Chronic Medication Core Formulary

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 inhibitors Accepted treatment Fluoxetine 20mg TAB Lorien Rezak Selective serotonin receptor inhibitors Accepted treatment Fluoxetine 20mg CAP Nuzak Lilly-fluoxetine Selective serotonin receptor inhibitors Accepted treatment Fluoxetine 20mg DSP Prohexal 20t Selective serotonin receptor inhibitors Accepted treatment Haloperidol 1.5mg TAB SANDOZ Haloperidol Antipsychotics Motivation required Haloperidol 5mg TAB SANDOZ Haloperidol Serenace Antipsychotics Motivation required Haloperidol 0.5mg CAP Serenace Antipsychotics Motivation required Haloperidol 10mg TAB Serenace Antipsychotics Motivation required Imipramine 25mg TAB Ethipramine Tofranil Heterocyclic antidepressants Accepted treatment Lamotrigine 100mg TAB Aspen Lamotrigine Arrow lamotrigine Mood stabilisers Accepted treatment Lamotrigine 50mg TAB Dyna-Lamotrigine Austell-Lamotrigine Mood stabilisers Accepted treatment Lamotrigine 200mg TAB Mylan-Lamotrigine Lamitor Mood stabilisers Accepted treatment Lamotrigine 25mg TAB SANDOZ Lamotrigine Austell-Lamotrigine Mood stabilisers Accepted treatment

Page 4 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM Lithium 250mg TAB Camcolit Mood stabilisers Accepted treatment Lithium 400mg TAB Camcolit Mood stabilisers Accepted treatment Lithium 50mg CAP Lithium succinate Mood stabilisers Accepted treatment Lithium 450mg TAB Quilonum retard Mood stabilisers Accepted treatment Maprotiline 25mg TAB Ludiomil Heterocyclic antidepressants Motivation required Maprotiline 75mg TAB Ludiomil Heterocyclic antidepressants Motivation required Olanzapine 2.5mg TAB Olexar Redilanz Antipsychotics Motivation required Olanzapine 5mg TAB Olexar Redilanz Antipsychotics Motivation required Olanzapine 10mg TAB Olexar Redilanz Antipsychotics Motivation required Risperidone 0.5mg TAB Aspen Risperidone Risperlet Antipsychotics Accepted treatment Risperidone 2mg TAB Aspen Risperidone Risperdal Quicklet Antipsychotics Accepted treatment Risperidone 3mg TAB Aspen Risperidone Risperidone-Hexal Antipsychotics Accepted treatment Risperidone 1.0mg TAB DRL-Risperidone Auroperdal Antipsychotics Accepted treatment Risperidone 1mg/ml SYR Risperdal Antipsychotics Accepted treatment Risperidone 4mg TAB Risperdal Risponz Antipsychotics Accepted treatment Sulpiride 200mg TAB Bio-Sulpiride Substituted benzamide Accepted treatment Sulpiride 50mg CAP Eglonyl Substituted benzamide Accepted treatment Sulpiride 50mg CAP Espiride Substituted benzamide Accepted treatment Sulpiride 50mg CAP SANDOZ Sulpiride Substituted benzamide Motivation required Trifluoperazine 1mg TAB Stelazine Antipsychotics Motivation required Trifluoperazine 5mg TAB Stelazine Antipsychotics Motivation required Valproic acid 150mg CAP Convulex Mood stabilisers Accepted treatment Valproic acid 300mg CAP Convulex Mood stabilisers Accepted treatment Valproic acid 500mg CAP Convulex Mood stabilisers Accepted treatment Valproic acid 200mg SRT Epilim cr 200 Mood stabilisers Accepted treatment Valproic acid 300mg SRT Epilim cr 300 Mood stabilisers Accepted treatment Valproic acid 500mg SRT Epilim cr 500 Mood stabilisers Accepted treatment Quetiapine 25mg TAB Quetoser 25 Serez 25 Antipsychotics Motivation required Quetiapine 100mg TAB Serez 100 Quetoser100 Antipsychotics Motivation required Quetiapine 200mg TAB Quetoser 200 Serez 200 Antipsychotics Motivation required Quetiapine 300mg TAB Serez 300mg Quetoser 300 Antipsychotics Motivation required Zuclopenthixol 10mg TAB Clopixol Antipsychotics Motivation required Zuclopenthixol 2mg TAB Clopixol Antipsychotics Motivation required

Page 5 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM BRONCHIECTASIS ICD10: Q33.4, J47 Oral antibiotics will be reimbursed in the treatment of Bronchiectasis Aminophylline 100mg TAB Norstan-ted Xanthines Motivation required Aminophylline 200mg TAB Norstan-ted Xanthines Motivation required Aminophylline 225mg SRT Phyllocontin Xanthines Motivation required Beclometasone 100mcg INH Beclate 100 Becotide 100 comp Corticosteroids, inhaled special investigations, LFT Beclometasone 200mcg INH Beclate 200 Corticosteroids, inhaled special investigations, LFT Beclometasone 50mcg INH Beclate 50 Becotide complete Corticosteroids, inhaled special investigations, LFT Budeflam 300 dose gentle- Inflammide 100 mac 300 Budesonide 100mcg INH Corticosteroids, inhaled special investigations, LFT haler hfa dose Budesonide 200mcg CPS Budeflam DP Caps Corticosteroids, inhaled special investigations, LFT Budesonide 100mcg CPS Inflacor 100 Corticosteroids, inhaled special investigations, LFT Budesonide 200mcg CPS Inflacor 200 Budeflam DP Caps Corticosteroids, inhaled special investigations, LFT Budesonide 400mcg CPS Inflacor 400 Corticosteroids, inhaled special investigations, LFT Inflammide 400 Novolizer Budesonide 400mcg INH Corticosteroids, inhaled special investigations, LFT Complete Inflammide 400 Novolizer Budesonide 400mcg INH Corticosteroids, inhaled special investigations, LFT refill 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 Symbicord turboh 120 dose Corticosteroids and beta agonists, long- Budesonide and formoterol 160/4.5mcg INH special investigations, LFT 160mcg;45mc acting Symbicord turboh 120dose Corticosteroids and beta agonists, long- Budesonide and formoterol 80/4.5mcg INH special investigations, LFT 80:4 5mcg acting Symbicord turboh 60 dose Corticosteroids and beta agonists, long- Budesonide and formoterol 160/4.5mcg INH special investigations, LFT 160mcg;45mcg acting Symbicord turboh 60dose Corticosteroids and beta agonists, long- Budesonide and formoterol 320/9mcg INH special investigations, LFT 320:9mcg acting Atrovent 20 HFA MDI Ipratropium bromide 20mcg INH Beta agonists, short-acting Accepted treatment 200dose 10ml Ipratropium bromide 40mcg INH Ipvent-40 300 dose Beta agonists, short-acting 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

Page 6 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM Salbutamol 200mcg CAP Asthavent DP Ventodisks(8 s) Beta agonists, short-acting Accepted treatment Salbutamol 100mcg INH Venteze CFC free Beta agonists, short-acting Accepted treatment Salbutamol 100mcg INH Venteze c omplete Beta agonists, short-acting Accepted treatment 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 Beta agonists, short-acting Motivation required Corticosteroids and beta agonists, long- Salmeterol and fluticasone 25/125mcg INH Foxair special investigations, LFT acting Corticosteroids and beta agonists, long- Salmeterol and fluticasone 25/250mcg INH Foxair special investigations, LFT acting Corticosteroids and beta agonists, long- Salmeterol and fluticasone 25/50mcg INH Foxair special investigations, LFT acting Corticosteroids and beta agonists, long- Salmeterol and fluticasone 50/100mcg ACC Foxair special investigations, LFT acting Corticosteroids and beta agonists, long- Salmeterol and fluticasone 50/250mcg ACC Foxair special investigations, LFT acting Corticosteroids and beta agonists, long- Salmeterol and fluticasone 50/500mcg ACC Foxair special investigations, LFT acting Corticosteroids and beta agonists, long- Salmeterol and fluticasone 25mcg/125mcg INH Sereflo HFA 25/125 Dose 120 special investigations, LFT acting Corticosteroids and beta agonists, long- Salmeterol and fluticasone 25mcg/250mcg INH Sereflo HFA 25/250 Dose 120 special investigations, LFT acting Corticosteroids and beta agonists, long- Salmeterol and fluticasone 25mcg/50mcg INH Sereflo HFA 25/50 120 Dose special investigations, LFT acting Corticosteroids and beta agonists, long- Salmeterol and fluticasone 25mcg/125mcg INH Seretide 25/125 120 dose special investigations, LFT acting Corticosteroids and beta agonists, long- Salmeterol and fluticasone 25mcg/250mcg INH Seretide 25/250 120 dose special investigations, LFT acting Corticosteroids and beta agonists, long- Salmeterol and fluticasone 25mcg/50mcg INH Seretide 25/50 1 20 dose special investigations, LFT acting Corticosteroids and beta agonists, long- Salmeterol and fluticasone 100mcg INH Seretide accuhaler 50/100 special investigations, LFT acting Corticosteroids and beta agonists, long- Salmeterol and fluticasone 250mcg INH Seretide Accuhaler 50/250 special investigations, LFT acting Corticosteroids and beta agonists, long- Salmeterol and fluticasone 500mcg INH Seretide accuhaler 50/500 special investigations, LFT acting Theophylline SYR Alcophyllin Xanthines Motivation required Theophylline 25mg/5ml SYR Nuelin liquid Xanthines Motivation required Theophylline 250mg SRT Euphyllin retard Xanthines Motivation required Theophylline 125mg SRC Microphyllin Xanthines Motivation required Theophylline 250mg SRC Microphyllin Xanthines Motivation required Page 7 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM 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 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 CARDIOMYOPATHY ICD10: I42.0, I42.1 Acetylsalicylic acid 81mg ECT Ecotrin Aspirin Accepted treatment

Page 8 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM Captopril 50mg TAB Captohexal Captomax ACE-inhibitors Accepted treatment Captopril and diuretics 50mg/25mg TAB Captoretic Zapto-co ACE-inhibitors and combinations Accepted treatment Carvedilol 12.5mg TAB Aspen-Carvidelol Carloc 12 5 Alpha/beta blockers Accepted treatment Carvedilol 25mg TAB Aspen-Carvidelol Carloc 25 Alpha/beta blockers Accepted treatment Carvedilol 6.25mg TAB Aspen-Carvidelol Carloc 6 25 Alpha/beta blockers Accepted treatment Digoxin 0.0625mg TAB Lanoxin Cardiac glycosides Accepted treatment Digoxin 0.25mg TAB Lanoxin Cardiac glycosides Accepted treatment Digoxin 0.05mg/ml SYR Lanoxin paed Cardiac glycosides Accepted treatment Digoxin 0.25mg TAB Purgoxin Cardiac glycosides Accepted treatment Diltiazem 60mg TAB Adco-Zildem Calcium channel blockers Motivation required Diltiazem 90mg TAB Adco-Zildem Calcium channel blockers Motivation required Diltiazem 180mg SRC Tilazem 180mg CR Calcium channel blockers Motivation required Diltiazem 240mg SRC Tilazem 240 CR Calcium channel blockers Motivation required Enalapril 10mg TAB Adco-enalapril Alapren 10 ACE-inhibitors Accepted treatment Enalapril 20mg TAB Adco-enalapril Alapren 20 ACE-inhibitors Accepted treatment Enalapril 5mg TAB Alapren 5 Ciplatec 5 ACE-inhibitors Accepted treatment Enalapril 2.5mg TAB Renitec 2 5 ACE-inhibitors Accepted treatment Enalapril and diuretics 20mg/12.5mg TAB Co-renitec Enap co ACE-inhibitors Accepted treatment Felodipine 10mg SRT Felodipine-Hexal Plendil Calcium channel blockers Accepted treatment Felodipine 5mg SRT Felodipine-Hexal Plendil Calcium channel blockers Accepted treatment Furosemide 40mg TAB Austell- Furosemide Beurises Diuretics Accepted treatment Furosemide 20mg TAB Lasix Diuretics Accepted treatment Furosemide 10mg/ml SYR Lasix oral Diuretics Motivation required Hydralazine 10mg TAB Hyperphen Vasodilators Accepted treatment Hydralazine 50mg TAB SANDOZ Hydralazine Hyperphen Vasodilators Accepted treatment Hydrochlorothiazide 12.5mg TAB Ridaq Diuretics Accepted treatment Hydrochlorothiazide 25mg TAB Ridaq Hexazide Diuretics Accepted treatment Hydrochlorothiazide and 50mg/300mg TAB Urirex-k Diuretics Accepted treatment potassium Hydrochlorothiazide and 50mg/5mg TAB Adco-retic Betaretic Diuretics Accepted treatment potassium-sparing agents Hydrochlorothiazide and 25mg/2.5mg TAB Amiloretic hs Diuretics Accepted treatment potassium-sparing agents Hydrochlorothiazide and 50mg/25mg TAB Dyazide Renezide Diuretics Accepted treatment potassium-sparing agents

Page 9 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM Indapamide 2.5mg TAB Cipla-Indapamide Dapamax Diuretics Accepted treatment Isosorbide dinitrate 40mg TAB Isordil tembid Organic nitrates Accepted treatment Isosorbide dinitrate 30mg TAB SANDOZ Isosorbide Isordil Organic nitrates Accepted treatment Isosorbide dinitrate 10mg TAB SANDOZ Isosorbide Dinitrate Isordil Organic nitrates Accepted treatment Isosorbide dinitrate 5mg TAB SANDOZ Isosorbide Dinitrate Isordil sublingual Organic nitrates Accepted treatment Lisinopril 10mg TAB Auro-Lisinopril Austell-Lisinopril ACE-inhibitors Accepted treatment Lisinopril 5mg TAB Auro-Lisinopril Hexal-lisinopril 5 ACE-inhibitors Accepted treatment Lisinopril 2.5mg TAB Austell-lisinopril ACE-inhibitors Accepted treatment Lisinopril 20mg TAB Zestril Zetomax ACE-inhibitors Accepted treatment Lisinopril and diuretics 10mg/12.5mg TAB Auro-Lisinopril Co HEXAL-Lisinopril Co ACE-inhibitors and combinations Accepted treatment Lisinopril and diuretics 20mg/12.5mg TAB Auro-Lisinopril Co HEXAL-Lisinopril Co ACE-inhibitors and combinations Accepted treatment Losartan 100mg TAB Cipla Losartan Cozaar Angiotensin receptor blockers Accepted treatment Losartan 50mg TAB Cipla Losartan Cozaar Angiotensin receptor blockers Accepted treatment Angiotensin receptor blockers and Losartan and diuretics 50mg/12.5mg TAB Zartan Co Losaar plus 50/12.5 Accepted treatment combinations Angiotensin receptor blockers and Losartan and diuretics 100mg/25mg TAB Zartan Co Lohype forte plus Accepted treatment combinations Nifedipine 20mg SRT Adco-Nifedpine Nifedalat SR 20mg Calcium channel blockers Accepted treatment Nifedipine 30mg TAB Adco-Vascard Fedaloc SR Calcium channel blockers Accepted treatment Nifedipine 60mg TAB Adco-Vascard Fedaloc SR Calcium channel blockers Accepted treatment Perindopril 4mg TAB Cipla Perindopril Ciplasyl ACE-inhibitors Accepted treatment Perindopril 8mg TAB Cipla-Perindopril Ciplasyl ACE-inhibitors Accepted treatment Perindopril 10mg TAB Prexum Coversyl ACE-inhibitors Accepted treatment Perindopril and diuretics 2mg/0.625mg TAB Acesyl Co Preterax ACE-inhibitors and combinations Accepted treatment Perindopril and diuretics 4mg/1.25mg TAB Acesyl Co 4/1.25 BiPreterax ACE-inhibitors and combinations Accepted treatment Potassium chloride 600mg TAB Plenish k SANDOZ K-600 Potassium supplements Accepted treatment Propranolol 10mg TAB Prodorol Purbloka Beta blockers Accepted treatment Propranolol 40mg TAB Prodorol Purbloka Beta blockers Accepted treatment Quinapril 10mg TAB Accumax Accupril ACE-inhibitors Accepted treatment Quinapril 20mg TAB Accumax Accupril ACE-inhibitors Accepted treatment Ramipril 10mg CAP Austell-Ramipril ACE-inhibitors Accepted treatment Ramipril 5mg CAP Austell-Ramipril ACE-inhibitors Accepted treatment Ramipril 5mg CAP Apex-Ramipril 5mg ACE-inhibitors Accepted treatment Ramipril 10mg CAP Apex-Ramipril 10mg ACE-inhibitors Accepted treatment

Page 10 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM Ramipril 2.5mg TAB Ramace RamiprilHexal ACE-inhibitors Accepted treatment Ramipril 5mg TAB Ramace RamiprilHexal ACE-inhibitors Accepted treatment Ramipril 2.5mg CAP Ramiwin ACE-inhibitors Accepted treatment Ramipril 5mg CAP RamiWin ACE-inhibitors Accepted treatment Ramipril 10mg CAP Rampil ACE-inhibitors Accepted treatment Ramipril 2.5mg CAP Rampil ACE-inhibitors Accepted treatment Ramipril 5mg CAP Rampil ACE-inhibitors Accepted treatment Ramipril 10mg CAP Ran-Ramipril ACE-inhibitors Accepted treatment Ramipril 10mg CAP Simayla Ramipril ACE-inhibitors Accepted treatment Ramipril 10mg CAP Tritace ACE-inhibitors Accepted treatment Spironolactone 25mg TAB Spiractin SAND OZ Spironolactone Diuretics Accepted treatment Spironolactone 100mg TAB Spiractin Aldactone Diuretics Accepted treatment Telimisartan 40mg TAB Pritor Micardis ACE-Inhibitor Accepted treatment Telimisartan 80mg TAB Pritor Micardis ACE-Inhibitor Accepted treatment Telimisatan and diuretic 40mg/12.5mg TAB Co-Pritor Co-Micardis ACE-Inhibitor and diuretic Accepted treatment Telimisatan and diuretic 80mg/12.5mg TAB Co-Pritor Co-Micardis ACE-Inhibitor and diuretic Accepted treatment Telimisatan and diuretic 80mg/25mg TAB Co-Pritor Co-Micardis ACE-Inhibitor and diuretic Accepted treatment Trandolapril 0.5mg CAP Mavik (was Gopten) ACE-inhibitors Accepted treatment Trandolapril 2mg CAP Mavik (was Gopten) ACE-inhibitors Accepted treatment Valsartan 160mg TAB Migroben Diovan Angiotensin receptor blockers Accepted treatment Valsartan 80mg TAB Migroben Diovan Angiotensin receptor blockers Accepted treatment Angiotensin receptor blockers and Valsartan and amlodipine 10mg/160mg TAB Exforge Accepted treatment combinations Angiotensin receptor blockers and Valsartan and amlodipine 5mg/160mg TAB Exforge Accepted treatment combinations Angiotensin receptor blockers and Valsartan and diuretics 320/12.5mg TAB Co-Diovan Accepted treatment combinations Angiotensin receptor blockers and Valsartan and diuretics 320mg/25mg TAB Co-Diovan Accepted treatment combinations Angiotensin receptor blockers and Valsartan and diuretics 160mg/12.5mg TAB Co-Migroben Co-diovan Accepted treatment combinations Angiotensin receptor blockers and Valsartan and diuretics 160mg/25mg TAB Co-Migroben Co-Diovan Plus Accepted treatment combinations Angiotensin receptor blockers and Valsartan and diuretics 80mg/12.5mg TAB Co-Migroben Co-diovan Accepted treatment combinations Verapamil 240mg SRT Calcicard sr 240 Verahexal 240 sr Calcium channel blockers Accepted treatment Verapamil 40mg TAB Vasomil Isoptin Calcium channel blockers Accepted treatment Page 11 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM Verapamil 80mg TAB Vasomil Isoptin Calcium channel blockers Accepted treatment Warfarin 1mg TAB Cipla Warfarin Anticoagulants Accepted treatment Warfarin 3mg TAB Cipla-Warfarin Anticoagulants Accepted treatment Warfarin 5mg TAB Warfarin Cipla Warfarin Anticoagulants Accepted treatment CHRONIC OBSTRUCTIVE PULMONARY DISEASE ICD10: J43.0, J43.1, J43.2, J43.8, J43.9, J44.0, J44.1, J44.8, J44.9 Aminophylline 100mg TAB Norstan-ted Xanthines Motivation required Aminophylline 200mg TAB Norstan-ted Xanthines Motivation required Aminophylline 225mg SRT Phyllocontin Xanthines Motivation required Beclometasone 200mcg INH Beclate 200 Corticosteroids, inhaled special investigations Beclometasone 100mcg INH Becotide 100 comp Beclate 100 Corticosteroids, inhaled special investigations Beclometasone 50mcg INH Becotide complete Beclate 50 Corticosteroids, inhaled special investigations Budeflam 300 dose gentle- Inflammide 100 mac 300 Budesonide 100mcg INH Corticosteroids, inhaled special investigations haler hfa dose Budesonide 200mcg CPS Budeflam DP Caps Inflacor 200 Corticosteroids, inhaled special investigations, LFT Budesonide 100mcg CPS Inflacor 100 Corticosteroids, inhaled special investigations Budesonide 400mcg CPS Inflacor 400 Corticosteroids, inhaled special investigations Budeflam 300 dose Budesonide 200mcg INH Inflammide 200 Novolizer Corticosteroids, inhaled special investigations, LFT gentle-haler hfa Inflammide 400 Novolizer Budesonide 400mcg INH Corticosteroids, inhaled special investigations Complete Inflammide 400 Novolizer Budesonide 400mcg INH Corticosteroids, inhaled special investigations refill 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 Atrovent 20 HFA MDI Ipratropium bromide 20mcg INH Anticholinergic agent Accepted treatment 200dose 10ml Ipratropium bromide 40mcg INH Ipvent-40 300 dose Anticholinergic agent 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 Ventodisks(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 12 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 Beta agonists, short-acting Motivation required Salbutamol and other drugs for INH Combivent Beta agonists, short-acting Accepted treatment obstructive airway diseases Corticosteroids and beta agonists, long- Salmeterol and fluticasone 25/125mcg INH Foxair special investigations, LFT acting Corticosteroids and beta agonists, long- Salmeterol and fluticasone 25/250mcg INH Foxair special investigations, LFT acting Corticosteroids and beta agonists, long- Salmeterol and fluticasone 25/50mcg INH Foxair special investigations, LFT acting Corticosteroids and beta agonists, long- Salmeterol and fluticasone 50/100mcg ACC Foxair special investigations, LFT acting Corticosteroids and beta agonists, long- Salmeterol and fluticasone 50/250mcg ACC Foxair special investigations, LFT acting Corticosteroids and beta agonists, long- Salmeterol and fluticasone 50/500mcg ACC Foxair special investigations, LFT acting Corticosteroids and beta agonists, long- Salmeterol and fluticasone 25mcg/125mcg INH Sereflo HFA 25/125 Dose 120 special investigations, LFT acting Corticosteroids and beta agonists, long- Salmeterol and fluticasone 25mcg/250mcg INH Sereflo HFA 25/250 Dose 120 special investigations, LFT acting Corticosteroids and beta agonists, long- Salmeterol and fluticasone 25mcg/50mcg INH Sereflo HFA 25/50 120 Dose special investigations, LFT acting Corticosteroids and beta agonists, long- Salmeterol and fluticasone 25mcg/125mcg INH Seretide 25/125 120 dose special investigations, LFT acting Corticosteroids and beta agonists, long- Salmeterol and fluticasone 25mcg/250mcg INH Seretide 25/250 120 dose special investigations, LFT acting Corticosteroids and beta agonists, long- Salmeterol and fluticasone 25mcg/50mcg INH Seretide 25/50 120 dose special investigations, LFT acting Corticosteroids and beta agonists, long- Salmeterol and fluticasone 100mcg INH Seretide accuhaler 50/100 special investigations, LFT acting Corticosteroids and beta agonists, long- Salmeterol and fluticasone 250mcg INH Seretide Accuhaler 50/250 special investigations, LFT acting Corticosteroids and beta agonists, long- Salmeterol and fluticasone 500mcg INH Seretide accuhaler 50/500 special investigations, LFT acting Theophylline SYR Alcophyllin Xanthines Motivation required Theophylline 25mg/5ml SYR Nuelin liquid Xanthines Motivation required 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

Page 13 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM Theophylline 300mg SRT Pulmophyllin sr 300 Xanthines Motivation required SANDOZ Theophyllin Theophylline 200mg SRT Xanthines Motivation required Anhydrous SR 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 Forvent complete with Tiotropium bromide 18µg KIT Anticolinergic agent Motivation required handihaler Tiotropium bromide 18µg CPS Forvent Refill Anticolinergic agent Motivation required Tiotropium bromide 18ug CPS Spiriva Anticolinergic agent Motivation required Spiriva inh caps 30 with Tiotropium bromide 18ug KIT Anticolinergic agent Motivation required handihaler Spiriva respimat inhaler Tiotropium bromide 18ug INH Anticolinergic agent Motivation required 60dose CHRONIC RENAL FAILURE ICD10: N03.0, N03.1, N03.2, N03.4, N03.5, N03.6, N03.7, N03.8, N03.9, N11.0, N11.1, N11.8, N11.9, N18.0, N18.8, N18.9, I12.0, I13.2, I13.2, O10.2 Alfacalcidol 0.25mcg CAP One alpha Alfacalcidol special investigations, CCL/GFR Alfacalcidol 1mcg CAP One alpha Alfacalcidol special investigations, CCL/GFR Amlodipine 5mg TAB Amtas Auro-Amlodipine Calcium channel blockers Accepted treatment CPL Alliance Amlodipine Amlodipine 10mg TAB Gulf Amlodipine Calcium channel blockers Accepted treatment besylate Amlodipine besylate 5mg TAB Calbloc Ciplavasc Calcium channel blockers Accepted treatment Pharma Dynamics Amlodipine Amlodipine Besylate 10mg TAB Norvasc Calcium channel blockers Accepted treatment Besylate Amlodipine maleate 10mg TAB Amlate Calcium channel blockers Accepted treatment Amlodipine maleate 5mg TAB Amlate Calcium channel blockers Accepted treatment Atenolol 25mg TAB Tenopress Tenormin 25 Beta blockers Accepted treatment Atenolol 100mg TAB Sandoz Atenolol Hexa-blok Beta blockers Accepted treatment Atenolol 50mg TAB Tenopress Tenormin 50 Beta blockers Accepted treatment Atenolol and other diuretics 100mg/25mg TAB SANDOZ Co-tenidone Tenchlor Beta blockers and combinations Accepted treatment Sandoz Co-tenidone Atenolol and other diuretics 50mg/12.5mg TAB Tenchlor hs Beta blockers and combinations Accepted treatment 50mg/12.5mg Atenolol and thiazides 100mg/25mg TAB Adco-loten Beta blockers and combinations Accepted treatment Bisoprolol 2.5mg TAB Cardicor Beta blockers Accepted treatment

