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Section H for Hospital Pharmaceuticals

Effective 1 March 2014

New Zealand Pharmaceutical Schedule

Including the Hospital Medicines List (HML)


Introducing PHARMAC

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March 2014

Volume 2 Number 0

Editors: Kaye Wilson, Donna Jennings & Sarah Le Leu email: schedule@pharmac.govt.nz Telephone +64 4 460 4990 Facsimile +64 4 460 4995 Level 9, 40 Mercer Street PO Box 10 254 Wellington 6143 Freephone Information Line 0800 66 00 50 (9am – 5pm weekdays) Circulation Accessible in an electronic format at no cost from the Health Professionals section of the PHARMAC website www.pharmac.govt.nz You can register to have an electronic version of the Pharmaceutical Schedule (link to PDF copy) emailed to your nominated email address each month. Alternatively there is a nominal charge for an annual subscription to the printed Schedule publications. To access either of these subscriptions visit our subscription website www.schedule.co.nz. Production Typeset automatically from XML and TEX. XML version of the Schedule available from www.pharmac.govt.nz/pub/schedule/archive/ Programmers Anrik Drenth & John Geering email: texschedule@pharmac.govt.nz c Pharmaceutical Management Agency ISSN 1179-3708 pdf ISSN 1172-9694 print This work is licensed under the Creative Commons Attribution 3.0 New Zealand licence. In essence, you are free to copy, distribute and adapt it, as long as you attribute the work to PHARMAC and abide by the other licence terms. To view a copy of this licence, visit: creativecommons.org/licenses/by/3.0/nz/. Attribution to PHARMAC should be in written form and not by reproduction of the PHARMAC logo. While care has been taken in compiling this Schedule, PHARMAC takes no responsibility for any errors or omissions, and shall not be liable for any consequences arising there from.

Part I Part II

General Rules

Alimentary Tract and Metabolism 12 Blood and Blood Forming Organs 26 Cardiovascular System 36 Dermatologicals 48 Genito-Urinary System 55 Hormone Preparations 59 Infections 65 Musculoskeletal System 88 Nervous System 97

Oncology Agents and Immunosuppressants 123 Respiratory System and Allergies 159 Sensory Organs 165 Various 171 Extemporaneous Compounds (ECPs) 179 Special Foods 182 Vaccines 196

Part III

Optional Pharmaceuticals 201 Index 203


Introducing PHARMAC

PHARMAC, the Pharmaceutical Management Agency, is a Crown entity established pursuant to the New Zealand Public Health and Disability Act 2000 (The Act). The primary objective of PHARMAC is to secure for eligible people in need of pharmaceuticals, the best health outcomes that are reasonably achievable from pharmaceutical treatment and from within the amount of funding provided. The PHARMAC Board consists of up to six members appointed by the Minister of Health. All decisions relating to PHARMAC’s operation are made by or under the authority of the Board. More information on the Board can be found at www.pharmac.govt.nz The functions of PHARMAC are set out in section 48 of the Act. PHARMAC is required to perform these functions within the amount of funding provided to it and in accordance with its statement of intent and any directions given by the Minister (Section 103 of the Crown Entities Act). The Government has agreed that PHARMAC will assume responsibility for the assessment, prioritisation and procurement of medical devices on behalf of DHBs. Medical devices come within the definition of Pharmaceuticals in the Act. PHARMAC is assuming responsibility for procurement of some medical devices categories immediately, as a first step to full PHARMAC management of these categories within the Pharmaceutical Schedule.

Decision Criteria

PHARMAC takes into account the following criteria when considering amendments to the Schedule: a) the health needs of all eligible people within New Zealand; b) the particular health needs of M¯ ori and Pacific peoples; a c) the availability and suitability of existing medicines, therapeutic medical devices and related products and related things; d) the clinical benefits and risks of pharmaceuticals; e) the cost-effectiveness of meeting health needs by funding pharmaceuticals rather than using other publicly funded health and disability support services; f) the budgetary impact (in terms of the pharmaceutical budget and the Government’s overall health budget) of any changes to the Schedule; g) the direct cost to health service users; h) the Government’s priorities for health funding, as set out in any objectives notified by the Crown to PHARMAC, or in PHARMAC’s Funding Agreement, or elsewhere; and i) such other criteria as PHARMAC thinks fit. PHARMAC will carry out appropriate consultation when it intends to take any such “other criteria” into account.

PHARMAC’s clinical advisors

Pharmacology and Therapeutics Advisory Committee (PTAC) PHARMAC works closely with the Pharmacology and Therapeutics Advisory Committee (PTAC), an expert medical committee which provides independent advice to PHARMAC on health needs and the clinical benefits of particular pharmaceuticals for use in the community and/or in DHB Hospitals. The chair of PTAC sits with the PHARMAC Board in an advisory capacity. Contact PTAC C/-PTAC Secretary, Pharmaceutical Management Agency, PO Box 10 254, WELLINGTON 6143, Email: PTAC@pharmac.gov PTAC Subcommittees PTAC has subcommittees from which it can seek specialist advice in relation to funding applications. PTAC may seek advice from one or more subcommittees in relation to a funding application, or may make recommendations to PHARMAC without seeking the advice of a subcommittee: Analgesic Subcommittee Haematology Subcommittee Reproductive and Sexual Health Anti-Infective Subcommittee Hospital Pharmaceuticals Subcommittee Subcommittee Cancer Treatments Subcommittee Immunisation Subcommittee Respiratory Subcommittee Cardiovascular Subcommittee Mental Health Subcommittee Rheumatology Subcommittee Dermatology Subcommittee Neurological Subcommittee Special Foods Subcommittee Diabetes Subcommittee Ophthalmology Subcommittee Transplant Immunosuppressants Endocrinology Subcommittee Pulmonary Arterial Hypertension Subcommittee Gastrointestinal Subcommittee Subcommittee PTAC also has a Tender Medical Evaluation Subcommittee to provide advice on clinical matters relating to PHARMAC’s annual multi-product tender and other purchasing strategies. Current membership of PTAC’s subcommittees can be found on PHARMAC’s website: http://www.pharmac.health. nz/about/committees/ptac

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Named Patient Pharmaceutical Assessment policy

Named Patient Pharmaceutical Assessment (NPPA) provides a mechanism for individual patients to receive funding for medicines not listed in the Pharmaceutical Schedule (either at all or for their clinical circumstances). PHARMAC will assess applications that meet the prerequisites according to its Decision Criteria before deciding whether to approve applications for funding. The Decision Criteria will be used to assess both the individual clinical circumstances of each NPPA applicant, and the implications of each NPPA funding decision on PHARMAC’s ability to carry out its legislative functions. For more information on NPPA, or to apply, visit the PHARMAC website at http://www.pharmac.health.nz/tools- resources/forms/namedpatient-pharmaceutical-assessment-nppa-forms, or call the Panel Coordinators at (04) 9167553 or (04) 9167521.

The Pharmaceutical Schedule

The purpose of the Schedule is to list: G the Community Pharmaceuticals that are subsidised by the Government and to show the amount of the subsidy paid to contractors, as well as the manufacturer’s price and any access conditions that may apply; G the Hospital Pharmaceuticals that may be used in DHB Hospitals, as well as any access conditions that may apply; and G the Pharmaceuticals,including Medical Devices, used in DHB Hospitals for which national prices have been negotiated by PHARMAC. The purpose of the Schedule is not to show the final cost to Government of subsidising each Community Pharmaceutical or to DHBs in purchasing each Hospital Pharmaceutical or other Pharmaceuticals, including Medical Devices, used in DHB Hospitals, since that will depend on any rebate and other arrangements PHARMAC has with the supplier and, for some Hospital Pharmaceuticals, or other Pharmaceuticals, including Medical Devices, used in DHB Hospitals, on any logistics arrangements put in place by individual DHB Hospitals.

Finding Information in Section H

Section H lists Pharmaceuticals that can be used in DHB Hospitals, and is split into the following parts: G Part I lists the rules in relation to use of Pharmaceuticals by DHB Hospitals. G Part II lists Hospital Pharmaceuticals that are funded for use in DHB Hospitals. These are classified based on the Anatomical Therapeutic Chemical (ATC) system used for Community Pharmaceuticals. It also provides information on any National Contracts that exist, and an indication of which products have Hospital Supply Status (HSS). G Part III lists Optional Pharmaceuticals for which National Contracts exist, and DHB Hospitals may choose to fund. These are listed alphabetically by generic chemical entity name and line item, the relevant Price negotiated by PHARMAC and, if applicable, an indication of whether it has Hospital Supply Status (HSS) and any associated Discretionary Variance Limit (DV Limit). The index located at the back of the Section H can be used to find page numbers for generic chemical entities and product brand names, for Hospital Pharmaceuticals The listings are displayed alphabetically (where practical) within each level of the classification system. Each anatomical section contains a series of therapeutic headings, some of which may contain a further classificatio

Glossary

Units of Measure gram ..................................................g kilogram ...........................................kg international unit ...............................iu Abbreviations application .....................................app capsule ..........................................cap cream.............................................crm dispersible .................................... disp effervescent .....................................eff emulsion ......................................emul HSS microgram.....................................mcg milligram .........................................mg millilitre.............................................ml millimole......................................mmol unit.....................................................u

enteric coated.................................EC granules......................................grans injection ........................................... inj linctus ............................................ linc liquid ................................................ liq lotion..............................................lotn

ointment.........................................oint solution ......................................... soln suppository .............................. suppos tablet...............................................tab tincture........................................... tinc

Hospital Supply Status (Refer to Rule 20)

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PART I: GENERAL RULES

INTRODUCTION

Section H contains general rules that apply, and other information relating, to Hospital Pharmaceuticals and Optional Pharmaceuticals. Where relevant, Section H shows the Price at which a Pharmaceutical can be purchased directly from the Pharmaceutical supplier by DHBs, providers of logistics services, wholesalers or other such distributors, or Contract Manufacturers. The Price is determined via contractual arrangements between PHARMAC and the relevant Pharmaceutical supplier. Where a Pharmaceutical is listed in Part II of Section H, but no Price and/or brand of Pharmaceutical is indicated, each DHB may purchase any brand and/or pay the price that the DHB negotiates with the relevant Pharmaceutical supplier. As required by section 23(7) of the Act, in performing any of its functions in relation to the supply of Pharmaceuticals, a DHB must not act inconsistently with the Pharmaceutical Schedule.

