthrop, Efrin, Erige,

Hevaz, Sonke-Efavirenz,

Stocrin,

J05AG04

Intelence Intelence Intelence Subject to clinical


Protease Inhibitors (PIs)

J05AE01

Invirase Invirase Invirase Subject to clinical


J05AE02

Crixivan Crixivan Crixivan

J05AE03

Norvir, Norvir, Norvir,

J05AE08 Crixivan, Aspen atazanavir,

Atazor, Reyataz,

Crixivan, Aspen atazanavir,

Atazor, Reyataz,

Crixivan, Aspen atazanavir,

Atazor, Reyataz,

J05AE10 Prezista Prezista Prezista

Integrase Inhibitors

J05AX08 Isentress Isentress Isentress Subject to clinical


Fixed Dose Combination Drugs

J05AR02 Kivexa, Dumiva Kivexa, Dumiva Kivexa, Dumiva Subject to clinical


J05AF01

Adco

Lamivudine/zidovudine,

Aspen-lamzid, Auro-

Lamzido, Avocomb,

Cipla-Douvir, Combivir,

Combizil, Divuwin, Duovir,

Lodiz, Sonke-

Lamivudine/Zidovudine,

Zidolam, Zovilam,

Adco Lamivudine/zidovudine,

Aspen-lamzid, Auro-Lamzido, Avocomb, Cipla-Douvir,

Combivir, Combizil, Divuwin,

Duovir, Lodiz, Sonke-


Zidolam, Zovilam,

Adco

Lamivudine/zidovudine,

Aspen-lamzid, Auro-

Lamzido, Avocomb, Cipla-

Douvir, Combivir, Combizil,

Divuwin, Duovir, Lodiz,

Sonke-


Zidolam, Zovilam,

Subject to clinical


J05AR03

Adco-emtevir, Didivir,

Tencitab, Temecit,

Tenemcom, Tenemine,

Truvada, Tyricten


Tencitab, Temecit, Tenemcom,

Tenemine, Truvada, Tyricten


Tencitab, Temecit,

Tenemcom, Tenemine,

Truvada, Tyricten

Subject to clinical


J05AR04 Trizivar, Sonke-

Abaclamizid

Trizivar, Sonke-Abaclamizid Trizivar, Sonke-Abaclamizid Subject to clinical


J05AF05 Triomune, Sonke-

Laminevstav

Triomune, Sonke-Laminevstav Triomune, Sonke-

Laminevstav

Subject to clinical


J05AR01 Cipla Duovir & Efivarenz Cipla Duovir & Efivarenz co- Cipla Duovir & Efivarenz co- Subject to clinical

