CHRONIC MEDICATION COMPREHENSIVE FORMULARY Effective 1 June 2013
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CHRONIC MEDICATION COMPREHENSIVE FORMULARY Effective 1 June 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 CPS Capsule (Inhaler) INH Inhaler SLN Sublingual CRM Cream INJ Injection SRC Slow release capsule DRP Drops LOT Lotion SRT Slow release tablet DSP Dispersable NAS Nasal spray SUP Suppository SYR Syrup TAB Tablet UNG Ointment ECT Enteric-coated tablet NOD Nasal drops SUS Suspension ACTIVE INGREDIENT STRENGTH DOSAGE EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM CHRONIC DISEASE LIST CONDITIONS (CDLs) ADDISON'S DISEASE ICD10: E27.1 Page 1 of 108 ACTIVE INGREDIENT STRENGTH DOSAGE EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM 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 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 Becloforte inhaler Corticosteroids, inhaled Accepted treatment Beclometasone 50mcg INH Beclate 50 Becotide Corticosteroids, inhaled Accepted treatment Budesonide 100mcg INH Budeflam 300 dose gentle- Inflammide 100 Corticosteroids, inhaled Accepted treatment haler hfa mac 300 dose Budesonide 200mcg INH Budeflam 300 dose gentle- Inflammide 200 Corticosteroids, inhaled Accepted treatment haler hfa mac 300 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 Budesonide 400mcg INH Inflammide 400 Novolizer Pulmicort Corticosteroids, inhaled Accepted treatment turbuhaler 100dose Ciclesonide 160mcg INH Alvesco ( 60 doses) Corticosteroids, inhaled Motivation required Ciclesonide 80mcg INH Alvesco ( 60 doses) Corticosteroids, inhaled Motivation required Ciclesonide 160mcg INH Alvesco (120 doses) Corticosteroids, inhaled Motivation required Fenoterol INH Berotec HFA Beta agonists , short acting Motivation required Fenoterol and other drugs for 200mcg INH Duovent HFA 200 dose Beta agonists & anticholinergic Accepted treatment obstructive airway diseases combination Fluticasone 125mcg INH Flixotide 125 cfc free 120 Corticosteroids, inhaled Motivation required actuations Fluticasone 250mcg INH Flixotide 250 cfc free 120 Corticosteroids, inhaled Motivation required actuations Fluticasone 50mcg INH Flixotide 50 CFC FREE 120 Corticosteroids, inhaled Motivation required Fluticasone 100mcg ACC Flixotide accuhaler Corticosteroids, inhaled Motivation required Fluticasone 250mcg ACC Flixotide accuhaler Corticosteroids, inhaled Motivation required Fluticasone 500mcg ACC Flixotide accuhaler Corticosteroids, inhaled Motivation required Fluticasone 50mcg ACC Flixotide accuhaler Corticosteroids, inhaled Motivation required Page 2 of 108 ACTIVE INGREDIENT STRENGTH DOSAGE EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM 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 Formoterol 9mcg INH Oxis turbuhaler 9mcg 60 dose Beta agonists, long acting Motivation required Formoterol and other drugs for 160/4.5mcg INH Symbicord turboh Corticosteroids and beta agonists, Motivation required obstructive airway disease 160mcg;45mc long acting Formoterol and other drugs for 80/4.5mcg INH Symbicord turboh 80:4 5mcg Corticosteroids and beta agonists, Motivation required obstructive airway disease long acting Ipratropium bromide 40mcg INH Ipvent anticholinergics Accepted treatment Ipratropium bromide 20mcg INH Atrovent anticholinergics Accepted treatment Ketotifen 1mg SYR Adco-ketotifen Antihistamines for systemic use Motivation required Ketotifen 1mg SYR Zaditen Antihistamines for systemic use Motivation required Ketotifen 1mg SYR Zetofen Antihistamines for systemic use Motivation required Montelukast 10mg TAB Singulair Sintrine Leukotriene receptor antagonists Motivation required