INTERPRETATION AND DEFINITIONS

1 Interpretation and Definitions 1.1 In this Schedule, unless the context otherwise requires: “Act” means the New Zealand Public Health and Disability Act 2000. “Combined Pharmaceutical Budget” means the pharmaceutical budget set for PHARMAC by the Crown for the subsidised supply of Community Pharmaceuticals and Pharmaceutical Cancer Treatments including for named patients in exceptional circumstances. “Community” means any setting outside of a DHB Hospital. “Community Pharmaceutical” means a Pharmaceutical listed in Sections A to G or I of the Pharmaceutical Schedule that is subsidised by the Funder from the Combined Pharmaceutical Budget and, for the purposes of this Section H, includes Pharmaceutical Cancer Treatments (PCTs). “Contract Manufacturer” means a manufacturer or a supplier that is a party to a contract with the relevant DHB Hospital to compound Pharmaceuticals, on request from that DHB Hospital. “Designated Delivery Point” means at a DHB Hospital’s discretion: a) a delivery point agreed between a Pharmaceutical supplier and the relevant DHB Hospital, to which delivery point that Pharmaceutical supplier must supply a National Contract Pharmaceutical directly at the Price; and/or b) any delivery point designated by the relevant DHB Hospital or PHARMAC, such delivery point being within 30 km of the relevant Pharmaceutical supplier’s national distribution centre. “DHB” means an organisation established as a District Health Board by or under Section 19 of the Act. “DHB Hospital” means a hospital (including community trust hospitals) and/or an associated health service that is funded by a DHB including (but not limited to) district nursing services and child dental services. “DV Limit” means, for a particular National Contract Pharmaceutical with HSS, the National DV Limit or the Individual DV Limit. “DV Pharmaceutical” means a discretionary variance Pharmaceutical that does not have HSS but is used in place of one that does. Usually this means it is the same chemical entity, at the same strength, and in the same or a similar presentation or form, as the relevant National Contract Pharmaceutical with HSS. Where this is not the case, a note will be included with the listing of the relevant Hospital Pharmaceutical. “Extemporaneously Compounded Product” means a Pharmaceutical that is compounded from two or more Pharmaceuticals, for the purposes of reconstitution, dilution or otherwise. “First Transition Period” means the period of time after notification that a Pharmaceutical has been awarded HSS and before HSS is implemented. “Funder” means the body or bodies responsible, pursuant to the Act, for the funding of Pharmaceuticals listed on the Schedule (which may be one or more DHBs and/or the Ministry of Health) and their successors. “Give” means to administer, provide or dispense (or, in the case of a Medical Device, use) a Pharmaceutical, or to arrange for the administration, provision or dispensing (or, in the case of a Medical Device, use) of a Pharmaceutical, and “Given” has a corresponding meaning. “Hospital Pharmaceuticals” means the list of Pharmaceuticals set out in Section H Part II of the Schedule which includes some National Contract Pharmaceuticals. “HSS” stands for hospital supply status, which means the status of being the brand of the relevant National Contract Pharmaceutical that DHBs are obliged to purchase, subject to any DV Limit, for the period of hospital supply, as awarded under an agreement between PHARMAC and the relevant Pharmaceutical supplier. Pharmaceuticals with HSS are listed in

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PART I: GENERAL RULES

Section H in bold text. “Indication Restriction” means a limitation placed by PHARMAC on the funding of a Hospital Pharmaceutical which restricts funding to treatment of particular clinical circumstances. “Individual DV Limit” means, for a particular National Contract Pharmaceutical with HSS and a particular DHB Hospital, the discretionary variance limit, being the specified percentage of that DHB Hospital’s Total Market Volume up to which that DHB Hospital may purchase DV Pharmaceuticals of that National Contract Pharmaceutical. “Local Restriction” means a restriction on the use of a Pharmaceutical in specific DHB Hospitals on the basis of prescriber type that is implemented by the relevant DHB in accordance with rule 7. “Medical Device” has the meaning set out in the Medicines Act 1981. “Named Patient Pharmaceutical Assessment Advisory Panel” means the panel of clinicians, appointed by the PHARMAC Board, that is responsible for advising PHARMAC, in accordance with its Terms of Reference, on Named Patient Pharmaceutical Assessment applications and any Exceptional Circumstances renewal applications submitted after 1 March 2012. “National Contract” means a contractual arrangement between PHARMAC and a Pharmaceutical supplier which sets out the basis on which any Pharmaceutical may be purchased for use in a DHB Hospital, including an agreement as to a national price. “National Contract Pharmaceutical” means a brand of Pharmaceutical listed in Section H, where PHARMAC has entered into contractual arrangements with the relevant Pharmaceutical supplier that specify the terms and conditions of listing, including the Price. Such Pharmaceuticals are recognisable in Section H because the relevant listing identifies the brand and Price. “National DV Limit” means, for a particular National Contract Pharmaceutical with HSS, the discretionary variance limit, being the specified percentage of the Total Market Volume up to which all DHB Hospitals may collectively purchase DV Pharmaceuticals of that National Contract Pharmaceutical. “Optional Pharmaceuticals” means the list of National Contract Pharmaceuticals set out in Section H Part III of the Schedule. “PHARMAC” means the Pharmaceutical Management Agency established by Section 46 of the Act. “Pharmacode” means the six or seven digit identifier assigned to a Pharmaceutical by the Pharmacy Guild following application from a Pharmaceutical supplier. “Pharmaceutical” means a medicine, therapeutic medical device, or related product or related thing listed in Sections B to I of the Schedule. “Pharmaceutical Cancer Treatment” means Pharmaceuticals for the treatment of cancer, listed in Sections A to G of the Schedule and identified therein as a “PCT” or “PCT only” Pharmaceutical that DHBs must fund for use in their DHB hospitals, and/or in association with outpatient services provided by their DHB Hospitals, in relation to the treatment of cancers. “Prescriber Restriction” means a restriction placed by PHARMAC on the funding of a Pharmaceutical on the basis of prescriber type (and where relevant in these rules, includes a Local Restriction). “Price” means the standard national price for a National Contract Pharmaceutical, and, unless agreed otherwise between PHARMAC and the Pharmaceutical supplier, includes any costs associated with the supply of the National Contract Pharmaceutical to, at a DHB Hospital’s discretion, any Designated Delivery Point, or to a Contract Manufacturer (expressly for the purpose of compounding), but does not include the effect of any rebates which may have been negotiated between PHARMAC and the Pharmaceutical supplier. “Restriction” means a limitation, put in place by PHARMAC or a DHB, restricting the funding of a Pharmaceutical and includes Indication Restrictions, Local Restrictions and Prescriber Restrictions (as defined in this Part I of Section H). “Schedule” means this Pharmaceutical Schedule and all its sections and appendices. “Special Authority Approval” means an approval for funding of a Community Pharmaceutical that is marked in Sections B-G of the Schedule as being subject to a Special Authority restriction. “Total Market Volume” means, for a particular Hospital Pharmaceutical with HSS in any given period, in accordance with the data available to PHARMAC, the sum of: a) the total number of Units of the relevant Hospital Pharmaceutical with HSS purchased by all DHB Hospitals, or by a particular DHB Hospital in the case of the Individual DV Limit; and b) the total number of Units of all the relevant DV Pharmaceuticals purchased by all DHB Hospitals, or by a particular DHB Hospital in the case of the Individual DV Limit. “Unapproved Indication” means, for a Pharmaceutical, an indication for which it is not approved under the Medicines Act 1981. Clinicians prescribing Pharmaceuticals for Unapproved Indications should be aware of, and comply with, their obligations under Section 25 and/or Section 29 of the Medicines Act 1981 and as set out in rule 23. “Unit” means an individual unit of a Pharmaceutical (e.g. a tablet, 1 ml of an oral liquid, an ampoule or a syringe).

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PART I: GENERAL RULES

“Unlisted Pharmaceutical” means a Pharmaceutical that is within the scope of a Hospital Pharmaceutical, but is not listed in Section H Part II. 1.2 In addition to the above interpretations and definitions, unless the content requires otherwise, a reference in the Schedule to: a) the singular includes the plural; and b) any legislation includes a modification and re-enactment of, legislation enacted in substitution for, and a regulation, Order in Council, and other instrument from time to time issued or made under, that legislation.

HOSPITAL SUPPLY OF PHARMACEUTICALS

2 Hospital Pharmaceuticals 2.1 Section H Part II contains the list of Hospital Pharmaceuticals that must be funded by DHB Hospitals. Section H Part II does not currently encompass the following categories of pharmaceuticals except for any items specifically listed in this Section H Part II: a) Medical Devices; b) whole or fractionated blood products; c) diagnostic products which have an ex vivo use, such as pregnancy tests and reagents; d) disinfectants and sterilising products, except those that are to be used in or on a patient; e) foods and probiotics; f) radioactive materials; g) medical gases; and h) parenteral nutrition. Subject to rule 2.2, the funding of pharmaceuticals identified in a) - h) above is a decision for individual DHB Hospitals. 2.2 Section H Part III lists Optional Pharmaceuticals that PHARMAC and the relevant Pharmaceutical supplier have entered into contractual arrangements for the purchase of, including an agreement on a national price and other obligations such as HSS. DHB Hospitals may choose whether or not to fund the Optional Pharmaceuticals listed in Part III of Section H, but if they do, they must comply with any National Contract requirements. 2.3 Section H Part II does not encompass the provision of pharmaceutical treatments for DHB Hospital staff as part of an occupational health and safety programme. DHB Hospitals may choose whether or not to fund pharmaceutical treatments for such use, but if they do, they must comply with any National Contract requirements. 3 DHB Supply Obligations 3.1 In accordance with section 23(7) of the Act, in performing any of its functions in relation to the supply of pharmaceuticals, a DHB must not act inconsistently with the Pharmaceutical Schedule, which includes these General Rules. 3.2 DHB Hospitals are not required to hold stock of every Hospital Pharmaceutical listed in Section H Part II, but they must Give it within a reasonable time if it is prescribed. 3.3 DHB Hospitals are able to hold stock of an Unlisted Pharmaceutical if doing so is considered necessary for the DHB Hospital to be able to Give the Unlisted Pharmaceutical in a timely manner under rules 11-17 inclusive. 3.4 Except where permitted in accordance with rule 11, DHBs must not Give: a) an Unlisted Pharmaceutical; or b) a Hospital Pharmaceutical outside of any relevant Restrictions. 4 Funding 4.1 The purchase costs of Hospital Pharmaceuticals or Optional Pharmaceuticals administered, provided or dispensed by DHB Hospitals must be funded by the relevant DHB Hospital from its own budget, with the exception of: a) Pharmaceutical Cancer Treatments; b) Community Pharmaceuticals that have been brought to the DHB hospital by the patient who is being treated by outpatient Services or who is admitted as an inpatient; c) Community Pharmaceuticals that have been dispensed to a mental health day clinic under a Practitioner’s Supply Order; and d) Unlisted Pharmaceutical that have been brought to the DHB Hospital by the patient who is admitted as an inpatient. 4.2 For the avoidance of doubt, Pharmaceutical Cancer Treatments and Community Pharmaceuticals are funded through the Combined Pharmaceutical Budget, and Unlisted Pharmaceuticals are funded by the patient.