co-pack pack pack Criteria & protocols

J05AR06 Atripla, Atroiza, Odimune,

Tribuss, Citenvir, Trivenz

Atripla, Atroiza, Odimune,


Atripla, Atroiza, Odimune,


As Above

J05AR00 Tenarenz Tenarenz Tenarenz As Above

J05AR05 Triplavar Triplavar Triplavar As Above

J05AR10 Aluvia, Kaletra Aluvia, Kaletra Aluvia, Kaletra As Above

18. HYPERLIPIDAEMIA


Requirements




Aspirin, Gulf Aspirin,

Genpharma Aspirin,



CV, Myoprin, Lo-Aspirin, Gulf

Aspirin, Genpharma Aspirin,




Aspirin, Gulf Aspirin,

Genpharma Aspirin, Aspirin

Teva, Ecotrin

REF Entry Criteria

Fibrates

C10AB02 Bezalip, Sandoz Bezalip,

Bezachole SR, Dyna

Bezafibrate

Bezalip, Sandoz Bezalip,

Bezachole SR, Dyna Bezafibrate

Bezalip, Sandoz Bezalip,

Bezachole SR, Dyna

Bezafibrate

REF Entry Criteria

Statins

C10AA01 Adco Simvastatin, Arrow

Simvastatin, Aspen

Simvastatin, Austell

Simvastatin, Biovac

Simvastatin, Choleste,

Cipla-Simvastatin, Michol,

Redicor, Simvacor,

Simvotin, Zysim

Adco Simvastatin, Arrow

Simvastatin, Aspen Simvastatin,

Austell Simvastatin, Biovac

Simvastatin, Choleste, Cipla-

Simvastatin, Michol, Redicor,

Simvacor, Simvotin, Zysim

Adco Simvastatin, Arrow

Simvastatin, Aspen

Simvastatin, Austell

Simvastatin, Biovac

Simvastatin, Choleste, Cipla-

Simvastatin, Michol, Redicor,

Simvacor, Simvotin, Zysim

REF Entry Criteria

C10AA02 Lovachol Lovachol Lovachol REF Entry Criteria

C10AA03 Aspen Pravastatin, Arrow

pravastatin, Colite, Pixeta,

Sandoz pravastatin


C10AA04 Lescol - - REF Entry Criteria

C10AA05 Adco Atorvastatin,

Aspavor, Atolip,

Atorvastatin Unicorn,

Atorvastatin Winthrop,

Dynator,Lipogen


C10AA07 Crestor - - REF Entry Criteria

Other lipid modifyingagents

C10AX09 Ezetrol - - REF Entry Criteria with

Motivation

HMG CoA Reductase inhibitors in combination

C10BA02 Inegy - - REF Entry Criteria

Motivation reqd

C10BX03 Caduet - - REF Entry Criteria

Motivation reqd

19. HYPERTENSION






Ecotrin







Ecotrin

REF Entry Criteria

Potassium Chloride

A12BA51 Plenish K, Sandoz -K Plenish K, Sandoz -K Plenish K, Sandoz -K

Diuretics



C03BA11 Natrilix SR , Adco-Dapamax,

Cipla indapamide, Dyna


Sandoz-indapamide

Adco-Dapamax, Cipla

indapamide, Dyna


Sandoz-indapamide

Adco-Dapamax, Cipla

indapamide, Dyna


Sandoz-indapamide

REF Entry Criteria

C03CA01 A lennon Furosemide, Austell

Furosemide, Beuresis, Lasix,

Lasix Soln, Mylan-Furosemide,


Furobe


Austell Furosemide,


Mylan-Furosemide, Puresis, Sandoz-furosemide,

Furobe


Austell Furosemide,


Mylan-Furosemide, Puresis, Sandoz-furosemide, Furobe

REF Entry Criteria ,




Spiractin,


Spiractin,


Spiractin,

REF Entry Criteria


Betaretic


Betaretic


Betaretic

REF Entry Criteria

ACE Inhibitors & combinations




Zapto,

Adco Captomax, Bio-



Captopril, Zapto,

Adco Captomax, Bio-



Zapto,

REF Entry Criteria

C09AA02 Alapren, Ciplatec, Enap, Envas,

HR-Enalapril, Pharmapress,



Pharmapress,



Pharmapress,

REF Entry Criteria

C09AA03 Adco Zetomax, Austell



Zemax, Zestozide



Simayla Lisinopril,

Sinopren, Zemax,

Zestozide




Zemax, Zestozide

REF Entry Criteria











Lisinopril,Vectoryl






Lisinopril,Vectoryl

REF Entry Criteria

C09AA05 Austell-Ramipril; Ramipril -

Hexal, Ramiwin, Rampil, Ran-

ramipril, Retace, Simayla

Ramipril

Austell-Ramipril; Ramipril -

Hexal, Ramiwin, Rampil,


Simayla Ramipril

Austell-Ramipril, Ramipril-

Hexal, Ramiwin,; Rampil,

Ran-ramipril, Retace, Simayla

Ramipril

REF Entry Criteria

C09AA06 Accumax, Quinaspen; Accumax, Quinaspen; Accumax, Quinaspen REF Entry Criteria