Page 14 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM Bisoprolol 10mg TAB Bilocor Bisohexal 10 Beta blockers Accepted treatment Bisoprolol 5mg TAB Bisoprolol Hexal Cardicor Beta blockers Accepted treatment Bumetanide 0.5mg TAB Burinex Duiretics Motivation required Calcium carbonate TAB Titralac Phosphate binder Accepted treatment Calcitriol 0.25mcg CAP Rocaltrol Calcitriol special investigations, CCL/GFR Captopril 25mg TAB Capoten Captohexal ACE-inhibitors Accepted treatment Captopril 12.5mg TAB Capoten hs Captohexal ACE-inhibitors Accepted treatment Captopril 50mg TAB Mylan-captopril 50 SANDOZ Captopril ACE-inhibitors Accepted treatment Captopril and diuretics 50mg/25mg TAB Captoretic Zapto-co ACE-inhibitors and combinations Accepted treatment Cinacalcet 30mg TAB Sensipar Hormone inhibitors Motivation required Cinacalcet 60mg TAB Sensipar Hormone inhibitors Motivation required Darbepoetin alfa 10mcg INJ Aranesp Darbepoetin alfa special investigations, Full blood count Darbepoetin alfa 150mcg INJ Aranesp Darbepoetin alfa special investigations, Full blood count Darbepoetin alfa 20mcg INJ Aranesp Darbepoetin alfa special investigations, Full blood count Darbepoetin alfa 300mcg INJ Aranesp Darbepoetin alfa special investigations, Full blood count Darbepoetin alfa 30mcg INJ Aranesp Darbepoetin alfa special investigations, Full blood count Darbepoetin alfa 60mcg INJ Aranesp Darbepoetin alfa special investigations, Full blood count Dextriferron 50mg/ml INJ CosmoFer Iron Supplements special investigations, Full blood count Dextriferron 50mg/2ml INJ CosmoFer Iron Supplements special investigations, Full blood count Diltiazem 60mg TAB Zildem 60 Calcium channel blockers Accepted treatment Diltiazem 90mg TAB Zildem 90 Calcium channel blockers Accepted treatment Diltiazem 180mg SRC Tilazem 180 cr Zilde m 180 sr Calcium channel blockers Accepted treatment Diltiazem 240mg SRC Tilazem 240 cr Zildem 240 sr Calcium channel blockers Accepted treatment Enalapril 10mg TAB Ciplatec 10 Enap 10 ACE-inhibitors Accepted treatment Enalapril 20mg TAB Ciplatec 20 Enap 20 ACE-inhibitors Accepted treatment Enalapril 5mg TAB Enap 5 Envas ACE-inhibitors Accepted treatment Enalapril 2.5mg TAB Renitec 2 5 ACE-inhibitors Accepted treatment Enalapril and diuretics 20mg/12.5mg TAB Co-renitec Enap co ACE-inhibitors and combinations Accepted treatment Ergocalciferol 1.25mg TAB Calciferol Ergocalciferol special investigations, CCL/GFR Erythropoietin 6000iu INJ Eprex Recormon Pre-Filled Erythropoietin special investigations, CCL/GFR Erythropoietin 40000iu INJ Eprex 1ml Prefilled Erythropoietin special investigations, CCL/GFR Erythropoietin 10000u/ml INJ Eprex prefill Recormon Pre-Filled Erythropoietin special investigations, CCL/GFR Erythropoietin 2000u/05ml INJ Eprex prefill Erythropoietin special investigations, CCL/GFR

Page 15 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM Erythropoietin 4000u/04ml INJ Eprex prefill Erythropoietin special investigations, CCL/GFR Erythropoietin 2000iu INJ Recormon Pre-Filled Repotin 1ml Erythropoietin special investigations, CCL/GFR Erythropoietin 30000iu INJ Recormon Pre-filled Erythropoietin special investigations, CCL/GFR Erythropoietin 4000iu INJ Recormon Pre-Filled Repotin 1ml Erythropoietin special investigations, CCL/GFR Erythropoietin 500iu INJ Recormon Pre-Filled Erythropoietin special investigations, CCL/GFR Erythropoietin 6000iu INJ Recormon Pre-Filled Erythropoietin special investigations, CCL/GFR Felodipine 10mg SRT Felodipine-Hexal Plendil Calcium channel blockers Accepted treatment Felodipine 5mg SRT Felodipine-Hexal Plendil Calcium channel blockers Accepted treatment Ferrous fumarate TAB Pregamal Iron Supplements special investigations, Full blood count Ferrous sulfate TAB Ferrous sulph co Iron Supplements special investigations, Full blood count Ferrous sulfate 100mg TAB Ferrous sulphate Iron Supplements special investigations, Full blood count Ferrous sulfate 30mg TAB Ferrous sulphate Iron Supplements special investigations, Full blood count Ferrous Lactate 25mg DRP Ferro L drops Iron Supplements special investigations, Full blood count Folic acid 0.5mg TAB Folic acid Folic acid Accepted treatment Folic acid CAP Folic acid forte Folic acid Accepted treatment Folic acid 5mg TAB Be-tabs folic acid Folic acid Accepted treatment Folic acid 5mg CAP Folic acid Folic acid Accepted treatment Furosemide 40mg TAB Diuresix Lasix Diuretics Accepted treatment Furosemide 20mg TAB Lasix Diuretics Accepted treatment Furosemide 10mg/ml SYR Lasix oral Diuretics Motivation required Hydrochlorothiazide 12.5mg TAB Ridaq Diuretics Accepted treatment Hydrochlorothiazide 25mg TAB Ridaq Hexazide Diuretics Accepted treatment Hydrochlorothiazide and 50mg/300mg TAB Urirex-k Diuretics Accepted treatment potassium Hydrochlorothiazide and 50mg/5mg TAB Adco-retic Betaretic Diuretics Accepted treatment potassium-sparing agents Hydrochlorothiazide and 25mg/2.5mg TAB Amiloretic hs Diuretics Accepted treatment potassium-sparing agents Hydrochlorothiazide and 50mg/25mg TAB Dyazide Renezide Diuretics Accepted treatment potassium-sparing agents Indapamide 2.5mg TAB Daptril Hydro-less Diuretics Accepted treatment Iron in other combinations 20mg/ml INJ Venofer Iron in other combinations special investigations Iron multivitamins and folic acid 100mg TAB Foliferr Iron multivitamins and folic acid special investigations, Full blood count Lisinopril 5mg TAB Auro-Lisinopril Hexal-lisinopril 5 ACE-inhibitors Accepted treatment Lisinopril 2.5mg TAB Austell-lisinopril ACE-inhibitors Accepted treatment

Page 16 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM Lisinopril 10mg TAB Hexal-lisinopril 10 Simayla Lisinopril ACE-inhibitors Accepted treatment Lisinopril 20mg TAB Sinopren 20 Zemax ACE-inhibitors Accepted treatment Lisinopril and diuretics 10mg/12.5mg TAB Lisinozide Lisoretic ACE-inhibitors and combinations Accepted treatment Lisinopril and diuretics 20mg/12.5mg TAB Lisinozide Lisoretic ACE-inhibitors and combinations Accepted treatment Losartan 50mg TAB Los-arb Losartan-Winthrop Angiotensin receptor blockers Accepted treatment Losartan 100mg TAB Spec Losartan 100 Zartan Angiotensin receptor blockers Accepted treatment Angiotensin receptor blockers and Losartan and diuretics 100mg/25mg TAB Netrasol Co Losaar plus Accepted treatment combinations Angiotensin receptor blockers and Losartan and diuretics 50mg/12.5mg TAB Cozaar comp Lozaan Co Accepted treatment combinations Erythropoietin 0.05mg/03ml INJ Mircera Erythropoeitin special investigations, CCL/GFR Erythropoietin 0.075mg/0.3ml INJ Mircera Erythropoeitin special investigations, CCL/GFR Erythropoietin 0.15mg/0.3ml INJ Mircera Erythropoeitin special investigations, CCL/GFR Erythropoietin 0.25mg/0.3ml INJ Mircera Erythropoeitin special investigations, CCL/GFR Erythropoietin 0.2mg/0.3ml INJ Mircera Erythropoeitin special investigations, CCL/GFR Nifedipine 20mg SRT Adalat Retard Cipalat Reta rd Calcium channel blockers Accepted treatment Nifedipine 30mg TAB Adalat xl Calcium channel blockers Accepted treatment Nifedipine 60mg TAB Adalat xl Calcium channel blockers Accepted treatment Nifedipine 30mg SRT Adco-Vascard SR Fedaloc Calcium channel blockers Accepted treatment Nifedipine 60mg SRT Fedaloc Calcium channel blockers Accepted treatment Nifedipine 60mg SRT Macorel 60 SR Calcium channel blockers Accepted treatment Nifedipine 60mg SRT Spec Nifedipine SR Calcium channel blockers Accepted treatment Perindopril 4mg TAB Coversyl Prexum ACE-inhibitors Accepted treatment Perindopril 10mg TAB Prexum Coversyl ACE-inhibitors Accepted treatment Perindopril 8mg TAB Spec-Perindopril Vectoryl ACE-inhibitors Accepted treatment Perindopril and diuretics 2mg/0.625mg TAB Acesyl Co Preterax ACE-inhibitors and combinations Accepted treatment Perindopril and diuretics 4mg/1.25mg TAB Coversyl Plus Pearinda Plus ACE-inhibitors and combinations Accepted treatment Potassium chloride 600mg TAB Slow-k Plenish k Potassium supplements Accepted treatment Propranolol 10mg TAB Prodorol Purbloka Beta blockers Accepted treatment Propranolol 40mg TAB Prodorol Purbloka Beta blockers Accepted treatment Quinapril 10mg TAB Quinagen Quinaspen ACE-inhibitors Accepted treatment Quinapril 20mg TAB Quinagen Quinaspen ACE-inhibitors Accepted treatment Ramipril 1.25mg CAP Austell-Ramipril RamiprilHexal ACE-inhibitors Accepted treatment Ramipril 10mg CAP Rampil Apex-Ramipril 10mg ACE-inhibitors Accepted treatment

Page 17 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM Ramipril 2.5mg CAP Retace Ramiwin ACE-inhibitors Accepted treatment Ramipril 5mg CAP RamiprilHexal Ramace ACE-inhibitors Accepted treatment Spironolactone 100mg TAB Spiractin Aldactone Diuretics Accepted treatment Telimisartan 40mg TAB Pritor Micardis ACE-Inhibitor Accepted treatment Telimisartan 80mg TAB Pritor Micardis ACE-Inhibitor Accepted treatment Telimisatan and diuretic 40mg/12.5mg TAB Co-Pritor Co-Micardis ACE-Inhibitor and diuretic Accepted treatment Telimisatan and diuretic 80mg/12.5mg TAB Co-Pritor Co-Micardis ACE-Inhibitor and diuretic Accepted treatment Telimisatan and diuretic 80mg/25mg TAB Co-Pritor Co-Micardis ACE-Inhibitor and diuretic Accepted treatment Trandolapril 0.5mg CAP Mavik (was Gopten) ACE-inhibitors and combinations Accepted treatment Trandolapril 2mg CAP Mavik (was Gopten) ACE-inhibitors and combinations Accepted treatment Valsartan 160mg TAB Zomevek Tareg Angiotensin receptor blockers Accepted treatment Valsartan 80mg TAB Zomevek Tareg Angiotensin receptor blockers Accepted treatment Angiotensin receptor blockers and Valsartan and amlodipine 10mg/160mg TAB Exforge Accepted treatment combinations Angiotensin receptor blockers and Valsartan and amlodipine 5mg/160mg TAB Exforge Accepted treatment combinations Angiotensin receptor blockers and Valsartan and diuretics 320/12.5mg TAB Co-Diovan Accepted treatment combinations Angiotensin receptor blockers and Valsartan and diuretics 320mg/25mg TAB Co-Diovan Accepted treatment combinations Angiotensin receptor blockers and Valsartan and diuretics 160mg/25mg TAB Co-Zomevek Co-Tareg Plus Accepted treatment combinations Angiotensin receptor blockers and Valsartan and diuretics 80mg/12.5mg TAB Co-Zomevek Co-Tareg Accepted treatment combinations Angiotensin receptor blockers and Valsartan and diuretics 160mg/12.5mg TAB Co-Zomevek Co-Tareg Accepted treatment combinations Verapamil 240mg SRT Calcicard sr 240 Verahex al 240 sr Calcium channel blockers Accepted treatment Verapamil 40mg TAB Vasomil Isoptin Calcium channel blockers Accepted treatment Verapamil 80mg TAB Vasomil Isoptin Calcium channel blockers Accepted treatment CORONARY ARTERY DISEASE ICD10: I20.0, I20.1, I20.8, I20.9, I25.0, I25.1, I25.2, I25.4, I25.5, I25.6, I25.8, I25.9 Acetylsalicylic acid 81mg ECT Ecotrin Aspirin Accepted treatment

Disprin CV 100 disp TAB Acetylsalicylic acid 100mg TAB Bayer aspirin cardio Aspirin Accepted treatment 100mg Acetylsalicylic acid 300mg TAB Be-tabs aspirin (white) Disprin Aspirin Accepted treatment Genpharma Children Acetylsalicylic acid 60mg TAB Aspirin Accepted treatment Aspirin(prev.Asp.jnr) Acetylsalicylic acid 125mg TAB Lo-aspirin Aspirin Accepted treatment Page 18 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM Amlodipine 10mg TAB Amlodac Keysal Calcium channel blockers Accepted treatment Amlodipine 5mg TAB Klodip Stamlo Calcium channel blockers Accepted treatment Amlodipine besylate 5mg TAB Austell-Amlodipine Lomanor Calcium channel blockers Accepted treatment Pharma Dynamics Amlodipine besylate 10mg TAB Calbloc Calcium channel blockers Accepted treatment Amlodipine Besylate Amlodipine maleate 10mg TAB Amlate Calcium channel blockers Accepted treatment Amlodipine maleate 5mg TAB Amlate Calcium channel blockers Accepted treatment Atenolol 50mg TAB Adco-atenolol B-Block Beta blockers Accepted treatment Atenolol 100mg TAB Gulf Atenolol 100 Sandoz Atenolol Beta blockers Accepted treatment Atenolol 25mg TAB Tenopress Tenormin 25 Beta blockers Accepted treatment Atenolol and other diuretics 100mg/25mg TAB Tenchlor Tenoretic Beta blocker and diuretics Accepted treatment Atenolol and other diuretics 50mg/12.5mg TAB Tenchlor hs Tenoret 50 Beta blocker and diuretics Accepted treatment Bisoprolol 2.5mg TAB Cardicor Beta blockers Accepted treatment Bisoprolol 5mg TAB Cardicor Concor Beta blockers Accepted treatment Bisoprolol 10mg TAB Concor Bilocor Beta blockers Accepted treatment Carvedilol 12.5mg TAB Carvedilol-Hexal Carvetrend Alpha/beta blockers Accepted treatment Carvedilol 25mg TAB Carvedilol-Hexal Carvetrend Alpha/beta blockers Accepted treatment Carvedilol 6.25mg TAB Carvedilol-Hexal Carve trend Alpha/beta blockers Accepted treatment Diltiazem 60mg TAB Zildem 60 Calcium channel blockers Accepted treatment Diltiazem 90mg TAB Zildem 90 Calcium channel blockers Accepted treatment Diltiazem 180mg SRC Tilazem 180 cr Zildem 180 sr Calcium channel blockers Accepted treatment Diltiazem 240mg SRC Tilazem 240 cr Zildem 240 sr Calcium channel blockers Accepted treatment Dipyridimole 200mg SRC Persantin 200 Regards Antithrombotic agent Motivation required Dipyridimole 100mg TAB Plato Antithrombotic agent Motivation required Dipyridimole & Acetylsalicylic 200mg/25 CAP Asasantin Antithrombotic agent Motivation required acid Felodipine 10mg SRT Felodipine-Hexal Plendil Calcium channel blockers Accepted treatment Felodipine 5mg SRT Felodipine-Hexal Plendil Calcium channel blockers Accepted treatment Glyceryl trinitrate 0.5mg TAB Angised Organic nitrates Accepted treatment Isosorbide dinitrate 40mg TAB Isordil tembid Organic nitrates Accepted treatment Isosorbide dinitrate 30mg TAB SANDOZ Isosorbide Isordil Organic nitrates Accepted treatment Isosorbide dinitrate 10mg TAB SANDOZ Isosorbide Dinitrate Isordil Organic nitrates Accepted treatment Isosorbide dinitrate 5mg TAB SANDOZ Isosorbide Dinitrate Isordil sublingual Organic nitrates Accepted treatment Isosorbide mononitrate 20mg TAB Elantan Ismo 20 Organic nitrates Accepted treatment

Page 19 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM Isosorbide mononitrate 50mg SRC Elantan la Organic nitrates Accepted treatment Isosorbide-5-mononitrate 60mg SRT Imdur Monicor SR Organic nitrates Accepted treatment Nifedipine 30mg TAB Adalat xl Calcium channel blockers Accepted treatment Nifedipine 60mg TAB Adalat xl Calcium channel blockers Accepted treatment Nifedipine 60mg SRT Fedaloc Calcium channel blockers Accepted treatment Nifedipine 60mg SRT Macorel 60 SR Calcium channel blockers Accepted treatment Nifedipine 20mg SRT Nifedalat SR Cipalat Retard Calcium channel blockers Accepted treatment Nifedipine 30mg SRT Spec Nifedipine SR Macorel 30 SR Calcium channel blockers Accepted treatment Nifedipine 60mg SRT Spec Nifedipine SR Calcium channel blockers Accepted treatment Propranolol 10mg TAB Prodorol Purbloka Beta blockers Accepted treatment Propranolol 40mg TAB Prodorol Purbloka Beta blockers Accepted treatment Verapamil 240mg SRT Calcicard sr 240 Calcium channel blockers Accepted treatment Verapamil 240mg SRT Isoptin sr Calcium channel blockers Accepted treatment Verapamil 240mg SRT Ravamil sr Calcium channel blockers Accepted treatment Verapamil 40mg TAB Vasomil Isoptin Calcium channel blockers Accepted treatment Verapamil 80mg TAB Vasomil Calcium channel blockers Accepted treatment Verapamil 240mg SRT Verahexal 240 sr Calcium channel blockers Accepted treatment Warfarin 1mg TAB Cipla Warfarin Anticoagulants Accepted treatment Warfarin 3mg TAB Cipla-Warfarin Anticoagulants Accepted treatment Warfarin 5mg TAB Cipla Warfarin Aspen Warfarin Anticoagulants Accepted treatment CROHN'S DISEASE ICD10: K50.0, K50.1, K50.8, K50.9 Azathioprine 50mg TAB Azapress Azathioprine Immunosuppressants Accepted treatment INTESTINAL ANTIINFLAMMATORY Budesonide 0.02mg/ml ENE Entocord Motivation required AGENTS Folic acid 5mg TAB Be-tabs folic acid Folic acid Accepted treatment Folic acid 5mg CAP Folic acid Folic acid Accepted treatment Hydrocortisone 10mg TAB Covocort Corticoseriod, oral Accepted treatment Loperamide 10mg TAB Prodium Imodium Antipropulsives Accepted treatment Mesalazine 800mg TAB Asacol 5-ASA agents Motivation required Mesalazine 2g/50ml ENE Asacol 5-ASA agents Motivation required Mesalazine 400mg TAB Asacol 5-ASA agents Motivation required Mesalazine 500mg SUP Asacol 5-ASA agents Motivation required Mesalazine 1000mg SUP Pentasa 5-ASA agents Motivation required

Page 20 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM Mesalazine 500mg TAB Pentasa 5-ASA agents Motivation required Methotrexate 2.5mg TAB Methotrexate Emthexate Immunosuppressants Accepted treatment Metronidazole 200mg TAB Bemetrazole Acuzole Antibacterial Accepted treatment Metronidazole 400mg TAB Adco-Metronidazole Metazol Antibacterial Accepted treatment Olsalazine 250mg CAP Dipentum 5-ASA agents Motivation required Prednisolone 5mg TAB Prelone Capsoid Corticosteroids , oral Accepted treatment Prednisone 5mg TAB Be-tabs prednisone Panafcort Corticosteroids, oral Accepted treatment Sulfasalazine 500mg TAB Salazopyrin 5-ASA agents Accepted treatment Sulfasalazine 500mg ECT Salazopyrin e n 5-ASA agents Accepted treatment DIABETES INSIPIDUS ICD10: E23.2 Carbamazepine 200mg TAB Degranol SANDOZ Carba mazepine Anticonvulsants Accepted treatment Carbamazepine 400mg SRT SANDOZ Carbamazepine CR Tegretol CR Anticonvulsants Accepted treatment Carbamazepine 200mg SRT SAND OZ Carbamazepine CR Tegretol CR Anticonvulsants Accepted treatment Desmopressin 0.1mg TAB Ddavp Vasopressin analogues Motivation required Desmopressin 0.2mg TAB Ddavp Vasopressin analogues Motivation required Desmopressin 0.1mg/ml NOD Ddavp 2 5ml Vasopressin analogues Motivation required Desmopressin 0.1mg/ml NAS Ddavp na sal spray 5ml Vasopressin analogues Motivation required DYSRHYTHMIAS ICD10: I47.2, I48 Acetylsalicylic acid 81mg ECT Ecotrin Aspirin Accepted treatment

Page 21 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM Bisoprolol 2.5mg TAB Cardicor Beta blockers Accepted treatment Digoxin 0.0625mg TAB Lanoxin Cardiac glycosides Accepted treatment Digoxin 0.25mg TAB Lanoxin Cardiac glycosides Accepted treatment Digoxin 0.05mg/ml SYR Lanoxin paed Cardiac glycosides Motivation required Digoxin 0.25mg TAB Purgoxin Cardiac glycosides Accepted treatment Diltiazem 180mg SRC Tilazem 180 cr Zildem 180 sr Calcium channel blockers Accepted treatment Diltiazem 240mg SRC Tilazem 240 cr Zildem 240 sr Calcium channel blockers Accepted treatment Flecainide 100mg TAB Tambocor Antiarrhythmics Motivation required Potassium chloride 600mg TAB Plenish k SANDOZ K-600 Potassium supplements Accepted treatment Propranolol 40mg TAB Prodorol Purbloka Beta blockers Accepted treatment Quinidine 200mg TAB Quinidine sulph Antiarrhythmics Motivation required Sotalol 160mg TAB Sotahexal Beta blockers Motivation required Sotalol 80mg TAB Sotahexal Beta blockers Motivation required Verapamil 240mg SRT Calcicard sr 240 Calcium channel blockers Accepted treatment Verapamil 240mg SRT Isoptin sr Calcium channel blockers Accepted treatment Verapamil 240mg SRT Ravamil sr Calcium channel blockers Accepted treatment Verapamil 40mg TAB Vasomil Isoptin Calcium channel blockers Accepted treatment Verapamil 80mg TAB Vasomil Calcium channel blockers Accepted treatment Verapamil 240mg SRT Verahexal 240 sr Calcium channel blockers Accepted treatment Warfarin 1mg TAB Cipla Warfarin Anticoagulants Accepted treatment Warfarin 3mg TAB Cipla-Warfarin Anticoagulants Accepted treatment Warfarin 5mg TAB Cipla Warfarin Aspen Warfarin Anticoagulants Accepted treatment EPILEPSY ICD10: G40.0, G40.1, G40.2, G40.3, G40.4, G40.5, G40.6, G40.7, G40.8, G40.9, G41.0, G41.2, G41.8, G41.9 Carbamazepine 100mg/5ml SUS Tegretol s Anticonvulsants Accepted treatment Carbamazepine 200mg TAB Degranol SANDOZ Carbamazepine Anticonvulsants Accepted treatment Carbamazepine 400mg SRT SANDOZ Cabamazepine CR Tegretol CR Anticonvulsants Accepted treatment Carbamazepine 200mg SRT SANDOZ Carbamazepine CR Tegretol CR Anticonvulsants Accepted treatment Clonazepam 0.5mg TAB Rivotril Benzodiazepine derivatives Motivation required Clonazepam 2.5mg DRP Rivotril Benzodiazepine derivatives Motivation required Clonazepam 2mg TAB Rivotril Benzodiazepine derivatives Motivation required Ethosuximide 250mg/5ml SYR Zarontin Ethosuximide Accepted treatment Folic acid 0.5mg TAB Folic acid Folic acid Accepted treatment

Page 22 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM Folic acid CAP Folic acid forte Folic acid Accepted treatment Folic acid 5mg TAB Be-tabs folic acid Folic acid Accepted treatment Folic acid 5mg CAP Folic acid Folic acid Accepted treatment Gabapentin 100mg CAP Epleptin Ran-Gabapentin Anticonvulsants Motivation required Gabapentin 300mg CAP Epleptin Anticonvulsants Motivation required Gabapentin 600mg TAB Neurontin Anticonvulsants Motivation required Gabapentin 800mg TAB Neurontin Anticonvulsants Motivation required Gabapentin 400mg CAP Ran-Gabapentin Anticonvulsants Motivation required Lamotrigine 2mg DSP Lamictin P 2 Anticonvulsants Accepted treatment Lamotrigine 5mg DSP Lamictin p5 Anticonvulsants Accepted treatment Lamotrigine 100mg TAB Aspen Lamotrigine Epitec Anticonvulsants Accepted treatment Lamotrigine 200mg TAB Dyna-Lamotrigine Lamidus Anticonvulsants Accepted treatment Lamotrigine 25mg TAB Epitec Lamitor Anticonvulsants Accepted treatment Lamotrigine 50mg TAB Epitec SANDOZ Lamotrigine Anticonvulsants Accepted treatment Phenobarbital SYR Adco-phenobarb vital Anticonvulsants Accepted treatment Phenobarbital 30mg TAB Lethyl Sedabarb Anticonvulsants Accepted treatment Phenytoin 100mg CAP Epanutin Anticonvulsants Accepted treatment Phenytoin 125mg/5ml SUS Epanutin Anticonvulsants Motivation required Phenytoin 100mg TAB Phenytoin sod Anticonvulsants Accepted treatment Phenytoin 100mg CAP Epanutin Anticonvulsants Accepted treatment Topiramate 15mg CAP Topamax sc sprinkle Anticonvulsants Motivation required Topiramate 200mg TAB Adco-topiramate Piramax Anticonvulsants Motivation required Topiramate 25mg TAB Adco-topiramate Epitoz Anticonvulsants Motivation required Topiramate 50mg TAB Epitoz Topalex Anticonvulsants Motivation required Topiramate 25mg CAP Topamax sc sprinkle Anticonvulsants Motivation required Topiramate 50mg CAP Topamax sc sprinkle Anticonvulsants Motivation required Topiramate 100mg TAB Toplep Topalex Anticonvulsants Motivation required Valproic acid 50mg/ml SYR Convulex Anticonvulsants Accepted treatment Valproic acid 100mg TAB Epilim 100 crushable Anticonvulsants Accepted treatment Valproic acid 200mg/5ml SYR Epilim sugar free Anticonvulsants Accepted treatment Valproic acid 150mg CAP Convulex Anticonvulsants Accepted treatment Valproic acid 300mg CAP Convulex Anticonvulsants Accepted treatment Valproic acid 500mg CAP Convulex Anticonvulsants Accepted treatment

Page 23 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM Valproic acid 200mg SRT Epilim cr 200 Anticonvulsants Accepted treatment Valproic acid 300mg SRT Epilim cr 300 Anticonvulsants Accepted treatment Valproic acid 500mg SRT Epilim cr 500 Anticonvulsants Accepted treatment GLAUCOMA ICD10: H40.0, H40.1, H40.2, H40.3, H40.5, H40.6, H40.8, H40.8, H40.9, Q15.0 Acetazolamide 250mg TAB Azomid Diamox Carbonic anhydrase inhbitor Accepted treatment Betaxolol 5mg/ml OPD Betoptic 5ml Beta blockers Accepted treatment Betaxolol 0.25% OPD Betoptic s 5ml Beta blockers Accepted treatment Bimatoprost 0.3mg/3ml OPD Lumigan 3ml Prostaglandin analogues Accepted treatment Brimonidine 1.5mg/1ml OPD Alphagan 5ml Sympathomimetics Motivation required Brinzolamide 1% OPD Azoptic 5ml eye suspension Carbonic anhydrase inhbitor Accepted treatment Carteolol 2% OPD Teoptic 5ml Beta blockers Accepted treatment Dorzolamide 2% OPD Trusopt 5ml owi Carbonic anhydrase inhbitor Accepted treatment Latanoprost 50ug OPD Xalatan 2 5ml Ocuprost Prostaglandin analogues Accepted treatment Levobunolol 0.50% OPD Betagan 7 5ml Beta blockers Accepted treatment Metipranolol 3% OPD Beta-opthiole 5ml Beta blockers Accepted treatment Metipranolol 6% OPD Beta-opthiole 5ml Beta blockers Accepted treatment Pilocarpine 10mg/ml OPD Isopto carpine 1% 15ml Parasympathomimetics Accepted treatment Pilocarpine 20mg/ml OPD Isopto carpine 2% 15ml Parasympathomimetics Accepted treatment Pilocarpine 40mg/ml OPD Isopto carpine 4% 15ml Parasympathomimetics Accepted treatment Pilocarpine 40mg/g OPD Pilogel gel 5gm Parasympathomimetics Accepted treatment Timolol 5mg/ml OPD Glaucosan 5ml Beta blockers Accepted treatment Timolol 1mg/g OPD Nyogel eye gel 5g Beta blockers Accepted treatment Timolol 2.5mg/ml OPD Timoptol 5ml Beta blockers Accepted treatment Timolol 5mg/ml OPD Timoptol 5ml Beta blockers Accepted treatment Timolol 2.5mg/ml OPD Timoptol-xe 2 5ml Beta blockers Accepted treatment Timolol 5mg/ml OPD Timoptol-xe 2 5ml Beta blockers Accepted treatment Timolol combinations 0.50% OPD Cosopt 5ml Beta blockers Combination Motivation required Timolol combinations OPD DuoTrav 2.5ml Beta blockers Combination Motivation required Timolol combinations 0.3mg/5mg/ml OPD Ganfort Beta blockers Combination Motivation required Timolol combinations OPD Xalacom 2 5ml Beta blockers Combination Motivation required Travoprost 40ug/ml OPD Travatan 25ml Prostaglandin analogues Accepted treatment