LIMITS ON SUPPLY

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PART I: GENERAL RULES

5 Prescriber Restrictions 5.1 A DHB Hospital may only Give a Hospital Pharmaceutical that has a Prescriber Restriction if it is prescribed: a) by a clinician of the type specified in the restriction for that Pharmaceutical or, subject to rule 5.2, pursuant to a recommendation from such a clinician; b) in accordance with a protocol or guideline that has been endorsed by the DHB Hospital; or c) in an emergency situation, provided that the prescriber has made reasonable attempts to comply with rule 5.1(a) above. If on-going treatment is required (i.e. beyond 24 hours) subsequent prescribing must comply with rule 5.1(a). 5.2 Where a Hospital Pharmaceutical is prescribed pursuant to a recommendation from a clinician of the type specified in the restriction for that Pharmaceutical: a) the prescriber must consult with a clinician of the type specified in the restriction for that Pharmaceutical; and b) the consultation must relate to the patient for whom the prescription is written; and c) the consultation may be in person, by telephone, letter, facsimile or email; and d) appropriate records are kept of the consultation, including recording the name of the advising clinician on the prescription/chart. 5.3 Where a clinician is working under supervision of a consultant who is of the type specified in the restriction for that Pharmaceutical, the requirements of rule 5.2 can be deemed to have been met. 6 Indication Restrictions 6.1 A DHB Hospital may only Give a Hospital Pharmaceutical that has an Indication Restriction, if it is prescribed for treatment of a patient with the particular clinical circumstances set out in the Indication Restriction. 6.2 If a patient has a current Special Authority Approval for the Hospital Pharmaceutical that the DHB Hospital wishes to Give, then the Indication Restriction is deemed to have been met. 6.3 If a Hospital Pharmaceutical has an Indication Restriction that is “for continuation only” then the DHB Hospital should only Give the Hospital Pharmaceutical where: a) the patient has been treated with the Pharmaceutical in the Community; or b) the patient is unable to be treated with an alternative Hospital Pharmaceutical, and the prescriber has explained to the patient that the Pharmaceutical is not fully subsidised in the Community. 7 Local Restrictions 7.1 A DHB Hospital may implement a Local Restriction, provided that: a) in doing so, it ensures that the Local Restriction does not unreasonably limit funded access to the Hospital Pharmaceutical or undermine PHARMAC’s decision that the Hospital Pharmaceutical must be funded; b) it provides PHARMAC with details of each Local Restriction that it implements; and 7.2 PHARMAC may, when it considers that a Local Restriction does not conform to rule 7.1 above, require a DHB to amend or remove that Local Restriction. 8 Community use of Hospital Pharmaceuticals 8.1 Except where otherwise specified in Section H, DHB Hospitals can Give any Hospital Pharmaceutical to a patient for use in the Community, provided that: a) the quantity does not exceed that sufficient for up to 30 days’ treatment, unless: i) it would be inappropriate to provide less than the amount in an original pack; or ii) the relevant DHB Hospital has a Dispensing for Discharge Policy and the quantity dispensed is in accordance with that policy; and b) the Hospital Pharmaceutical is supplied consistent with any applicable Restrictions. 9 Community use of Medical Devices 9.1 Subject to rules 9.2 and 9.3, DHB Hospitals may Give a Medical Device for patients for use in the Community. 9.2 Where a Medical Device (or a similar Medical Device) is a Community Pharmaceutical, the DHB Hospital must supply: a) the brand of Medical Device that is listed in Sections A-G of the Schedule; and b) only to patients who meet the funding eligibility criteria set out in Sections A-G of the Schedule. 9.3 Where a DHB Hospital has supplied a Medical Device to a patient; and a) that Medical Device (or a similar Medical Device) is subsequently listed in Sections A-G of the Schedule ; and b) the patient would not meet any funding eligibility criteria for the Medical Device set out in Sections A-G of the Schedule; and c) the Medical Device has consumable components that need to be replaced throughout its usable life; then DHB Hospitals may continue to fund consumable products for that patient until the end of the usable life of the Medical Device. At the end of the usable life of the device, funding for a replacement device must be consistent with

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PART I: GENERAL RULES

the Pharmaceutical Schedule and/or in accordance with the Named Patient Pharmaceutical Assessment policy. 9.4 DHB Hospitals may also continue to fund consumable products, as in rule 9.3 above, in situations where the DHB has been funding consumable products but where the Medical Device was funded by the patient. 10 Extemporaneous Compounding 10.1 A DHB Hospital may Give any Extemporaneously Compounded Product for a patient in its care, provided that: a) all of the component Pharmaceuticals of the Extemporaneously Compounded Product are Hospital Pharmaceuticals; and b) the Extemporaneously Compounded Product is supplied consistent with any applicable rules or Restrictions for its component Hospital Pharmaceuticals. 10.2 For the avoidance of doubt, this rule 10.1 applies to any Extemporaneously Compounded Product, whether it is manufactured by the DHB Hospital or by a Contract Manufacturer.

EXCEPTIONS

11 Named Patient Pharmaceutical Assessment 11.1 A DHB Hospitals may only Give: a) an Unlisted Pharmaceutical; or b) a Hospital Pharmaceutical outside of any relevant Restrictions, in accordance with the Named Patient Pharmaceutical Assessment Policy or rules 12 – 17 inclusive. 12 Continuation 12.1 Where a patient’s clinical circumstances have been stabilised via treatment in the Community with a pharmaceutical that has not been funded by the Funder, and that patient is admitted to hospital as an inpatient, a DHB Hospital may fund that pharmaceutical for the duration of the patient’s stay, where: a) the patient has not brought (or cannot arrange to bring) the pharmaceuticals to the DHB Hospital, or pharmacy staff consider that the pharmaceuticals brought to the DHB Hospital by the patient cannot be used; and b) interrupted or delayed treatment would have significant adverse clinical consequences; and c) it is not considered appropriate to switch treatment to a Hospital Pharmaceutical. 13 Pre-Existing Use 13.1 Subject to 13.2, where a DHB Hospital has Given a pharmaceutical for a patient prior to 1 July 2013, and the pharmaceutical: a) is an Unlisted Pharmaceutical; or b) treatment of the patient would not comply with any relevant Restrictions; the DHB Hospital may continue to Give that pharmaceutical if it is considered that there would be significant adverse clinical consequences from ceasing or switching treatment. 13.2 Each DHB Hospital must, by no later than 1 October 2013, provide PHARMAC with a report on pharmaceuticals it has Given in accordance with this rule 13 where treatment has continued beyond 1 August 2013. 14 Clinical Trials and Free Stock 14.1 DHB Hospitals may Give any pharmaceutical that is funded by a third party and is being used: 14.1.1 as part of a clinical trial that has Ethics Committee approval; or 14.1.2 for on-going treatment of patients following the end of such a clinical trial. 14.2 DHB Hospitals may Give any pharmaceutical that is provided free of charge by a supplier, provided that the pharmaceutical is provided as part of a programme of which the DHB, or supplier, has notified PHARMAC. 15 Pharmaceutical Cancer Treatments in Paediatrics DHB Hospitals may Give any pharmaceutical for use within a paediatric oncology/haematology service for the treatment of cancer. 16 Other Government Funding DHB Hospitals may Give any pharmaceutical where funding for that pharmaceutical has been specifically provided by a Government entity other than PHARMAC or a DHB. 17 Other Exceptions 17.1 PHARMAC may also approve the funding of a pharmaceutical within a single DHB Hospital for information gathering purposes or otherwise related to PHARMAC’s decision-making process for considering additions to or amendments to the Pharmaceutical Schedule. 17.2 Funding approvals granted under rule 17.1 will be subject to specific limitations on use as determined appropriate by PHARMAC in each circumstance, in consultation with the relevant DHB Hospital and/or DHB.

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PART I: GENERAL RULES

NATIONAL CONTRACTING

18 Hospital Pharmaceutical Contracts 18.1 A DHB Hospital may enter into a contract for the purchase of any Pharmaceutical, including any Medical Device, that it is entitled to fund in accordance with this Schedule H and that is not a National Contract Pharmaceutical, provided that such a contract: a) does not oblige the relevant DHB Hospital to purchase a volume of that Pharmaceutical, if that Pharmaceutical is a DV Pharmaceutical, that is greater than the relevant DV Limit; b) enables PHARMAC to access and use future price and volume data in respect of that Pharmaceutical; and c) enables the relevant DHB Hospital to terminate the contract or relevant parts of the contract in order to give full effect to the National Contract on no more than 3 months’ written notice to the supplier. 18.2 From 1 July 2013, where a DHB Hospital has a pre-existing supply contract for a particular brand of chemical entity for which there is a National Contract Pharmaceutical, the DHB may continue purchasing the chemical entity in accordance with its pre-existing supply contract however: a) from the day its pre-existing supply contract expires, that DHB Hospital is to purchase the relevant National Contract Pharmaceutical listed in Section H at the Price, and is to comply with any DV Limits for the National Contract Pharmaceutical where it has HSS; b) if purchase of the relevant National Contract Pharmaceutical listed in Section H at the Price, where it has HSS, would not cause the relevant DHB Hospital to be in breach of its pre-existing supply contract for a particular brand of chemical entity; the DHB Hospital must purchase the National Contract Pharmaceutical. 18.3 Following written notification from PHARMAC that a Pharmaceutical is a National Contract Pharmaceutical, either through Section H updates or otherwise, DHB Hospitals must, unless PHARMAC expressly notifies otherwise: a) take any steps available to them to terminate pre-existing contracts or relevant parts of such a contract, and b) not enter any new contracts or extend the period of any current contracts, for the supply of that National Contract Pharmaceutical or the relevant chemical entity or Medical Device. 19 National Contract Pharmaceuticals 19.1 DHB Hospitals must take all necessary steps to enable any contracts between PHARMAC and a Pharmaceutical supplier in relation to National Contract Pharmaceuticals to be given full effect. 19.2 The contractual arrangement between PHARMAC and the relevant supplier of a National Contract Pharmaceutical requires it to be made available for purchase at the relevant Price by any or all of the following: a) DHB Hospitals at Designated Delivery Points; and/or b) Contract Manufacturers (expressly for the purpose of compounding). In the case of Medical Devices, a National Contract may require the Medical Device to be purchased by, and/or supplied to, a third party logistics provider. 20 Hospital Supply Status (HSS) 20.1 The DV Limit for any National Contract Pharmaceutical which has HSS is set out in the listing of the relevant National Contract Pharmaceutical in Section H, and may be amended from time to time. 20.2 If a National Contract Pharmaceutical is listed in Section H as having HSS, DHB Hospitals: a) are expected to use up any existing stocks of DV Pharmaceuticals during the First Transition Period; b) must not purchase DV Pharmaceuticals in volumes exceeding their usual requirements, or in volumes exceeding those which they reasonably expect to use, within the First Transition Period; c) must ensure that Contract Manufacturers, when manufacturing an Extemporaneously Compounded Product on their behalf, use the National Contract Pharmaceutical with HSS; and d) must purchase the National Contract Pharmaceutical with HSS except: i) to the extent that the DHB Hospital may use its discretion to purchase a DV Pharmaceutical within the DV Limit, provided that (subject to rule 20.2(d)(iii) below) the DV Limit has not been exceeded nationally; ii) if the Pharmaceutical supplier fails to supply that National Contract Pharmaceutical, in which case the relevant DHB Hospital does not have to comply with the DV Limit for that National Contract Pharmaceutical during that period of non-supply (and any such month(s) included in a period of non- supply will be excluded in any review of the DV Limit in accordance with rule 20.3 below); iii) that where the DV Limit has been exceeded nationally, the DHB Hospital may negotiate with the Pharmaceutical supplier that supplies the National Contract Pharmaceutical with HSS for written permission to vary the application of that DHB Hospital’s Individual DV Limit for any patient whose exceptional

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PART I: GENERAL RULES

needs require a DV Pharmaceutical. 20.3 PHARMAC may, in its discretion, for any period or part period: a) review usage by DHB Hospitals of the National Contract Pharmaceutical and DV Pharmaceuticals to determine whether the DV Limit has been exceeded; and b) audit compliance by DHB Hospitals with the DV Limits and related requirements. 20.4 PHARMAC will address any issues of non-compliance by any individual DHB or DHB Hospital with a DV Limit by: a) obtaining the relevant DHB or DHB Hospital’s assurance that it will comply with the DV Limit for that National Contract Pharmaceutical with HSS in the remainder of the applicable period and any subsequent periods; and b) informing the relevant supplier of the HSS Pharmaceutical of any individual DHB or DHB Hospital’s noncompliance with the DV Limit for that HSS Pharmaceutical. 20.5 In addition to the steps taken by PHARMAC under rule 20.4 above to address any issues of non-compliance by any individual DHB or DHB Hospital with a DV Limit, the relevant Pharmaceutical supplier may require, in its discretion, financial compensation from the relevant DHB or DHB Hospital: a) an amount representing that DHB or DHB Hospital’s contribution towards exceeding the DV Limit (where PHARMAC is able to quantify this based on the information available to it); or b) the sum of $1,000 or $5,000 (depending on the terms of the applicable national contract applying to the HSS Pharmaceutical), whichever is the greater as between sub-paragraphs (a) and (b) within the number of business days specified in the notice from the Pharmaceutical supplier requiring such payment to be made. 21 Collection of rebates and payment of financial compensation 21.1 Following the receipt of any rebates from a Pharmaceutical supplier in respect of a particular National Contract Pharmaceutical, PHARMAC will notify each relevant DHB and DHB Hospital of the amount of the rebate owing to it, being a portion of the total rebate determined by PHARMAC on the basis of that DHB Hospital’s usage of that National Contract Pharmaceutical, where this is able to be determined. Where data to determine individual DHB Hospitals’ usage is not available, PHARMAC will apportion rebates on the basis of an alternative method agreed between the relevant DHBs and PHARMAC. 21.2 PHARMAC will pay each DHB Hospital the rebate amounts (if any) owing to it, no less frequently than once each calendar quarter in respect of rebates received quarterly (or more often). 22 Price and Volume Data 22.1 DHB Hospitals must provide to PHARMAC, on a monthly basis in accordance with PHARMAC’s requirements, any volume data and, unless it would result in a breach of a pre-existing contract, price data held by those DHB Hospitals in respect of any Pharmaceutical (including any Medical Device) listed in Section H. 22.2 All price and volume data provided to PHARMAC under rule 22.1 above should identify the relevant Hospital Pharmaceutical by using a Pharmacode or some other unique numerical identifier, and the date (month and year) on which the DHB Hospital incurred a cost for the purchase of that Hospital Pharmaceutical. Volume is to be measured in units (that being the smallest possible whole Unit – e.g. a capsule, a vial, a millilitre etc).