C09BA03 Adco Zetomax, Diace Co,

Hexal-lisinopril Co, Lisoretic,


Unicorm


Hexal-lisinopril Co,




Hexal-lisinopril Co, Lisoretic,


Unicorm

REF Entry Criteria

C09BA04 Acesyl co, Prexum Plus, Spec


Acesyl co, Prexum Plus,


Vectoryl Plus


Perindopril plus, Vectoryl

Plus

REF Entry Criteria

C09BA06 Accumax Co, Adco-

Quinaretic

Accumax Co, Adco-

Quinaretic

Accumax Co, Adco-

Quinaretic

REF Entry Criteria

Angiotensin Receptor Blockers & combinations

C09CA01 Cipla Losartan, Cozaar, Lohype


Winthprop, Netrasol co,

Sartoc, Zartan,



Losartan Winthprop,


Zartan,



Losartan Winthprop,


REF Entry Criteria

C09CA03 Co Tareg, Diovan, Co-

migroben, Co-zomevek,

Migroben, Sartoc, Tareg,

Zomevek

Co Tareg, Diovan, Sartoc, Tareg,

Co Tareg, Diovan, Sartoc,

Tareg,

REF Entry Criteria

C09CA04 Irbewin, Dynarb - - REF Entry Criteria


C09DA01 Ciplazar, Ciplazar co, Cozaar


Plus, Lozaan co, Zartan co

Ciplazar, Ciplazar co,



co, Zartan co


Comp, Fortzaar, Lohype

Forte Plus, Lozaan co, Zartan

co

REF Entry Criteria

C09DA03 Co Tareg - - REF Entry Criteria




C09CA01 Cipla Losartan, Cozaar, Lohype


Winthrop, Netrasol co, Sartoc,

Zartan,



Losartan Winthrop,


Zartan,



Losartan Winthrop, Netrasol

co, Sartoc, Zartan,

REF Entry Criteria

Beta Blockers & combinations

C07AA05 Prodorol; Purbloka; Sandoz-



Hexablok

Prodorol; Purbloka;







Atenolol, Hexablok

REF Entry Criteria


C07AB07 Adco-Bisocor, Betacor,Bilocor,


Unicorn

Adco-Bisocor,



Unicorn

Adco-Bisocor,



REF Entry Criteria

C07AB07 Bisoprolol Hydrochlorothiazide - - REF Entry Criteria

C07BB03 Tenchlor Tenchlor Tenchlor REF Entry Criteria

C07AA05 Prodorol; Purbloka; Sandoz-



Hexablok

Prodorol; Purbloka;







Atenolol, Hexablok

REF Entry Criteria


C08CA01 Almadin, Amitas, Amlate,

Amloc, Amlodac, Amlosyn,

Austell-amlodipine, Calbloc,

Ciplavasc, Lomanor, Pharma

Dynamics Amlodipine Besylate,

Almadin, Amitas, Amlate,


Austell-amlodipine,

Calbloc, Ciplavasc,

Lomanor, Pharma

Dynamics Amlodipine

Besylate,

Almadin, Amitas, Amlate,


Austell-amlodipine, Calbloc,

Ciplavasc, Lomanor, Pharma

Dynamics Amlodipine

Besylate,

REF Entry Criteria

C08CA02 Felodipine Hexal Felodipine Hexal Felodipine Hexal REF Entry Criteria


C08CA05 Adco-Vascard, Cipalat Retard,






nifedipine SR


Retard, Fedaloc, Macorel sr,

Nifedalat SR, Spec nifedipine

SR

REF Entry Criteria



Vasomil, Verahexal,


Vasomil, Verahexal,


Vasomil, Verahexal,

REF Entry Criteria


Alpha & Beta Blockers


C02CA04 Cardura XL, Adco-Doxazosin,

Cardugen, Carzin

Adco-Doxazosin,

Cardugen, Carzin


Carzin

REF Entry Criteria







REF Entry Criteria

Vasodilators


Hydralazine

Hyperphen, Sandoz

Hydralazine

Hyperphen, Sandoz

Hydralazine

REF Entry Criteria

C02DC01 Loniten Loniten Loniten REF Entry Criteria

Centrally Acting Sympathetic NS Inhibitors

C02LB01 Hypotone, Sandoz Methyldopa,

Mylan Methyldopa

Hypotone, Sandoz

Methyldopa, Mylan

Methyldopa

Hypotone, Sandoz

Methyldopa, Mylan

Methyldopa

REF Entry Criteria



C10BX03 Caduet - - REF Entry Criteria , &

Motivation

20. HYPOTHYROIDISM


Requirements

Thyroid Replacement Hormones

H03AA01 Eltroxin, Euthyrox Eltroxin, Euthyrox Eltroxin, Euthyrox REF Entry Criteria