Page 24 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM HAEMOPHILIA ICD10: D66, D67 Paracetamol will be reimbursed in the treatment of Haemophilia Kogenate fs powder for Coagulation factor VIII 500iu INJ Blood coagulation factor special investigations, pathology report injection vial Coagulation factor VIII 500iu INJ Haemosolvate viii Blood coagulation factor special investigations, pathology report Coagulation factor IX 1000iu/10ml INJ Octanine F1000 Blood coagulation factor special investigations, pathology report Coagulation factor IX 250iu/5ml INJ Octanine F250 Blood coagulation factor special investigations, pathology report Coagulation factor IX 500iu/5ml INJ Octanine F500 Blood coagulation factor special investigations, pathology report Coagulation Factor II, VII, IX, X 1000iu INJ Haemosolvex Factor IX Blood coagulation factor special investigations, pathology report Coagulation Factor II, VII, IX, X 300iu INJ Haemosolvex Factor IX Blood coagulation factor special investigations, pathology report Coagulation Factor II, VII, IX, X 500iu INJ Haemosolvex Factor IX Blood coagulation factor special investigations, pathology report Desmopressin 0.2mg TAB DDAVP Desmopressin special investigations, pathology report Desmopressin 0.1mg TAB DDAVP Desmopressin special investigations, pathology report Phytomenadion 10mg/ml INJ Konakion Vitamin K special investigations, pathology report Tranexamic acid 500mg TAB Cyklokapron Tranexamic acid Medwich Antifibrinolytics special investigations, pathology report HEART FAILURE ICD10: I50.0, I50.1, I50.9, I11.0, I13.0, I3.2 Acetylsalicylic acid 81mg ECT Ecotrin Aspirin Accepted treatment

Page 25 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM Atenolol and other diuretics 100mg/25mg TAB SANDOZ Co-tenidone Tenchlor Beta blockers and combinations Accepted treatment Sandoz Co-tenidone Atenolol and other diuretics 50mg/12.5mg TAB Tenchlor hs Beta blockers and combinations Accepted treatment 50mg/12.5mg Atenolol and thiazides 100mg/25mg TAB Adco-loten Beta blockers and combinations Accepted treatment Bisoprolol 5mg TAB Bisohexal 5 Betacor Beta blockers Accepted treatment Bisoprolol 10mg TAB Bisoprolol Hexal Concor Beta blockers Accepted treatment Bisoprolol 2.5mg TAB Cardicor Beta blockers Accepted treatment Bumetanide 0.5mg TAB Burinex Duiretics Motivation required Captopril 12.5mg TAB Capoten hs Captohexal ACE-inhibitors Accepted treatment Captopril 50mg TAB Captohexal Zapto ACE-inhibitors Accepted treatment Captopril 25mg TAB Mylan-captopril 25 SANDOZ Cap topril ACE-inhibitors Accepted treatment Captopril and diuretics 50mg/25mg TAB Zapto-co Captoretic ACE-inhibitors and combinations Accepted treatment Carvedilol 12.5mg TAB Dilatrend Vediblok Alpha/beta blockers Accepted treatment Carvedilol 25mg TAB Dilatrend Vediblok Alpha/beta blockers Accepted treatment Carvedilol 6.25mg TAB Dilatrend Vediblok Alpha/beta blockers Accepted treatment Digoxin 0.0625mg TAB Lanoxin Cardiac glycosides Accepted treatment Digoxin 0.25mg TAB Lanoxin Cardiac glycosides Accepted treatment Digoxin 0.05mg/ml SYR Lanoxin paed Cardiac glycosides Accepted treatment Digoxin 0.25mg TAB Purgoxin Cardiac glycosides Accepted treatment Diltiazem 60mg TAB Zildem 60 Calcium channel blockers Accepted treatment Diltiazem 90mg TAB Zildem 90 Calcium channel blockers Accepted treatment Diltiazem 180mg SRC Tilazem 180 cr Zildem 180 sr Calcium channel blockers Accepted treatment Diltiazem 240mg SRC Tilazem 240 cr Zildem 240 sr Calcium channel blockers Accepted treatment Enalapril 5mg TAB Hr-enalapril 5 Pharmapress ACE-inhibitors Accepted treatment Enalapril 20mg TAB HR-Enalapril MAL FP Pharm apress ACE-inhibitors Accepted treatment Enalapril 10mg TAB Renitec 10 Pharmapress ACE-inhibitors Accepted treatment Enalapril 2.5mg TAB Renitec 2 5 ACE-inhibitors Accepted treatment Enalapril and diuretics 20mg/12.5mg TAB Co-renitec Enap co ACE-inhibitors and combinations Accepted treatment Felodipine 10mg SRT Felodipine-Hexal Plendil Calcium channel blockers Accepted treatment Felodipine 5mg SRT Felodipine-Hexal Plendil Calcium channel blockers Accepted treatment Furosemide 20mg TAB Lasix Diuretics Accepted treatment Furosemide 10mg/ml SYR Lasix oral Diuretics Motivation required Furosemide 40mg TAB Mylan-furosemide Puresis Diuretics Accepted treatment Hydralazine 10mg TAB Hyperphen Vasodilators Accepted treatment

Page 26 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM Hydralazine 50mg TAB SANDOZ Hydralazine Hyperphen Vasodilators Accepted treatment Hydrochlorothiazide 12.5mg TAB Ridaq Diuretics Accepted treatment Hydrochlorothiazide 25mg TAB Ridaq Hexazide Diuretics Accepted treatment Hydrochlorothiazide and 50mg/300mg TAB Urirex-k Diuretics Accepted treatment potassium Hydrochlorothiazide and 50mg/5mg TAB Adco-retic Betaretic Diuretics Accepted treatment potassium-sparing agents Hydrochlorothiazide and 25mg/2.5mg TAB Amiloretic hs Diuretics Accepted treatment potassium-sparing agents Hydrochlorothiazide and 50mg/25mg TAB Dyazide Renezide Diuretics Accepted treatment potassium-sparing agents Indapamide 2.5mg TAB Lixamide Mylan-Indapamide Diuretics Accepted treatment Isosorbide dinitrate 40mg TAB Isordil tembid Organic nitrates Accepted treatment Isosorbide dinitrate 30mg TAB SANDOZ Isosorbide Isordil Organic nitrates Accepted treatment Isosorbide dinitrate 10mg TAB SANDOZ Isosorbide Dinitrate Isordil Organic nitrates Accepted treatment Isosorbide dinitrate 5mg TAB SANDOZ Isosorbide Dinitrate Isordil sublingual Organic nitrates Accepted treatment Lisinopril 2.5mg TAB Austell-lisinopril ACE-inhibitors Accepted treatment Lisinopril 20mg TAB Simayla Lisinopril Sinopren 20 ACE-inhibitors Accepted treatment Lisinopril 10mg TAB Sinopren 10 Zemax ACE-inhibitors Accepted treatment Lisinopril 5mg TAB Zemax Zestril ACE-inhibitors Accepted treatment Lisinopril and diuretics 10mg/12.5mg TAB Lisozide Zestoretic 10 ACE-inhibitors and combinations Accepted treatment Lisinopril and diuretics 20mg/12.5mg TAB Lisozide Zestoretic ACE-inhibitors and combinations Accepted treatment Losartan 100mg TAB Cipla Losartan Cozaar Angiotensin receptor blockers Accepted treatment Losartan 50mg TAB Renicard Spec Losartan 50 Angiotensin receptor blockers Accepted treatment Angiotensin receptor blockers and Losartan and diuretics 100mg/25mg TAB Fortzaar Lozaan Co Accepted treatment combinations Angiotensin receptor blockers and Losartan and diuretics 50mg/12.5mg TAB Sartoc Lozaan Co Accepted treatment combinations Perindopril 8mg TAB Ciplasyl Cipla-Perindopril ACE-inhibitors Accepted treatment Perindopril 10mg TAB Prexum Coversyl ACE-inhibitors Accepted treatment Perindopril 4mg TAB Ran-Perindopril Spec-Perindopril ACE-inhibitors Accepted treatment Perindopril and diuretics 2mg/0.625mg TAB Acesyl Co Spec-Perindopril Plus 2 ACE-inhibitors and combinations Accepted treatment Perindopril and diuretics 4mg/1.25mg TAB Prexum Plus Spec-Perindopril Plus 4 ACE-inhibitors and combinations Accepted treatment Potassium chloride 600mg TAB Slow-k Plenish k Potassium supplements Accepted treatment Propranolol 10mg TAB Prodorol Purbloka Beta blockers Accepted treatment Propranolol 40mg TAB Prodorol Purbloka Beta blockers Accepted treatment

Page 27 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM Quinapril 10mg TAB Accupril Accumax ACE-inhibitors Accepted treatment Quinapril 20mg TAB Accupril Accumax ACE-inhibitors Accepted treatment Ramipril 1.25mg CAP Austell-Ramipril ACE-inhibitors Accepted treatment Ramipril 10mg CAP Austell-Ramipril ACE-inhibitors Accepted treatment Ramipril 2.5mg CAP Austell-Ramipril ACE-inhibitors Accepted treatment Ramipril 5mg CAP Austell-Ramipril ACE-inhibitors Accepted treatment Ramipril 2.5mg CAP Apex-Ramipril 2.5mg ACE-inhibitors Accepted treatment Ramipril 5mg CAP Apex-Ramipril 5mg ACE-inhibitors Accepted treatment Ramipril 10mg CAP Apex-Ramipril 10mg ACE-inhibitors Accepted treatment Ramipril 5mg TAB Ramace RamiprilHexal ACE-inhibitors Accepted treatment Ramipril 1.25mg TAB RamiprilHexal Tritace ACE-inhibitors Accepted treatment Ramipril 2.5mg TAB RamiprilHexal Ramace ACE-inhibitors Accepted treatment Ramipril 2.5mg CAP Ramiwin ACE-inhibitors Accepted treatment Ramipril 5mg CAP RamiWin ACE-inhibitors Accepted treatment Ramipril 1.25mg CAP Rampil ACE-inhibitors Accepted treatment Ramipril 10mg CAP Rampil ACE-inhibitors Accepted treatment Ramipril 2.5mg CAP Rampil ACE-inhibitors Accepted treatment Ramipril 5mg CAP Rampil ACE-inhibitors Accepted treatment Ramipril 10mg CAP Ran-Ramipril ACE-inhibitors Accepted treatment Ramipril 10mg CAP Simayla Ramipril ACE-inhibitors Accepted treatment Ramipril 10mg CAP Tritace ACE-inhibitors Accepted treatment Spironolactone 100mg TAB Spiractin Aldactone Diuretics Accepted treatment Spironolactone 25mg TAB Spiractin SANDOZ Spironolactone Diuretics Accepted treatment Telimisartan 40mg TAB Pritor Micardis ACE-Inhibitor Accepted treatment Telimisartan 80mg TAB Pritor Micardis ACE-Inhibitor Accepted treatment Telimisatan and diuretic 40mg/12.5mg TAB Co-Pritor Co-Micardis ACE-Inhibitor and diuretic Accepted treatment Telimisatan and diuretic 80mg/12.5mg TAB Co-Pritor Co-Micardis ACE-Inhibitor and diuretic Accepted treatment Telimisatan and diuretic 80mg/25mg TAB Co-Pritor Co-Micardis ACE-Inhibitor and diuretic Accepted treatment Trandolapril 0.5mg CAP Mavik (was Gopten) ACE-inhibitors and combinations Accepted treatment Trandolapril 2mg CAP Mavik (was Gopten) ACE-inhibitors and combinations Accepted treatment Valsartan 160mg TAB Migroben Diovan Angiotensin receptor blockers Accepted treatment Valsartan 80mg TAB Migroben Diovan Angiotensin receptor blockers Accepted treatment Angiotensin receptor blockers and Valsartan and amlodipine 10mg/160mg TAB Exforge Accepted treatment combinations

Page 28 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM Angiotensin receptor blockers and Valsartan and amlodipine 5mg/160mg TAB Exforge Accepted treatment combinations Angiotensin receptor blockers and Valsartan and diuretics 320/12.5mg TAB Co-Diovan Accepted treatment combinations Angiotensin receptor blockers and Valsartan and diuretics 320mg/25mg TAB Co-Diovan Accepted treatment combinations Angiotensin receptor blockers and Valsartan and diuretics 160mg/12.5mg TAB Co-Migroben Co-diovan Accepted treatment combinations Angiotensin receptor blockers and Valsartan and diuretics 160mg/25mg TAB Co-Migroben Co-Diovan Plus Accepted treatment combinations Angiotensin receptor blockers and Valsartan and diuretics 80mg/12.5mg TAB Co-Migroben Co-diovan Accepted treatment combinations Warfarin 1mg TAB Cipla Warfarin Anticoagulants Accepted treatment Warfarin 3mg TAB Cipla-Warfarin Anticoagulants Accepted treatment Warfarin 5mg TAB Cipla Warfarin Aspen Warfarin Anticoagulants Accepted treatment HYPERLIPIDAEMIA ICD10: E78.0,E78.1, E78.2, E78.3, E78.4, E78.5 Acetylsalicylic acid 81mg ECT Ecotrin Aspirin Accepted treatment Disprin CV 100 disp TAB Acetylsalicylic acid 100mg TAB Bayer aspirin cardio Aspirin Accepted treatment 100mg Acetylsalicylic acid 300mg TAB Be-tabs aspirin (white) Bayer aspirin Aspirin Accepted treatment Genpharma Children Acetylsalicylic acid 60mg TAB Aspirin Accepted treatment Aspirin(prev.Asp.jnr) Acetylsalicylic acid 125mg TAB Lo-aspirin Aspirin Accepted treatment Bezafibrate 400mg TAB Bezachole SR SANDOZ Bezafibrate Fibrates special investigations, lipogram Bezafibrate 200mg TAB Bezalip Fibrates special investigations, lipogram Lovastatin 20mg TAB Lovachol Statins special investigations, lipogram Lovastatin 40mg TAB Lovachol Statins special investigations, lipogram Simvastatin 10mg TAB Adco-Simvastatin Arrow Simvastatin Statins special investigations, lipogram Simvastatin 20mg TAB Aspen Simvastatin Austell-Simvastatin Statins special investigations, lipogram Simvastatin 40mg TAB Simvacor Michol Statins special investigations, lipogram Simvastatin 80mg TAB Zysim Michol Statins special investigations, lipogram Atorvastatin 10mg TAB Lipogen Atolip Statins special investigations, lipogram Atorvastatin 20mg TAB Aspavor Atorvastatin Winthrop Statins special investigations, lipogram special investigations, lipogram Atorvastatin 40mg TAB Aspavor Lipogen Statins (reserved for high risk patients only) special investigations, lipogram Atorvastatin 80mg TAB Atolip Lipogen Statins (reserved for high risk patients only)

Page 29 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM HYPERTENSION ICD10: I10, I11.0, I11.9, I12.0, I12.9, I13.0, I13.1, I13.2, I13.9, I15.0, I15.1, I15.1, I15.2, I15.8< I15.9, O10.0, O10.1, O10.2, O10.3, O10.4, O10.9, O11 Acetylsalicylic acid 81mg ECT Ecotrin Aspirin Accepted treatment Disprin CV 100 disp TAB Acetylsalicylic acid 100mg TAB Bayer aspirin cardio Aspirin Accepted treatment 100mg Genpharma Children Acetylsalicylic acid 60mg TAB Aspirin Accepted treatment Aspirin(prev.Asp.jnr) Acetylsalicylic acid 300mg TAB Gulf aspirin Bayer aspirin Aspirin Accepted treatment Acetylsalicylic acid 125mg TAB Lo-aspirin Aspirin Accepted treatment Amlodipine 5mg TAB Keysal Indo-Amlodipine Calcium channel blockers Accepted treatment Amlodipine 10mg TAB Stamlo Amtas Calcium channel blockers Accepted treatment Amlodipine besylate 5mg TAB Calbloc Lomanor Calcium channel blockers Accepted treatment Pharma Dynamics Amlodipine besylate 10mg TAB Ciplavasc Calcium channel blockers Accepted treatment Amlodipine Besylate Amlodipine maleate 10mg TAB Amlate Calcium channel blockers Accepted treatment Amlodipine maleate 5mg TAB Amlate Calcium channel blockers Accepted treatment Atenolol 50mg TAB SANDOZ Atenolol Bio-atenolol Beta blockers Accepted treatment Atenolol 100mg TAB Tenopress Gulf Atenolol 100 Beta blockers Accepted treatment Atenolol 25mg TAB Tenopress Tenormin 25 Beta blockers Accepted treatment Atenolol and other diuretics 100mg/25mg TAB SANDOZ Co-tenidone Tenchlor Beta blockers and combinations Accepted treatment Sandoz Co-tenidone Atenolol and other diuretics 50mg/12.5mg TAB Tenchlor hs Beta blockers and combinations Accepted treatment 50mg/12.5mg Atenolol and thiazides 100mg/25mg TAB Adco-loten Beta blockers and combinations Accepted treatment Bisoprolol 5mg TAB Bisoprolol Unicorn Adco-Bisocor Beta blockers Accepted treatment Bisoprolol 10mg TAB Cardicor Betacor Beta blockers Accepted treatment Bisoprolol 2.5mg TAB Cardicor Beta blockers Accepted treatment Bumetanide 0.5mg TAB Burinex Duiretics Motivation required Captopril 12.5mg TAB Capoten hs Captohexal ACE-inhibitors Accepted treatment Captopril 50mg TAB Captomax Captohexal ACE-inhibitors Accepted treatment Captopril 25mg TAB Zapto Capoten ACE-inhibitors Accepted treatment Captopril 50mg TAB Zapto Mylan-captopril 50 ACE-inhibitors Accepted treatment Captopril and diuretics 50mg/25mg TAB Zapto-co Captoretic ACE-inhibitors and combinations Accepted treatment Carvedilol 6.25mg TAB Carvedilol-Hexal Carloc 6.25 Alpha/beta blockers Accepted treatment Carvedilol 12.5mg TAB Carvetrend Carloc 12.5 Alpha/beta blockers Accepted treatment Carvedilol 25mg TAB Vediblok Carvedilol-Hexal Alpha/beta blockers Accepted treatment

Page 30 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM Diltiazem 60mg TAB Zildem 60 Calcium channel blockers Accepted treatment Diltiazem 90mg TAB Zildem 90 Calcium channel blockers Accepted treatment Diltiazem 180mg SRC Tilazem 180 cr Zildem 180 sr Calcium channel blockers Accepted treatment Diltiazem 240mg SRC Tilazem 240 cr Zildem 240 sr Calcium channel blockers Accepted treatment Cardugen (Prev Mylan- Doxazosin 1mg TAB Adco-doxazosin Alpha blockers Motivation required Doxasozin) Doxazosin 2mg TAB Adco-doxazosin Alpha blockers Motivation required Cardugen (prev Mylan- Doxazosin 4mg TAB Adco-doxazosin Alpha blockers Motivation required Doxasozin) Doxazosin extended release 4mg TAB Cardura XL Carzin XL Alpha blockers Motivation required Doxazosin 8mg TAB Cardura xl Alpha blockers Motivation required Enalapril 5mg TAB Alapren 5 Renitec 5 ACE-inhibitors Accepted treatment Enalapril 10mg TAB Envas Hr-enalapril 10 ACE-inhibitors Accepted treatment Enalapril 20mg TAB Pharmapress Renitec 20 ACE-inhibitors Accepted treatment Enalapril 2.5mg TAB Renitec 2 5 ACE-inhibitors Accepted treatment Enalapril and diuretics 20mg/12.5mg TAB Co-renitec Enap co ACE-inhibitors and combinations Accepted treatment Felodipine 10mg SRT Felodipine-Hexal Plendil Calcium channel blockers Accepted treatment Felodipine 5mg SRT Felodipine-Hexal Plendil Calcium channel blockers Accepted treatment Furosemide 20mg TAB Lasix Diuretics Accepted treatment Furosemide 10mg/ml SYR Lasix oral Diuretics Motivation required Furosemide 40mg TAB Puresis SANDOZ Furosemide Diuretics Accepted treatment Hydralazine 10mg TAB Hyperphen Vasodilators Accepted treatment Hydralazine 50mg TAB SA NDOZ Hydralazine Hyperphen Vasodilators Accepted treatment Hydrochlorothiazide 12.5mg TAB Ridaq Diuretics Accepted treatment Hydrochlorothiazide 25mg TAB Ridaq Hexazide Diuretics Accepted treatment Hydrochlorothiazide and 50mg/300mg TAB Urirex-k Diuretics Accepted treatment potassium Hydrochlorothiazide and 50mg/5mg TAB Adco-retic Betaretic Diuretics Accepted treatment potassium-sparing agents Hydrochlorothiazide and 25mg/2.5mg TAB Amiloretic hs Diuretics Accepted treatment potassium-sparing agents Hydrochlorothiazide and 50mg/25mg TAB Dyazide Renezide Diuretics Accepted treatment potassium-sparing agents Indapamide 2.5mg TAB SANDOZ Indapamide Dapamax Diuretics Accepted treatment Lisinopril 20mg TAB Auro-Lisinopril Hexal-lisinopril 20 ACE-inhibitors Accepted treatment Lisinopril 2.5mg TAB Austell-lisinopril ACE-inhibitors Accepted treatment

Page 31 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM Lisinopril 5mg TAB Zestril Zetomax ACE-inhibitors Accepted treatment Lisinopril and diuretics 10mg/12.5mg TAB Zestoretic 10 Zetomax-Co ACE-inhibitors and combinations Accepted treatment Lisinopril and diuretics 20mg/12.5mg TAB Zestozide Zetomax-Co ACE-inhibitors and combinations Accepted treatment Losartan 100mg TAB Spec Losartan 100 Zartan Angiotensin receptor blockers Accepted treatment Losartan 50mg TAB Zartan Cipla Losartan Angiotensin receptor blockers Accepted treatment Angiotensin receptor blockers and Losartan and diuretics 50mg/12.5mg TAB Losaar plus 50/12.5 Zartan Co Accepted treatment combinations Angiotensin receptor blockers and Losartan and diuretics 100mg/25mg TAB Lozaan Co Zartan Co Accepted treatment combinations Methyldopa (levorotatory) 250mg TAB Hypotone SANDOZ Methyldopa Antiadrenegic agents, centrally acting Accepted treatment Methyldopa (levorotatory) 500mg TAB Hypotone Antiadrenegic agents, centrally acting Accepted treatment Minoxidil 10mg TAB Loniten Vasodilators Motivation required Minoxidil 5mg TAB Loniten Vasodilators Motivation required Nifedipine 30mg TAB Adalat xl Calcium channel blockers Accepted treatment Nifedipine 60mg TAB Adalat xl Calcium channel blockers Accepted treatment Nifedipine 30mg SRT Adco-Vascard SR Fedaloc Calcium channel blockers Accepted treatment Nifedipine 60mg SRT Fedaloc Calcium channel blockers Accepted treatment Nifedipine 60mg SRT Macorel 60 SR Calcium channel blockers Accepted treatment Nifedipine 20mg SRT Nifedalat SR Cipalat Retard Calcium channel blockers Accepted treatment Nifedipine 60mg SRT Spec Nifedipine SR Calcium channel blockers Accepted treatment Perindopril 10mg TAB Prexum Coversyl ACE-inhibitors Accepted treatment Perindopril 4mg TAB Vectoryl Acesyl ACE-inhibitors Accepted treatment Perindopril 8mg TAB Vectoryl Spec-Perindopril ACE-inhibitors Accepted treatment Perindopril and diuretics 2mg/0.625mg TAB Spec-Perindopril Plus 2 Preterax ACE-inhibitors and combinations Accepted treatment Perindopril and diuretics 4mg/1.25mg TAB Vectoryl plus Prexum Plus ACE-inhibitors and combinations Accepted treatment Potassium chloride 600mg TAB Slow-k Plenish k Potassium supplements Accepted treatment Prazosin 1mg TAB Pratsiol Alpha blockers Motivation required Prazosin 2mg TAB Pratsiol Alpha blockers Motivation required Prazosin 5mg TAB Pratsiol Alpha blockers Motivation required Propranolol 10mg TAB Prodorol Purbloka Beta blockers Accepted treatment Propranolol 40mg TAB Prodorol Purbloka Beta blockers Accepted treatment Quinapril 10mg TAB Quinaspen Quinagen ACE-inhibitors Accepted treatment Quinapril 20mg TAB Quinaspen Quinagen ACE-inhibitors Accepted treatment Ramipril 10mg CAP Austell-Ramipril ACE-inhibitors Accepted treatment

Page 32 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM Ramipril 2.5mg CAP Austell-Ramipril ACE-inhibitors Accepted treatment Ramipril 5mg CAP Austell-Ramipril ACE-inhibitors Accepted treatment Ramipril 2.5mg CAP Apex-Ramipril 2.5mg ACE-inhibitors Accepted treatment Ramipril 5mg CAP Apex-Ramipril 5mg ACE-inhibitors Accepted treatment Ramipril 10mg CAP Apex-Ramipril 10mg ACE-inhibitors Accepted treatment Ramipril 5mg TAB Ramace RamiprilHexal ACE-inhibitors Accepted treatment Ramipril 2.5mg CAP Ramiwin ACE-inhibitors Accepted treatment Ramipril 5mg CAP RamiWin ACE-inhibitors Accepted treatment Ramipril 10mg CAP Rampil ACE-inhibitors Accepted treatment Ramipril 2.5mg CAP Rampil ACE-inhibitors Accepted treatment Ramipril 5mg CAP Rampil ACE-inhibitors Accepted treatment Ramipril 10mg CAP Ran-Ramipril ACE-inhibitors Accepted treatment Ramipril 10mg CAP Simayla Ramipril ACE-inhibitors Accepted treatment Ramipril 10mg CAP Tritace ACE-inhibitors Accepted treatment Ramipril 2.5mg TAB Tritace Retace ACE-inhibitors Accepted treatment Reserpine 0.25mg TAB Reserpine Antiadrenegic agents, centrally acting Accepted treatment Reserpine and diuretics TAB Brinerdin Antiadrenegic agents, centrally acting Motivation required Spironolactone 100mg TAB Spiractin Aldactone Diuretics Accepted treatment Spironolactone 25mg TAB Spiractin SANDOZ Spironolactone Diuretics Accepted treatment Telimisartan 40mg TAB Pritor Micardis ACE-Inhibitor Accepted treatment Telimisartan 80mg TAB Pritor Micardis ACE-Inhibitor Accepted treatment Telimisatan and diuretic 40mg/12.5mg TAB Co-Pritor Co-Micardis ACE-Inhibitor and diuretic Accepted treatment Telimisatan and diuretic 80mg/12.5mg TAB Co-Pritor Co-Micardis ACE-Inhibitor and diuretic Accepted treatment Telimisatan and diuretic 80mg/25mg TAB Co-Pritor Co-Micardis ACE-Inhibitor and diuretic Accepted treatment Trandolapril 0.5mg CAP Mavik (was Gopten) ACE-inhibitors and combinations Accepted treatment Trandolapril 2mg CAP Mavik (was Gopten) ACE-inhibitors and combinations Accepted treatment Valsartan 160mg TAB Zomevek Tareg Angiotensin receptor blockers Accepted treatment Valsartan 80mg TAB Zomevek Tareg Angiotensin receptor blockers Accepted treatment Angiotensin receptor blockers and Valsartan and amlodipine 10mg/160mg TAB Exforge Accepted treatment combinations Angiotensin receptor blockers and Valsartan and amlodipine 5mg/160mg TAB Exforge Accepted treatment combinations Angiotensin receptor blockers and Valsartan and diuretics 320/12.5mg TAB Co-Diovan Accepted treatment combinations Valsartan and diuretics 320mg/25mg TAB Co-Diovan Angiotensin receptor blockers and Accepted treatment

