Sizwe Medical Fund: CDL Formulary - All Options

1 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: 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.

2 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.

3 PLEASE NOTE: Claims will not be paid as a PMB without the correct and specific ICD10 codes on prescriptions and claims. 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 Be-tabs Prednisone, Capsoid, Pulmison, Panafcort, Lenisolone REF Entry Criteria H02AB09 Covocort Covocort Covocort REF Entry Criteria 2. ASTHMA Drug Class Full Budget Affordable Primary Care Special 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.

4 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 Theophyllin, Nuelin, Sandoz 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.

5 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 Carbamazepine; Tegretol 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 Aspen Lamotrigine, Dyna Lamotrigine, Epitec, Lamidus, Lamitor, Sandoz Lamotrigine REF Entry Criteria Antipsychotics.

6 - 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, Mylan Quetiapine, Quetoser, 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, Perizal, Risnia Rispacor, Risperdal Drops, Risperidone Hexal, Risperlet, Risponz, Schizorol,Mylan Risperidone, Zoxadon Aspen risperidone, Drl risperidone, Perizal, Risnia Rispacor, Risperdal Drops, Risperidone Hexal, Risperlet, Risponz, Schizorol,Mylan Risperidone.

7 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, Deprozan, Lorien, Nuzak, Prohexal, Ranflocs, Rezak, Sandoz fluoxetine, Trizac, Zydus Fluoxetine A-Lennon Fluoxetine, Deprozan, Lorien, Nuzak, Prohexal, Ranflocs, Rezak, Sandoz fluoxetine, Trizac, 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.

8 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 REF Entry Criteria N06AB05 Adco-Paroxetine, Austell-paroxetine, Deparoc, Parax,Paroxetine unicorn, Paxil, Serrapress, Xet, Paroxetine Unicorn Adco-Paroxetine, Austell-paroxetine, Deparoc, Paroxetine unicorn, Parax,Paxil, Serrapress, Xet, Paroxetine Unicorn Adco-Paroxetine, Austell-paroxetine, Deparoc, Paroxetine unicorn, Paxil, Parax, Serrapress, Xet, Paroxetine Unicorn REF Entry Criteria N06AB06 Arrow sertraline, Austell sertraline, Serdep, Serlife, Sertraline-winthrop, Zylin Arrow sertraline, Austell sertraline, Serdep, Serlife, Sertraline-winthrop, Zylin Arrow sertraline, Austell sertraline, Serdep, Serlife, Sertraline-winthrop, Zylin 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.

9 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 - - REF Entry Criteria 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 - - REF Entry Criteria N06AX21 Cymgen, Yelate - - REF Entry Criteria Melatonergic Antidepressabt N06AX22 Valdoxane - - REF Entry Criteria 4. BRONCHIECTASIS Drug Class Full Budget Affordable Primary Care Special 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.

10 CARDIAC FAILURE & CARDIOMYOPATHY Drug Class Full Budget Affordable Primary Care Special 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 El