H03AA02 Tertroxin Tertroxin Tertroxin REF Entry Criteria

H03AA03 Diotroxin Diotroxin Diotroxin REF Entry Criteria

21. MULTIPLE SCLEROSIS


Requirements

Heterocyclic antidepressants


N06AA09 Trepiline, Sandoz Amytriptiline Trepiline, Sandoz

Amytriptiline

Trepiline, Sandoz

Amytriptiline

REF Entry Criteria

Anticonvulsants

N03AF01 Degranol, Sandoz-


Carbamazepine, CPL


Tegretol Syrup

Degranol, Sandoz-

Carbamazepine CR,

Sandoz-Carbamazepine,

CPL Carbamazepine

Tegretol CR, Tegretol

Syrup

Degranol, Sandoz-


Carbamazepine, CPL


Tegretol Syrup

REF Entry Criteria

Corticosteroids

H02AB04 Solumedrol Solumedrol Solumedrol REF Entry Criteria

H02AB07 Be-tabs Prednisone, Capsoid,


Lenisolone

Be-tabs Prednisone,

Capsoid, Pulmison,




Lenisolone

REF Entry Criteria

Immunosuppressants



Lederle


Lederle


Lederle

REF Entry Criteria


B03BB01 Betabs Folic Acid Betabs Folic Acid Betabs Folic Acid REF Entry Criteria

L01AA01 Endoxan - - REF Entry Criteria


Zaprine


Zaprine


Zaprine

REF Entry Criteria

Muscle Relaxants

M03BX01 Bio-Baclofen, Teva Baclofen Bio-Baclofen, Teva

Baclofen

Bio-Baclofen, Teva Baclofen REF Entry Criteria

Anticholinergics

G04BD04 Lenditro, Mylan Oxybutinin,

Urihexal

Lenditro, Mylan

Oxybutinin, Urihexal

Lenditro, Mylan Oxybutinin,

Urihexal

REF Entry Criteria

Immunostimulants

Motivation is required

Reimbursement - Strictly according to clinical criteria and protocol.

22. PARKINSONS DISEASE


Requirements

Dopaminergic agents

Carbidopa, and Levodopa derivatives

N04BA01 Carbilev, Sinemet CR, Sinemet,

Madopar, Teva Carbi-Levo

Carbilev, Sinemet CR,

Sinemet, Madopar, Teva

Carbi-Levo

Carbilev, Sinemet CR,

Sinemet, Madopar, Teva

Carbi-Levo

REF Entry Criteria

Anticholinergics

N04AA02 Akineton, Disipal Akineton, Disipal Akineton, Norflex, Disipal REF Entry Criteria

Adamantane derivatives

N04BB01 Symmetrel - - REF Entry Criteria

Monoamine oxidase B Inhibitors

N04BD01 Parkilyne Parkilyne Parkilyne REF Entry Criteria

Dopamine agonists

N04BC01 Aspen Bromocriptine Aspen Bromocriptine Aspen Bromocriptine REF Entry Criteria

N04BC04 Requip - - REF Entry Criteria

N04BC04 RequipXL - - Motivation reqd

N04BC05 Oxpola, Pramiola Oxpola, Pramiola Oxpola, Pramiola REF Entry Criteria

23. RHEUMATOID ARTHRITIS

Disease: Special Requirements Biological Alternatives: Reimbursement strictly according to the clinical criteria & reimbursement policy.