Page 33 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM combinations Angiotensin receptor blockers and Valsartan and diuretics 160mg/25mg TAB Co-Zomevek Co-Tareg Plus Accepted treatment combinations Angiotensin receptor blockers and Valsartan and diuretics 80mg/12.5mg TAB Co-Zomevek Co-Tareg Accepted treatment combinations Angiotensin receptor blockers and Valsartan and diuretics 160mg/12.5mg TAB Co-Zomevek Co-Tareg Accepted treatment combinations Verapamil 240mg SRT Calcicard sr 240 Calcium channel blockers Accepted treatment Verapamil 240mg SRT Isoptin sr Calcium channel blockers Accepted treatment Verapamil 240mg SRT Ravamil sr Calcium channel blockers Accepted treatment Verapamil 240mg SRT Verahexal 240 sr Calcium channel blockers Accepted treatment HYPOTHYROIDISM ICD10: E01.8, E02, E03.0, E03.1, E03.2, E03.3, E03.4, E03.5, E03.8, E03.9, E89.0 Levothyroxine sodium 0.05mg TAB Eltroxin Thyroid hormones Accepted treatment Levothyroxine sodium 0.1mg TAB Eltroxin Thyroid hormones Accepted treatment Levothyroxine sodium 100mcg TAB Euthyrox Synthroid Thyroid hormones Accepted treatment Levothyroxine sodium 25mcg TAB Euthyrox Synthroid Thyroid hormones Accepted treatment Levothyroxine sodium 50mcg TAB Euthyrox Synthroid Thyroid hormones Accepted treatment Levothyroxine sodium 88mcg TAB Synthroid Thyroid hormones Accepted treatment Levothyroxine sodium 112mcg TAB Synthroid Thyroid hormones Accepted treatment Liothyronine sodium TAB Diotroxin Thyroid hormones Accepted treatment Liothyronine sodium 20mcg TAB Tertroxin Thyroid hormones Accepted treatment INSULIN-DEPENDENT DIABETES ICD10: E10.0, E10.1, E10.2, E10.3, E10.4, E10.5, E 10.6, E10.7, E10.8, E10.9 Insu Humulin 30/70 3 0ml Insu Actraph HM ge 3 0ml Insulin (human) INJ Insulin Accepted treatment pre-fill disp Pensets+syringe Insu Novomix 30 Flexpen 3ml Insulin aspart 100U/ml INJ Insu Novorapid Insulin Accepted treatment pf device Insulin detemir 100U/ml INJ Insu Levemir Insulin Accepted treatment Insulin glargine 100iu/ml INJ Lantus Insulin Accepted treatment Insulin glulisine 100iu/ml INJ Insu Apidra Insulin Accepted treatment Insulin lispro 100IU/ml INJ Insu Humalog 10ml Insu humalog mix Insulin Accepted treatment MULTIPLE SCLEROSIS ICD10: G35 Amitriptyline 10mg TAB Trepiline Heterocyclic antidepressant Accepted treatment Azathioprine 50mg TAB Azamun Imuran Immunosuppressants Accepted treatment

Page 34 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM Baclofen 10mg TAB Bio-Baclofen Lioresal Muscle relaxants Accepted treatment Baclofen 25mg TAB Lioresal Muscle relaxants Motivation required Carbamazepine 400mg SRT SANDOZ Cabamazepine CR Tegretol CR Anticonvulsants Accepted treatment Carbamazepine 200mg TAB SANDOZ Carbamazepine Degranol Anticonvulsants Accepted treatment Carbamazepine 200mg SRT SANDOZ Carbamazepine CR Tegretol CR Anticonvulsants Accepted treatment Cyclophosphamide 50mg TAB Endoxan Immunosuppressants Motivation required Folic acid 5mg TAB Be-tabs folic acid Folic acid Accepted treatment Folic acid 0.5mg TAB Folic acid Folic acid Accepted treatment Folic acid 5mg CAP Folic acid Folic acid Accepted treatment Folic acid CAP Folic acid forte Folic acid Accepted treatment Imipramine 10mg TAB Ethipramine Tofranil Heterocyclic antidepressants Accepted treatment Imipramine 25mg TAB Ethipramine Tofranil Heterocyclic antidepressants Accepted treatment Methotrexate 2.5mg TAB Emthexate Emthexate Immunosuppressants Accepted treatment Orphenadrine (citrate) 100mg TAB Norflex Muscle relaxants Accepted treatment Oxybutynin 5mg TAB Urihexal Lenditro Anticholinergics, oral Accepted treatment Prednisolone 5mg TAB Lenisolone Capsoid Corticosteroids , oral Accepted treatment Prednisone 5mg TAB Be-tabs prednisone Panafcort Corticosteroids, oral Accepted treatment NON INSULIN-DEPENDENT DIABETES ICD10: E11.0, E11.1, E11.02, E11.3, E11.4, E11.5, E11.6, E11.7, E11.8, E11.9 Glibenclamide 5mg TAB SANDOZ Glibenclamide Diacare Suphonylureas Accepted treatment Gliclazide 40mg TAB Austell-Gliclazide Gliclazide Accepted treatment Gliclazide 80mg TAB Glucomed Diaglucide Gliclazide Accepted treatment Gliclazide 30mg SRT Diaran Dyna-Gliclazide SR Gliclazide Accepted treatment Insu Humulin 30/70 3 0ml Insu Actraph HM ge 3 0ml Insulin (human) INJ Insulin Accepted treatment pre-fill disp Pensets+syringe Insu Novomix 30 Flexpen 3ml Insulin aspart 100U/ml INJ Insu Novorapid Insulin Accepted treatment pf device Insulin detemir 100U/ml INJ Insu Levemir Insulin Accepted treatment Insulin glargine 100iu/ml INJ Lantus Insulin Accepted treatment Insulin glulisine 100iu/ml INJ Insu Apidra Insulin Accepted treatment Insulin lispro 100IU/ml INJ Insu Humalog 10ml Insu humalog mix Insulin Accepted treatment SANDOZ Metformin HCL Metformin 500mg TAB Arrow Metformin Biguanides Accepted treatment FC Metformin 850mg TAB Auro-Metformin Mylan-metformin Biguanides Accepted treatment Metformin 1000mg TAB Bigsens Glucophage Biguanides Accepted treatment

Page 35 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM Pioglitazone 15mg TAB Cipla Pioglitazone Actos Thiazolidinediones Motivation required Pioglitazone 30mg TAB Cipla Pioglitazone Actos Thiazolidinediones Motivation required Saxagliptin 2.5mg TAB Onglyza DPP-4 Motivation required Saxagliptin 5mg TAB Onglyza DPP-4 Motivation required Sitagliptin 25mg TAB Januvia DPP-4 Motivation required Sitagliptin 50mg TAB Januvia DPP-4 Motivation required Sitagliptin 100mg TAB Januvia DPP-4 Motivation required Vildagliptin 50mg TAB Galvus DPP-4 Motivation required PARKINSON'S DISEASE ICD10: G20, G21.0, G21.1, G21.2, G21.3, G21.8, G21.9 Amantadine 100mg CAP Symmetrel Symadin (was Flu-st op) Amantadine derivate Accepted treatment Biperiden 2mg TAB Akineton Anticholinergics, oral Accepted treatment Bromocriptine 2.5mg TAB Aspen Bromocriptine Parlodel Dopamine agonist Motivation required Levodopa and decarboxylase 25mg/100mg TAB Carbilev 25/100 Sinemet Dopa and dopa derivatives Accepted treatment inhibitor Levodopa and decarboxylase 200mg/50mg TAB Madopar Dopa and dopa derivatives Accepted treatment inhibitor Levodopa and decarboxylase 100mg/25mg CAP Madopar hbs Dopa and dopa derivatives Accepted treatment inhibitor Levodopa and decarboxylase 25mg/250mg TAB Sinemet Teva Carbi-Levo Dopa and dopa derivatives Accepted treatment inhibitor Levodopa and decarboxylase 50mg/200mg SRT Sinemet cr Dopa and dopa derivatives Accepted treatment inhibitor Orphenadrine (chloride) 50mg TAB Disipal Muscle relaxants Accepted treatment Orphenadrine (citrate) 100mg TAB Norflex Muscle relaxants Accepted treatment Pramipexole 0.125mg TAB Pexola Dopamine agonists Motivation required Pramipexole 0.25mg TAB Pexola Dopamine agonists Motivation required Pramipexole 1mg TAB Pexola Dopamine agonists Motivation required Ropinirole 0.25mg TAB Requip 025 Resure Dopamine agonists Motivation required Ropinirole 0.5mg TAB Requip 05 Resure Dopamine agonists Motivation required Ropinirole 1mg TAB Requip 10 Resure Dopamine agonists Motivation required Ropinirole 2mg TAB Requip 20 Resure Dopamine agonists Motivation required Ropinirole 5mg TAB Requip 50 Resure Dopamine agonists Motivation required Ropinirole 2mg TAB Requip XL Resure Dopamine agonists Motivation required Ropinirole 4mg TAB Requip XL Dopamine agonists Motivation required Ropinirole 8mg TAB Requip XL Dopamine agonists Motivation required

Page 36 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM Selegiline 5mg TAB Parkilyne Monoamine oxidase type B inhibitors Accepted treatment Trihexyphenidyl 2mg TAB Benzhexol Anticholinergics, oral Accepted treatment RHEUMATOID ARTHRITIS ICD10: M05.00-M05.29, M05.80-M05.99, M06.00-M06.49, M06.80-M06.99, M08.00-M08.09, M05 Paracetamol will be reimbursed in the treatment of Rheumatoid Arthritis. Azathioprine 50mg TAB Zaprine Azathioprine 50 PCH Immunosuppressants Accepted treatment Chloroquine 200mg TAB Nivaquine Plasmoquine Other Accepted treatment SANDOZ Chloroquine Chloroquine 250mg TAB Other Accepted treatment phosphate Diclofenac 25mg TAB Adco-diclofenac Panamor-25 Non-steroidal anti-inflammatory drugs Accepted treatment Diclofenac 100mg SUP Diclohexal 100s Panamor supp-100 Non-steroidal anti-inflammatory drugs Motivation required Diclofenac 50mg TAB Diclohexal 50t Panamor at-50 Non-steroidal anti-inflammatory drugs Accepted treatment Diclofenac 100mg CAP Fortfen SR Non-steroidal anti-inflammatory drugs Accepted treatment SANDOZ Diclofenac Diclofenac 100mg SRT Panamor-100 sr Non-steroidal anti-inflammatory drugs Accepted treatment Sodium SR Diclofenac 75mg SRT Panamor-75 sr Voltaren 75 Non-steroidal anti-inflammatory drugs Accepted treatment Folic acid 0.5mg TAB Folic acid Folic acid Accepted treatment Folic acid CAP Folic acid forte Folic acid Accepted treatment Folic acid 5mg TAB Be-tabs folic acid Folic acid Accepted treatment Folic acid 5mg CAP Folic acid Folic acid Accepted treatment Ibuprofen 400mg TAB Adco-ibuprofen Ranfen Non-steroidal anti-inflammatory drugs Accepted treatment Ibuprofen 100mg/5ml SUS Brufen paed susp Ibumax Non-steroidal anti-inflammatory drugs Accepted treatment Ibuprofen 200mg TAB SANDOZ Ibuprofen Inza Non-steroidal anti-inflammatory drugs Accepted treatment Ibuprofen 600mg TAB SANDOZ Ibupr ofen Brufen Non-steroidal anti-inflammatory drugs Accepted treatment Indomethacin 100mg SUP Arthrexin Indocid Non-steroidal anti-inflammatory drugs Motivation required Indomethacin 25mg CAP SANDOZ Idomethacin Arthrexin Non-steroidal anti-inflammatory drugs Accepted treatment Ketoprofen 200mg SRC Ketoflam Non-steroidal anti-inflammatory drugs Accepted treatment Leflunomide 10mg TAB Arava Immunosuppressants Motivation required Leflunomide 20mg TAB Arava Immunosuppressants Motivation required Meloxicam 15mg TAB Loxiflam Arrow Meloxicam Non-steroidal anti-inflammatory drugs Accepted treatment Meloxicam 7.5mg TAB SANDOZ Melox icam Coxflam Non-steroidal anti-inflammatory drugs Accepted treatment Methotrexate 2.5mg TAB Emthexate Emthexate Immunosuppressants Accepted treatment Naproxen 250mg TAB Adco-naproxen Mylan-naproxen Non-steroidal anti-inflammatory drugs Accepted treatment Naproxen 500mg SUP Nafasol Non-steroidal anti-inflammatory drugs Motivation required

Page 37 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM Naproxen 250mg ECT Nafasol ec-250 Non-steroidal anti-inflammatory drugs Accepted treatment Naproxen 500mg ECT Nafasol ec-500 Non-steroidal anti-inflammatory drugs Accepted treatment Naproxen 500mg TAB Napflam Non-steroidal anti-inflammatory drugs Accepted treatment Piroxicam 10mg CAP Adco-piroxicam Rolab-piroxicam Non-steroidal anti-inflammatory drugs Accepted treatment Piroxicam 20mg CAP Adco-piroxicam Xycam Non-steroidal anti-inflammatory drugs Accepted treatment Piroxicam 20mg TAB Brexecam Non-steroidal anti-inflammatory drugs Accepted treatment Piroxicam 20mg DSP Pixicam Xycam dispers Non-steroidal anti-inflammatory drugs Accepted treatment Prednisolone 5mg TAB Lenisolone Capsoid Corticosteroids , oral Motivation required Prednisone 5mg TAB Be-tabs prednisone Panafcort Corticosteroids, oral Motivation required Sulfasalazine 500mg TAB Salazopyrin 5-ASA agents Accepted treatment Sulfasalazine 500mg ECT Salazopyrin e n 5-ASA agents Accepted treatment SCHIZOPHRENIA ICD10: F20.0, F20.1, F20.2, F20.3, F20.4, F20.5, F20.6, F20.8, F20.9 Amisulpiride 50mg TAB Solian Antipsychotics Accepted treatment Amisulpiride 200mg TAB Solian Antipsychotics Accepted treatment Amitriptyline 25mg TAB SANDOZ Amitryptyline Trepiline Heterocyclic antidepressant Accepted treatment Aripiprazole 5mg TAB Abilify Antipsychotics Motivation required Aripiprazole 10mg TAB Abilify Antipsychotics Motivation required Aripiprazole 15mg TAB Abilify Antipsychotics Motivation required Chlorpromazine 100mg TAB Largactil Antipsychotics Accepted treatment Chlorpromazine 25mg TAB Largactil Antipsychotics Accepted treatment Chlorpromazine 50mg TAB Largactil Antipsychotics Accepted treatment Citalopram 20mg TAB Auro-Citalopram Austell-Citalopram Selective serotonin receptor inhibitors Accepted treatment Citalopram 10mg TAB Austell-Citalopram Selective serotonin receptor inhibitors Accepted treatment Citalopram 40mg TAB Depramil Arrow 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 Clozapine 100mg TAB Cloment Leponex Mood stabilisers Accepted treatment Clozapine 25mg TAB Cloment Leponex Mood stabilisers Accepted treatment Dothiepin 25mg CAP Prothiaden Thaden Heterocyclic antidepressants Accepted treatment Dothiepin 75mg TAB Thaden Heterocyclic antidepressants Accepted treatment Fluoxetine 20mg CAP Nuzak Lilly-fluoxetine Selective serotonin receptor inhibitors Accepted treatment Fluoxetine 20mg TAB Lorien Rezak Selective serotonin receptor inhibitors Accepted treatment

Page 38 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM Fluoxetine 20mg DSP Prohexal 20t Selective serotonin receptor inhibitors Accepted treatment Flupenthixol 0.5mg TAB Fluanxol Antipsychotics Accepted treatment Flupenthixol 1mg TAB Fluanxol Antipsychotics Accepted treatment Haloperidol 1.5mg TAB SANDOZ Haloperidol Antipsychotics Accepted treatment Haloperidol 5mg TAB SANDOZ Haloperidol Serenace Antipsychotics Accepted treatment Haloperidol 0.5mg CAP Serenace Antipsychotics Accepted treatment Haloperidol 10mg TAB Serenace Antipsychotics Accepted treatment Imipramine 25mg TAB Ethipramine Tofranil Heterocyclic antidepressants Accepted treatment Lithium 250mg TAB Camcolit Mood stabilisers Accepted treatment Lithium 400mg TAB Camcolit Mood stabilisers Accepted treatment Lithium 50mg CAP Lithium succinate Mood stabilisers Accepted treatment Lithium 450mg TAB Quilonum retard Mood stabilisers Accepted treatment Maprotiline 25mg TAB Ludiomil Heterocyclic antidepressants Motivation required Maprotiline 75mg TAB Ludiomil Heterocyclic antidepressants Motivation required Paliperidone 3mg TAB Invega Antipsychotics Motivation required Paliperidone 6mg TAB Invega Antipsychotics Motivation required Paliperidone 9mg TAB Invega Antipsychotics Motivation required Quetiapine 25mg TAB Dopaquel Serez Antipsychotics Motivation required Quetiapine 100mg TAB Truvalin Quetoser Antipsychotics Motivation required Quetiapine 200mg TAB Mylan Quetiapine Dopaquel Antipsychotics Motivation required Quetiapine 300mg TAB Serez Truvalin Antipsychotics Motivation required Quetiapine 200mg TAB Seroquel XR 200 Antipsychotics Motivation required Quetiapine 300mg TAB Seroquel XR 300 Antipsychotics Motivation required Quetiapine 400mg TAB Seroquel XR 400 Antipsychotics Motivation required Risperidone 0.5mg TAB Aspen Risperidone Risperlet Antipsychotics Motivation required Risperidone 2mg TAB Aspen Risperidone Risperdal Quicklet Antipsychotics Motivation required Risperidone 3mg TAB Aspen Risperidone Risperidone-Hexal Antipsychotics Motivation required Risperidone 1.0mg TAB DRL-Risperidone Auroperdal Antipsychotics Motivation required Risperidone 1mg/ml SYR Risperdal Antipsychotics Motivation required Risperidone 4mg TAB Risperdal Risponz Antipsychotics Motivation required Sulpiride 200mg TAB Bio-Sulpiride Substituted benzamide Accepted treatment Sulpiride 50mg CAP Eglonyl Substituted benzamide Accepted treatment Sulpiride 50mg CAP Espiride Substituted benzamide Accepted treatment

Page 39 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM Sulpiride 50mg CAP SANDOZ Sulpiride Substituted benzamide Accepted treatment Trifluoperazine 1mg TAB Stelazine Selective serotonin receptor inhibitors Accepted treatment Trifluoperazine 5mg TAB Stelazine Selective serotonin receptor inhibitors Accepted treatment Ziprasidone 20mg CAP Geodon Antipsychotics Motivation required Ziprasidone 40mg CAP Geodon Antipsychotics Motivation required Ziprasidone 60mg CAP Geodon Antipsychotics Motivation required Ziprasidone 80mg CAP Geodon Antipsychotics Motivation required Zuclopenthixol 10mg TAB Clopixol Antipsychotics Accepted treatment Zuclopenthixol 2mg TAB Clopixol Antipsychotics Accepted treatment SYSTEMIC LUPUS ERYTHEMATOSUS ICD10: L93.0, L93.1, L93.2, M32.0, M32.1†I32.8*, M32.1†I39.0*, M32.1†I39.1*, M32.1†I39.2*, M32.1†I39.3*, M32.1†I39.4*, M32.1†I39.8*, M32.1†N08.5*, M32.1†N16.4* , M32.1†J99.1* Azathioprine 50mg TAB Zaprine Azathioprine 50 PCH Immunosuppressants Accepted treatment Betamethasone 0.10% CRE Adco-betamethasone Betamethasone valer Corticosteroids, topical Accepted treatment Betamethasone 0.05g/100g CRE Betnovate Corticosteroids, topical Accepted treatment Betamethasone 0.1g/100g OIN Persivate Lenovate Corticosteroids, topical Accepted treatment Betamethasone 0.1g/100g LOT Betnovate scalp Corticosteroids, topical Accepted treatment Chloroquine 200mg TAB Nivaquine Plasmoquine Other Accepted treatment SANDOZ Chloroquine Chloroquine 250mg TAB Other Accepted treatment phosphate Clobetasol 0.5mg CRE Dermovate Xenovate Corticosteroids, topical Motivation required Clobetasol 0.5mg OIN Dermovate Dovate Corticosteroids, topical Motivation required Clobetasone CRE Eumovate Corticosteroids, topical Accepted treatment Clobetasone OIN Eumovate Corticosteroids, topical Accepted treatment Diclofenac 25mg TAB Adco-diclofenac Panamor-25 Non-steroidal anti-inflammatory drugs Accepted treatment Diclofenac 100mg SUP Diclohexal 100s Panamor supp-100 Non-steroidal anti-inflammatory drugs Motivation required Diclofenac 50mg TAB Diclohexal 50t Panamor at-50 Non-steroidal anti-inflammatory drugs Accepted treatment Diclofenac 100mg CAP Fortfen SR Non-steroidal anti-inflammatory drugs Accepted treatment SANDOZ Diclofenac Diclofenac 100mg SRT Panamor-100 sr Non-steroidal anti-inflammatory drugs Accepted treatment Sodium SR Diclofenac 75mg SRT Panamor-75 sr Voltaren 75 Non-steroidal anti-inflammatory drugs Accepted treatment Fluocinolone acetonide 0.25mg/g CRE CORTODERM (PPF) Synalar Corticosteroids, topical Accepted treatment Fluocinolone acetonide 0.25mg/g OIN CORTODERM (PPF) Synalar Corticosteroids, topical Accepted treatment Folic acid 0.5mg TAB Folic acid Folic acid Accepted treatment Folic acid CAP Folic acid forte Folic acid Accepted treatment

Page 40 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM Folic acid 5mg TAB Be-tabs folic acid Folic acid Accepted treatment Folic acid 5mg CAP Folic acid Folic acid Accepted treatment Hydrocortisone 0.50% LOT Cutaderm Corticosteroids, topical Accepted treatment Hydrocortisone 0.5g OIN Dilucort Corticosteroids, topical Accepted treatment Hydrocortisone 5mg/g CRE Dilucort Skincalm Corticosteroids, topical Accepted treatment Hydrocortisone 10mg/g OIN Mylocort Procutan Corticosteroids, topical Accepted treatment Hydrocortisone 10mg/g CRE Mylocort Procutan Corticosteroids, topical Accepted treatment Ibuprofen 400mg TAB Adco-ibuprofen Ranfen Non-steroidal anti-inflammatory drugs Accepted treatment Ibuprofen 100mg/5ml SUS Brufen paed susp Ibumax Non-steroidal anti-inflammatory drugs Accepted treatment Ibuprofen 200mg TAB SANDOZ Ibuprofen Inza Non-steroidal anti-inflammatory drugs Accepted treatment Ibuprofen 600mg TAB SANDOZ Ibuprofen Brufen Non-steroidal anti-inflammatory drugs Accepted treatment Indomethacin 100mg SUP Arthrexin Indocid Non-steroidal anti-inflammatory drugs Motivation required Indomethacin 25mg CAP SANDOZ Idomethacin Arthrexin Non-steroidal anti-inflammatory drugs Accepted treatment Ketoprofen 200mg SRC Ketoflam Non-steroidal anti-inflammatory drugs Accepted treatment Loperamide 2mg TAB Adco-loperamide Betaperamide Antipropulsives Accepted treatment Meloxicam 15mg TAB Loxiflam Arrow Meloxicam Non-steroidal anti-inflammatory drugs Accepted treatment Meloxicam 7.5mg TAB SANDOZ Meloxicam Coxflam Non-steroidal anti-inflammatory drugs Accepted treatment Methotrexate 2.5mg TAB Emthexate Emthexate Immunosuppressants Accepted treatment Naproxen 250mg TAB Adco-naproxen Mylan-naproxen Non-steroidal anti-inflammatory drugs Accepted treatment Naproxen 500mg SUP Nafasol Non-steroidal anti-inflammatory drugs Motivation required Naproxen 250mg ECT Nafasol ec-250 Non-steroidal anti-inflammatory drugs Accepted treatment Naproxen 500mg ECT Nafasol ec-500 Non-steroidal anti-inflammatory drugs Accepted treatment Naproxen 500mg TAB Napflam Non-steroidal anti-inflammatory drugs Accepted treatment Piroxicam 10mg CAP Adco-piroxicam Rolab-piroxicam Non-steroidal anti-inflammatory drugs Accepted treatment Piroxicam 20mg CAP Adco-piroxicam Xycam Non-steroidal anti-inflammatory drugs Accepted treatment Piroxicam 20mg TAB Brexecam Non-steroidal anti-inflammatory drugs Accepted treatment Piroxicam 20mg DSP Pixicam Xycam dispers Non-steroidal anti-inflammatory drugs Accepted treatment Prednisolone 5mg TAB Lenisolone Capsoid Corticosteroids , oral Motivation required Prednisone 5mg TAB Be-tabs prednisone Panafcort Corticosteroids, oral Motivation required Salicylic acid PWD Salicylic acid BP Salicylic Acid Accepted treatment ULCERATIVE COLITIS ICD10: K51.0, K51.1, K51.2, K51.3, K51.4, K51.5, K51.8, K51.9 Azathioprine 50mg TAB Azapress Imuran Immunosuppressants Accepted treatment

Page 41 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM Budesonide 0.02mg/ml ENE Entocord Intestinal antiinflammatory agent Motivation required Loperamide 2mg TAB Adco-loperamide Betaperamide Antipropulsives Accepted treatment Hydrocortisone 10mg TAB Covocort Corticosteroids , oral Accepted treatment Mesalazine 800mg TAB Asacol 5-ASA agents Motivation required Mesalazine 2g/50ml ENE Asacol 5-ASA agents Motivation required Mesalazine 400mg TAB Asacol 5-ASA agents Motivation required Mesalazine 500mg SUP Asacol 5-ASA agents Motivation required Mesalazine 1000mg SUP Pentasa 5-ASA agents Motivation required Mesalazine 500mg TAB Pentasa 5-ASA agents Motivation required Methotrexate 2.5mg TAB Emthexate Emthexate Immunosuppressants Accepted treatment Olsalazine 250mg CAP Dipentum 5-ASA agents Motivation required Prednisolone 5mg TAB Lenisolone Capsoid Corticosteroids , oral Accepted treatment Prednisone 5mg TAB Be-tabs prednisone Panafcort Corticosteroids, oral Accepted treatment Sulfasalazine 500mg TAB Salazopyrin 5-ASA agents Accepted treatment Sulfasalazine 500mg ECT Salazopyrin e n 5-ASA agents Accepted treatment