MISCELLANEOUS PROVISIONS

23 Unapproved Pharmaceuticals Prescribers should, where possible, prescribe Hospital Pharmaceuticals that are approved under the Medicines Act 1981. However, the funding criteria (including Restrictions) under which a Hospital Pharmaceutical is listed in Section H of the Schedule may: 23.1 in some cases, explicitly permit a DHB to fund a Pharmaceutical that is not approved under the Medicines Act 1981 or for an Unapproved Indication; or 23.2 not explicitly prohibit a DHB from funding a Pharmaceutical for use for an Unapproved Indication; Accordingly, if clinicians are planning on prescribing an unapproved Pharmaceutical or a Pharmaceutical for an Unapproved Indication, they should: 23.1 be aware of and comply with their obligations under sections 25 and/or 29 of the Medicines Act 1981, as applicable, and otherwise under that Act and the Medicines Regulations 1984; 23.2 be aware of and comply with their obligations under the Health and Disability Commissioner’s Code of Consumer Rights, including the requirement to obtain informed consent from the patient (PHARMAC recommends that clinicians obtain written consent); and 23.3 exercise their own skill, judgment, expertise and discretion, and make their own prescribing decisions with respect to

10


PART I: GENERAL RULES

the use of an unapproved Pharmaceutical or a Pharmaceutical for an Unapproved Indication. Clinicians should be aware that simply by listing a Pharmaceutical on the Pharmaceutical Schedule, PHARMAC makes no representations about whether that Pharmaceutical has any form of approval or consent under, or whether the supply or use of the Pharmaceutical otherwise complies with, the Medicines Act 1981. Further, the Pharmaceutical Schedule does not constitute an advertisement, advertising material or a medical advertisement as defined in the Medicines Act or otherwise.

11


Part II: ALIMENTARY TRACT AND METABOLISM

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

Antacids and Antiflatulents Antacids and Reflux Barrier Agents

ALUMINIUM HYDROXIDE WITH MAGNESIUM HYDROXIDE AND SIMETHICONE Tab 200 mg with magnesium hydroxide 200 mg and simethicone 20 mg Oral liq 200 mg with magnesium hydroxide 200 mg and simethicone 20 mg per 5 ml Oral liq 400 mg with magnesium hydroxide 400 mg and simethicone 30 mg per 5 ml SIMETHICONE Oral drops 100 mg per ml SODIUM ALGINATE WITH MAGNESIUM ALGINATE Powder for oral soln 225 mg with magnesium alginate 87.5 mg, sachet SODIUM ALGINATE WITH SODIUM BICARBONATE AND CALCIUM CARBONATE Tab 500 mg with sodium bicarbonate 267 mg and calcium carbonate 160 mg Oral liq 500 mg with sodium bicarbonate 267 mg and calcium carbonate 160 mg per 10 ml ................................................................................. 4.95 SODIUM CITRATE Oral liq 8.8% (300 mmol/l) e.g. Gaviscon Infant e.g. Mylanta e.g. Mylanta e.g. Mylanta Double Strength

e.g. Gaviscon Double Strength 500 ml Acidex

Phosphate Binding Agents

ALUMINIUM HYDROXIDE Tab 600 mg CALCIUM CARBONATE – Restricted see terms below Oral liq 250 mg per ml (100 mg elemental per ml) .........................................39.00 ¯Restricted Only for use in children under 12 years of age for use as a phosphate binding agent ¯ ¯ 500 ml Roxane

Antidiarrhoeals and Intestinal Anti-Inflammatory Agents Antipropulsives

DIPHENOXYLATE HYDROCHLORIDE WITH ATROPINE SULPHATE Tab 2.5 mg with atropine sulphate 25 mcg LOPERAMIDE HYDROCHLORIDE Tab 2 mg Cap 2 mg ..........................................................................................................8.95

400

Diamide Relief

Rectal and Colonic Anti-Inflammatories

BUDESONIDE – Restricted see terms on the next page Cap 3 mg

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Item restricted (see ° above); Item restricted (see ¯ below) e.g. Brand indicates brand example only. It is not a contracted product.

¯


ALIMENTARY TRACT AND METABOLISM

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

¯Restricted Crohn’s disease Both: 1 Mild to moderate ileal, ileocaecal or proximal Crohn’s disease; and 2 Any of the following: 2.1 Diabetes; or 2.2 Cushingoid habitus; or 2.3 Osteoporosis where there is significant risk of fracture; or 2.4 Severe acne following treatment with conventional corticosteroid therapy; or 2.5 History of severe psychiatric problems associated with corticosteroid treatment; or 2.6 History of major mental illness (such as bipolar affective disorder) where the risk of conventional corticosteroid treatment causing relapse is considered to be high; or 2.7 Relapse during pregnancy (where conventional corticosteroids are considered to be contraindicated). Collagenous and lymphocytic colitis (microscopic colitis) Patient has a diagnosis of microscopic colitis (collagenous or lymphocytic colitis) by colonoscopy with biopsies Gut Graft versus Host disease Patient has a gut Graft versus Host disease following allogenic bone marrow transplantation HYDROCORTISONE ACETATE Rectal foam 10% (14 applications) – 1% DV Jan-13 to 2015 ........................25.30 21.1 g Colifoam MESALAZINE Tab EC 400 mg ...............................................................................................49.50 Tab EC 500 mg ...............................................................................................49.50 Tab long-acting 500 mg ..................................................................................59.05 Modified release granules 1 g ......................................................................141.72 Suppos 500 mg – 1% DV Sep-11 to 2014 .....................................................22.80 Suppos 1 g .....................................................................................................54.60 Enema 1 g per 100 ml – 1% DV Sep-12 to 2015...........................................44.12 OLSALAZINE Tab 500 mg Cap 250 mg SODIUM CROMOGLYCATE Cap 100 mg SULPHASALAZINE Tab 500 mg – 1% DV Oct-13 to 2016 ............................................................11.68 Tab EC 500 mg – 1% DV Oct-13 to 2016 ......................................................12.89 100 100 Salazopyrin Salazopyrin EN 100 100 100 120 g 20 30 7 Asacol Asamax Pentasa Pentasa Asacol Pentasa Pentasa

Local Preparations for Anal and Rectal Disorders Antihaemorrhoidal Preparations

CINCHOCAINE HYDROCHLORIDE WITH HYDROCORTISONE Oint 5 mg with hydrocortisone 5 mg per g ......................................................15.00 Suppos 5 mg with hydrocortisone 5 mg per g ..................................................9.90 30 g 12 Proctosedyl Proctosedyl

FLUOCORTOLONE CAPROATE WITH FLUOCORTOLONE PIVALATE AND CINCHOCAINE Oint 950 mcg with fluocortolone pivalate 920 mcg and cinchocaine hydrochloride 5 mg per g ........................................................................... 6.35 30 g Suppos 630 mcg with fluocortolone pivalate 610 mcg and cinchocaine hydrochloride 1 mg .................................................................................... 2.66 12

Ultraproct Ultraproct

Products with Hospital Supply Status (HSS) are in bold Expiry date of HSS period is 30 June of the year indicated unless otherwise stated.

13


ALIMENTARY TRACT AND METABOLISM

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

Management of Anal Fissures

GLYCERYL TRINITRATE Oint 0.2% ........................................................................................................22.00 30 g Rectogesic

Rectal Sclerosants

OILY PHENOL [PHENOL OILY] Inj 5%, 5 ml vial

Antispasmodics and Other Agents Altering Gut Motility

GLYCOPYRRONIUM BROMIDE Inj 200 mcg per ml, 1 ml ampoule – 1% DV Oct-13 to 2016..........................28.56 HYOSCINE BUTYLBROMIDE Tab 10 mg – 1% DV Sep-11 to 2014 ...............................................................1.48 Inj 20 mg, 1 ml ampoule – 1% DV Nov-11 to 2014..........................................9.57 MEBEVERINE HYDROCHLORIDE Tab 135 mg – 1% DV Sep-11 to 2014 ...........................................................18.00 10 20 5 90 Max Health Gastrosoothe Buscopan Colofac

Antiulcerants Antisecretory and Cytoprotective

MISOPROSTOL Tab 200 mcg

H2 Antagonists

CIMETIDINE Tab 200 mg Tab 400 mg RANITIDINE Tab 150 mg – 1% DV Sep-11 to 2014 .............................................................6.79 Tab 300 mg – 1% DV Sep-11 to 2014 .............................................................9.34 Oral liq 150 mg per 10 ml – 1% DV Sep-11 to 2014........................................5.92 Inj 25 mg per ml, 2 ml ampoule ........................................................................8.75 250 250 300 ml 5 Arrow-Ranitidine Arrow-Ranitidine Peptisoothe Zantac

Proton Pump Inhibitors

LANSOPRAZOLE Cap 15 mg – 1% DV Jan-13 to 2015 ...............................................................2.00 Cap 30 mg – 1% DV Jan-13 to 2015 ...............................................................2.32 OMEPRAZOLE Tab dispersible 20 mg ¯Restricted Only for use in tube-fed patients Cap 10 mg – 1% DV Oct-11 to 2014 ...............................................................2.91 Cap 20 mg – 1% DV Oct-11 to 2014 ...............................................................3.78 Cap 40 mg – 1% DV Oct-11 to 2014 ...............................................................5.57 Powder for oral liq – 1% DV Sep-11 to 2014..................................................42.50 Inj 40 mg ampoule – 1% DV Sep-11 to 2014.................................................19.00 Inj 40 mg ampoule with diluent – 1% DV Sep-11 to 2014..............................28.65 ¯ 28 28 Solox Solox

90 90 90 5g 5 5

Omezol Relief Omezol Relief Omezol Relief Midwest Dr Reddy’s Omeprazole Dr Reddy’s Omeprazole

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Item restricted (see ° above); Item restricted (see ¯ below) e.g. Brand indicates brand example only. It is not a contracted product.