Requirements

Non Steroidal Anti-inflammatories

M01AB01 Arthrexin, Adco-Indomethacin,

Betacin, Flamecid, Methocaps

Arthrexin, Adco-

Indomethacin, Betacin,

Flamecid, Methocaps

Arthrexin, Adco-


Flamecid, Methocaps

REF Entry Criteria

M01AB05 Fortfen SR , Adco-Diclofenac,

A-Lennon

Diclofenac,Diclohexal, Mylan

Diclofenac, Panamor, Panamor

SR, Sandoz Diclofenac Sodium,

Veltex

Fortfen SR , Adco-

Diclofenac, A-Lennon

Diclofenac,Diclohexal,

Mylan Diclofenac,

Panamor, Panamor SR,

Sandoz Diclofenac Sodium,

Veltex

Fortfen SR , Adco-



Diclofenac, Panamor,

Panamor SR, Sandoz

Diclofenac Sodium, Veltex

REF Entry Criteria

M01AC01 Rheugesic, Xycam,Brexecam,

Pixicam, Pyrocaps

Rheugesic, Xycam,

Pixicam, Pyrocaps

Rheugesic, Xycam, Pixicam,

Pyrocaps

REF Entry Criteria

M01AE01 Adco-Ibuprofen, Betaprofen,

Iboflam, Inza, Ranfen, Sandoz

Adco-Ibuprofen,

Betaprofen, Iboflam, Inza,

Adco-Ibuprofen, Betaprofen,


REF Entry Criteria

Ibuprofen, Ranfen, Sandoz Ibuprofen, Ibuprofen,

M01AE02 Adco-Naproxen, Aspen

Naproxen, Bio

Naproxen,Mylan Naproxen,

Nafasol, Napflam

Adco-Naproxen, Aspen

Naproxen, Bio

Naproxen,Mylan

Naproxen, Nafasol,

Napflam


Naproxen, Bio


Nafasol, Napflam

REF Entry Criteria

M01AE03 Ketoflam Ketoflam Ketoflam REF Entry Criteria

M01AE06 Adco Meloxicam, Arrow

Meloxicam, Coxflam,

Flexocam, Loxiflam, M-Cam,

Melflam, Meloxicam Unicorn,

Mobic, Zydus Meloxicam

Adco Meloxicam, Arrow

Meloxicam, Coxflam,

Flexocam, Loxiflam, M-

Cam, Melflam, Meloxicam

Unicorn, Mobic, Zydus

Meloxicam


Meloxicam, Coxflam,




REF Entry Criteria

M01AH01 Celebrex - - Motivation rqd

M01AH05 Arcoxia Arcoxia Arcoxia Motivations rqd

Immunosuppressants




(Wyeth)



(Wyeth)



(Wyeth)

REF Entry Criteria



Other Immunosuppressants


Zaprine


Zaprine


Zaprine

REF Entry Criteria

A07EC01 Salazopyrin, Salazopyrin EN Salazopyrin, Salazopyrin

EN

Salazopyrin, Salazopyrin EN REF Entry Criteria

L04AA13

Arava Arava Arava Motivation Reqd

Chloroquine

P01BA01 Nivaquine, Plasmoquine Nivaquine, Plasmoquine Nivaquine, Plasmoquine, REF Entry Criteria

Oral Corticosteroids



Lenisolone

Be-tabs Prednisone,

Capsoid, Pulmison,




Lenisolone

Approval for 6months at

a time.

Paracetamol

N02BE01 Panado, Feverpain,

Gencetamol, Adco

Paracetamol, Antalgic, Austell

Paracetamol, Napamol,

Painamol, Betab

Paracetamol,Prolief, Varipan

Panado, Feverpain,

Gencetamol, Adco




Paracetamol,Prolief,

Varipan

Panado, Feverpain,

Gencetamol, Adco




Paracetamol,Prolief, Varipan

REF Entry Criteria

24. SCHIZOPHRENIA


Requirements

Antipsychotics - Phenothiazines

N05AA01 Largactil Largactil Largactil REF Entry Criteria

N05AB02 Modecate Modecate Modecate REF Entry Criteria

N05AB06 Stelazine Stelazine Stelazine REF Entry Criteria

Butyrophenones

N05AD01 Sandoz Haloperidol Sandoz Haloperidol Sandoz Haloperidol REF Entry Criteria