Page 42 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM DIAGNOSIS AND TREATMENT PAIRS (DTP) CONDITIONS ADRENOCORTICAL HYPERSECRETION ICD 10: E25.0 E25.8 E25.9 E26.0 E26.1 E26.8 E26.9 Hydrochlorothiazide and 50mg/5mg TAB Amiloretic Betaretic Diuretics Accepted treatment potassium-sparing agents Hydrochlorothiazide and 25mg/2.5mg TAB Amiloretic hs Diuretics Accepted treatment potassium-sparing agents Hydrochlorothiazide and 50mg/25mg TAB Dyazide Renezide Diuretics Accepted treatment potassium-sparing agents Spironolactone 25mg TAB SAN DOZ Spironolactone Spiractin Diuretics Accepted treatment ADRENOCORTICAL INSUFFICIENCY ICD 10: E27.0 E27.1 E27.2 E27.3 E27.4 E27.5 E27.8 E27.9 Fludrocortisone 0.1mg TAB Florinef acetate Corticosteroids , oral Motivation required Hydrocortisone 10mg TAB Covocort Corticosteroids , oral Accepted treatment Prednisone 5mg TAB Be-tabs prednisone Panafcort Corticosteroids , oral Accepted treatment Prednisolone 5mg TAB Lenisolone Capsoid Corticosteroids , oral Accepted treatment ANAEMIA ICD 10: D50.0 D51.0 D50.8 D50.9 D51.0 D51.1 D51.2 D51.3 D51.8 D51.9 D52.0 D52.1 D52.8 D52.9 D53.0 D53.1 D53.2 D53.8 D53.9 D55.0 D55.1 D55.2 D55.3 D55.8 D55.9 D57.0 D57.1 D57.2 D57.8 D58.0 D58.1 D59.0 D59.1 D59.2 D59.3 D59.4 D59.6 D59.8 D59.9 D60.0 D60.1 D60.8 D60.9 D61.0 D61.1 D61.2 D61.3 D61.8 D61.9 D62 D63.0 special investigations, FULL BLOOD Cyanocobalamin 1000mcg/ml INJ Vitamin b12 10ml Iron supplementation, oral COUNT special investigations, FULL BLOOD Cyanocobalamin 1000mcg/ml INJ Vitamin b12 1ml Iron supplementation, oral COUNT special investigations, FULL BLOOD Ferrous fumarate TAB Pregamal Iron Supplements COUNT Ferrous Lactate 25mg DRP Ferro L drops special investigations, Full blood count special investigations, FULL BLOOD Ferrous sulfate TAB Ferrous sulph co Iron Supplements COUNT special investigations, FULL BLOOD Ferrous sulfate 100mg TAB Ferrous sulphate Iron Supplements COUNT special investigations, FULL BLOOD Ferrous sulfate 30mg TAB Ferrous sulphate Iron Supplements COUNT Folic acid 0.5mg TAB Folic acid Folic acid Accepted treatment Folic acid CAP Folic acid forte Folic acid Accepted treatment Folic acid 5mg TAB Be-tabs folic acid Folic acid Accepted treatment Folic acid 5mg CAP Folic acid Folic acid Accepted treatment special investigations, FULL BLOOD Iron multivitamins and folic acid 100mg TAB Foliferr Iron multivitamins and folic acid COUNT

Page 43 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM special investigations, FULL BLOOD Iron Polymaltose 50mg CAP Ferrimed Iron Supplements COUNT ARRHYTHMIAS ICD 10: I44.0 I44.1 I44.2 I44.3 I44.4 I44.5 I44.6 I44.7 I45.0 I45.0 I45.1 I45.2 I45.3 I45.4 I45.5 I45.6 I45.8 I46.0 I46.9 I47.0 I47.1 I47.2 I47.9 I48 I49.0 I49.1 I49.3 I49.4 I49.5 I49.8 I49.9 P29.1 Acetylsalicylic acid 81mg ECT Ecotrin Aspirin Accepted treatment

Page 44 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM Sotalol 160mg TAB Sotahexal Beta blockers Motivation required Sotalol 80mg TAB Sotahexal Beta blockers Motivation required Verapamil 40mg TAB Isoptin Vasomil Calcium channel blockers Accepted treatment Verapamil 80mg TAB Vasomil Calcium channel blockers Accepted treatment Verapamil 240mg SRT Calcicard sr 240 Verahexal 240 sr Calcium channel blockers Accepted treatment Warfarin 1mg TAB Cipla Warfarin Anticoagulants Accepted treatment Warfarin 5mg TAB Cipla Warfarin Aspen Warfarin Anticoagulants Accepted treatment Warfarin 3mg TAB Cipla-Warfarin Anticoagulants Accepted treatment BENIGN PROSTATIC HYPERTROPHY ICD 10: N40 Alfuzosin 10mg TAB Alfuwin xl Rantral MR Alpha-adrenoreceptor antagonists Motivation required Cardugen (Prev Mylan- Doxazosin 1mg TAB Adco-doxazosin Alpha blockers Accepted treatment Doxasozin) Doxazosin 2mg TAB Adco-doxazosin Alpha blockers Accepted treatment Cardugen (prev Mylan- Doxazosin 4mg TAB Adco-doxazosin Alpha blockers Accepted treatment Doxasozin) Doxazosin (extended release) 4mg TAB Cardura XL Carzin XL Alpha blockers Motivation required Doxazosin (extended release) 8mg TAB Cardura xl Alpha blockers Motivation required Testosterone-5-alpha reductase Dutasteride CAP Avodart Motivation required inhibitors Testosterone-5-alpha reductase Finasteride 5mg TAB Fincar Finpro Motivation required inhibitors Prazosin 1mg TAB Pratsiol Alpha blockers Accepted treatment Prazosin 2mg TAB Pratsiol Alpha blockers Accepted treatment Prazosin 5mg TAB Pratsiol Alpha blockers Accepted treatment Testosterone-5-alpha reductase Tamsulosin 0,4mg SRC Prostaflo sr Beniprosin Motivation required inhibitors COAGULATION DEFECTS ICD 10: D68.0 D68.1 D68.2 D68.3 D68.4 D68.8 D68.9 D69.1 D69.3 D69.4 D69.5 D69.6 D69.8 Acetylsalicylic acid 81mg ECT Ecotrin Aspirin Accepted treatment

Disprin CV 100 disp TAB Acetylsalicylic acid 100mg TAB Bayer aspirin cardio Aspirin Accepted treatment 100mg Acetylsalicylic acid 300mg DSP Disprin cv 300 disp Bayer aspirin Aspirin Accepted treatment Genpharma Children Acetylsalicylic acid 60mg TAB Aspirin Accepted treatment Aspirin(prev.Asp.jnr) Acetylsalicylic acid 125mg TAB Lo-aspirin Aspirin Accepted treatment Amlodipine 10mg TAB Almadin Gulf Amlodipine Calcium channel blockers Accepted treatment Amlodipine 5mg TAB Almadin Gulf Amlodipine Calcium channel blockers Accepted treatment Digoxin 0.0625mg TAB Lanoxin Cardiac glycosides Accepted treatment Digoxin 0.25mg TAB Lanoxin Purgoxin Cardiac glycosides Accepted treatment Digoxin 0.05mg/ml SYR Lanoxin paed Cardiac glycosides Accepted treatment Diltiazem 60mg TAB Zildem 60 Calcium channel blockers Accepted treatment Diltiazem 90mg TAB Zildem 90 Calcium channel blockers Accepted treatment Diltiazem 180mg SRC Tilazem 180 cr Zil dem 180 sr Calcium channel blockers Accepted treatment Diltiazem 240mg SRC Tilazem 240 cr Zildem 240 sr Calcium channel blockers Accepted treatment Dipyridamole 200mg/25mg CAP Asasantin 200/25 retard Antithrombotic agents Accepted treatment Dipyridamole 200mg SRC Persantin 200 retard Antithrombotic agents Accepted treatment Page 46 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM Dipyridamole 100mg TAB Plato Antithrombotic agents Accepted treatment Dipyridamole 25mg TAB Plato Antithrombotic agents Accepted treatment Felodipine 10mg SRT Felodipine-Hexal Plendil Calcium channel blockers Accepted treatment Felodipine 5mg SRT Felodipine-Hexal Plendil Calcium channel blockers Accepted treatment Furosemide 20mg TAB Lasix Diuretics Accepted treatment Furosemide 10mg/ml SYR Lasix oral Diuretics Motivation required Furosemide 40mg TAB Mylan-fu rosemide Beurises Diuretics Accepted treatment Hydrochlorothiazide and 50mg/5mg TAB Adco-retic Spec-Co-Amiloride Diuretics Accepted treatment potassium-sparing agents Hydrochlorothiazide and 25mg/2.5mg TAB Amiloretic hs Diuretics Accepted treatment potassium-sparing agents Hydrochlorothiazide and 50mg/25mg TAB Dyazide Renezide Diuretics Accepted treatment potassium-sparing agents Hydralazine 10mg TAB Hyperphen Vasodilators Accepted treatment Hydralazine 50mg TAB Hyperphen Vasodilators Accepted treatment Indapamide 2.5mg TAB Cipla-Indapamide Daptril Diuretics Accepted treatment Methyldopa (levorotatory) 250mg TAB Hypotone SANDOZ Methyldopa Antiadrenegic agents, centrally acting Accepted treatment Methyldopa (levorotatory) 500mg TAB Hypotone Antiadrenegic agents, centrally acting Accepted treatment Nifedipine 20mg SRT Cipalat Retard Nifedalat SR Calcium channel blockers Accepted treatment Nifedipine 30mg SRT Fedaloc Spec Nifedipine SR Calcium channel blockers Accepted treatment Nifedipine 60mg SRT Fedaloc Spec Nifedipine SR Calcium channel blockers Accepted treatment Reserpine 0.25mg TAB Reserpine Antiadrenegic agents, centrally acting Accepted treatment Sildenafil 20mg TAB Revatio Vasodilators Motivation required Spironolactone 100mg TAB Aldactone Diuretics Accepted treatment Spironolactone 25mg TAB Aldactone SANDOZ Spironolactone Diuretics Accepted treatment Spironolactone 100mg TAB Spiractin Diuretics Accepted treatment Verapamil 40mg TAB Isoptin Vasomil Calcium channel blockers Accepted treatment Verapamil 80mg TAB Vasomil Calcium channel blockers Accepted treatment Verapamil 240mg SRT Calcicard sr 240 Verahexal 240 sr Calcium channel blockers Accepted treatment Warfarin 1mg TAB Cipla Warfarin Anticoagulants Accepted treatment Warfarin 5mg TAB Cipla Warfarin Aspen Warfarin Anticoagulants Accepted treatment Warfarin 3mg TAB Cipla-Warfarin Anticoagulants Accepted treatment CONGENITAL IODINE DEFICIENCY ICD 10: E00.0 E00.1 E00.2 E00.9 Levothyroxine sodium 0.05mg TAB Eltroxin Thyroid hormones Accepted treatment

Page 47 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM Levothyroxine sodium 0.1mg TAB Eltroxin Thyroid hormones Accepted treatment Levothyroxine sodium 100mcg TAB Euthyrox Synthroid Thyroid hormones Accepted treatment Levothyroxine sodium 25mcg TAB Euthyrox Thyroid hormones Accepted treatment Levothyroxine sodium 50mcg TAB Euthyrox Thyroid hormones Accepted treatment Levothyroxine sodium 88mcg TAB Synthroid Thyroid hormones Accepted treatment Levothyroxine sodium 112mcg TAB Synthroid Thyroid hormones Accepted treatment Liothyronine sodium 90mcg TAB Diotroxin Thyroid hormones Accepted treatment Liothyronine sodium 20mcg TAB Tertroxin Thyroid hormones Accepted treatment CUSHING'S SYNDROME ICD 10: E24.0 E24.1 E24.2 E24.3 E24.8 E24.9 Octreotide 0.05mg INJ Sandostatin Growth hormone release inhibitor Motivation required Octreotide 0.1mg INJ Sandostatin Growth hormone release inhibitor Motivation required Octreotide 0.2mg INJ Sandostatin Growth hormone release inhibitor Motivation required Octreotide 10mg INJ Sandostatin LAR prefilled Growth hormone release inhibitor Motivation required Octreotide 20mg INJ Sandostatin LAR prefilled Growth hormone release inhibitor Motivation required DELUSIONAL DISORDERS ICD 10: F22.0 F22.8 F22.9 Amisulpiride 50mg TAB Solian Antipsychotics Accepted treatment Amisulpiride 200mg TAB Solian Antipsychotics Accepted treatment Amitriptyline 25mg TAB SANDOZ Amitryptyline Trepiline Heterocyclic antidepressant Accepted treatment Aripiprazole 5mg TAB Abilify Antipsychotics Motivation required Aripiprazole 10mg TAB Abilify Antipsychotics Motivation required Aripiprazole 15mg TAB Abilify Antipsychotics Motivation required Chlorpromazine 100mg TAB Largactil Antipsychotics Accepted treatment Chlorpromazine 25mg TAB Largactil Antipsychotics Accepted treatment Chlorpromazine 50mg TAB Largactil Antipsychotics Accepted treatment Citalopram 20mg TAB Auro-Citalopram Austell-Citalopram Selective serotonin receptor inhibitors Accepted treatment Citalopram 10mg TAB Austell-Citalopram Selective serotonin receptor inhibitors Accepted treatment Citalopram 40mg TAB Depramil Arrow 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 Clozapine 100mg TAB Cloment Leponex Mood stabilisers Accepted treatment Clozapine 25mg TAB Cloment Leponex Mood stabilisers Accepted treatment

Page 48 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM Dothiepin 25mg CAP Prothiaden Thaden Heterocyclic antidepressants Accepted treatment Dothiepin 75mg TAB Thaden Heterocyclic antidepressants Accepted treatment Fluoxetine 20mg CAP Nuzak Lilly-fluoxetine Selective serotonin receptor inhibitors Accepted treatment Fluoxetine 20mg TAB Lorien Rezak Selective serotonin receptor inhibitors Accepted treatment Fluoxetine 20mg DSP Prohexal 20t Selective serotonin receptor inhibitors Accepted treatment Flupenthixol 0.5mg TAB Fluanxol Antipsychotics Accepted treatment Flupenthixol 1mg TAB Fluanxol Antipsychotics Accepted treatment Haloperidol 1.5mg TAB SANDOZ Halope ridol Antipsychotics Accepted treatment Haloperidol 5mg TAB SANDOZ Haloperidol Serenace Antipsychotics Accepted treatment Haloperidol 0.5mg CAP Serenace Antipsychotics Accepted treatment Haloperidol 10mg TAB Serenace Antipsychotics Accepted treatment Imipramine 25mg TAB Ethipramine Tofranil Heterocyclic antidepressants Accepted treatment Lithium 250mg TAB Camcolit Mood stabilisers Accepted treatment Lithium 400mg TAB Camcolit Mood stabilisers Accepted treatment Lithium 50mg CAP Lithium succinate Mood stabilisers Accepted treatment Lithium 450mg TAB Quilonum retard Mood stabilisers Accepted treatment Maprotiline 25mg TAB Ludiomil Heterocyclic antidepressants Motivation required Maprotiline 75mg TAB Ludiomil Heterocyclic antidepressants Motivation required Paliperidone 3mg TAB Invega Antipsychotics Motivation required Paliperidone 6mg TAB Invega Antipsychotics Motivation required Paliperidone 9mg TAB Invega Antipsychotics Motivation required Quetiapine 25mg TAB Dopaquel Serez Antipsychotics Motivation required Quetiapine 100mg TAB Truvalin Quetoser Antipsychotics Motivation required Quetiapine 200mg TAB Mylan Quetiapine Dopaquel Antipsychotics Motivation required Quetiapine 300mg TAB Serez Truvalin Antipsychotics Motivation required Quetiapine 200mg TAB Seroquel XR 200 Antipsychotics Motivation required Quetiapine 300mg TAB Seroquel XR 300 Antipsychotics Motivation required Quetiapine 400mg TAB Seroquel XR 400 Antipsychotics Motivation required Risperidone 0.5mg TAB Aspen Risperidone Risperlet Antipsychotics Accepted treatment Risperidone 2mg TAB Aspen Risperidone Risperdal Quicklet Antipsychotics Accepted treatment Risperidone 3mg TAB Aspen Risperidone Risperidone-Hexal Antipsychotics Accepted treatment Risperidone 3mg TAB Auropidone Antipsychotics Accepted treatment Risperidone 1.0mg TAB DRL-Risperidone Auroperdal Antipsychotics Accepted treatment

Page 49 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM Risperidone 1mg/ml SYR Risperdal Antipsychotics Accepted treatment Risperidone 4mg TAB Risperdal Risponz Antipsychotics Accepted treatment Risperidone 1mg TAB Risperlet Rispacor Antipsychotics Accepted treatment Sulpiride 200mg TAB Bio-Sulpiride Substituted benzamide Accepted treatment Sulpiride 50mg CAP Eglonyl Substituted benzamide Accepted treatment Sulpiride 50mg CAP Espiride Substituted benzamide Accepted treatment Sulpiride 50mg CAP SANDOZ Sulpiride Substituted benzamide Accepted treatment Trifluoperazine 1mg TAB Stelazine Selective serotonin receptor inhibitors Accepted treatment Trifluoperazine 5mg TAB Stelazine Selective serotonin receptor inhibitors Accepted treatment Ziprasidone 20mg CAP Geodon Antipsychotics Motivation required Ziprasidone 40mg CAP Geodon Antipsychotics Motivation required Ziprasidone 60mg CAP Geodon Antipsychotics Motivation required Ziprasidone 80mg CAP Geodon Antipsychotics Motivation required Zuclopenthixol 10mg TAB Clopixol Antipsychotics Accepted treatment Zuclopenthixol 2mg TAB Clopixol Antipsychotics Accepted treatment DISSEMINATED BULLOUS SKIN DISEASE ICD 10: L10.0 L10.1 L10.2 L10.3 L10.4 L10.5 L10.8 L10.9 L12.0 L12.1 L12.2 L12.3 L12.8 L12.9 L13.0 L13.1 L13.8 L13.9 Q81.0 Q81.1 Q81.2 Q81.8 Q81.9 Azathioprine 50mg TAB Azamun Azathioprine Immunosuppressants Accepted treatment Ciclosporin 100mg CAP Sandimmun Neoral soft gel Immuosuppressants Motivation required Ciclosporin 25mg CAP Sandimmun Neoral soft gel Immuosuppressants Motivation required Cyclophosphamide 50mg TAB Endoxan Immunosuppressants Motivation required Methotrexate 2.5mg TAB Emthexate Methotrexate Immunosuppressants Accepted treatment Prednisolone 5mg TAB Lenisolone Prelone Corticosteroids , oral Accepted treatment Prednisone 20mg TAB Pulmison Corticosteroids , oral Accepted treatment Prednisone 5mg TAB Be-tabs prednisone Panafcort Corticosteroids , oral Accepted treatment ENDOMETRIOSIS ICD 10: N80.0 N80.1 N80.2 Cyproterone & Estrogen 2mg TAB Diva-35 Hormonal preparations, oral Motivation required Cyproterone acetate 50mg TAB Cipla-cyproterone acetate Cyproplex Hormonal preparations, oral Motivation required Cyproterone acetate 2mg TAB Adco-fem Diane-35 Hormonal preparations, oral Motivation required Danazol 100mg CAP Danogen Ladazol (Ladogar) Antigonadotropins Motivation required Danazol 200mg CAP Danogen Ladazol (Ladogar) Antigonadotropins Motivation required Desogestrel and estrogen TAB Marvelon 150/30 Hormonal preparations, oral Motivation required

Page 50 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM Desogestrel and estrogen TAB Mercilon Hormonal preparations, oral Motivation required Drospirenone and estrogen TAB Yasmin Ruby Hormonal preparations, oral Motivation required Drospirenone and estrogen TAB Yaz Hormonal preparations, oral Motivation required Gestodene and estrogen TAB Femodene ed Minulette Hormonal preparations, oral Motivation required Gestodene and estrogen TAB Melodene Hormonal preparations, oral Motivation required Gestodene and estrogen TAB Mirelle Minesse Hormonal preparations, oral Motivation required Gestodene and estrogen TAB Tri-minulet Hormonal preparations, oral Motivation required Gestodene and estrogen TAB Triodene ed Hormonal preparations, oral Motivation required Goserelin 10.8mg INJ Zoladex Hormones and related agents Motivation required Goserelin 3.6mg INJ Zoladex Hormones and related agents Motivation required Leuprorelin 3.75mg INJ Lucrin Hormones and related agents Motivation required Leuprorelin 11.25mg INJ Lucrin Hormones and related agents Motivation required Levonorgestrel and estrogen TAB Biphasil Hormonal preparations, oral Motivation required Levonorgestrel and estrogen TAB Logynon ed Hormonal preparations, oral Motivation required Levonorgestrel and estrogen TAB Triphasil Hormonal preparations, oral Motivation required Medroxyprogesterone 10mg TAB HEXAL-MPA 10 Provera Hormone replacement therapy Accepted treatment Medroxyprogesterone 5mg TAB HEXAL-MPA 5 Provera Hormone replacement therapy Accepted treatment Medroxyprogesterone 10mg TAB HEXAL-MPA 10 Provera Hormonal preparations, oral Accepted treatment Medroxyprogesterone 5mg TAB HEXAL-MPA 5 Provera Hormonal preparations, oral Accepted treatment Norethisterone 5mg TAB Primolut n Hormonal preparations, oral Accepted treatment Gonadotrophin Releasing Hormones Nafarelin NAS Synarel Motivation required and analogues Norethisterone 5mg TAB Primolut n Hormonal preparations, oral Accepted treatment Norethisterone and estrogen 0.5mg TAB Trinovum Hormonal preparations, oral Motivation required Norgestimate & oestrogen 0.180mg TAB Tricilest Hormonal preparations, oral Motivation required HYPERPARATHYROIDISM ICD 10: E21.0 E21.1 E21.2 E21.3 E21.4 E21.5 Calcitonin (salmon synthetic) 200iu NAS Miacalcic nas spray Anti-Parathyroid hormones Motivation required Calcitonin (salmon synthetic) 100iu INJ Miacalcic(calcitonin) Anti-Parathyroid hormones Motivation required Chloroquine 200mg TAB Nivaquine Aminoquinolines Accepted treatment Chloroquine 200mg CAP Plasmoquine Aminoquinolines Accepted treatment SANDOZ Chloroquine Chloroquine 250mg TAB Aminoquinolines Accepted treatment phosphate Cinacalcet 30mg TAB Sensipar Hormone inhibitors Motivation required

Page 51 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM Cinacalcet 60mg TAB Sensipar Hormone inhibitors Motivation required HYPERTHYROIDISM ICD 10: E05.0 E05.1 E05.2 E05.3 E05.4 E05.5 E05.8 E05.9 Carbimazole 5mg TAB Neo-mercazole Imidazole derivatives Motivation required Propranolol 10mg TAB Indoblok 10 Prodorol Beta blockers Accepted treatment Propranolol 40mg TAB Indoblok 40 Prodorol Beta blockers Accepted treatment HYPOPARATHYROIDISM ICD 10: E20.0 E20.1 E20.8 E20.9 E89.2 Calcium 500mg CHU B-cal Mineral Supplement Accepted treatment Calcium (different salts in 500mg CHU Virtual Care Calcium D Chewy Mineral Supplement Accepted treatment combination) Calcium (different salts in 500mg TAB Virtual Care Calcium D solid Mineral Supplement Accepted treatment combination) Calcium carbonate 500mg CHU Calcichew 500mg chewable Mineral Supplement Accepted treatment Calcium carbonate 500mg SAC Calcidose vit d oral powder Mineral Supplement Accepted treatment Calcium carbonate 500mg EFT Calcium-hexal 500 Fizzical 500 Mineral Supplement Accepted treatment Calcium carbonate 500mg TAB Calsuba calcium Mineral Supplement Accepted treatment Calcium carbonate 300mg CHU Caltrate 300 Link calcium Mineral Supplement Accepted treatment Calcium carbonate 600mg EFT Caltrate 600 + D effervescent Mineral Supplement Accepted treatment Calcium carbonate 600mg TAB Caltrate d Mineral Supplement Accepted treatment Calcium gluconate 300mg TAB Calcium gluconate (fams) Calcium gluconate chew Mineral Supplement Accepted treatment Calcium, combinations with 500mg CHU B-cal-d vitamin & Mineral Supplement Accepted treatment other drugs Calcium, combinations with 500mg TAB B-cal-d vitamin & Mineral Supplement Accepted treatment other drugs ISCHAEMIC HEART DISEASE ICD 10: I21.0 I21.1 I21.2 I21.3 I21.4 I21.9 I22.0 I22.1 I22.8 I22.9 I23.0 I23.1 I23.2 I23.5 I23.6 I23.8 I24.1 I24.8 I24.9 I51.0 I51.1 I51.2 I51.3 I51.5 I51.7 Acetylsalicylic acid 81mg ECT Ecotrin Aspirin Accepted treatment

Page 52 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM Amlodipine besylate 5mg TAB Austell-Amlodipine Lomanor Calcium channel blockers Accepted treatment Pharma Dynamics Amlodipine besylate 10mg TAB Calbloc Calcium channel blockers Accepted treatment Amlodipine Besylate Amlodipine maleate 10mg TAB Amlate Calcium channel blockers Accepted treatment Amlodipine maleate 5mg TAB Amlate Calcium channel blockers Accepted treatment Atenolol 50mg TAB Adco-atenolol B-Block Beta blockers Accepted treatment Atenolol 100mg TAB Gulf Atenolol 100 Sandoz Atenolol Beta blockers Accepted treatment Atenolol 25mg TAB Tenopress Tenormin 25 Beta blockers Accepted treatment Bisoprolol 2.5mg TAB Cardicor Beta blockers Accepted treatment Bisoprolol 5mg TAB Cardicor Concor Beta blockers Accepted treatment Bisoprolol 10mg TAB Concor Bilocor Beta blockers Accepted treatment Carvedilol 12.5mg TAB Carvedilol-Hexal Carvetren d Alpha/beta blockers Accepted treatment Carvedilol 25mg TAB Carvedilol-Hexal Carvetrend Alpha/beta blockers Accepted treatment Carvedilol 6.25mg TAB Carvedilol-Hexal Carvetrend Alpha/beta blockers Accepted treatment Diltiazem 60mg TAB Zildem 60 Calcium channel blockers Accepted treatment Diltiazem 90mg TAB Zildem 90 Calcium channel blockers Accepted treatment Diltiazem 180mg SRC Tilazem 180 cr Zildem 180 sr Calcium channel blockers Accepted treatment Diltiazem 240mg SRC Tilazem 240 cr Zildem 240 sr Calcium channel blockers Accepted treatment Dipyridimole 200mg SRC Persantin 200 Regards Antithrombotic agent Motivation required Dipyridimole 100mg TAB Plato Antithrombotic agent Motivation required Dipyridimole & Acetylsalicylic 200mg/25 CAP Asasantin Antithrombotic agent Motivation required acid Felodipine 10mg SRT Felodipine-Hexal Plendil Calcium channel blockers Accepted treatment Felodipine 5mg SRT Felodipine-Hexal Plendil Calcium channel blockers Accepted treatment Glyceryl trinitrate 0.5mg TAB Angised Organic nitrates Accepted treatment Isosorbide dinitrate 40mg TAB Isordil tembid Organic nitrates Accepted treatment Isosorbide dinitrate 30mg TAB SANDOZ Isosorbide Isordil Organic nitrates Accepted treatment Isosorbide dinitrate 10mg TAB SANDOZ Isosorbide Dinitrate Isordil Organic nitrates Accepted treatment Isosorbide dinitrate 5mg TAB SANDOZ Isosorbide Dinitrate Isordil sublingual Organic nitrates Accepted treatment Isosorbide mononitrate 20mg TAB Elantan Ismo 20 Organic nitrates Accepted treatment Isosorbide mononitrate 50mg SRC Elantan la Organic nitrates Accepted treatment Isosorbide-5-mononitrate 60mg SRT Imdur Monicor SR Organic nitrates Accepted treatment Nifedipine 30mg TAB Adalat xl Calcium channel blockers Accepted treatment Nifedipine 60mg TAB Adalat xl Calcium channel blockers Accepted treatment