Montelukast 4mg CHU Singulair Sintrine Leukotriene receptor antagonists Motivation required Montelukast 5mg CHU Singulair Sintrine Leukotriene receptor antagonists Motivation required Montelukast 4mg SAC Singulair Sprinkles Leukotriene receptor antagonists Motivation required Prednisolone 5mg TAB Capsoid Lenisolone Corticosteroids , oral Motivation required Prednisone 5mg TAB Be-tabs prednisone Panafcort Corticosteroids , oral Motivation required Salbutamol 100mcg INH Asthavent Venteze CFC free Beta agonists , short acting Accepted treatment Salbutamol 200mcg CAP Asthavent DP Ventodisks(8 s) Beta agonists , short acting Accepted treatment Salbutamol 400mcg CPS Ventodisks(8 s) Beta agonists , short acting Motivation required Salbutamol 2.5mg SLN Ventolin nebules Salbu-neb Beta agonists , short acting Motivation required Salbutamol and other drugs for INH Combivent Beta agonists & anticholinergic Accepted treatment obstructive airway diseases combination Salmeterol 50mcg INH Serevent accuhaler Beta agonists, long acting Motivation required Salmeterol 25mcg INH Serevent inhal (120) Beta agonists, long acting Motivation required Salmeterol and other drugs for 25mcg/125mcg INH Foxair Sereflo HFA 25/125 Salmeterol and fluticasone Accepted treatment obstructive airway diseases Dose 120 Salmeterol and other drugs for 25mcg/50mcg INH Foxair Sereflo HFA 25/50 Corticosteroids and beta agonists, Accepted treatment obstructive airway diseases 120 Dose long acting Salmeterol and other drugs for 50/100mcg ACC Foxair Seretide accuhaler Corticosteroids and beta agonists, Accepted treatment obstructive airway diseases 50/100 long acting Salmeterol and other drugs for 50/250mcg ACC Foxair Seretide Accuhaler Corticosteroids and beta agonists, Motivation required obstructive airway diseases 50/250 long acting Salmeterol and other drugs for 50/500mcg ACC Foxair Seretide accuhaler Corticosteroids and beta agonists, Motivation required obstructive airway diseases 50/500 long acting Page 3 of 108 ACTIVE INGREDIENT STRENGTH DOSAGE EXAMPLE 1 EXAMPLE 2 CLASS COMMENT FORM Salmeterol and other drugs for 25mcg/250mcg INH Sereflo HFA 25/250 Dose 120 Seretide 25/250 Corticosteroids and beta agonists, Accepted treatment obstructive airway diseases 120 dose long acting Terbutaline 05mg INH Bricanyl turbuhaler 200dose Beta agonists , short acting Motivation required Theophylline 250mg SRT Euphyllin retard Microphyllin Xanthines Motivation required Theophylline 125mg SRC Microphyllin Xanthines Motivation required Theophylline 300mg SRT Pulmophyllin sr 300 SANDOZ Xanthines Motivation required Theophyllin Anhydrous SR Theophylline 200mg SRT SANDOZ Theophyllin Theoplus Xanthines Motivation required Anhydrous SR Theophylline 400mg SRT Uniphyl 400 Xanthines Motivation required Theophylline 600mg SRT Uniphyl 600 Xanthines Motivation required Zafirlukast 20mg TAB Accolate 20 Leukotriene receptor antagonists 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 Bupropion 150mg SRT Wellbutrin SR OTHER NERVOUS SYSTEM DRUGS Motivation required Bupropion Extended release 150mg SRT Wellbutrin XL OTHER NERVOUS SYSTEM DRUGS Motivation required Bupropion Extended release 300mg SRT Wellbutrin XL OTHER NERVOUS SYSTEM DRUGS Motivation required Carbamazepine 200mg TAB CPL-Carbamazepine Degranol Mood Stabilisers Accepted treatment Carbamazepine 400mg SRT SANDOZ Cabamazepine CR Tegretol CR Mood Stabilisers Accepted treatment Chlorpromazine 100mg TAB Largactil Antipsychotics Accepted treatment Chlorpromazine 25mg TAB Largactil Antipsychotics Accepted treatment Chlorpromazine 50mg TAB Largactil Antipsychotics Accepted treatment Citalopram 20mg TAB Adco-Talomil Arrow Citalopram