Atypical Antipsychotics

N05AF01 Fluanxol Depot, Fluanxol

Tablets

Fluanxol Depot Fluanxol Depot REF Entry Criteria

N05AF05 Clopixol Clopixol Clopixol REF Entry Criteria

N05AH02 Aspen Clozapine Aspen Clozapine Aspen Clozapine REF Entry Criteria

N05AH03 Oleanz, Olexar,Redilanz Oleanz, Olexar,Redilanz Oleanz, Olexar,Redilanz REF Entry Criteria

N05AH04 Mylan Quetiapine, Quetoser,

Serez, Seroquel xr


Serez, Seroquel xr


Serez, Seroquel xr

REF Entry Criteria

N05AL05 Solian Solian - REF Entry Criteria

N05AX08 Aspen risperidone, Drl



Risperidone Hexal,

Risperlet, Risponz,


Zoxadon




Risperidone Hexal,

Risperlet, Risponz,


Zoxadon




Risperidone Hexal,

Risperlet, Risponz,


Zoxadon

REF Entry Criteria

Mood stabilisers

N05AN01 Camcolit, Quilonum Camcolit, Quilonum Camcolit, Quilonum REF Entry Criteria

N03AF01 Degranol; Sandoz

Carbamazepine; Tegretol Syrup

Degranol; Sandoz


Syrup

Degranol; Sandoz


Syrup

REF Entry Criteria

N03AG01 Convulex, Epilim Convulex, Epilim Convulex, Epilim REF Entry Criteria

N03AX09 Aspen Lamotrigine, Dyna









REF Entry Criteria

Tricyclic antidepressants & Sulpiride

N05AL01

Bio Sulpiride, Espiride Bio Sulpiride, Espiride Bio Sulpiride, Espiride REF Entry Criteria


N06AA04 Edronax, Equinorm Equinorm 25mg Equinorm 25mg REF Entry Criteria

N06AA07 Emdalen - - REF Entry Criteria

N06AA10 Tydamine - - REF Entry Criteria

N06AA16 Thaden Thaden Thaden REF Entry Criteria

Selective Serotonin Re-uptake Inhibitors (SSIRs)

N06AB03 A-Lennon Fluoxetine,




Zydus Fluoxetine





Zydus Fluoxetine





Zydus Fluoxetine

REF Entry Criteria

N06AB04 Adco-Talomil, Arrow

Citalopram, Austell citalopram,

Bio citalopram, Cilate, Cilift ,

Citalohexal, Citalopram

Winthrop, Depramil, DRL

Citalopram, Simayla

Citalopram,Sandoz Citalopram


citalopram, Arrow






Citalopram


citalopram, Arrow






Citalopram

REF Entry Criteria

N06AB05 Adco-Paroxetine, Austell-


Parax,Paroxetine unicorn,

Paxil,


Unicorn



Paroxetine unicorn,

Parax,Paxil,


Unicorn



Paroxetine unicorn, Paxil,

Parax,


Unicorn

REF Entry Criteria

N06AB06 Arrow sertraline, Austell









REF Entry Criteria

N06AB08 Faverin, Fluvoxamine-Hexal - - REF Entry Criteria

N06AB10 Aspen Escitalopram, Citraz,


Zytomil

Aspen Escitalopram, Citraz,


Zytomil

- REF Entry Criteria

Mono-amine oxidase

N06AF04 Parnate Parnate Parnate

N06AG02 Depnil, Adco-meclobemide Depnil, Adco-meclobemide Depnil, Adco-meclobemide