Page 53 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM Nifedipine 60mg SRT Fedaloc Calcium channel blockers Accepted treatment Nifedipine 60mg SRT Macorel 60 SR Calcium channel blockers Accepted treatment Nifedipine 20mg SRT Nifedalat SR Cipalat Retard Calcium channel blockers Accepted treatment Nifedipine 30mg SRT Spec Nifedipine SR Macorel 30 SR Calcium channel blockers Accepted treatment Nifedipine 60mg SRT Spec Nifedipine SR Calcium channel blockers Accepted treatment Propranolol 10mg TAB Prodorol Purbloka Beta blockers Accepted treatment Propranolol 40mg TAB Prodorol Purbloka Beta blockers Accepted treatment Verapamil 240mg SRT Calcicard sr 240 Calcium channel blockers Accepted treatment Verapamil 240mg SRT Isoptin sr Calcium channel blockers Accepted treatment Verapamil 240mg SRT Ravamil sr Calcium channel blockers Accepted treatment Verapamil 40mg TAB Vasomil Isoptin Calcium channel blockers Accepted treatment Verapamil 80mg TAB Vasomil Calcium channel blockers Accepted treatment Verapamil 240mg SRT Verahexal 240 sr Calcium channel blockers Accepted treatment Warfarin 1mg TAB Cipla Warfarin Anticoagulants Accepted treatment Warfarin 5mg TAB Cipla Warfarin Aspen Warfarin Anticoagulants Accepted treatment Warfarin 3mg TAB Cipla-Warfarin Anticoagulants Accepted treatment MENOPAUSE ICD 10: N95.0 N95.1 N95.2 N95.3 N95.8 N95.9 Clonidine 0.025mg TAB Dixarit Menograine Alpha-2 agonists Accepted treatment Conjugated estrogens 0.3mg TAB Premarin Hormonal preparations, oral Accepted treatment Conjugated estrogens 0.625mg TAB Premarin Hormonal preparations, oral Accepted treatment Conjugated estrogens 0.625mg/g VCR Premarin Hormonal preparations, oral Motivation required Conjugated estrogens 1.25mg TAB Premarin Hormonal preparations, oral Accepted treatment Cyproterone and estrogen TAB Climen Hormonal preparations, oral Accepted treatment Drospirenone and estrogen 1mg/2mg TAB Angeliq Hormonal preparations, oral Accepted treatment Dydrogesterone 10mg TAB Duphaston 10mg Hormonal preparations, oral Accepted treatment Dydrogesterone 50g CRE Progesterone cream 3 Hormonal preparations, oral Motivation required Dydrogesterone and estrogen TAB Femoston 1/10 Hormonal preparations, oral Accepted treatment Dydrogesterone and estrogen TAB Femoston-Conti Hormonal preparations, oral Accepted treatment Estradiol 7.8mg PAD Climara 100 Hormonal preparations, oral Accepted treatment Estradiol 3.9mg PAD Climara 50 Hormonal preparations, oral Accepted treatment Estradiol 100mcg/day PAD Estraderm tts Estradot Hormonal preparations, oral Accepted treatment Estradiol 25mcg/day PAD Estraderm tts Estradot Hormonal preparations, oral Accepted treatment

Page 54 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM Estradiol 37.5mcg PAD Estradot Hormonal preparations, oral Accepted treatment Estradiol 50mcg PAD Estradot Evorel 50 tts Hormonal preparations, oral Accepted treatment Estradiol 75mcg PAD Estradot Evorel 75 tts Hormonal preparations, oral Accepted treatment Estradiol 1mg TAB Estrofem Estro-pause 1mg Hormonal preparations, oral Accepted treatment Estradiol 2mg TAB Estrofem Estro-pause 2mg Hormonal preparations, oral Accepted treatment Estradiol JEL Femigel pump Hormonal preparations, oral Accepted treatment Estradiol 20mg IMP Oestradiol Hormonal preparations, oral Accepted treatment Estradiol 1mg TAB Progynova Hormonal preparations, oral Accepted treatment Estradiol 2mg TAB Progynova Hormonal preparations, oral Accepted treatment Estradiol VAT Vagifem Hormonal preparations, oral Motivation required Estradiol; combinations TAB Menoflush Hormonal preparations, oral Accepted treatment Estriol VCR Synapause vag Hormonal preparations, oral Motivation required Estriol 2mg TAB Synapause-e3 Hormonal preparations, oral Accepted treatment Medrogestone and estrogen 25mg TAB Premelle Hormonal preparations, oral Accepted treatment Medrogestone and estrogen 5mg TAB Premelle Hormonal preparations, oral Accepted treatment Medrogestone and estrogen 0.3mg/1.5mg TAB Premelle LD Hormonal preparations, oral Accepted treatment Medrogestone and estrogen TAB Premelle-cycle 5 Hormonal preparations, oral Accepted treatment Medrogestone and estrogen 1.25mg TAB Prempak-n Hormonal preparations, oral Accepted treatment Medroxyprogesterone 10mg TAB HEXAL-MPA 10 Provera Hormonal preparations, oral Motivation required Medroxyprogesterone 5mg TAB HEXAL-MPA 5 Provera Hormonal preparations, oral Motivation required Norethisterone 5mg TAB Primolut n Hormonal preparations, oral Motivation required Norethisterone and estrogen TAB Activelle Hormonal preparations, oral Accepted treatment Norethisterone and estrogen 50/140 PAD Estalis Hormonal preparations, oral Motivation required Norethisterone and estrogen 50/250 PAD Estalis Hormonal preparations, oral Motivation required Norethisterone and estrogen PAD Evorel conti Evorel sequi Hormonal preparations, oral Motivation required Norethisterone and estrogen TAB Novofem Hormonal preparations, oral Accepted treatment Norethisterone and estrogen TAB Estro-pause n Hormonal preparations, oral Accepted treatment Norethisterone and estrogen TAB Estro-pause n forte Hormonal preparations, oral Accepted treatment Norethisterone and estrogen 2mg/1mg TAB Kliogest Hormonal preparations, oral Accepted treatment Norethisterone and estrogen TAB Trisequens Hormonal preparations, oral Accepted treatment Norgestimate and estrogen TAB Cilest Hormonal preparations, oral Accepted treatment Norgestrel and estrogen TAB Postoval Hormonal preparations, oral Accepted treatment Progesterone 100mg CAP Utrogestan Hormonal preparations, oral Motivation required

Page 55 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM MUSCULAR DYSTROPHY ICD 10: G71.0 Acetylsalicylic acid 81mg ECT Ecotrin Aspirin Accepted treatment

Disprin CV 100 disp TAB Acetylsalicylic acid 100mg TAB Bayer aspirin cardio Aspirin Accepted treatment 100mg Acetylsalicylic acid 300mg DSP Disprin cv 300 disp Aspirin Accepted treatment Genpharma Children Acetylsalicylic acid 60mg TAB Aspirin Accepted treatment Aspirin(prev.Asp.jnr) Acetylsalicylic acid 300mg TAB Gulf aspirin Bayer aspirin Aspirin Accepted treatment Acetylsalicylic acid 125mg TAB Lo-aspirin Aspirin Accepted treatment Amiodarone 100mg TAB AryCor Hexarone Antiarrhythmics Motivation required Amiodarone 200mg TAB Hexarone Bio-Amiodarone Antiarrhythmics Motivation required Amlodipine 10mg TAB Almadin Amloc Calcium channel blockers Accepted treatment Amlodipine 5mg TAB Amlodac Amlosyn Calcium channel blockers Accepted treatment Amlodipine besylate 10mg TAB Austell-Amlodipine Calbloc Calcium channel blockers Accepted treatment Amlodipine Besylate 5mg TAB Lomanor Ciplavasc Calcium channel blockers Accepted treatment Amlodipine maleate 10mg TAB Amlate Calcium channel blockers Accepted treatment Amlodipine maleate 5mg TAB Amlate Calcium channel blockers Accepted treatment Atenolol 25mg TAB Tenormin 25 Tenopress Beta blockers Accepted treatment Atenolol 100mg TAB Adco-atenolol B-Block Beta blockers Accepted treatment Atenolol 50mg TAB Bio-atenolol Gulf Atenolol Beta blockers Accepted treatment Atenolol and other diuretics 100mg/25mg TAB SANDOZ Co-tenidone Tenchlor Beta blockers and combinations Accepted treatment Sandoz Co-tenidone Atenolol and other diuretics 50mg/12.5mg TAB Tenchlor hs Beta blockers and combinations Accepted treatment 50mg/12.5mg Atenolol and thiazides 100mg/25mg TAB Adco-loten Beta blockers and combinations Accepted treatment Bisoprolol 5mg TAB Bilocor Bisoprolol Hexal Beta blockers Accepted treatment Bisoprolol 10mg TAB Bisohexal 10 Betacor Beta blockers Accepted treatment Bisoprolol 2.5mg TAB Cardicor Beta blockers Accepted treatment Bumetanide 0.5mg TAB Burinex Duiretics Motivation required Captopril 25mg TAB Bio-Captopril Capace ACE-inhibitors Accepted treatment Captopril 12.5mg TAB Capoten hs Captohexal ACE-inhibitors Accepted treatment Captopril 50mg TAB Captohexal Captomax ACE-inhibitors Accepted treatment Captopril and diuretics 50mg/25mg TAB Captoretic Zapto-co ACE-inhibitors and combinations Accepted treatment Carbamazepine 100mg/5ml SUS Tegretol s Anticonvulsants Accepted treatment Carbamazepine 200mg TAB Degranol SANDOZ Carbamazepine Anticonvulsants Accepted treatment

Page 56 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM Carbamazepine 400mg SRT SANDOZ Cabamazepine CR Tegretol CR Anticonvulsants Accepted treatment Carbamazepine 200mg SRT SANDOZ Carbamazepine CR Tegretol CR Anticonvulsants Accepted treatment Carvedilol 12.5mg TAB Aspen-Carvidelol Carloc Alpha/beta blockers Accepted treatment Carvedilol 25mg TAB Aspen-Carvidelol Carloc Alpha/beta blockers Accepted treatment Carvedilol 6.25mg TAB Aspen-Carvidelol Carloc Alpha/beta blockers Accepted treatment Clonazepam 0.5mg TAB Rivotril Benzodiazepine derivatives Motivation required Clonazepam 2.5mg DRP Rivotril Benzodiazepine derivatives Motivation required Clonazepam 2mg TAB Rivotril Benzodiazepine derivatives Motivation required Digoxin 0.0625mg TAB Lanoxin Cardiac glycosides Accepted treatment Digoxin 0.25mg TAB Lanoxin Cardiac glycosides Accepted treatment Digoxin 0.05mg/ml SYR Lanoxin paed Cardiac glycosides Accepted treatment Digoxin 0.25mg TAB Purgoxin Cardiac glycosides Accepted treatment Diltiazem 180mg SRC Tilazem 180 cr Zildem 180 sr Calcium channel blockers Accepted treatment Diltiazem 240mg SRC Tilazem 240 cr Zildem 240 sr Calcium channel blockers Accepted treatment Diltiazem 60mg TAB Adco-Zildem Calcium channel blockers Motivation required Diltiazem 90mg TAB Adco-Zildem Calcium channel blockers Motivation required Disopyramide 100mg CAP Rythmodan Antiarrhythmics Motivation required Disopyramide 250mg TAB Rythmodan retard Antiarrhythmics Motivation required Enalapril 10mg TAB Adco-enalapril Alapren 10 ACE-inhibitors Accepted treatment Enalapril 20mg TAB Adco-enalapril Alapren 20 ACE-inhibitors Accepted treatment Enalapril 5mg TAB Alapren 5 Ciplatec 5 ACE-inhibitors Accepted treatment Enalapril 2.5mg TAB Renitec 2 5 ACE-inhibitors Accepted treatment Enalapril and diuretics 20mg/12.5mg TAB Co-renitec Enap co ACE-inhibitors Accepted treatment Ethosuximide 250mg/5ml SYR Zarontin Ethosuximide Accepted treatment Felodipine 10mg SRT Felodipine-Hexal Plendil Calcium channel blockers Accepted treatment Felodipine 5mg SRT Felodipine-Hexal Plendil Calcium channel blockers Accepted treatment Flecainide 100mg TAB Tambocor Antiarrhythmics Motivation required Folic acid 0.5mg TAB Folic acid Folic acid Accepted treatment Folic acid CAP Folic acid forte Folic acid Accepted treatment Folic acid 5mg TAB Be-tabs folic acid Folic acid Accepted treatment Folic acid 5mg CAP Folic acid Folic acid Accepted treatment Furosemide 40mg TAB Austell- Furosemide Beurises Diuretics Accepted treatment Furosemide 20mg TAB Lasix Diuretics Accepted treatment

Page 57 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM Furosemide 10mg/ml SYR Lasix oral Diuretics Motivation required Gabapentin 100mg CAP Epleptin Ran-Gabapentin Anticonvulsants Motivation required Gabapentin 300mg CAP Epleptin Anticonvulsants Motivation required Gabapentin 600mg TAB Neurontin Anticonvulsants Motivation required Gabapentin 800mg TAB Neurontin Anticonvulsants Motivation required Gabapentin 400mg CAP Ran-Gabapentin Anticonvulsants Motivation required Hydralazine 10mg TAB Hyperphen Vasodilators Accepted treatment Hydralazine 50mg TAB SANDOZ Hydralazine Hyperphen Vasodilators Accepted treatment Hydrochlorothiazide 12.5mg TAB Ridaq Diuretics Accepted treatment Hydrochlorothiazide 25mg TAB Ridaq Hexazide Diuretics Accepted treatment Hydrochlorothiazide and 50mg/300mg TAB Urirex-k Diuretics Accepted treatment potassium Hydrochlorothiazide and 50mg/5mg TAB Adco-retic Betaretic Diuretics Accepted treatment potassium-sparing agents Hydrochlorothiazide and 25mg/2.5mg TAB Amiloretic hs Diuretics Accepted treatment potassium-sparing agents Hydrochlorothiazide and 50mg/25mg TAB Dyazide Renezide Diuretics Accepted treatment potassium-sparing agents Indapamide 2.5mg TAB Cipla-Indapamide Dapamax Diuretics Accepted treatment Isosorbide dinitrate 40mg TAB Isordil tembid Organic nitrates Accepted treatment Isosorbide dinitrate 30mg TAB SANDOZ Isosorbide Isordil Organic nitrates Accepted treatment Isosorbide dinitrate 10mg TAB SANDOZ Isosorbide Dinitrate Isordil Organic nitrates Accepted treatment Isosorbide dinitrate 5mg TAB SANDOZ Isosorbide Dinitrate Isordil sublingual Organic nitrates Accepted treatment Lamotrigine 2mg DSP Lamictin P 2 Anticonvulsants Accepted treatment Lamotrigine 5mg DSP Lamictin p5 Anticonvulsants Accepted treatment Lamotrigine 100mg TAB Aspen Lamotrigine Epitec Anticonvulsants Accepted treatment Lamotrigine 200mg TAB Dyna-Lamotrigine Lamidus Anticonvulsants Accepted treatment Lamotrigine 25mg TAB Epitec Lamitor Anticonvulsants Accepted treatment Lamotrigine 50mg TAB Epitec SANDOZ Lamotrigine Anticonvulsants Accepted treatment Lisinopril 10mg TAB Auro-Lisinopril Austell-Lisinopril ACE-inhibitors Accepted treatment Lisinopril 5mg TAB Auro-Lisinopril Hexal-lisinopril 5 ACE-inhibitors Accepted treatment Lisinopril 2.5mg TAB Austell-lisinopril ACE-inhibitors Accepted treatment Lisinopril 20mg TAB Zestril Zetomax ACE-inhibitors Accepted treatment Lisinopril and diuretics 10mg/12.5mg TAB Auro-Lisinopril Co HEXAL-Lisinopril Co ACE-inhibitors and combinations Accepted treatment Lisinopril and diuretics 20mg/12.5mg TAB Auro-Lisinopril Co HEXAL-Lisinopril Co ACE-inhibitors and combinations Accepted treatment

Page 58 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM Losartan 100mg TAB Cipla Losartan Cozaar Angiotensin receptor blockers Accepted treatment Losartan 50mg TAB Cipla Losartan Cozaar Angiotensin receptor blockers Accepted treatment Angiotensin receptor blockers and Losartan and diuretics 50mg/12.5mg TAB Zartan Co Losaar plus 50/12.5 Accepted treatment combinations Angiotensin receptor blockers and Losartan and diuretics 100mg/25mg TAB Zartan Co Lohype forte plus Accepted treatment combinations Nifedipine 20mg SRT Adco-Nifedpine Nifedalat SR 20mg Calcium channel blockers Accepted treatment Nifedipine 30mg TAB Adco-Vascard Fedaloc SR Calcium channel blockers Accepted treatment Nifedipine 60mg TAB Adco-Vascard Fedaloc SR Calcium channel blockers Accepted treatment Perindopril 4mg TAB Cipla Perindopril Ciplasyl ACE-inhibitors Accepted treatment Perindopril 8mg TAB Cipla-Perindopril Ciplasyl ACE-inhibitors Accepted treatment Perindopril 10mg TAB Prexum Coversyl ACE-inhibitors Accepted treatment Perindopril and diuretics 2mg/0.625mg TAB Acesyl Co Preterax ACE-inhibitors and combinations Accepted treatment Perindopril and diuretics 4mg/1.25mg TAB Acesyl Co 4/1.25 BiPreterax ACE-inhibitors and combinations Accepted treatment Phenobarbital SYR Adco-phenobarb vital Anticonvulsants Accepted treatment Phenobarbital 30mg TAB Lethyl Sedabarb Anticonvulsants Accepted treatment Phenytoin 100mg CAP Epanutin Anticonvulsants Accepted treatment Phenytoin 125mg/5ml SUS Epanutin Anticonvulsants Motivation required Phenytoin 100mg TAB Phenytoin sod Anticonvulsants Accepted treatment Phenytoin 100mg CAP Epanutin Anticonvulsants Accepted treatment Potassium chloride 600mg TAB Plenish k SANDOZ K-600 Potassium supplements Accepted treatment Prednisone 5mg/ml SYR Pulmison paed oral solution Corticosteroids , oral Motivation required Prednisone 20mg TAB Pulmison Corticosteroids , oral Accepted treatment Prednisone 5mg TAB Be-tabs prednisone Panafcort Corticosteroids , oral Accepted treatment Propafenone 150mg TAB Rythmol Antiarrhythmics Motivation required Propafenone 300mg TAB Rythmol Antiarrhythmics Motivation required Propranolol 10mg TAB Prodorol Purbloka Beta blockers Accepted treatment Propranolol 40mg TAB Prodorol Purbloka Beta blockers Accepted treatment Quinapril 10mg TAB Accumax Accupril ACE-inhibitors Accepted treatment Quinapril 20mg TAB Accumax Accupril ACE-inhibitors Accepted treatment Quinidine 200mg TAB Quinidine sulph Antiarrhythmics Motivation required Ramipril 2.5mg TAB Ramace RamiprilHexal ACE-inhibitors Accepted treatment Ramipril 5mg TAB Ramace RamiprilHexal ACE-inhibitors Accepted treatment Ramipril 5mg CAP RamiWin ACE-inhibitors Accepted treatment

Page 59 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM Ramipril 10mg CAP Rampil ACE-inhibitors Accepted treatment Ramipril 2.5mg CAP Rampil ACE-inhibitors Accepted treatment Sotalol 160mg TAB Sotahexal Beta blockers Motivation required Sotalol 80mg TAB Sotahexal Beta blockers Motivation required Spironolactone 25mg TAB Spiractin SANDOZ S pironolactone Diuretics Accepted treatment Spironolactone 100mg TAB Spiractin Aldactone Diuretics Accepted treatment Telimisartan 40mg TAB Pritor Micardis ACE-Inhibitor Accepted treatment Telimisartan 80mg TAB Pritor Micardis ACE-Inhibitor Accepted treatment Telimisatan and diuretic 40mg/12.5mg TAB Co-Pritor Co-Micardis ACE-Inhibitor and diuretic Accepted treatment Telimisatan and diuretic 80mg/12.5mg TAB Co-Pritor Co-Micardis ACE-Inhibitor and diuretic Accepted treatment Telimisatan and diuretic 80mg/25mg TAB Co-Pritor Co-Micardis ACE-Inhibitor and diuretic Accepted treatment Topiramate 15mg CAP Topamax sc sprinkle Anticonvulsants Motivation required Topiramate 200mg TAB Adco-topiramate Piramax Anticonvulsants Motivation required Topiramate 25mg TAB Adco-topiramate Epitoz Anticonvulsants Motivation required Topiramate 50mg TAB Epitoz Topalex Anticonvulsants Motivation required Topiramate 25mg CAP Topamax sc sprinkle Anticonvulsants Motivation required Topiramate 50mg CAP Topamax sc sprinkle Anticonvulsants Motivation required Topiramate 100mg TAB Toplep Topalex Anticonvulsants Motivation required Trandolapril 0.5mg CAP Mavik (was Gopten) ACE-inhibitors Accepted treatment Trandolapril 2mg CAP Mavik (was Gopten) ACE-inhibitors Accepted treatment Valproic acid 50mg/ml SYR Convulex Anticonvulsants Accepted treatment Valproic acid 100mg TAB Epilim 100 crushable Anticonvulsants Accepted treatment Valproic acid 200mg/5ml SYR Epilim sugar free Anticonvulsants Accepted treatment Valproic acid 150mg CAP Convulex Anticonvulsants Accepted treatment Valproic acid 300mg CAP Convulex Anticonvulsants Accepted treatment Valproic acid 500mg CAP Convulex Anticonvulsants Accepted treatment Valproic acid 200mg SRT Epilim cr 200 Anticonvulsants Accepted treatment Valproic acid 300mg SRT Epilim cr 300 Anticonvulsants Accepted treatment Valproic acid 500mg SRT Epilim cr 500 Anticonvulsants Accepted treatment Valsartan 160mg TAB Migroben Diovan Angiotensin receptor blockers Accepted treatment Valsartan 80mg TAB Migroben Diovan Angiotensin receptor blockers Accepted treatment Angiotensin receptor blockers and Valsartan and amlodipine 10mg/160mg TAB Exforge Accepted treatment combinations Valsartan and amlodipine 5mg/160mg TAB Exforge Angiotensin receptor blockers and Accepted treatment

Page 60 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM combinations Angiotensin receptor blockers and Valsartan and diuretics 320mg/25mg TAB Co-Diovan Accepted treatment combinations Angiotensin receptor blockers and Valsartan and diuretics 160mg/25mg TAB Co-Migroben Co-Diovan Plus Accepted treatment combinations Angiotensin receptor blockers and Valsartan and diuretics 80mg/12.5mg TAB Co-Migroben Co-diovan Accepted treatment combinations Verapamil 240mg SRT Ravamil sr Verahexal 240 sr Calcium channel blockers Accepted treatment Verapamil 40mg TAB Vasomil Isoptin Calcium channel blockers Accepted treatment Verapamil 80mg TAB Vasomil Calcium channel blockers Accepted treatment Warfarin 1mg TAB Cipla Warfarin Anticoagulants Accepted treatment Warfarin 3mg TAB Cipla-Warfarin Anticoagulants Accepted treatment

Warfarin 5mg TAB Cipla Warfarin Aspen Warfarin Anticoagulants Accepted treatment MYCOBACTERIAL INFECTION (EXCL TB) ICD 10: A30.0 A30.1 A30.2 A30.3 A30.4 A30.5 A30.8 A30.9 A31.0 Amikacin 1000mg INJ Amikacin-fresenius Aminoglycoside Antibacterial Motivation required, Sputum Test Amikacin 100mg INJ Amikacin-fresenius Aminoglycoside Antibacterial Motivation required, Sputum Test Amikacin 250mg INJ Amikacin-fresenius Aminoglycoside Antibacterial Motivation required, Sputum Test Amikacin 500mg INJ Amikacin-fresenius Aminoglycoside Antibacterial Motivation required, Sputum Test Ciprofloxacin 250mg TAB Austell-Ciprofloxacin Cpl alliance ciprofloxacin Fluoroquinolones Motivation required, Sputum Test Ciprofloxacin 500mg TAB Austell-Ciprofloxacin Cpl alliance ciprofloxacin Fluoroquinolones Motivation required, Sputum Test Cycloserine 250mg CAP Aspen Cycloserine Antimycobacterial Motivation required, Sputum Test Dapsone 100mg TAB Dapsone Antimycobacterial special investigations, Sputum Test Ethambutol 400mg TAB Sandoz ethambutol Antimycobacterial special investigations, Sputum Test Ethionamide 250mg TAB Ethatyl Antimycobacterial Motivation required, Sputum Test Isoniazid 100mg TAB Norstan Isoniazid Be-tabs isoniazid Antimycobacterial special investigations, Sputum Test Kanamycin 1g/3ml INJ Kanamycin Aminoglycoside antibacterial Motivation required, Sputum Test Ofloxacin 200mg TAB Tafloc Tarivid Quinolone antibacterial Motivation required, Sputum Test Pyrazinamide 500mg TAB Pyrazide Sandoz pyrazinamide Antimycobacterial special investigations, Sputum Test special investigations, Pathology report Pyridoxine (vit B6) 25mg TAB Be-tabs pyridoxine hcl Pyridoxine Vitamin supplement indicating deficiency special investigations, Pathology report Pyridoxine (vit B6) 25mg TAB Pyridoxine Vitamin B6 Vitamin supplement indicating deficiency Rifampicin 150mg CAP Rimactane Antimycobacterial special investigations, Sputum Test Rifampicin 450mg TAB Rimactane Antimycobacterial special investigations, Sputum Test Rifampicin 600mg TAB Rimactane Antimycobacterial special investigations, Sputum Test

Page 61 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM Rifampicin & isoniazid 150/150mg TAB Rifinah Antimycobacterial special investigations, Sputum Test Rifampicin & isoniazid 300mg TAB Rifinah Antimycobacterial special investigations, Sputum Test Rifampicin & isoniazid 150/75mg TAB Rimactazid Antimycobacterial special investigations, Sputum Test Rifampicin & isoniazid 300/150mg TAB Rimactazid Antimycobacterial special investigations, Sputum Test Rifampicin & isoniazid 60/30mg TAB Rimactazid paed Antimycobacterial special investigations, Sputum Test Rifampicin & isoniazid 60/60mg TAB Rimactazid paed Antimycobacterial special investigations, Sputum Test Rifampicin, isoniazid, 150/75/400/27 TAB Rifafour E-275 Rimstar 4-FDC Antimycobacterial special investigations, Sputum Test pyrazinamide & ethambutol 5mg Terizidone 250mg CAP Terivalidin Antimycobacterial Motivation required, Sputum Test NEONATAL CARDIAC DYSRHYTHMIA ICD 10: P29.1 Adenosine 6mg/2mg INJ Adenocor Antiarrhythmics Motivation required Amiodarone 100mg TAB AryCor Hexarone Antiarrhythmics Motivation required Amiodarone 200mg TAB AryCor Hexarone Antiarrhythmics Motivation required Atenolol 50mg TAB Gulf Atenolol Tenopress Beta blockers Accepted treatment Atenolol 100mg TAB Gulf Atenolol 100 Tenopress Beta blockers Accepted treatment Atenolol 25mg TAB Tenopress Tenormin 25 Beta blockers Accepted treatment Bisoprolol 10mg TAB Bilocor Cardicor Beta blockers Accepted treatment Bisoprolol 5mg TAB Bilocor Cardicor Beta blockers Accepted treatment Bisoprolol 2.5mg TAB Cardicor Beta blockers Accepted treatment Digoxin 0.05mg/ml SYR Lanoxin paed Cardiac glycosides Accepted treatment Disopyramide 100mg CAP Rythmodan Antiarrhythmics Motivation required Disopyramide 250mg TAB Rythmodan retard Antiarrhythmics Motivation required Flecainide 100mg TAB Tambocor Antiarrhythmics Motivation required special investigations, Pathology report Nicotinic acid 100mg TAB Be-tabs nicotinic acid Peripheral vasodilator indicating deficiency Propafenone 150mg TAB Rythmol Antiarrhythmics Motivation required Propafenone 300mg TAB Rythmol Antiarrhythmics Motivation required Propranolol 10mg TAB Indoblok 10 Prodorol Beta blockers Accepted treatment Propranolol 40mg TAB Indoblok 40 Prodorol Beta blockers Accepted treatment Quinidine 200mg TAB Quinidine sulph Antiarrhythmics Motivation required Sotalol 160mg TAB Sotahexal Beta blockers Motivation required Sotalol 80mg TAB Sotahexal Beta blockers Motivation required

