Chronic Medication Core Formulary
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CHRONIC MEDICATION CORE FORMULARY Effective 1 January 2013 • This formulary represents drugs covered for chronic use for 25 Chronic Disease List (CDL) conditions and individual Diagnosis and Treatment Pairs (DTP) conditions. • Reimbursement of medicines for non-CDL and non-DTP conditions is subject to Scheme Rules and the Metropolitan Health Risk Management Medicine Reimbursement Policy. • Unless stipulated, all active ingredients listed in this formulary are subject to the Metropolitan Health Reference Price (MetRef). • The examples below serve as a guide on the trade names available for the active ingredients listed and not for marketing a specific brand. • Any product within the MetRef category may be used, however a co-payment may be attracted if the product selected is above the generic reference threshold. • The dispensing pharmacist may make a generic substitution to assist members in avoiding a co-payment. • Treatment designated as "Accepted treatment" indicates that this is a medicine covered as first line, according to the Metropolitan Health Risk Management Medicine Reimbursement Policy. • For treatment designated as "Motivation required", certain criteria as specified in the Metropolitan Health Risk Management Medicine Reimbursement Policy should be met. • For treatment designated as "Special investigation", the relevant clinical investigation reports as specified in the Metropolitan Health Risk Management Medicine Reimbursement Policy are required. Abbreviations of dosage form CAP Capsule ENE Enema OPD Eye drops SYR Syrup CPS Capsule (Inhaler) INH Inhaler SLN Sublingual TAB Tablet CRM Cream INJ Injection SRC Slow release capsule UNG Ointment DRP Drops LOT Lotion SRT Slow release tablet DSP Dispersible NAS Nasal spray SUP Suppository ECT Enteric-coated tablet NOD Nasal drops SUS Suspension DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM CHRONIC DISEASE LIST CONDITIONS (CDLs) ADDISON'S DISEASE ICD10: E27.1 Fludrocortisone 0.1mg TAB Florinef acetate Corticosteroids , oral Motivation required Hydrocortisone 10mg TAB Covocort Corticosteroids , oral Accepted treatment Prednisolone 5mg TAB Capsoid Lenisolone Corticosteroids , oral Accepted treatment Prednisone 5mg TAB Be-tabs prednisone Panafcort Corticosteroids , oral Accepted treatment Page 1 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM ASTHMA ICD10: J45.0, J45.1, J45.8, J45.9 Aminophylline 225mg SRT Phyllocontin Xanthines Motivation required Beclometasone 100mcg INH Beclate 100 Becotide 100 comp Corticosteroids, inhaled Accepted treatment Beclometasone 200mcg INH Beclate 200 Corticosteroids, inhaled Accepted treatment Beclometasone 50mcg INH Beclate 50 Becotide complete Corticosteroids, inhaled Accepted treatment Budeflam 300 dose gentle- Inflammide 100 mac 300 Budesonide 100mcg INH Corticosteroids, inhaled Accepted treatment haler hfa dose Budeflam 300 dose gentle- Inflammide 200 mac 300 Budesonide 200mcg INH Corticosteroids, inhaled Accepted treatment haler hfa dose Budesonide 200mcg CPS Budeflam DP Caps Inflacor 200 Corticosteroids, inhaled Accepted treatment Budesonide 100mcg CPS Inflacor 100 Corticosteroids, inhaled Accepted treatment Budesonide 400mcg CPS Inflacor 400 Corticosteroids, inhaled Accepted treatment Inflammide 400 Novolizer Budesonide 400mcg INH Corticosteroids, inhaled Accepted treatment Complete Inflammide 400 Novolizer Budesonide 400mcg INH Corticosteroids, inhaled Accepted treatment refill Symbicord turboh 120 dose Corticosteroids and beta agonists, long Budesonide and formoterol 160/4.5mcg INH Motivation required 160mcg;45mc acting Symbicord turboh 120dose Corticosteroids and beta agonists, long Budesonide and formoterol 80/4.5mcg INH Motivation required 80:4 5mcg acting Symbicord turboh 60 dose Corticosteroids and beta agonists, long Budesonide and formoterol 160/4.5mcg INH Motivation required 160mcg;45mcg acting Symbicord turboh 60dose Corticosteroids and beta agonists, long Budesonide and formoterol 320/9mcg INH Motivation required 320:9mcg acting Fenoterol 100mcg INH Berotec HFA Beta agonists , short acting Motivation required Fenoterol and ipratropium 200mcg INH Duovent HFA 200 dose Beta agonists , short acting Accepted treatment bromide Formoterol 12mcg CPS Foradil dry powder inhalation Foratec DP Caps Beta agonists, long acting Accepted treatment Formoterol 12mcg INH Foratec HFA Beta agonists, long acting Accepted treatment Ipratropium bromide 40mcg INH Ipvent anticholinergics Accepted treatment Ipratropium bromide 20mcg INH Atrovent anticholinergics Accepted treatment Salbutamol 100mcg INH Asthavent 200 dose Beta agonists , short acting Accepted treatment Asthavent 300d ecohaler cfc Salbutamol 100mcg INH Beta agonists , short acting Accepted treatment free Salbutamol 200mcg CAP Asthavent DP Ventodis ks(8 s) Beta agonists , short acting Accepted treatment Salbutamol 100mcg INH Venteze CFC free Beta agonists , short acting Accepted treatment Salbutamol 100mcg INH Venteze complete Beta agonists , short acting Accepted treatment Page 2 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM Salbutamol 400mcg CPS Ventodisks(8 s) Beta agonists , short acting Motivation required Salbutamol 100mcg INH Ventolin inhaler 200 cfc-free Beta agonists , short acting Accepted treatment Salbutamol 2.5mg SLN Ventolin nebules Salbu-neb Beta agonists , short acting Motivation required Salbutamol and other drugs for INH Combivent Beta agonist & anticholinergic Accepted treatment obstructive airway diseases Salmeterol and fluticasone 25/125mcg INH Foxair Salmeterol and fluticasone Motivation required Corticosteroids and beta agonists, long Salmeterol and fluticasone 25/250mcg INH Foxair Motivation required acting Corticosteroids and beta agonists, long Salmeterol and fluticasone 25/50mcg INH Foxair Motivation required acting Corticosteroids and beta agonists, long Salmeterol and fluticasone 50/100mcg ACC Foxair Motivation required acting Corticosteroids and beta agonists, long Salmeterol and fluticasone 50/250mcg ACC Foxair Motivation required acting Corticosteroids and beta agonists, long Salmeterol and fluticasone 50/500mcg ACC Foxair Motivation required acting Corticosteroids and beta agonists, long Salmeterol and fluticasone 25mcg/125mcg INH Sereflo HFA 25/125 Dose 120 Motivation required acting Corticosteroids and beta agonists, long Salmeterol and fluticasone 25mcg/250mcg INH Sereflo HFA 25/250 Dose 120 Motivation required acting Corticosteroids and beta agonists, long Salmeterol and fluticasone 25mcg/50mcg INH Sereflo HFA 25/50 120 Dose Motivation required acting Corticosteroids and beta agonists, long Salmeterol and fluticasone 25mcg/125mcg INH Seretide 25/125 120 dose Motivation required acting Corticosteroids and beta agonists, long Salmeterol and fluticasone 25mcg/250mcg INH Seretide 25/250 120 dose Motivation required acting Corticosteroids and beta agonists, long Salmeterol and fluticasone 25mcg/50mcg INH Seretide 25/50 120 dose Motivation required acting Corticosteroids and beta agonists, long Salmeterol and fluticasone 100mcg INH Seretide accuhaler 50/100 Motivation required acting Corticosteroids and beta agonists, long Salmeterol and fluticasone 250mcg INH Seretide Accuhaler 50/250 Motivation required acting Corticosteroids and beta agonists, long Salmeterol and fluticasone 500mcg INH Seretide accuhaler 50/500 Motivation required acting Theophylline 250mg SRT Euphyllin retard Xanthines Motivation required Theophylline 125mg SRC Microphyllin Xanthines Motivation required Theophylline 250mg SRC Microphyllin Xanthines Motivation required Theophylline 250mg SRT Nuelin sa 250 Xanthines Motivation required Theophylline 300mg SRT Pulmophyllin sr 300 Xanthines Motivation required SANDOZ Theophyllin Theophylline 200mg SRT Xanthines Motivation required Anhydrous SR Page 3 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM SANDOZ Theophyllin Theophylline 300mg SRT Xanthines Motivation required Anhydrous SR Theophylline 200mg SRT Theoplus Xanthines Motivation required Theophylline 300mg SRT Theoplus Xanthines Motivation required Theophylline 400mg SRT Uniphyl 400 Xanthines Motivation required Theophylline 600mg SRT Uniphyl 600 Xanthines Motivation required BIPOLAR MOOD DISORDER ICD10: F31.0, F31.1, F31.2, F31.3, F31.4, F31.5, F31.6, F31.8, F31.9 Amitriptyline 25mg TAB SANDOZ Amitryptyline Trepiline Heterocyclic antidepressant Accepted treatment Carbamazepine 200mg TAB CPL-Carbamazepine Degranol Mood Stabilisers Accepted treatment Carbamazepine 400mg SRT SANDOZ Cabamazepine CR Tegretol CR Mood Stabilisers Accepted treatment Carbamazepine 200mg SRT SANDOZ Carbamazepine CR Tegretol CR Mood Stabilisers Accepted treatment Chlorpromazine 100mg TAB Largactil Antipsychotics Motivation required Chlorpromazine 25mg TAB Largactil Antipsychotics Motivation required Chlorpromazine 50mg TAB Largactil Antipsychotics Motivation required Citalopram 20mg TAB Adco-Talomil Arrow Citalopram Selective serotonin receptor inhibitors Accepted treatment Citalopram 10mg TAB Austell-Citalopram Selective serotonin receptor inhibitors Accepted treatment Citalopram 40mg TAB DRL-Citalopram Ran-Citalopram Selective serotonin receptor inhibitors Accepted treatment Clomipramine 10mg TAB Equinorm Clomidep Heterocyclic antidepressants Accepted treatment Clomipramine 25mg TAB Equinorm Clomidep Heterocyclic antidepressants Accepted treatment Dosulepin 25mg CAP Prothiaden Thaden Heterocyclic antidepressants Accepted treatment Dosulepin 75mg TAB Thaden Selective serotonin receptor