¯


ALIMENTARY TRACT AND METABOLISM

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

PANTOPRAZOLE Tab EC 20 mg – 1% DV May-14 to 2016 ........................................................1.23 2.68 Tab EC 40 mg – 1% DV May-14 to 2016 ........................................................1.54 3.54 Inj 40 mg vial (Dr Reddy’s Pantoprazole Tab EC 20 mg to be delisted 1 May 2014) (Dr Reddy’s Pantoprazole Tab EC 40 mg to be delisted 1 May 2014)

28 100 28 100

Dr Reddy’s Pantoprazole Pantoprazole Actavis 20 Dr Reddy’s Pantoprazole Pantoprazole Actavis 40

Site Protective Agents

BISMUTH TRIOXIDE Tab 120 mg .....................................................................................................32.50 SUCRALFATE Tab 1 g 112 De-Nol

Bile and Liver Therapy

L-ORNITHINE L-ASPARTATE – Restricted see terms below Grans for oral liquid 3 g ¯Restricted For patients with chronic hepatic encephalopathy who have not responded to treatment with, or are intolerant to lactulose, or where lactulose is contraindicated. ¯ ¯¯

Diabetes Alpha Glucosidase Inhibitors

ACARBOSE Tab 50 mg – 1% DV Dec-12 to 2015 ...............................................................9.82 Tab 100 mg – 1% DV Dec-12 to 2015 ...........................................................15.83 90 90 Accarb Accarb

Hyperglycaemic Agents

DIAZOXIDE – Restricted see terms below Cap 25 mg ....................................................................................................110.00 Cap 100 mg ..................................................................................................280.00 ¯Restricted For patients with confirmed hypoglycaemia caused by hyperinsulinism. GLUCAGON HYDROCHLORIDE Inj 1 mg syringe kit .........................................................................................32.00 GLUCOSE Tab 1.5 g Tab 3.1 g Gel 40% GLUCOSE WITH SUCROSE AND FRUCTOSE Gel 19.7% with sucrose 35% and fructose 19.7%, 18 g sachet 100 100 Proglicem Proglicem

1

Glucagen Hypokit

Products with Hospital Supply Status (HSS) are in bold Expiry date of HSS period is 30 June of the year indicated unless otherwise stated.

15


ALIMENTARY TRACT AND METABOLISM

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

Insulin - Intermediate-Acting Preparations

INSULIN ASPART WITH INSULIN ASPART PROTAMINE Inj insulin aspart 30% with insulin aspart protamine 70%, 100 u per ml, 3 ml prefilled pen ..................................................................................... 52.15 INSULIN ISOPHANE Inj insulin human 100 u per ml, 10 ml vial Inj insulin human 100 u per ml, 3 ml cartridge INSULIN LISPRO WITH INSULIN LISPRO PROTAMINE Inj insulin lispro 25% with insulin lispro protamine 75%, 100 u per ml, 3 ml cartridge ........................................................................................... 42.66 Inj insulin lispro 50% with insulin lispro protamine 50%, 100 u per ml, 3 ml cartridge ........................................................................................... 42.66 INSULIN NEUTRAL WITH INSULIN ISOPHANE Inj insulin neutral 30% with insulin isophane 70%, 100 u per ml, 10 ml vial Inj insulin neutral 30% with insulin isophane 70%, 100 u per ml, 3 ml cartridge Inj insulin neutral 40% with insulin isophane 60%, 100 u per ml, 3 ml cartridge Inj insulin neutral 50% with insulin isophane 50%, 100 u per ml, 3 ml cartridge

5

NovoMix 30 FlexPen

5 5

Humalog Mix 25 Humalog Mix 50

Insulin - Long-Acting Preparations

INSULIN GLARGINE Inj 100 u per ml, 3 ml disposable pen .............................................................94.50 Inj 100 u per ml, 3 ml cartridge .......................................................................94.50 Inj 100 u per ml, 10 ml vial ..............................................................................63.00 5 5 1 Lantus SoloStar Lantus Lantus

Insulin - Rapid-Acting Preparations

INSULIN ASPART Inj 100 u per ml, 10 ml vial Inj 100 u per ml, 3 ml cartridge INSULIN GLULISINE Inj 100 u per ml, 10 ml vial ..............................................................................27.03 Inj 100 u per ml, 3 ml cartridge .......................................................................46.07 Inj 100 u per ml, 3 ml disposable pen .............................................................46.07 INSULIN LISPRO Inj 100 u per ml, 10 ml vial Inj 100 u per ml, 3 ml cartridge 1 5 5 Apidra Apidra Apidra Solostar

Insulin - Short-Acting Preparations

INSULIN NEUTRAL Inj human 100 u per ml, 10 ml vial Inj human 100 u per ml, 3 ml cartridge

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16

Item restricted (see ° above); Item restricted (see ¯ below) e.g. Brand indicates brand example only. It is not a contracted product.

¯


ALIMENTARY TRACT AND METABOLISM

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

Oral Hypoglycaemic Agents

GLIBENCLAMIDE Tab 5 mg GLICLAZIDE Tab 80 mg – 1% DV Sep-11 to 2014 .............................................................17.60 GLIPIZIDE Tab 5 mg – 1% DV Dec-12 to 2015 .................................................................3.00 METFORMIN Tab immediate-release 500 mg – 1% DV Oct-12 to 2015..............................12.30 Tab immediate-release 850 mg – 1% DV Oct-12 to 2015..............................10.10 PIOGLITAZONE Tab 15 mg – 1% DV Sep-12 to 2015 ...............................................................1.50 Tab 30 mg – 1% DV Sep-12 to 2015 ...............................................................2.50 Tab 45 mg – 1% DV Sep-12 to 2015 ...............................................................3.50 500 100 1,000 500 28 28 28 Apo-Gliclazide Minidiab Apotex Apotex Pizaccord Pizaccord Pizaccord

Digestives Including Enzymes

PANCREATIC ENZYME Cap EC 10,000 BP u lipase, 9,000 BP u amylase and 210 BP u protease Cap EC 25,000 BP u lipase, 18,000 BP u amylase and 1,000 BP u protease Cap EC 25,000 BP u lipase, 22,500 BP u amylase and 1,250 BP u protease Powder 25,000 u lipase with 30,000 u amylase and 1,400 u protease per g URSODEOXYCHOLIC ACID – Restricted see terms below Cap 250 mg – 1% DV May-12 to 2014 ..........................................................71.50 ¯ 100 Ursosan

¯Restricted Alagille syndrome or progressive familial intrahepatic cholestasis Either: 1 Patient has been diagnosed with Alagille syndrome; or 2 Patient has progressive familial intrahepatic cholestasis. Chronic severe drug induced cholestatic liver injury All of the following: 1 Patient has chronic severe drug induced cholestatic liver injury; and 2 Cholestatic liver injury not due to Total Parenteral Nutrition (TPN) use in adults; and 3 Treatment with ursodeoxycholic acid may prevent hospital admission or reduce duration of stay. Cirrhosis Either: 1 Primary biliary cirrhosis confirmed by antimitochondrial antibody titre (AMA) > 1:80, and raised cholestatic liver enzymes with or without raised serum IgM or, if AMA is negative by liver biopsy; and 2 Patient not requiring a liver transplant (bilirubin > 100 µmol/l; decompensated cirrhosis. Pregnancy Patient diagnosed with cholestasis of pregnancy. Haematological transplant Both: continued. . .

Products with Hospital Supply Status (HSS) are in bold Expiry date of HSS period is 30 June of the year indicated unless otherwise stated.

17


ALIMENTARY TRACT AND METABOLISM

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

continued. . . 1 Patient at risk of veno-occlusive disease or has hepatic impairment and is undergoing conditioning treatment prior to allogenic stem cell or bone marrow transplantation; and 2 Treatment for up to 13 weeks. Total parenteral nutrition induced cholestasis Both: 1 Paediatric patient has developed abnormal liver function as indicated on testing which is likely to be induced by TPN; and 2 Liver function has not improved with modifying the TPN composition.

Laxatives Bowel-Cleansing Preparations

CITRIC ACID WITH MAGNESIUM OXIDE AND SODIUM PICOSULFATE Powder for oral soln 12 g with magnesium oxide 3.5 g and sodium picosulfate 10 mg per sachet MACROGOL 3350 WITH ASCORBIC ACID, POTASSIUM CHLORIDE AND SODIUM CHLORIDE Powder for oral soln 755.68 mg with ascorbic acid 85.16 mg, potassium chloride 10.55 mg, sodium chloride 37.33 mg and sodium sulphate 80.62 mg per g, 210 g sachet Powder for oral soln 755.68 mg with ascorbic acid 85.16 mg, potassium chloride 10.55 mg, sodium chloride 37.33 mg and sodium sulphate 80.62 mg per g, 70 g sachet

e.g. PicoPrep

e.g. Glycoprep-C

e.g. Glycoprep-C

MACROGOL 3350 WITH POTASSIUM CHLORIDE, SODIUM BICARBONATE, SODIUM CHLORIDE AND SODIUM SULPHATE Powder for oral soln 59 g with potassium chloride 0.7425 g, sodium bicarbonate 1.685 g, sodium chloride 1.465 g and sodium sulphate 5.685 g per sachet ................................................................................... 14.31 4 Klean Prep

Bulk-Forming Agents

ISPAGHULA (PSYLLIUM) HUSK Powder for oral soln – 1% DV Sep-13 to 2016.................................................5.51 STERCULIA WITH FRANGULA – Restricted: For continuation only ¬ Powder for oral soln 500 g Konsyl-D

Faecal Softeners

DOCUSATE SODIUM Cap 50 mg – 1% DV Sep-11 to 2014...............................................................2.57 Cap 120 mg – 1% DV Sep-11 to 2014.............................................................3.48 DOCUSATE SODIUM WITH SENNOSIDES Tab 50 mg with sennosides 8 mg .....................................................................6.38 PARAFFIN Oral liquid 1 mg per ml Enema 133 ml POLOXAMER Oral drops 10% – 1% DV Sep-11 to 2014 .......................................................3.78 30 ml Coloxyl 100 100 200 Laxofast 50 Laxofast 120 Laxsol

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Item restricted (see ° above); Item restricted (see ¯ below) e.g. Brand indicates brand example only. It is not a contracted product.

¯


ALIMENTARY TRACT AND METABOLISM

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

Osmotic Laxatives

GLYCEROL Suppos 1.27 g Suppos 2.55 g Suppos 3.6 g – 1% DV Jan-13 to 2015 ...........................................................6.50 LACTULOSE Oral liq 10 g per 15 ml – 1% DV May-14 to 2014.............................................3.84

20 500 ml

PSM Laevolac

MACROGOL 3350 WITH POTASSIUM CHLORIDE, SODIUM BICARBONATE AND SODIUM CHLORIDE – Restricted see terms below Powder for oral soln 6.563 g with potassium chloride 23.3 mg, sodium bicarbonate 89.3 mg and sodium chloride 175.4 mg Powder for oral soln 13.125 g with potassium chloride 46.6 mg, sodium bicarbonate 178.5 mg and sodium chloride 350.7 mg – 1% DV Nov-13 to 2014 ........................................................................................ 10.00 30 Lax-Sachets ¯Restricted Either: 1 The patient has problematic constipation requiring intervention with a per rectal preparation despite an adequate trial of other oral pharmacotherapies including lactulose where lactulose is not contraindicated; or 2 For short-term use for faecal disimpaction. SODIUM CITRATE WITH SODIUM LAURYL SULPHOACETATE Enema 90 mg with sodium lauryl sulphoacetate 9 mg per ml, 5 ml – 1% DV Sep-13 to 2016 ............................................................................ 19.95 50 Micolette

¯ ¯ ¯¯ ¯

SODIUM PHOSPHATE WITH PHOSPHORIC ACID Oral liq 16.4% with phosphoric acid 25.14% Enema 10% with phosphoric acid 6.58% .........................................................2.50

1

Fleet Phosphate Enema

Stimulant Laxatives

BISACODYL Tab 5 mg ...........................................................................................................4.99 Suppos 5 mg ....................................................................................................3.00 Suppos 10 mg ..................................................................................................3.00 DANTHRON WITH POLOXAMER – Restricted see terms below Oral liq 25 mg with poloxamer 200 mg per 5 ml .............................................21.30 Oral liq 75 mg with poloxamer 1 g per 5 ml ....................................................43.60 ¯Restricted Only for the prevention or treatment of constipation in the terminally ill SENNOSIDES Tab 7.5 mg 200 6 6 300 ml 300 ml Lax-Tabs Dulcolax Dulcolax Pinorax Pinorax Forte

Metabolic Disorder Agents

ARGININE Powder Inj 600 mg per ml, 25 ml vial BETAINE – Restricted see terms below Powder ¯Restricted Metabolic disorders physician or metabolic disorders dietitian

Products with Hospital Supply Status (HSS) are in bold Expiry date of HSS period is 30 June of the year indicated unless otherwise stated.