Page 62 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM NEONATAL CARDIAC FAILURE ICD 10: P29.0 Digoxin 0.05mg/ml SYR Lanoxin paed Cardiac glycosides Accepted treatment Furosemide 10mg/ml SYR Lasix oral Diuretics Motivation required NEPHRITIC SYNDROME ICD 10: N01.0 N01.1 N01.2 N01.3 N01.4 N01.5 N01.6 N01.7 N01.8 N01.9 N04.0 N04.1 N04.2 N04.3 N04.4 N04.5 N04.6 N04.7 N04.8 N04.9 N11.8 N11.9 N12 Alfacalcidol 0.25mcg CAP One alpha Alfacalcidol Accepted treatment Alfacalcidol 1mcg CAP One alpha Alfacalcidol Accepted treatment Amlodipine 10mg TAB Almadin Gulf Amlodipine Calcium channel blockers Accepted treatment Amlodipine 5mg TAB Almadin Gulf Amlodipine Calcium channel blockers Accepted treatment Amlodipine besylate 5mg TAB Calbloc Ciplavasc Calcium channel blockers Accepted treatment Pharma Dynamics Amlodipine Amlodipine Besylate 10mg TAB Norvasc Calcium channel blockers Accepted treatment Besylate Amlodipine maleate 10mg TAB Amlate Calcium channel blockers Accepted treatment Amlodipine maleate 5mg TAB Amlate Calcium channel blockers Accepted treatment Atenolol 25mg TAB Tenopress Tenormin 25 Beta blockers Accepted treatment Atenolol 100mg TAB Sandoz Atenolol Hexa-blok Beta blockers Accepted treatment Atenolol 50mg TAB Tenopress Tenormin 50 Beta blockers Accepted treatment Atenolol 25mg TAB Tenormin 25 Tenopress Beta blockers Accepted treatment Atenolol and other diuretics 100mg/25mg TAB SANDOZ Co-tenidone Tenchlor Beta blockers and combinations Accepted treatment Sandoz Co-tenidone Atenolol and other diuretics 50mg/12.5mg TAB Tenchlor hs Beta blockers and combinations Accepted treatment 50mg/12.5mg Atenolol and thiazides 100mg/25mg TAB Adco-loten Beta blockers and combinations Accepted treatment Sandoz Co-tenidone Atenolol and other diuretics 50mg/12.5mg TAB Tenchlor hs Beta blockers and combinations Accepted treatment 50mg/12.5mg Bisoprolol 10mg TAB Bilocor Cardicor Beta blockers Accepted treatment Bisoprolol 5mg TAB Bilocor Cardicor Beta blockers Accepted treatment Bisoprolol 2.5mg TAB Cardicor Beta blockers Accepted treatment Bumetanide 0.5mg TAB Burinex Duiretics Motivation required Calcitriol 0.25mcg CAP Rocaltrol Calcitriol special investigations, CCL/GFR Calcium carbonate TAB Titralac Mineral Supplement Accepted treatment, CCL/GFR Captopril 12.5mg TAB Captohexal ACE-inhibitors Accepted treatment Captopril 25mg TAB Captohexal Mylan-captopril 25 ACE-inhibitors Accepted treatment Captopril 50mg TAB Captohexal Mylan-captopril 50 ACE-inhibitors Accepted treatment Captopril and diuretics 50mg/25mg TAB Captoretic Zapto-co ACE-inhibitors and combinations Accepted treatment

Page 63 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM Cinacalcet 30mg TAB Sensipar Hormone inhibitors Motivation required Cinacalcet 60mg TAB Sensipar Hormone inhibitors Motivation required Darbepoetin alfa 10mcg INJ Aranesp Erythropoeitin, combinations Motivation required, CCL/ GFR Darbepoetin alfa 150mcg INJ Aranesp Erythropoeitin, combinations Motivation required, CCL/ GFR Darbepoetin alfa 20mcg INJ Aranesp Erythropoeitin, combinations Motivation required, CCL/ GFR Darbepoetin alfa 300mcg INJ Aranesp Erythropoeitin, combinations Motivation required, CCL/ GFR Darbepoetin alfa 30mcg INJ Aranesp Erythropoeitin, combinations Motivation required, CCL/ GFR Darbepoetin alfa 60mcg INJ Aranesp Erythropoeitin, combinations Motivation required, CCL/ GFR Motivation required, FULL BLOOD Dextriferron 50mg/ml INJ CosmoFer Erythropoeitin, combinations COUNT Motivation required, FULL BLOOD Dextriferron 50mg/2ml INJ CosmoFer Erythropoeitin, combinations COUNT Diltiazem 60mg TAB Zildem 60 Calcium channel blockers Accepted treatment Diltiazem 90mg TAB Zildem 90 Calcium channel blockers Accepted treatment Diltiazem 180mg SRC Tilazem 180 cr Zildem 180 sr Calcium channel blockers Accepted treatment Diltiazem 240mg SRC Tilazem 240 cr Zildem 240 sr Calcium channel blockers Accepted treatment Enalapril 5mg TAB Pharmapress Ciplatec 5 ACE-inhibitors Accepted treatment Enalapril 10mg TAB Pharmapress Ciplatec 10 ACE-inhibitors Accepted treatment Enalapril 20mg TAB Pharmapress Ciplatec 20 ACE-inhibitors Accepted treatment Enalapril 2.5mg TAB Renitec 2 5 ACE-inhibitors Accepted treatment Enalapril and diuretics 20mg/12.5mg TAB Enap co Pharmapress co ACE-inhibitors and combinations Accepted treatment Motivation required, Pathology report Ergocalciferol 50000u TAB Calciferol Ergocalciferol indicating deficiency Erythropoeitin 6000iu INJ Eprex Erythropoeitin Motivation required, CCL/ GFR Erythropoietin 40000iu INJ Eprex 1ml Prefilled Erythropoeitin Motivation required, CCL/ GFR Erythropoietin 10000u/ml INJ Eprex prefill Erythropoeitin Motivation required, CCL/ GFR Erythropoietin 2000u/05ml INJ Eprex prefill Erythropoeitin Motivation required, CCL/ GFR Erythropoietin 4000u/04ml INJ Eprex prefill Erythropoeitin Motivation required, CCL/ GFR Erythropoietin 10000iu INJ Recormon Pre-Filled Erythropoeitin Motivation required, CCL/ GFR Erythropoietin 2000iu INJ Recormon Pre-Filled Erythropoeitin Motivation required, CCL/ GFR Erythropoietin 30000iu INJ Recormon Pre-filled Erythropoeitin Motivation required, CCL/ GFR Erythropoietin 4000iu INJ Recormon Pre-Filled Erythropoeitin Motivation required, CCL/ GFR Erythropoietin 500iu INJ Recormon Pre-Filled Erythropoeitin Motivation required, CCL/ GFR Erythropoietin 6000iu INJ Recormon Pre-Filled Erythropoeitin Motivation required, CCL/ GFR Erythropoietin 2000iu INJ Repotin 1ml Erythropoeitin Motivation required, CCL/ GFR

Page 64 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM Erythropoietin 4000iu INJ Repotin 1ml Erythropoeitin Motivation required, CCL/ GFR Felodipine 10mg SRT Felodipine-Hexal Plendil Calcium channel blockers Accepted treatment Felodipine 5mg SRT Felodipine-Hexal Plendil Calcium channel blockers Accepted treatment Ferrous fumarate TAB Pregamal Iron Preparations Special investigations, Full blood count Ferrous Lactate 25mg DRP Ferro L drops Iron Supplements Special investigations, Full blood count Ferrous sulfate TAB Ferrous sulph co Iron Preparations Special investigations, Full blood count Ferrous sulfate 100mg TAB Ferrous sulphate Iron Preparations Special investigations, Full blood count Ferrous sulfate 30mg TAB Ferrous sulphate Iron Preparations Special investigations, Full blood count Folic acid 0.5mg TAB Folic acid Folic acid Special investigations, Full blood count Folic acid CAP Folic acid forte Folic acid Accepted treatment Folic acid 5mg TAB Be-tabs folic acid Folic acid Folic acid Accepted treatment Furosemide 40mg TAB Mylan-furosemide Beurises Diuretics Accepted treatment Furosemide 20mg TAB Lasix Diuretics Accepted treatment Furosemide 10mg/ml SYR Lasix oral Diuretics Motivation required Hydrochlorothiazide 25mg TAB Hexazide Ridaq Diuretics Accepted treatment Hydrochlorothiazide 12.5mg TAB Ridaq Diuretics Accepted treatment Hydrochlorothiazide and 50mg/300mg TAB Urirex-k Diuretics Accepted treatment potassium Hydrochlorothiazide and 50mg/5mg TAB Adco-retic Moduretic Diuretics Accepted treatment potassium-sparing agents Hydrochlorothiazide and 25mg/2.5mg TAB Amiloretic hs Diuretics Accepted treatment potassium-sparing agents Hydrochlorothiazide and 50mg/25mg TAB Dyazide Renezide Diuretics Accepted treatment potassium-sparing agents Indapamide 2.5mg TAB Cipla-Indapamide Dapamax Diuretics Accepted treatment Motivation required, FULL BLOOD Iron in other combinations 20mg/ml INJ Venofer Iron Preparations COUNT Accepted treatment, FULL BLOOD Iron multivitamins and folic acid 100mg TAB Folifer Iron in other combinations COUNT Lisinopril 10mg TAB Sinopren 10 Simayla Lisinopril ACE-inhibitors Accepted treatment Lisinopril 20mg TAB Sinopren 20 Simayla Lisinopril ACE-inhibitors Accepted treatment Lisinopril 5mg TAB Sinopren 5 Zemax ACE-inhibitors Accepted treatment Lisinopril and diuretics 10mg/12.5mg TAB Lisoretic Lisozide ACE-inhibitors and combinations Accepted treatment Lisinopril and diuretics 20mg/12.5mg TAB Lisoretic Lisozide ACE-inhibitors and combinations Accepted treatment Losartan 100mg TAB Cipla Losartan Zartan Angiotensin receptor blockers Accepted treatment Losartan 50mg TAB Cipla Losartan Zartan Angiotensin receptor blockers Accepted treatment

Page 65 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM Angiotensin receptor blockers and Losartan and diuretics 50mg/12.5mg TAB Zartan Co Losaar plus 50/12.5 Accepted treatment combinations Angiotensin receptor blockers and Losartan and diuretics 100mg/25mg TAB Zartan Co Losaar plus Accepted treatment combinations Erythropoeitin 0.05mg/03ml INJ Mircera Erythropoeitin special investigationss, CCL / GFR Erythropoeitin 0.075mg/0.3ml INJ Mircera Erythropoeitin special investigationss, CCL / GFR Erythropoeitin 0.15mg/0.3ml INJ Mircera Erythropoeitin special investigationss, CCL / GFR Erythropoeitin 0.25mg/0.3ml INJ Mircera Erythropoeitin special investigationss, CCL / GFR Erythropoeitin 0.2mg/0.3ml INJ Mircera Erythropoeitin special investigationss, CCL / GFR Nifedipine 20mg SRT Cipalat Retard Nifedalat SR Calcium channel blockers Accepted treatment Nifedipine 30mg SRT Fedaloc Spec Nifedipine SR Calcium channel blockers Accepted treatment Nifedipine 60mg SRT Fedaloc Spec Nifedipine SR Calcium channel blockers Accepted treatment Perindopril 4mg TAB Cipla Perindopril Vectoryl ACE-inhibitors Accepted treatment Perindopril 10mg TAB Coversyl Prexum ACE-inhibitors Accepted treatment Perindopril and diuretics 2mg/0.625mg TAB Acesyl Co Spec-Perindopril Plus 2 ACE-inhibitors and combinations Accepted treatment Perindopril and diuretics 4mg/1.25mg TAB Pearinda Plus Spec-Perindopril Plus 4 ACE-inhibitors and combinations Accepted treatment Perindopril 8mg TAB Spec-Perindopril Ciplasyl 8 ACE-inhibitors Accepted treatment Potassium chloride 600mg TAB Plenish k SANDOZ K-600 Potassium supplements Accepted treatment Propranolol 10mg TAB Indoblok 10 Prodorol Beta blockers Accepted treatment Propranolol 40mg TAB Indoblok 40 Prodorol Beta blockers Accepted treatment Quinapril 10mg TAB Accumax Quinaspen ACE-inhibitors Accepted treatment Quinapril 20mg TAB Accumax Quinaspen ACE-inhibitors Accepted treatment Ramipril 2.5mg CAP Ramiwin Rampil ACE-inhibitors Accepted treatment Ramipril 5mg CAP RamiWin Rampil ACE-inhibitors Accepted treatment Ramipril 10mg CAP Rampil Tritace ACE-inhibitors Accepted treatment Spironolactone 100mg TAB Aldactone Spiractin Diuretics Accepted treatment Telimisartan 80mg TAB Pritor Micardis ACE-Inhibitor Accepted treatment Telimisatan and diuretic 40mg/12.5mg TAB Co-Pritor Co-Micardis ACE-Inhibitor and diuretic Accepted treatment Telimisatan and diuretic 80mg/12.5mg TAB Co-Pritor Co-Micardis ACE-Inhibitor and diuretic Accepted treatment Telimisatan and diuretic 80mg/25mg TAB Co-Pritor Co-Micardis ACE-Inhibitor and diuretic Accepted treatment Trandolapril 0.5mg CAP Mavik (was Gopten) ACE-inhibitors Accepted treatment Trandolapril 2mg CAP Mavik (was Gopten) ACE-inhibitors Accepted treatment Valsartan 160mg TAB Migroben Tareg Angiotensin receptor blockers Accepted treatment Valsartan 80mg TAB Migroben Tareg Angiotensin receptor blockers Accepted treatment

Page 66 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM Angiotensin receptor blockers and Valsartan and amlodipine 10mg/160mg TAB Exforge Accepted treatment combinations Angiotensin receptor blockers and Valsartan and amlodipine 5mg/160mg TAB Exforge Accepted treatment combinations Angiotensin receptor blockers and Valsartan and diuretics 320/12.5mg TAB Co-Diovan Accepted treatment combinations Angiotensin receptor blockers and Valsartan and diuretics 320mg/25mg TAB Co-Diovan Accepted treatment combinations Angiotensin receptor blockers and Valsartan and diuretics 80mg/12.5mg TAB Co-diovan Accepted treatment combinations Angiotensin receptor blockers and Valsartan and diuretics 160mg/12.5mg TAB Co-Migroben Co-Tareg Accepted treatment combinations Angiotensin receptor blockers and Valsartan and diuretics 160mg/25mg TAB Co-Migroben Co-Tareg Plus Accepted treatment combinations Angiotensin receptor blockers and Valsartan and diuretics 80mg/12.5mg TAB Co-Migroben Co-Tareg Accepted treatment combinations Verapamil 240mg SRT Calcicard sr 240 Verahexal 240 sr Calcium channel blockers Accepted treatment Verapamil 40mg TAB Vasomil Isoptin Calcium channel blockers Accepted treatment Verapamil 80mg TAB Vasomil Isoptin Calcium channel blockers Accepted treatment NEPHROGENIC DIABETES INSIPIDUS ICD 10: N25.1 Carbamazepine 200mg TAB Degranol SANDOZ Carbamazepine Anticonvulsants Accepted treatment Carbamazepine 400mg SRT SANDOZ Cabamazepine CR Tegretol CR Anticonvulsants Accepted treatment Carbamazepine 200mg SRT SANDOZ Carbamazepine CR Tegretol CR Anticonvulsants Accepted treatment Diclofenac 25mg TAB Adco-diclofenac Panamor-25 Non-steroidal anti-inflammatory drugs Accepted treatment Diclofenac 100mg SUP Diclohexal 100s Panamor supp-100 Non-steroidal anti-inflammatory drugs Motivation required Diclofenac 50mg TAB Diclohexal 50t Panamor at-50 Non-steroidal anti-inflammatory drugs Accepted treatment Diclofenac 100mg CAP Fortfen SR Non-steroidal anti-inflammatory drugs Accepted treatment SANDOZ Diclofenac Diclofenac 100mg SRT Panamor-100 sr Non-steroidal anti-inflammatory drugs Accepted treatment Sodium SR Diclofenac 75mg SRT Panamor-75 sr Voltaren 75 Non-steroidal anti-inflammatory drugs Accepted treatment Hydrochlorothiazide 25mg TAB Hexazide Ridaq Diuretics Accepted treatment Hydrochlorothiazide 12.5mg TAB Ridaq Diuretics Accepted treatment Hydrochlorothiazide and 50mg/5mg TAB Adco-retic Moduretic Diuretics Accepted treatment potassium-sparing agents Hydrochlorothiazide and 25mg/2.5mg TAB Amiloretic hs Diuretics Accepted treatment potassium-sparing agents Ibuprofen 400mg TAB Adco-ibuprofen Ranfen Non-steroidal anti-inflammatory drugs Accepted treatment Ibuprofen 100mg/5ml SUS Brufen paed susp Ibumax Non-steroidal anti-inflammatory drugs Accepted treatment Page 67 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM Ibuprofen 200mg TAB SANDOZ Ibuprofen Inza Non-steroidal anti-inflammatory drugs Accepted treatment Ibuprofen 600mg TAB SANDOZ Ibuprofen Brufen Non-steroidal anti-inflammatory drugs Accepted treatment Indomethacin 100mg SUP Arthrexin Indocid Non-steroidal anti-inflammatory drugs Motivation required Indomethacin 25mg CAP SANDOZ Idomethacin Arthrexin Non-steroidal anti-inflammatory drugs Accepted treatment Ketoprofen 200mg SRC Ketoflam Non-steroidal anti-inflammatory drugs Motivation required Meloxicam 15mg TAB Loxiflam Arrow Meloxicam Non-steroidal anti-inflammatory drugs Accepted treatment Meloxicam 7.5mg TAB SANDOZ Meloxicam Coxflam Non-steroidal anti-inflammatory drugs Accepted treatment Methotrexate 2.5mg TAB Emthexate Emthexate Immunosuppressants Accepted treatment Naproxen 250mg TAB Adco-naproxen Mylan-naproxen Non-steroidal anti-inflammatory drugs Accepted treatment Naproxen 500mg SUP Nafasol Non-steroidal anti-inflammatory drugs Motivation required Naproxen 250mg ECT Nafasol ec-250 Non-steroidal anti-inflammatory drugs Accepted treatment Naproxen 500mg ECT Nafasol ec-500 Non-steroidal anti-inflammatory drugs Accepted treatment Naproxen 500mg TAB Napflam Non-steroidal anti-inflammatory drugs Accepted treatment Piroxicam 10mg CAP Adco-piroxicam Rolab-piroxicam Non-steroidal anti-inflammatory drugs Accepted treatment Piroxicam 20mg CAP Adco-piroxicam Xycam Non-steroidal anti-inflammatory drugs Accepted treatment Piroxicam 20mg TAB Brexecam Non-steroidal anti-inflammatory drugs Accepted treatment Piroxicam 20mg DSP Pixicam Xycam d ispers Non-steroidal anti-inflammatory drugs Accepted treatment NEUROLOGICAL ABNORMALITIES OF THE NEWBORN ICD 10: G80.0 G80.1 G80.2 G80.3 G80.4 G80.8 G80.9 Baclofen 10mg TAB Bio-Baclofen Teva Baclofen Muscle relaxants Accepted treatment Baclofen 25mg TAB Lioresal Muscle relaxants Motivation required Carbamazepine 100mg/5ml SUS Tegretol s Anticonvulsants Accepted treatment Carbamazepine 200mg TAB Degranol SANDOZ Carbamazepine Anticonvulsants Accepted treatment Carbamazepine 400mg SRT SANDOZ Cabamazepine CR T egretol CR Anticonvulsants Accepted treatment Dantrolene 25mg CAP Dantrium Muscle relaxants Motivation required Valproic acid 50mg/ml SYR Convulex Anticonvulsants Accepted treatment Valproic acid 100mg TAB Epilim 100 crushable Anticonvulsants Accepted treatment Valproic acid 200mg/5ml SYR Epilim sugar free Anticonvulsants Accepted treatment Valproic acid 150mg CAP Convulex Anticonvulsants Accepted treatment Valproic acid 300mg CAP Convulex Anticonvulsants Accepted treatment Valproic acid 500mg CAP Convulex Anticonvulsants Accepted treatment Valproic acid 200mg SRT Epilim cr 200 Anticonvulsants Accepted treatment Valproic acid 300mg SRT Epilim cr 300 Anticonvulsants Accepted treatment

Page 68 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM Valproic acid 500mg SRT Epilim cr 500 Anticonvulsants Accepted treatment NUTRITIONAL DEFICIENCIES ICD 10: E40 E41 E42 E43 E46 E50.0-E50.9 E51.1 E51.2 E51.8 E51.9 E52 E53.0 E53.1 E53.8 E53.9 E54 E55.0 E55.9 E56.1 E56.9 E61.1 E61.7 E63.0 special investigations, Pathology report Alfacalcidol 0.25mcg CAP One alpha Alfacalcidol indicating deficiency special investigations, Pathology report Alfacalcidol 1mcg CAP One alpha Alfacalcidol indicating deficiency Motivation required, Pathology report Ascorbic acid (vit C) 100mg TAB Ascorbic acid Ascorbic acid (xpressmed) Vitamin supplement indicating deficiency Motivation required, Pathology report Ascorbic acid (vit C) 200mg TAB Ascorbic acid Vitamin supplement indicating deficiency Motivation required, Pathology report Ascorbic acid (vit C) 250mg TAB Ascorbic acid Ascorbic acid (xpressmed) Vitamin supplement indicating deficiency Motivation required, Pathology report Ascorbic acid (vit C) 50mg TAB Ascorbic acid Vitamin supplement indicating deficiency Motivation required, Pathology report Ascorbic acid (vit C) 250mg CHU Ascorbic Acid Vitamin supplement indicating deficiency Motivation required, Pathology report Ascorbic acid (vit C) 500mg TAB Ascorbic Acid Vitamin supplement indicating deficiency Motivation required, Pathology report Ascorbic acid (vit C) 100mg TAB Ascorbic acid (fams) Vitaforce acerola Vitamin supplement indicating deficiency Motivation required, Pathology report Ascorbic acid (vit C) 500mg TAB Be-tabs ascorbic acid Vitamin supplement indicating deficiency Motivation required, Pathology report Ascorbic acid (vit C) 300mg TAB Vitaforce Acerola Vital vit c Vitamin supplement indicating deficiency Motivation required, Pathology report Ascorbic acid (vit C) 500mg TAB Vitaforce acerola Vitamin supplement indicating deficiency Motivation required, Pathology report Ascorbic acid (vit C) 600mg TAB Vital vit c hp Vitamin c Vitamin supplement indicating deficiency Vitamin c (150mg) bio- Motivation required, Pathology report Ascorbic acid (vit C) 150mg TAB Vitamin supplement organics indicating deficiency Motivation required, Pathology report Ascorbic acid (vit C) 1000mg TAB Vitamin C 1000mg Vitamin supplement indicating deficiency Motivation required, Pathology report Ascorbic acid (vit C) 500mg TAB Vitamin c 500 Vitamin supplement indicating deficiency Motivation required, Pathology report Ascorbic acid (vit C) 500mg CAP Vitamin c 500 Vitamin supplement indicating deficiency Motivation required, Pathology report Calcitriol 0.25mg CAP Rocaltrol Calcitriol indicating deficiency Motivation required, Pathology report Combinations of vitamins TAB Vitaforce vit a+d+e Combinations of vitamins indicating deficiency Motivation required, Pathology report Ergocalciferol 50000u TAB Calciferol Ergocalciferol indicating deficiency Page 69 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM Motivation required, Pathology report Ergocalciferol DRP Calciferol oily Ergocalciferol indicating deficiency Motivation required, Pathology report MULTIVITAMINS COMBINATIONS TAB VIT B CO CHOCOLATE MULTIVITAMINS COMBINATIONS indicating deficiency Motivation required, Pathology report MULTIVITAMINS COMBINATIONS TAB VIT B CO PINK MULTIVITAMINS COMBINATIONS indicating deficiency Motivation required, Pathology report Nicotinamide 100mg TAB Be-tabs nicotinamide Vitaforce nicotinamide Vitamin supplement indicating deficiency Motivation required, Pathology report Nicotinic acid 100mg TAB Holland and barrett niacin b3 Vitamin supplement indicating deficiency Motivation required, Pathology report Nicotinic acid 330mg CAP Niacin (flush free) Vitamin supplement indicating deficiency Niacin(Nicotinic Acid)(Vitamin Motivation required, Pathology report Nicotinic acid 100mg TAB Be-tabs nicotinic acid Vitamin supplement B3) indicating deficiency Motivation required, Pathology report Nicotinic acid CAP Vitamin B3 Vitamin supplement indicating deficiency Motivation required, Pathology report Pyridoxine (vit B6) 25mg TAB Be-tabs pyridoxine hcl Vitamin supplement indicating deficiency Motivation required, Pathology report Pyridoxine (vit B6) 200mg TAB Lactosec Vitamin supplement indicating deficiency Motivation required, Pathology report Pyridoxine (vit B6) 25mg TAB Pyridoxine Vitamin supplement indicating deficiency Motivation required, Pathology report Pyridoxine (vit B6) 25mg TAB Pyridoxine Vitamin supplement indicating deficiency Motivation required, Pathology report Pyridoxine (vit B6) 25mg TAB Vitamin B6 Vitamin supplement indicating deficiency Motivation required, Pathology report Retinol (vit A) 50000u TAB Arovit Vitamin supplement indicating deficiency Holland and barrett b2 Motivation required, Pathology report Riboflavin (vit B2) 100mg TAB Vitamin supplement riboflavin indicating deficiency Motivation required, Pathology report Thiamine (vit B1) 100mg TAB Thiamine hcl Vitamin supplement indicating deficiency Motivation required, Pathology report Tocopherol (vit E) 1000iu CAP Vital vit e Vitamin supplement indicating deficiency Motivation required, Pathology report Tocopherol (vit E) 100iu CAP Vital vit e Vitamin supplement indicating deficiency Motivation required, Pathology report Tocopherol (vit E) 400iu CAP Vital vit e Vitamin supplement indicating deficiency Motivation required, Pathology report Tocopherol (vit E) 50iu CAP Vital vit e Vitamin supplement indicating deficiency Motivation required, Pathology report Tocopherol (vit E) 200iu CAP Vitamin e Vitamin supplement indicating deficiency Motivation required, Pathology report Tocopherol (vit E) 50mg CAP Vitamin e Vitamin supplement indicating deficiency Page 70 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM Motivation required, Pathology report Tocopherol (vit E) 500iu CAP VITAMIN E 500IU Vitamin supplement indicating deficiency Motivation required, Pathology report Tocopherol (vit E) TAB Vitamin e bio-organics Vitamin supplement indicating deficiency Motivation required, Pathology report Vitamin B-complex; plain SYR Vitamin b co Vitamin b co syrup Vitamin supplement indicating deficiency Motivation required, Pathology report Vitamin B-complex; plain TAB Vitamin b co Vitamin supplement indicating deficiency Vitamin b co (pink) Motivation required, Pathology report Vitamin B-complex; plain TAB Vitamin b co pink Vitamin supplement xpressmed indicating deficiency Motivation required, Pathology report Vitamin B-complex; plain TAB Vitamin b co (xpressmed) Vitamin supplement indicating deficiency Vitamin b co forte Motivation required, Pathology report Vitamin B-complex; plain TAB Vitamin b co chocolate Vitamin supplement chocolate indicating deficiency Vitamin b co forte Motivation required, Pathology report Vitamin B-complex; plain TAB Vitamin supplement (xpressmed) indicating deficiency Motivation required, Pathology report Vitamin B-complex; plain SYR VITAMIN B CO SYRUP Vitamin b co syrup(fams) Vitamin supplement indicating deficiency Motivation required, Pathology report Vitamin B-complex; plain TAB VITAMIN B CO TAB Vitamin supplement indicating deficiency Motivation required, Pathology report Vitamin B-complex; plain TAB Vitamin B Complex Vitamin supplement indicating deficiency Motivation required, Pathology report Vitamin B-complex; plain CAP Vitamin b complex Vitamin supplement indicating deficiency Motivation required, Pathology report Vitamin B-complex; plain INJ Vitamin b complex Vitamin supplement indicating deficiency OVARIAN DYSFUNCTION ICD 10: E28.0 E28.1 E28.2 E28.3 E28.8 E28.9 L68.0 N34.2 N83.3 N91.0 N91.1 N91.2 N91.4 Cyproterone & Estrogen 2mg TAB Diva-35 Hormonal preparations, oral Motivation required Cyproterone acetate 50mg TAB Androcur Hormonal preparations, oral Motivation required Cyproterone acetate 50mg TAB Cipla-cyproterone acetate Hormonal preparations, oral Motivation required Cyproterone acetate 50mg TAB Cyproplex Hormonal preparations, oral Motivation required Cyproterone acetate 2mg TAB Diane-35 Ginette Hormonal preparations, oral Motivation required Desogestrel and estrogen TAB Marvelon 150/30 Hormonal preparations, oral Motivation required Desogestrel and estrogen TAB Mercilon Hormonal preparations, oral Motivation required Drospirenone and estrogen TAB Yasmin Ruby Hormonal preparations, oral Motivation required Drospirenone and estrogen TAB Yaz Hormonal preparations, oral Motivation required Gestodene and estrogen TAB Femodene ed Minulette Hormonal preparations, oral Motivation required Gestodene and estrogen TAB Melodene Hormonal preparations, oral Motivation required Gestodene and estrogen TAB Mirelle Hormonal preparations, oral Motivation required Page 71 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM Gestodene and estrogen TAB Minesse Hormonal preparations, oral Motivation required Gestodene and estrogen TAB Tri-minulet Hormonal preparations, oral Motivation required Gestodene and estrogen TAB Triodene ed Hormonal preparations, oral Motivation required Levonorgestrel and estrogen TAB Biphasil Hormonal preparations, oral Motivation required Levonorgestrel and estrogen TAB Logynon ed Hormonal preparations, oral Motivation required Levonorgestrel and estrogen TAB Triphasil Hormonal preparations, oral Motivation required Norethisterone and estrogen TAB Trinovum Hormonal preparations, oral Motivation required Norgestimate & oestrogen TAB Tricilest Hormonal preparations, oral Motivation required PEPTIC ULCER DISEASE ICD 10: K25.0 K25.1 K25.2 K25.4 K25.5 K25.6 K26.0 K26.1 K26.2 K26.4 K26.5 K27.0 K27.1 K27.2 K27.4 K27.5 K27.6 K28.0 K28.1 K28.2 K28.4 K28.5 K28.6 K29.0 K26.6 K26.6 Cimetidine 200mg TAB Bio-cimetidine Cimlok H2-receptor antagonists Accepted treatment Cimetidine 400mg TAB Bio-cimetidine Cimlok H2-receptor antagonists Accepted treatment Lansoprazole 15mg TAB Lancap Lansoloc Proton Pump Inhibitors Motivation required Lansoprazole 30mg TAB Lancap Lansoloc Proton Pump Inhibitors Motivation required Omeprazole 10mg CAP Altosec Omez Proton Pump Inhibitors Accepted treatment Omeprazole 20mg CAP Altosec Omez Proton Pump Inhibitors Accepted treatment Omeprazole 40mg TAB Losec mups Omez Proton Pump Inhibitors Motivation required Pantoprazole 20mg ECT Topzole Pantoloc Proton Pump Inhibitors Motivation required Pantoprazole 40mg ECT Topzole Pantoloc Proton Pump Inhibitors Motivation required Rabeprazole 10mg TAB Pariet Proton Pump Inhibitors Motivation required Rabeprazole 20mg TAB Pariet Proton Pump Inhibitors Motivation required Ranitidine 75mg TAB Histak 75 Austac-75 H2-receptor antagonists Accepted treatment Ranitidine 150mg TAB Ranihexal 150 Ranit H2-receptor antagonists Accepted treatment Ranitidine 300mg TAB Ranihexal 300 Ranit H2-receptor antagonists Accepted treatment Ranitidine 150mg/10ml SYR Zantac H2-receptor antagonists Motivation required PERIPHERAL VASCULAR DISEASE ICD 10: I73.1 Acetylsalicylic acid 81mg ECT Ecotrin Aspirin Accepted treatment