Tetracyclics

N06AX03 Lantanon Lantanon Lantanon REF Entry Criteria

N06AX05 Aspen Trazodone, - - REF Entry Criteria

N06AX11 Adco-Mirteron, Aspen

Mitarzapine, Beron, Mylan

mirtazapine, Ramure, Sandoz

mirtazapine


Noadrenaline Re-uptake Inhibitors

N06AX12 Wellbutrin SR - - REF Entry Criteria

Serotonin & Noadrenaline Re-uptake Inhibitors

N06AX16 Efegen xr, Venlafaxine –Adco,

Odiven, Sandoz venlafaxine xl,

Venlor XR, Venlafaxine-Unicon


N06AX21 Cymgen, Yelate - - REF Entry Criteria

Melatonergic Antidepressants

N06AX22 Valdoxane - - REF Entry Criteria

25. SYSTEMIC LUPUS ERYTHEMATOSIS


Requirements

Non Steroidal Anti-inflammatories

M01AB01 Arthrexin, Adco-Indomethacin,


Arthrexin, Adco-Indomethacin,


Arthrexin, Adco-


Flamecid, Methocaps

REF Entry Criteria

M01AB05 Fortfen SR , Adco-Diclofenac,

A-Lennon




Veltex

Fortfen SR , Adco-Diclofenac,

A-Lennon




Veltex

Fortfen SR , Adco-


Diclofenac,Diclohexal,

Mylan Diclofenac,

Panamor, Panamor SR,

Sandoz Diclofenac

Sodium, Veltex

REF Entry Criteria

M01AC01 Rheugesic, Xycam,Brexecam,

Pixicam, Pyrocaps

Rheugesic, Xycam, Pixicam,

Pyrocaps

Rheugesic, Xycam,

Pixicam, Pyrocaps

REF Entry Criteria

M01AE01 Adco-Ibuprofen, Betaprofen,


Ibuprofen,

Adco-Ibuprofen, Betaprofen,


Ibuprofen,

Adco-Ibuprofen,

Betaprofen, Iboflam,

Inza, Ranfen, Sandoz

Ibuprofen,

REF Entry Criteria

M01AE02 Adco-Naproxen, Aspen

Naproxen, Bio


Nafasol, Napflam


Naproxen, Bio


Nafasol, Napflam


Naproxen, Bio

Naproxen,Mylan

Naproxen, Nafasol,

Napflam

REF Entry Criteria

M01AE03 Ketoflam Ketoflam Ketoflam REF Entry Criteria

M01AE06 Adco Meloxicam, Arrow

Meloxicam, Coxflam,





Meloxicam, Coxflam,





Meloxicam, Coxflam,

Flexocam, Loxiflam, M-

Cam, Melflam,

Meloxicam Unicorn,


REF Entry Criteria

M01AH01 Celebrex - - Motivation reqd

M01AH05 Arcoxia Arcoxia Arcoxia Motivation reqd

Oral Corticosteroids



Lenisolone



Lenisolone

Be-tabs Prednisone,

Capsoid, Pulmison,


Immunosuppressants



Lederle


Lederle

Abitrexate ,

Methotrexate-Lederle

REF Entry Criteria



Chloroquine

P01BA01 Nivaquine, Plasmoquine Nivaquine, Plasmoquine, Nivaquine, Plasmoquine REF Entry Criteria


B01AC06 Bayer Aspirin Cardio, Disprin









Disprin CV, Myoprin,

Lo-Aspirin, Gulf Aspirin,

Genpharma Aspirin,


REF Entry Criteria

26. ULCERATIVE COLITIS


Requirements

Steroids

A07EA06 Entocord Entocord Entocord REF Entry Criteria



Lenisolone



Lenisolone

Be-tabs Prednisone,

Capsoid, Pulmison,


A07EC01 Salazopyrin; Salazopyrin EN, Salazopyrin; Salazopyrin EN, Salazopyrin; Salazopyrin

EN,

REF Entry Criteria

A07EC01 Pentasa, Pentasa supp,

Dipentum, Asacol


Dipentum, Asacol


Dipentum, Asacol

Other immunosuppressants


Zaprine


Zaprine


Zaprine

REF Entry Criteria

Anti-TNF therapy and Biologics

Biologicals Biologicals Biologicals Strictly according to

clinical criteria & policy

Documents

Sizwe Medical Fund: CDL Formulary - All · PDF fileSizwe Medical Fund: CDL Formulary - All Options This formulary is a summary of treatment covered on the Chronic Disease List (CDL)