19


ALIMENTARY TRACT AND METABOLISM

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

BIOTIN – Restricted see terms below Cap 50 mg Cap 100 mg Inj 10 mg per ml, 5 ml vial ¯Restricted Metabolic disorders physician or metabolic disorders dietician. HAEM ARGINATE Inj 25 mg per ml, 10 ml ampoule IMIGLUCERASE – Restricted see terms below Inj 40 iu per ml, 5 ml vial Inj 40 iu per ml, 10 ml vial ¯Restricted Only for use in patients with approval by the Gaucher’s Treatment Panel LEVOCARNITINE – Restricted see terms below Cap 500 mg Oral soln 500 mg per 15 ml Inj 200 mg per ml, 5 ml vial ¯Restricted Metabolic disorders physician, metabolic disorders dietitian or neurologist PYRIDOXAL-5-PHOSPHATE – Restricted see terms below Tab 50 mg ¯Restricted Metabolic disorders physician, metabolic disorders dietician or neurologist SODIUM BENZOATE Cap 500 mg Powder Soln 100 mg per ml Inj 20%, 10 ml ampoule SODIUM PHENYLBUTYRATE Tab 500 mg Oral liq 250 mg per ml Inj 200 mg per ml, 10 ml ampoule TRIENTINE DIHYDROCHLORIDE Cap 300 mg

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Minerals Calcium

CALCIUM CARBONATE Tab 1.25 g (500 mg elemental) – 1% DV Feb-12 to 2014................................6.38 Tab 1.5 g (600 mg elemental) Tab eff 1.75 g (1 g elemental) – 1% DV Nov-11 to 2014 .................................6.21 250 30 Arrow-Calcium Calsource

Fluoride

SODIUM FLUORIDE Tab 1.1 mg (0.5 mg elemental)

20

Item restricted (see ° above); Item restricted (see ¯ below) e.g. Brand indicates brand example only. It is not a contracted product.

¯


ALIMENTARY TRACT AND METABOLISM

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

Iodine

POTASSIUM IODATE Tab 256 mcg (150 mcg elemental iodine) POTASSIUM IODATE WITH IODINE Oral liq 10% with iodine 5%

Iron

FERROUS FUMARATE Tab 200 mg (65 mg elemental) .........................................................................4.35 FERROUS FUMARATE WITH FOLIC ACID Tab 310 mg (100 mg elemental) with folic acid 350 mcg ..................................4.75 FERROUS GLUCONATE WITH ASCORBIC ACID Tab 170 mg (20 mg elemental) with ascorbic acid 40 mg FERROUS SULPHATE Tab long-acting 325 mg (105 mg elemental) ....................................................2.06 Oral liq 30 mg (6 mg elemental) per ml – 1% DV Apr-14 to 2016 .................10.28 FERROUS SULPHATE WITH ASCORBIC ACID Tab long-acting 325 mg (105 mg elemental) with ascorbic acid 500 mg FERROUS SULPHATE WITH FOLIC ACID Tab long-acting 325 mg (105 mg elemental) with folic acid 350 mcg IRON POLYMALTOSE Inj 50 mg per ml, 2 ml ampoule – 1% DV Oct-11 to 2014 .............................19.90 IRON SUCROSE Inj 20 mg per ml, 5 ml ampoule ....................................................................100.00 5 5 Ferrum H Venofer 30 500 ml Ferrograd Ferodan 100 60 Ferro-tab Ferro-F-Tabs

Magnesium

MAGNESIUM HYDROXIDE Tab 311 mg (130 mg elemental) MAGNESIUM OXIDE Cap 663 mg (400 mg elemental) MAGNESIUM SULPHATE Inj 0.4 mmol per ml, 250 ml bag Inj 2 mmol per ml, 5 ml ampoule – 1% DV Feb-13 to 2014 ...........................18.35

10

Martindale

Zinc

ZINC Oral liq 5 mg per 5 drops ZINC CHLORIDE Inj 5.3 mg per ml (5.1 mg per ml elemental), 2 ml ampoule ZINC SULPHATE Cap 137.4 mg (50 mg elemental) – 1% DV Nov-11 to 2014..........................11.00 100 Zincaps

Products with Hospital Supply Status (HSS) are in bold Expiry date of HSS period is 30 June of the year indicated unless otherwise stated.

21


ALIMENTARY TRACT AND METABOLISM

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

Mouth and Throat Agents Used in Mouth Ulceration

BENZYDAMINE HYDROCHLORIDE Soln 0.15% Spray 0.15% BENZYDAMINE HYDROCHLORIDE WITH CETYLPYRIDINIUM CHLORIDE Lozenge 3 mg with cetylpyridinium chloride CARBOXYMETHYLCELLULOSE Oral spray CHLORHEXIDINE GLUCONATE Mouthwash 0.2% – 1% DV Dec-12 to 2015.....................................................2.68 CHOLINE SALICYLATE WITH CETALKONIUM CHLORIDE Adhesive gel 8.7% with cetalkonium chloride 0.01% DICHLOROBENZYL ALCOHOL WITH AMYLMETACRESOL Lozenge 1.2 mg with amylmetacresol 0.6 mg SODIUM CARBOXYMETHYLCELLULOSE WITH PECTIN AND GELATINE Paste Powder TRIAMCINOLONE ACETONIDE Paste 0.1% – 1% DV Sep-11 to 2014 ..............................................................4.34 5g Oracort 200 ml healthE

Oropharyngeal Anti-Infectives

AMPHOTERICIN B Lozenge 10 mg .................................................................................................5.86 MICONAZOLE Oral gel 20 mg per g – 1% DV Feb-13 to 2015................................................4.95 NYSTATIN Oral liquid 100,000 u per ml – 1% DV Sep-11 to 2014 ....................................3.19 20 40 g 24 ml Fungilin Decozol Nilstat

Other Oral Agents

SODIUM HYALURONATE – Restricted see terms below Inj 20 mg per ml, 1 ml syringe ¯Restricted Otolaryngologist THYMOL GLYCERIN Compound, BPC ¯

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Item restricted (see ° above); Item restricted (see ¯ below) e.g. Brand indicates brand example only. It is not a contracted product.

¯


ALIMENTARY TRACT AND METABOLISM

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

Vitamins Multivitamin Preparations

MULTIVITAMINS Tab (BPC cap strength) Cap vitamin A 2500 u, betacarotene 3 mg, cholecalciferol 11 mcg, alpha tocopherol 150 u, phytomenadione 150 mcg, folic acid 0.2 mg, ascorbic acid 100 mg, thiamine 1.5 mg, pantothenic acid 12 mg, riboflavin 1.7 mg, niacin 20 mg, pyridoxine hydrochloride 1.9 mg, cyanocobalamin 3 mcg, zinc 7.5 mg and biotin 100 mcg ¯Restricted Either: 1 Patient has cystic fibrosis with pancreatic insufficiency; or 2 Patient is an infant or child with liver disease or short gut syndrome. Powder vitamin A 4200 mcg with vitamin D 155.5 mcg, vitamin E 21.4 mg, vitamin C 400 mg, vitamin K1 166 mcg thiamine 3.2 mg, riboflavin 4.4 mg, niacin 35 mg, vitamin B6 3.4 mg, folic acid 303 mcg, vitamin B12 8.6 mcg, biotin 214 mcg, pantothenic acid 17 mg, choline 350 mg and inositol 700 mg ¯Restricted Patient has inborn errors of metabolism. Inj thiamine hydrochloride 250 mg with riboflavin 4 mg and pyridoxine hydrochloride 50 mg, 5 ml ampoule (1) and inj ascorbic acid 500 mg with nicotinamide 160 mg and glucose 1000 mg, 5 ml ampoule (1) Inj thiamine hydrochloride 250 mg with riboflavin 4 mg and pyridoxine hydrochloride 50 mg, 5 ml ampoule (1) and inj ascorbic acid 500 mg with nicotinamide 160 mg, 2 ml ampoule (1) Inj thiamine hydrochloride 500 mg with riboflavin 8 mg and pyridoxine hydrochloride 100 mg, 10 ml ampoule (1) and inj ascorbic acid 1000 mg with nicotinamide 320 mg and glucose 2000 mg, 10 ml ampoule (1) VITAMIN A WITH VITAMINS D AND C Soln 1,000 u with vitamin D 400 u and ascorbic acid 30 mg per 10 drops e.g. Mvite

¯ ¯

e.g. Vitabdeck

e.g. Paediatric Seravit

e.g. Pabrinex IV

e.g. Pabrinex IM

e.g. Pabrinex IV

e.g. Vitadol C

Vitamin A

RETINOL Tab 10,000 iu Cap 25,000 iu Oral liq 150,000 iu per ml

Vitamin B

HYDROXOCOBALAMIN ACETATE Inj 1 mg per ml, 1 ml ampoule – 1% DV Sep-12 to 2015.................................5.10 3 ABM Hydroxocobalamin

Products with Hospital Supply Status (HSS) are in bold Expiry date of HSS period is 30 June of the year indicated unless otherwise stated.

23


ALIMENTARY TRACT AND METABOLISM

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

PYRIDOXINE HYDROCHLORIDE Tab 25 mg – 1% DV Sep-11 to 2014 ...............................................................2.20 Tab 50 mg – 1% DV Sep-11 to 2014 .............................................................12.16 Inj 100 mg per ml, 1 ml ampoule THIAMINE HYDROCHLORIDE Tab 50 mg Tab 100 mg Inj 100 mg per ml, 2 ml vial VITAMIN B COMPLEX Tab strong, BPC

90 500

PyridoxADE Apo-Pyridoxine

Vitamin C

ASCORBIC ACID Tab 100 mg – 1% DV Nov-13 to 2016 .............................................................7.00 Tab chewable 250 mg 500 Cvite

Vitamin D

ALFACALCIDOL Cap 0.25 mcg .................................................................................................26.32 Cap 1 mcg ......................................................................................................87.98 Oral drops 2 mcg per ml CALCITRIOL Cap 0.25 mcg ...................................................................................................3.03 10.10 Cap 0.5 mcg .....................................................................................................5.62 18.73 Oral liq 1 mcg per ml Inj 1 mcg per ml, 1 ml ampoule CHOLECALCIFEROL Tab 1.25 mg (50,000 iu) ....................................................................................7.76 100 100 One-Alpha One-Alpha

30 100 30 100

Airflow Calcitriol-AFT Airflow Calcitriol-AFT

12

Cal-d-Forte

Vitamin E

ALPHA TOCOPHERYL ACETATE – Restricted see terms below Cap 100 u Cap 500 u Oral liq 156 u per ml ¯Restricted Cystic fibrosis Both: 1 Cystic fibrosis patient; and 2 Either: 2.1 Patient has tried and failed the other available funded fat soluble vitamin A,D,E,K supplement (Vitabdeck); or 2.2 The other available funded fat soluble vitamin A,D,E,K supplement (Vitabdeck) is contraindicated or clinically inappropriate for the patient. Osteoradionecrosis For the treatment of osteoradionecrosis Other indications continued. . . ¯¯¯

°

24

Item restricted (see ° above); Item restricted (see ¯ below) e.g. Brand indicates brand example only. It is not a contracted product.

¯


ALIMENTARY TRACT AND METABOLISM

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

continued. . . All of the following: 1 Infant or child with liver disease or short gut syndrome; and 2 Requires vitamin supplementation; and 3 Either: 3.1 Patient has tried and failed the other available funded fat soluble vitamin A,D,E,K supplements (Vitabdeck); or 3.2 The other available funded fat soluble vitamin A,D,E,K supplement (Vitabdeck) is contraindicated or clinically inappropriate for patient.

Products with Hospital Supply Status (HSS) are in bold Expiry date of HSS period is 30 June of the year indicated unless otherwise stated.