Page 72 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM Dipyridamole 200mg/25mg CAP Asasantin 200/25 retard Antithrombotic agents Motivation required Dipyridamole 200mg SRC Persantin 200 retard Antithrombotic agents Motivation required Dipyridamole 100mg TAB Plato Antithrombotic agents Motivation required Dipyridamole 25mg TAB Plato Antithrombotic agents Motivation required Warfarin 1mg TAB Cipla Warfarin Anticoagulants Accepted treatment Warfarin 5mg TAB Cipla Warfarin Aspen Warfarin Anticoagulants Accepted treatment Warfarin 3mg TAB Cipla-Warfarin Anticoagulants Accepted treatment PITUITARY HYPERFUNCTION ICD 10: E22.0 E22.1 E22.2 E22.8 E22.9 E23.7 Bromocriptine 2.5mg TAB Aspen Bromocriptine Parlodel Dopamine agonists Motivation required Carbegoline 0.5mg TAB Dostinex Prolactin inhibitors Motivation required, Prolactin levels Octreotide 0.05mg INJ Sandostatin Growth hormone release inhibitor Motivation required Octreotide 0.1mg INJ Sandostatin Growth hormone release inhibitor Motivation required Octreotide 0.2mg INJ Sandostatin Growth hormone release inhibitor Motivation required Octreotide 10mg INJ Sandostatin LAR prefilled Growth hormone release inhibitor Motivation required Octreotide 20mg INJ Sandostatin LAR prefilled Growth hormone release inhibitor Motivation required PITUITARY HYPOFUNCTION ICD 10: E23.7 Conjugated estrogens 0.3mg TAB Premarin Corticosteroids , oral Accepted treatment Conjugated estrogens 0.625mg TAB Premarin Corticosteroids , oral Accepted treatment Hydrocortisone 10mg TAB Covocort Corticosteroids , oral Accepted treatment Levothyroxine sodium 0.05mg TAB Eltroxin Thyroid hormones Accepted treatment Levothyroxine sodium 0.1mg TAB Eltroxin Thyroid hormones Accepted treatment Levothyroxine sodium 100mcg TAB Euthyrox Synthroid Thyroid hormones Accepted treatment Levothyroxine sodium 25mcg TAB Euthyrox Synthroid Thyroid hormones Accepted treatment Levothyroxine sodium 50mcg TAB Euthyrox Synthroid Thyroid hormones Accepted treatment Liothyronine sodium 90mcg TAB Diotroxin Thyroid hormones Accepted treatment Liothyronine sodium 20mcg TAB Tertroxin Thyroid hormones Accepted treatment Liothyronine sodium 88mcg TAB Synthroid Thyroid hormones Accepted treatment Liothyronine sodium 112mcg TAB Synthroid Thyroid hormones Accepted treatment Somatropin 6mg TAB Humatrope Growth hormone Motivation required Somatropin 12mg TAB Humatrope Growth hormone Motivation required Testosterone cypionate 100mg/ml IMP Depo-testosterone 10ml androgens Motivation required

Page 73 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM SCHIZOAFFECTIVE DISORDER ICD 10: F25.0 F25.1 F25.2 F25.8 F25.9 Amisulpiride 50mg TAB Solian Antipsychotics Accepted treatment Amisulpiride 200mg TAB Solian Antipsychotics Accepted treatment Amitriptyline 25mg TAB SANDOZ Amitryptyline Trepiline Heterocyclic antidepressant Accepted treatment Aripiprazole 5mg TAB Abilify Antipsychotics Motivation required Aripiprazole 10mg TAB Abilify Antipsychotics Motivation required Aripiprazole 15mg TAB Abilify Antipsychotics Motivation required Chlorpromazine 100mg TAB Largactil Antipsychotics Accepted treatment Chlorpromazine 25mg TAB Largactil Antipsychotics Accepted treatment Chlorpromazine 50mg TAB Largactil Antipsychotics Accepted treatment Citalopram 20mg TAB Auro-Citalopram Austell-Citalopram Selective serotonin receptor inhibitors Accepted treatment Citalopram 10mg TAB Austell-Citalopram Selective serotonin receptor inhibitors Accepted treatment Citalopram 40mg TAB Depramil Arrow 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 Clozapine 100mg TAB Cloment Leponex Mood stabilisers Accepted treatment Clozapine 25mg TAB Cloment Leponex Mood stabilisers Accepted treatment Dothiepin 25mg CAP Prothiaden Thaden Heterocyclic antidepressants Accepted treatment Dothiepin 75mg TAB Thaden Heterocyclic antidepressants Accepted treatment Fluoxetine 20mg CAP Nuzak Lilly-fluoxetine Selective serotonin receptor inhibitors Accepted treatment Fluoxetine 20mg TAB Lorien Rezak Selective serotonin receptor inhibitors Accepted treatment Fluoxetine 20mg DSP Prohexal 20t Selective serotonin receptor inhibitors Accepted treatment Flupenthixol 0.5mg TAB Fluanxol Antipsychotics Accepted treatment Flupenthixol 1mg TAB Fluanxol Antipsychotics Accepted treatment Haloperidol 1.5mg TAB SANDOZ Haloperidol Antipsychotics Accepted treatment Haloperidol 5mg TAB SANDOZ Haloperidol Serenace Antipsychotics Accepted treatment Haloperidol 0.5mg CAP Serenace Antipsychotics Accepted treatment Haloperidol 10mg TAB Serenace Antipsychotics Accepted treatment Imipramine 25mg TAB Ethipramine Tofranil Heterocyclic antidepressants Accepted treatment Lithium 250mg TAB Camcolit Mood stabilisers Accepted treatment Lithium 400mg TAB Camcolit Mood stabilisers Accepted treatment Lithium 50mg CAP Lithium succinate Mood stabilisers Accepted treatment

Page 74 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM Lithium 450mg TAB Quilonum retard Mood stabilisers Accepted treatment Maprotiline 25mg TAB Ludiomil Heterocyclic antidepressants Motivation required Maprotiline 75mg TAB Ludiomil Heterocyclic antidepressants Motivation required Paliperidone 3mg TAB Invega Antipsychotics Motivation required Paliperidone 6mg TAB Invega Antipsychotics Motivation required Paliperidone 9mg TAB Invega Antipsychotics Motivation required Quetiapine 25mg TAB Dopaquel Serez Antipsychotics Motivation required Quetiapine 100mg TAB Truvalin Quetoser Antipsychotics Motivation required Quetiapine 200mg TAB Mylan Quetiapine Dopaquel Antipsychotics Motivation required Quetiapine 300mg TAB Serez Truvalin Antipsychotics Motivation required Quetiapine 200mg TAB Seroquel XR 200 Antipsychotics Motivation required Quetiapine 300mg TAB Seroquel XR 300 Antipsychotics Motivation required Quetiapine 400mg TAB Seroquel XR 400 Antipsychotics Motivation required Risperidone 0.5mg TAB Aspen Risperidone Risperlet Antipsychotics Accepted treatment Risperidone 2mg TAB Aspen Risperidone Risperdal Quicklet Antipsychotics Accepted treatment Risperidone 3mg TAB Aspen Risperidone Risperidone-Hexal Antipsychotics Accepted treatment Risperidone 3mg TAB Auropidone Antipsychotics Accepted treatment Risperidone 1.0mg TAB DRL-Risperidone Auroperdal Antipsychotics Accepted treatment Risperidone 1mg/ml SYR Risperdal Antipsychotics Accepted treatment Risperidone 4mg TAB Risperdal Risponz Antipsychotics Accepted treatment Risperidone 1mg TAB Risperlet Rispacor Antipsychotics Accepted treatment Sulpiride 200mg TAB Bio-Sulpiride Substituted benzamide Accepted treatment Sulpiride 50mg CAP Eglonyl Substituted benzamide Accepted treatment Sulpiride 50mg CAP Espiride Substituted benzamide Accepted treatment Sulpiride 50mg CAP SANDOZ Sulpiride Substituted benzamide Accepted treatment Trifluoperazine 1mg TAB Stelazine Selective serotonin receptor inhibitors Accepted treatment Trifluoperazine 5mg TAB Stelazine Selective serotonin receptor inhibitors Accepted treatment Ziprasidone 20mg CAP Geodon Antipsychotics Motivation required Ziprasidone 40mg CAP Geodon Antipsychotics Motivation required Ziprasidone 60mg CAP Geodon Antipsychotics Motivation required Ziprasidone 80mg CAP Geodon Antipsychotics Motivation required Zuclopenthixol 10mg TAB Clopixol Antipsychotics Accepted treatment Zuclopenthixol 2mg TAB Clopixol Antipsychotics Accepted treatment

Page 75 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM SPINAL CORD INJURIES ICD 10: G81.0 G81.1 G81.8 G81.9 G82.0 G82.2 G82.3 G82.4 G82.5 N31.0 N31.1 N31.2 N31.8 N31.9 Paracetamol will be reimbursed in the treatment of Rheumatoid Arthritis. Amitriptyline 10mg TAB Trepiline Heterocyclic antidepressant Accepted treatment Amitriptyline 25mg TAB SANDOZ Amitryptyline Trepiline Heterocyclic antidepressant Accepted treatment Baclofen 10mg TAB Bio-Baclofen Teva Baclofen Muscle relaxants Accepted treatment Baclofen 25mg TAB Lioresal Muscle relaxants Motivation required Bisacodyl 10mg SUP Dulcolax Laxatives Accepted treatment Bisacodyl 5mg TAB Dulcolax Laxatives Accepted treatment Bisacodyl paed SUP Dulcolax Laxatives Accepted treatment Bisacodyl TAB Megalax Laxatives Accepted treatment Carbamazepine 200mg TAB Degranol SANDOZ Carbamazepine Anticonvulsants Accepted treatment Carbamazepine 400mg SRT SANDOZ Cabamazepine CR Tegretol CR Anticonvulsants Accepted treatment Carbamazepine 200mg SRT SANDOZ Carbamazepine CR Tegretol CR Anticonvulsants Accepted treatment Dantrolene 25mg CAP Dantrium Muscle relaxants Motivation required Diclofenac 25mg TAB Adco-diclofenac Panamor-25 Non-steroidal anti-inflammatory drugs Accepted treatment Diclofenac 100mg SUP Diclohexal 100s Panamor supp-100 Non-steroidal anti-inflammatory drugs Motivation required Diclofenac 50mg TAB Diclohexal 50t Panamor at-50 Non-steroidal anti-inflammatory drugs Accepted treatment Diclofenac 100mg CAP Fortfen SR Non-steroidal anti-inflammatory drugs Accepted treatment SANDOZ Diclofenac Diclofenac 100mg SRT Panamor-100 sr Non-steroidal anti-inflammatory drugs Accepted treatment Sodium SR Diclofenac 75mg SRT Panamor-75 sr Voltaren 75 Non-steroidal anti-inflammatory drugs Accepted treatment Diphenoxylate/Atropine 2.5mf/0.025mg TAB Lomotil Antipropulsives Accepted treatment Gabapentin 300mg CAP Epleptin Anticonvulsants Motivation required Gabapentin 600mg TAB Neurontin Anticonvulsants Motivation required Gabapentin 800mg TAB Neurontin Anticonvulsants Motivation required Gabapentin 400mg CAP Ran-Gabapentin Anticonvulsants Motivation required Glycerol SUP Glycerine Adult Glycerine In fant Laxatives Accepted treatment Glycerol LIQ GLYCERINE BP Laxatives Accepted treatment Ibuprofen 400mg TAB Adco-ibuprofen Ranfen Non-steroidal anti-inflammatory drugs Accepted treatment Ibuprofen 100mg/5ml SUS Brufen paed susp Ibumax Non-steroidal anti-inflammatory drugs Accepted treatment Ibuprofen 200mg TAB SANDOZ Ibuprofen Inza Non-steroidal anti-inflammatory drugs Accepted treatment Ibuprofen 600mg TAB SANDOZ Ibuprofen Brufen Non-steroidal anti-inflammatory drugs Accepted treatment Imipramine 10mg TAB Ethipramine Tofranil Heterocyclic antidepressants Accepted treatment

Page 76 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM Imipramine 25mg TAB Ethipramine Tofranil Heterocyclic antidepressants Accepted treatment Indomethacin 100mg SUP Arthrexin Indocid Non-steroidal anti-inflammatory drugs Motivation required Indomethacin 25mg CAP SANDOZ Idomethacin Arthrexin Non-steroidal anti-inflammatory drugs Accepted treatment Ketoprofen 200mg SRC Ketoflam Non-steroidal anti-inflammatory drugs Motivation required Ispaghula 3.5g GRA Ispagel Agiobulk Laxatives Accepted treatment Ispaghula (psylla seeds) SAC Dis-Chem Ispaghula Fybogel orange Laxatives Accepted treatment Ispaghula; combinations POW Fibrelle Laxatives Accepted treatment Lactulose 3.3g/5ml SYR Aculax Duphalac Laxatives Accepted treatment Lactulose SAC Duphalac dry 10g Laxatives Accepted treatment Lactulose 10g SAC Laxette dry (10g) Laxatives Accepted treatment Senokot-Lactulose (creme Lactulose SYR Senokot-Lactulose (banana) Laxatives Accepted treatment caramel) Laurilsulfate; incl. combinations ENE Microlax 5ml Laxatives Accepted treatment Loperamide 2mg TAB Adco-loperamide Betaperamide Antipropulsives Accepted treatment Loperamide 1mg/5ml SYR Gastron Imodium Antipropulsives Accepted treatment Loperamide 2mg TAB Gastron Antipropulsives Accepted treatment Magnesium carbonate MLS Be-lax Laxatives Accepted treatment Meloxicam 15mg TAB Loxiflam Arrow Meloxicam Non-steroidal anti-inflammatory drugs Accepted treatment Meloxicam 7.5mg TAB SANDOZ Meloxicam Coxflam Non-steroidal anti-inflammatory drugs Accepted treatment Methotrexate 2.5mg TAB Emthexate Emthexate Immunosuppressants Accepted treatment Naproxen 250mg TAB Adco-naproxen Mylan-naproxen Non-steroidal anti-inflammatory drugs Accepted treatment Naproxen 500mg SUP Nafasol Non-steroidal anti-inflammatory drugs Motivation required Naproxen 250mg ECT Nafasol ec-250 Non-steroidal anti-inflammatory drugs Accepted treatment Naproxen 500mg ECT Nafasol ec-500 Non-steroidal anti-inflammatory drugs Accepted treatment Naproxen 500mg TAB Napflam Non-steroidal anti-inflammatory drugs Accepted treatment Oxybutynin 5mg TAB Urihexal Lenditro Anticholinergics, oral Accepted treatment Piroxicam 10mg CAP Adco-piroxicam Rolab-piroxicam Non-steroidal anti-inflammatory drugs Accepted treatment Piroxicam 20mg CAP Adco-piroxicam Xycam Non-steroidal anti-inflammatory drugs Accepted treatment Piroxicam 20mg TAB Brexecam Non-steroidal anti-inflammatory drugs Accepted treatment Piroxicam 20mg DSP Pixicam Xycam dispers Non-steroidal anti-inflammatory drugs Accepted treatment Mineral salts in combination PDR Golytely Laxatives Accepted treatment Mineral salts in combination POW Go-lytely 68 5775g Laxatives Accepted treatment Mineral salts in combination SAC Klean-prep Laxatives Accepted treatment Nalidixic acid 500mg TAB Puromylon Quinolone antibacterial Motivation required

Page 77 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM Nalidixic acid SUS Winlomylon susp Quinolone antibacterial Motivation required Nitrofurantoin 25mg/5ml SUS Furadantin Antibiotics, oral Motivation required Nitrofurantoin 100mg CAP Macrodantin Antibiotics, oral Motivation required Nitrofurantoin 50mg CAP Macrodantin Antibiotics, oral Motivation required Nitroxoline TAB Nicene-n Other antibacterial Motivation required Orphenadrine (citrate) 100mg TAB Norflex Muscle relaxants Accepted treatment Osmotically acting laxatives SAC Movicol Laxatives Accepted treatment Pipemidic acid CAP Deblaston Quinolone antibacterial Motivation required Senna glycosides CAP Depuran Laxatives Accepted treatment Senna glycosides PDR Senna fruit Laxatives Accepted treatment Senna glycosides TAB Senokot Soflax Laxatives Accepted treatment Senna glycosides combinations SAC AgioGel Agiolax Laxatives Accepted treatment Senna glycosides combinations GRA Agiolax Laxatives Accepted treatment Sodium phosphate ENE Fosenema enema 150ml Lenolax(fleet) Laxatives Accepted treatment Sodium phosphate ENE Lenolax paed enema Laxatives Accepted treatment Sorbitol PDR Sorbitol Laxatives Accepted treatment Sterculia GRA Normacol/special Laxatives Accepted treatment Sterculia; combinations GRA Alvercol Normacol plus Laxatives Accepted treatment STROKE ICD 10: I64 Acetylsalicylic acid 81mg ECT Ecotrin Aspirin Accepted treatment

Page 78 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM THALASSEMIA ICD 10: D56.0 D56.1 D56.2 D56.3 D56.4 D56.8 D56.9 D58.2 D74.0 D74.8 D74.9 Deferasirox 125mg DSP Exjade Iron Chelating agents Motivation required Deferasirox 250mg DSP Exjade Iron Chelating agents Motivation required Deferasirox 500mg DSP Exjade Iron Chelating agents Motivation required Deferoxamine 500mg INJ Desferal Iron Chelating agents Motivation required THROMBOEMBOLIC DISEASE ICD 10: G08 I26.0 I26.9 I67.6 I70.2 I74.0 I74.1 I74.4 I74.5 I74.8 I80.1 I80.2 I80.3 I80.8 I82.1 I82.2 I82.3 I82.8 K75.1 Acetylsalicylic acid 81mg ECT Ecotrin Aspirin Accepted treatment

Page 79 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM Warfarin 1mg TAB Cipla Warfarin Anticoagulants Accepted treatment Warfarin 5mg TAB Cipla Warfarin Aspen Warfarin Anticoagulants Accepted treatment Warfarin 3mg TAB Cipla-Warfarin Anticoagulants Accepted treatment TUBERCULOSIS ICD 10: A15.0-A15.9 A16.0 A16.1 A16.2 A16.3 A16.4 A16.5 A16.7 A16.8 A16.9 A17.8 A17.9 A18.0 A18.8 A18.9 A31.0 A98.0 A37.0 A19.0 A19.1 A19.2 A19.8 A19.9 Amikacin 1000mg INJ Amikacin-fresenius Aminoglycoside Antibacterial Motivation required, Sputum Test Amikacin 100mg INJ Amikacin-fresenius Aminoglycoside Antibacterial Motivation required, Sputum Test Amikacin 250mg INJ Amikacin-fresenius Aminoglycoside Antibacterial Motivation required, Sputum Test Amikacin 500mg INJ Amikacin-fresenius Aminoglycoside Antibacterial Motivation required, Sputum Test Ciprofloxacin 250mg TAB Austell-Ciprofloxacin Cpl alliance ciprofloxacin Fluoroquinolones Motivation required, Sputum Test Ciprofloxacin 500mg TAB Austell-Ciprofloxacin Cpl alliance ciprofloxacin Fluoroquinolones Motivation required, Sputum Test Cycloserine 250mg CAP Aspen Cycloserine Antimycobacterial Motivation required, Sputum Test Dapsone 100mg TAB Dapsone Antimycobacterial special investigations, Sputum Test Ethambutol 400mg TAB Sandoz ethambutol Antimycobacterial special investigations, Sputum Test Ethionamide 250mg TAB Ethatyl Antimycobacterial Motivation required, Sputum Test Isoniazid 100mg TAB Norstan Isoniazid Be-tabs isoniazid Antimycobacterial special investigations, Sputum Test Kanamycin 1g/3ml INJ Kanamycin Aminoglycoside antibacterial Motivation required, Sputum Test Ofloxacin 200mg TAB Tafloc Tarivid Quinolone antibacterial Motivation required, Sputum Test Pyrazinamide 500mg TAB Pyrazide Sandoz pyrazinamide Antimycobacterial special investigations, Sputum Test special investigations, Pathology report Pyridoxine (vit B6) 25mg TAB Be-tabs pyridoxine hcl Vitamin supplement indicating deficiency special investigations, Pathology report Pyridoxine (vit B6) 25mg TAB Pyridoxine Vitamin supplement indicating deficiency special investigations, Pathology report Pyridoxine (vit B6) 25mg TAB Pyridoxine Vitamin supplement indicating deficiency special investigations, Pathology report Pyridoxine (vit B6) 25mg TAB Vitamin B6 Vitamin supplement indicating deficiency Rifampicin 150mg CAP Rimactane Antimycobacterial special investigations, Sputum Test Rifampicin 450mg TAB Rimactane Antimycobacterial special investigations, Sputum Test Rifampicin 600mg TAB Rimactane Antimycobacterial special investigations, Sputum Test Rifampicin & isoniazid 150/150mg TAB Rifinah Antimycobacterial special investigations, Sputum Test Rifampicin & isoniazid 300mg TAB Rifinah Antimycobacterial special investigations, Sputum Test Rifampicin & isoniazid 150/75mg TAB Rimactazid Antimycobacterial special investigations, Sputum Test Rifampicin & isoniazid 300/150mg TAB Rimactazid Antimycobacterial special investigations, Sputum Test Rifampicin & isoniazid 60/30mg TAB Rimactazid paed Antimycobacterial special investigations, Sputum Test

Page 80 of 81 DOSAGE ACTIVE INGREDIENT STRENGTH EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM Rifampicin & isoniazid 60/60mg TAB Rimactazid paed Antimycobacterial special investigations, Sputum Test Rifampicin, isoniazid, 150/75/400/27 TAB Rimstar 4-FDC Antimycobacterial special investigations, Sputum Test pyrazinamide & ethambutol 5mg Terizidone 250mg CAP Terivalidin Antimycobacterial Motivation required, Sputum Test VALVULAR HEART DISEASE ICD 10: I05.0 I09.0 Note: medicines under "heart failure" will also be reimbursed under this condition. Benzylpenicillin INJ Bio-pen Bio-Pen 5 M U Antibiotics Accepted treatment Erythromycin 250mg TAB Betamycin Adco-erythromycin Antibiotics, oral Accepted treatment Phenoxymethylpenicillin 250mg TAB Betapen Len vk Antibiotics, oral Accepted treatment

Page 81 of 81