25


BLOOD AND BLOOD FORMING ORGANS

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

Antianaemics Hypoplastic and Haemolytic

ERYTHROPOIETIN ALPHA – Restricted see terms below Inj 1,000 iu in 0.5 ml syringe ...........................................................................48.68 Inj 2,000 iu in 0.5 ml syringe .........................................................................120.18 Inj 3,000 iu in 0.3 ml syringe .........................................................................166.87 Inj 4,000 iu in 0.4 ml syringe .........................................................................193.13 Inj 5,000 iu in 0.5 ml syringe .........................................................................243.26 Inj 6,000 iu in 0.6 ml syringe .........................................................................291.92 Inj 10,000 iu in 1 ml syringe ..........................................................................395.18 ¯Restricted Both: 1 Both: 1.1 Patient in chronic renal failure; and 1.2 Haemoglobin ≤ 100g/L; and 2 Any of the following: 2.1 Both: 2.1.1 Patient is not diabetic; and 2.1.2 Glomerular filtration rate ≤ 30ml/min; or 2.2 Both: 2.2.1 Patient is diabetic; and 2.2.2 Glomerular filtration rate ≤ 45ml/min; or 2.3 Patient is on haemodialysis or peritoneal dialysis. ERYTHROPOIETIN BETA – Restricted see terms below Inj 2,000 iu in 0.3 ml syringe .........................................................................120.18 Inj 3,000 iu in 0.3 ml syringe .........................................................................166.87 Inj 4,000 iu in 0.3 ml syringe .........................................................................193.13 Inj 5,000 iu in 0.3 ml syringe .........................................................................243.26 Inj 6,000 iu in 0.3 ml syringe .........................................................................291.92 Inj 10,000 iu in 0.6 ml syringe .......................................................................395.18 ¯Restricted Both: 1 Both: 1.1 Patient in chronic renal failure; and 1.2 Haemoglobin ≤ 100g/L; and 2 Any of the following: 2.1 Both: 2.1.1 Patient is not diabetic; and 2.1.2 Glomerular filtration rate ≤ 30ml/min; or 2.2 Both: 2.2.1 Patient is diabetic; and 2.2.2 Glomerular filtration rate ≤ 45ml/min; or 2.3 Patient is on haemodialysis or peritoneal dialysis. ¯¯¯¯¯¯¯ ¯¯¯¯¯¯ 6 6 6 6 6 6 6 Eprex Eprex Eprex Eprex Eprex Eprex Eprex

6 6 6 6 6 6

NeoRecormon NeoRecormon NeoRecormon NeoRecormon NeoRecormon NeoRecormon

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26

Item restricted (see ° above); Item restricted (see ¯ below) e.g. Brand indicates brand example only. It is not a contracted product.

¯


BLOOD AND BLOOD FORMING ORGANS

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

Megaloblastic

FOLIC ACID Tab 0.8 mg Tab 5 mg Oral liq 50 mcg per ml ....................................................................................24.00 Inj 5 mg per ml, 10 ml vial

25 ml

Biomed

Antifibrinolytics, Haemostatics and Local Sclerosants

APROTININ – Restricted see terms below Inj 10,000 kIU per ml (equivalent to 200 mg per ml), 50 ml vial ¯Restricted Cardiac anaesthetist Either: 1 Paediatric patient undergoing cardiopulmonary bypass procedure; or 2 Adult patient undergoing cardiac surgical procedure where the significant risk of massive bleeding outweighs the potential adverse effects of the drug. ELTROMBOPAG – Restricted see terms below Tab 25 mg ..................................................................................................1,771.00 28 Revolade Tab 50 mg ..................................................................................................3,542.00 28 Revolade ¯Restricted Haematologist Initiation (idiopathic thrombocytopenic purpura - post-splenectomy) Re-assessment required after 6 weeks All of the following: 1 Patient has had a splenectomy; and 2 Two immunosuppressive therapies have been trialled and failed after therapy of 3 months each (or 1 month for rituximab); and 3 Any of the following: 3.1 Patient has a platelet count of 20,000 to 30,000 platelets per microlitre and has evidence of significant mucocutaneous bleeding; or 3.2 Patient has a platelet count of ≤ 20,000 platelets per microlitre and has evidence of active bleeding; or 3.3 Patient has a platelet count of ≤ 10,000 platelets per microlitre. Initiation - (idiopathic thrombocytopenic purpura - preparation for splenectomy) Re-assessment required after 6 weeks The patient requires eltrombopag treatment as preparation for splenectomy. Continuation - (idiopathic thrombocytopenic purpura - post-splenectomy) Re-assessment required after 12 months The patient has obtained a response (see note) from treatment during the initial approval or subsequent renewal periods and further treatment is required. Note: Response to treatment is defined as a platelet count of > 30,000 platelets per microlitre. FERRIC SUBSULFATE Gel 25.9% Soln 500 ml POLIDOCANOL Inj 0.5%, 30 ml vial SODIUM TETRADECYL SULPHATE Inj 3%, 2 ml ampoule THROMBIN Powder ¯ ¯¯

Products with Hospital Supply Status (HSS) are in bold Expiry date of HSS period is 30 June of the year indicated unless otherwise stated.

27


BLOOD AND BLOOD FORMING ORGANS

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

TRANEXAMIC ACID Tab 500 mg .....................................................................................................32.92 Inj 100 mg per ml, 5 ml ampoule ..................................................................124.73

100 10

Cyklokapron Cyklokapron

Blood Factors

EPTACOG ALFA [RECOMBINANT FACTOR VIIA] – Restricted see terms below Inj 1 mg syringe .........................................................................................1,163.75 1 Inj 2 mg syringe .........................................................................................2,327.50 1 Inj 5 mg syringe .........................................................................................5,818.75 1 Inj 8 mg syringe .........................................................................................9,310.00 1 ¯Restricted When used in the treatment of haemophilia, treatment is managed by the Haemophilia Treaters National Haemophilia Management Group. FACTOR EIGHT INHIBITORS BYPASSING AGENT – Restricted see terms below Inj 500 U ....................................................................................................1,640.00 1 Inj 1,000 U .................................................................................................3,280.00 1 ¯Restricted When used in the treatment of haemophilia, treatment is managed by the Haemophilia Treaters National Haemophilia Management Group. MOROCTOCOG ALFA [RECOMBINANT FACTOR VIII] – Restricted see terms below Inj 250 iu vial .................................................................................................225.00 1 Inj 500 iu vial .................................................................................................450.00 1 Inj 1,000 iu vial ..............................................................................................900.00 1 Inj 2,000 iu vial ...........................................................................................1,800.00 1 Inj 3,000 iu vial ...........................................................................................2,700.00 1 ¯Restricted When used in the treatment of haemophilia, treatment is managed by the Haemophilia Treaters National Haemophilia Management Group. NONACOG ALFA [RECOMBINANT FACTOR IX] – Restricted see terms below Inj 250 iu vial .................................................................................................310.00 1 Inj 500 iu vial .................................................................................................620.00 1 Inj 1,000 iu vial ...........................................................................................1,240.00 1 Inj 2,000 iu vial ...........................................................................................2,480.00 1 ¯Restricted When used in the treatment of haemophilia, treatment is managed by the Haemophilia Treaters National Haemophilia Management Group. OCTOCOG ALFA [RECOMBINANT FACTOR VIII] – Restricted see terms on the next page Inj 250 iu vial .................................................................................................237.50 1 250.00 Inj 500 iu vial .................................................................................................475.00 1 500.00 Inj 1,000 iu vial ..............................................................................................950.00 1 1,000.00 Inj 1,500 iu vial ...........................................................................................1,425.00 1 Inj 2,000 iu vial ...........................................................................................1,900.00 1 2,000.00 Inj 3,000 iu vial ...........................................................................................2,850.00 1 3,000.00 ¯¯¯¯ ¯¯ ¯¯¯¯¯ ¯¯¯¯ ¯ ¯ ¯ NovoSeven RT NovoSeven RT NovoSeven RT NovoSeven RT Group in conjunction with the

FEIBA FEIBA Group in conjunction with the

Xyntha Xyntha Xyntha Xyntha Xyntha Group in conjunction with the

BeneFIX BeneFIX BeneFIX BeneFIX Group in conjunction with the

Advate Kogenate FS Advate Kogenate FS Advate Kogenate FS Advate Advate Kogenate FS Advate Kogenate FS

°

¯¯ ¯

28

Item restricted (see ° above); Item restricted (see ¯ below) e.g. Brand indicates brand example only. It is not a contracted product.

¯


BLOOD AND BLOOD FORMING ORGANS

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

¯Restricted When used in the treatment of haemophilia, treatment is managed by the Haemophilia Treaters Group in conjunction with the National Haemophilia Management Group.

Vitamin K

PHYTOMENADIONE Inj 2 mg in 0.2 ml ampoule ...............................................................................8.00 Inj 10 mg per ml, 1 ml ampoule ........................................................................9.21 5 5 Konakion MM Konakion MM

Antithrombotics Anticoagulants

BIVALIRUDIN – Restricted see terms below Inj 250 mg vial ¯Restricted Either: 1 For use in heparin-induced thrombocytopaenia, heparin resistance or heparin intolerance; or 2 For use in patients undergoing endovascular procedures. DABIGATRAN Cap 75 mg ....................................................................................................148.00 60 Cap 110 mg ..................................................................................................148.00 60 Cap 150 mg ..................................................................................................148.00 60 DALTEPARIN Inj 2,500 iu in 0.2 ml syringe ...........................................................................19.97 Inj 5,000 iu in 0.2 ml syringe ...........................................................................39.94 Inj 7,500 iu in 0.75 ml syringe .........................................................................60.03 Inj 10,000 iu in 1 ml syringe ............................................................................77.55 Inj 12,500 iu in 0.5 ml syringe .........................................................................99.96 Inj 15,000 iu in 0.6 ml syringe .......................................................................120.05 Inj 18,000 iu in 0.72 ml syringe .....................................................................158.47 ¯ ¯ 10 10 10 10 10 10 10 ¯

Pradaxa Pradaxa Pradaxa Fragmin Fragmin Fragmin Fragmin Fragmin Fragmin Fragmin

DANAPAROID – Restricted see terms below Inj 750 u in 0.6 ml ampoule ¯Restricted For use in heparin-induced thrombocytopaenia, heparin resistance or heparin intolerance DEFIBROTIDE – Restricted see terms below Inj 80 mg per ml, 2.5 ml ampoule ¯Restricted Haematologist Patient has moderate or severe sinusoidal obstruction syndrome as a result of chemotherapy or regimen-related toxicities DEXTROSE WITH SODIUM CITRATE AND CITRIC ACID [ACID CITRATE DEXTROSE A] Inj 24.5 mg with sodium citrate 22 mg and citric acid 7.3 mg per ml, 100 ml bag

Products with Hospital Supply Status (HSS) are in bold Expiry date of HSS period is 30 June of the year indicated unless otherwise stated.

29


BLOOD AND BLOOD FORMING ORGANS

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

ENOXAPARIN Inj 20 mg in 0.2 ml syringe – 1% DV Sep-12 to 2015 ....................................37.24 Inj 40 mg in 0.4 ml ampoule Inj 40 mg in 0.4 ml syringe – 1% DV Sep-12 to 2015 ....................................49.69 Inj 60 mg in 0.6 ml syringe – 1% DV Sep-12 to 2015 ....................................74.91 Inj 80 mg in 0.8 ml syringe – 1% DV Sep-12 to 2015 ....................................99.86 Inj 100 mg in 1 ml syringe – 1% DV Sep-12 to 2015 ...................................125.06 Inj 120 mg in 0.8 ml syringe – 1% DV Sep-12 to 2015 ................................155.40 Inj 150 mg in 1 ml syringe – 1% DV Sep-12 to 2015 ...................................177.60 FONDAPARINUX SODIUM – Restricted see terms below Inj 2.5 mg in 0.5 ml syringe Inj 7.5 mg in 0.6 ml syringe ¯Restricted For use in heparin-induced thrombocytopaenia, heparin resistance or heparin intolerance HEPARIN SODIUM Inj 100 iu per ml, 250 ml bag Inj 1,000 iu per ml, 1 ml ampoule ...................................................................66.80 Inj 1,000 iu per ml, 35 ml ampoule Inj 1,000 iu per ml, 5 ml ampoule ...................................................................11.44 46.30 Inj 5,000 iu in 0.2 ml ampoule Inj 5,000 iu per ml, 1 ml ampoule ...................................................................14.20 Inj 5,000 iu per ml, 5 ml ampoule .................................................................182.00 HEPARINISED SALINE Inj 10 iu per ml, 5 ml ampoule ........................................................................32.50 Inj 100 iu per ml, 2 ml ampoule Inj 100 iu per ml, 5 ml ampoule PHENINDIONE Tab 10 mg Tab 25 mg Tab 50 mg PROTAMINE SULPHATE Inj 10 mg per ml, 5 ml ampoule ¯¯ ¯

10 10 10 10 10 10 10

Clexane Clexane Clexane Clexane Clexane Clexane Clexane

50 10 50 5 50 50

Mayne Pfizer Pfizer Mayne Pfizer Pfizer

RIVAROXABAN – Restricted see terms below Tab 10 mg .....................................................................................................153.00 15 Xarelto ¯Restricted Either: 1 Limited to five weeks’ treatment for the prophylaxis of venous thromboembolism following a total hip replacement; or 2 Limited to two weeks’ treatment for the prophylaxis of venous thromboembolism following a total knee replacement. SODIUM CITRATE WITH SODIUM CHLORIDE AND POTASSIUM CHLORIDE Inj 4.2 mg with sodium chloride 5.7 mg and potassium chloride 74.6 mcg per ml, 5,000 ml bag TRISODIUM CITRATE Inj 4%, 5 ml ampoule Inj 46.7%, 5 ml ampoule

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30

Item restricted (see ° above); Item restricted (see ¯ below) e.g. Brand indicates brand example only. It is not a contracted product.

¯


BLOOD AND BLOOD FORMING ORGANS

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

WARFARIN SODIUM Tab 1 mg ...........................................................................................................6.86 Tab 2 mg Tab 3 mg ...........................................................................................................9.70 Tab 5 mg .........................................................................................................11.75

100 100 100

Marevan Marevan Marevan

Antiplatelets

ASPIRIN Tab 100 mg – 1% DV Mar-14 to 2016..............................................................1.60 10.50 Suppos 300 mg CLOPIDOGREL Tab 75 mg – 1% DV Dec-13 to 2016 ...............................................................5.48 DIPYRIDAMOLE Tab 25 mg Tab long-acting 150 mg – 1% DV Oct-11 to 2014 .........................................11.52 Inj 5 mg per ml, 2 ml ampoule ¯¯ 90 990 Ethics Aspirin EC Ethics Aspirin EC

84

Arrow - Clopid

60

Pytazen SR

EPTIFIBATIDE – Restricted see terms below Inj 2 mg per ml, 10 ml vial .............................................................................111.00 1 Integrilin Inj 750 mcg per ml, 100 ml vial .....................................................................324.00 1 Integrilin ¯Restricted Either: 1 For use in patients with acute coronary syndromes undergoing percutaneous coronary intervention; or 2 For use in patients with definite or strongly suspected intra-coronary thrombus on coronary angiography. PRASUGREL – Restricted see terms below Tab 5 mg .......................................................................................................108.00 28 Effient Tab 10 mg .....................................................................................................120.00 28 Effient ¯Restricted Bare metal stents Limited to 6 months’ treatment Patient has undergone coronary angioplasty in the previous 4 weeks and is clopidogrel-allergic. Drug-eluting stents Limited to 12 months’ treatment Patient has had a drug-eluting cardiac stent inserted in the previous 4 weeks and is clopidogrel-allergic. Stent thrombosis Patient has experienced cardiac stent thrombosis whilst on clopidogrel. Myocardial infarction Limited to 7 days’ treatment For short term use while in hospital following ST-elevated myocardial infarction. Note: Clopidogrel allergy is defined as a history of anaphylaxis, urticaria, generalised rash or asthma (in non-asthmatic patients) developing soon after clopidogrel is started and is considered unlikely to be caused by any other treatment. TICAGRELOR – Restricted see terms below Tab 90 mg .......................................................................................................90.00 56 Brilinta ¯Restricted Restricted to treatment of acute coronary syndromes specifically for patients who have recently been diagnosed with an ST-elevation or a non-ST-elevation acute coronary syndrome, and in whom fibrinolytic therapy has not been given in the last 24 hours and is not planned. TICLOPIDINE Tab 250 mg

¯¯ ¯

Products with Hospital Supply Status (HSS) are in bold Expiry date of HSS period is 30 June of the year indicated unless otherwise stated.

31


BLOOD AND BLOOD FORMING ORGANS

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

Fibrinolytic Agents

ALTEPLASE Inj 10 mg vial Inj 50 mg vial TENECTEPLASE Inj 50 mg vial UROKINASE Inj 10,000 iu vial Inj 50,000 iu vial Inj 100,000 iu vial Inj 500,000 iu vial

Colony-Stimulating Factors Granulocyte Colony-Stimulating Factors

FILGRASTIM – Restricted see terms below Inj 300 mcg in 0.5 ml syringe – 1% DV Jan-13 to 31 Dec 2015 ..................540.00 5 Zarzio Inj 300 mcg in 1 ml vial .................................................................................650.00 5 Neupogen Inj 480 mcg in 0.5 ml syringe – 1% DV Jan-13 to 31 Dec 2015 ..................864.00 5 Zarzio ¯Restricted Oncologist or haematologist PEGFILGRASTIM – Restricted see terms below Inj 6 mg per 0.6 ml syringe ........................................................................1,080.00 1 Neulastim ¯Restricted For prevention of neutropenia in patients undergoing high risk chemotherapy for cancer (febrile neutropenia risk ≥ 20%*). *Febrile neutropenia risk ≥ 20% after taking into account other risk factors as defined by the European Organisation for Research and Treatment of Cancer (EORTC) guidelines. ¯¯¯ ¯

Fluids and Electrolytes Intravenous Administration

CALCIUM CHLORIDE Inj 100 mg per ml, 10 ml vial CALCIUM GLUCONATE Inj 10%, 10 ml ampoule ..................................................................................21.40 COMPOUND ELECTROLYTES Inj sodium 140 mmol/l with potassium 5 mmol/l, magnesium 1.5 mmol/l, chloride 98 mmol/l, acetate 27 mmol/l and gluconate 23 mmol/l, bag ........................................................................................... 5.00 3.10 COMPOUND ELECTROLYTES WITH GLUCOSE Inj glucose 50 g with 140 mmol/l sodium, 5 mmol/l potassium, 1.5 mmol/l magnesium, 98 mmol/l chloride, 27 mmol/l acetate and 23 mmol/l gluconate, bag .......................................................................... 7.00 10 Mayne

500 ml 1,000 ml

Baxter Baxter

1,000 ml

Baxter

°

32

Item restricted (see ° above); Item restricted (see ¯ below) e.g. Brand indicates brand example only. It is not a contracted product.

¯


BLOOD AND BLOOD FORMING ORGANS

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

COMPOUND SODIUM LACTATE [HARTMANN’S SOLUTION] Inj sodium 131 mmol/l with potassium 5 mmol/l, calcium 2 mmol/l, bicarbonate 29 mmol/l, chloride 111 mmol/l, bag ......................................... 1.77 1.80 COMPOUND SODIUM LACTATE WITH GLUCOSE Inj sodium 131 mmol/l with potassium 5 mmol/l, calcium 2 mmol/l, bicarbonate 29 mmol/l, chloride 111 mmol/l and glucose 5%, bag .............. 5.38 GLUCOSE Inj 5%, bag ........................................................................................................2.87 2.84 3.87 1.77 1.80 Inj 10%, bag ......................................................................................................3.70 5.29 Inj 50%, bag ......................................................................................................6.84 Inj 50%, 10 ml ampoule – 1% DV Sep-11 to 2014.........................................19.50 Inj 50%, 90 ml bottle – 1% DV Sep-11 to 2014..............................................11.25 Inj 70%, 1,000 ml bag Inj 70%, 500 ml bag GLUCOSE WITH POTASSIUM CHLORIDE Inj 5% glucose with 20 mmol/l potassium chloride, bag ...................................7.36 Inj 5% glucose with 30 mmol/l potassium chloride, 1,000 ml bag Inj 10% glucose with 10 mmol/l potassium chloride, 500 ml bag GLUCOSE WITH POTASSIUM CHLORIDE AND SODIUM CHLORIDE Inj 4% glucose with potassium chloride 20 mmol/l and sodium chloride 0.18%, bag ................................................................................................ 3.45 4.30 Inj 4% glucose with potassium chloride 30 mmol/l and sodium chloride 0.18%, bag ................................................................................................ 3.62 Inj 2.5% glucose with potassium chloride 20 mmol/l and sodium chloride 0.45%, 3,000 ml bag Inj 10% glucose with potassium chloride 10 mmol/l and sodium chloride 15 mmol/l, 500 ml bag GLUCOSE WITH SODIUM CHLORIDE Inj glucose 2.5% with sodium chloride 0.45%, bag ..........................................4.95 Inj glucose 5% with sodium chloride 0.45%, bag .............................................9.87 5.80 Inj glucose 5% with sodium chloride 0.9%, bag ...............................................4.54 Inj glucose 5% with sodium chloride 0.2%, 500 ml bag POTASSIUM CHLORIDE Inj 75 mg (1 mmol) per ml, 10 ml ampoule Inj 225 mg (3 mmol) per ml, 20 ml ampoule

500 ml 1,000 ml

Baxter Baxter

1,000 ml 50 ml 100 ml 250 ml 500 ml 1,000 ml 500 ml 1,000 ml 500 ml 5 1

Baxter Baxter Baxter Baxter Baxter Baxter Baxter Baxter Baxter Biomed Biomed

1,000 ml

Baxter

500 ml 1,000 ml 1,000 ml

Baxter Baxter Baxter

500 ml 500 ml 1,000 ml 1,000 ml

Baxter Baxter Baxter Baxter

Products with Hospital Supply Status (HSS) are in bold Expiry date of HSS period is 30 June of the year indicated unless otherwise stated.

33


BLOOD AND BLOOD FORMING ORGANS

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Per

POTASSIUM CHLORIDE WITH SODIUM CHLORIDE Inj 20 mmol/l potassium chloride with 0.9% sodium chloride, bag ...................3.85 Inj 30 mmol/l potassium chloride with 0.9% sodium chloride, bag ...................2.59 Inj 40 mmol/l potassium chloride with 0.9% sodium chloride, bag ...................6.62 Inj 10 mmol potassium chloride with 0.29% sodium chloride, 100 ml bag Inj 40 mmol/l potassium chloride with 0.9% sodium chloride, 100 ml bag POTASSIUM DIHYDROGEN PHOSPHATE Inj 1 mmol per ml, 10 ml ampoule RINGER’S SOLUTION Inj sodium 147 mmol/l with potassium 4 mmol/l, calcium 2.2 mmol/l, chloride 156 mmol/l, bag ........................................................................... 5.13 SODIUM ACETATE Inj 4 mmol per ml, 20 ml ampoule SODIUM BICARBONATE Inj 8.4%, 10 ml vial Inj 8.4%, 50 ml vial .........................................................................................19.95 Inj 8.4%, 100 ml vial .......................................................................................20.50 SODIUM CHLORIDE Inj 0.45%, bag ...................................................................................................5.50 Inj 0.9%, 3 ml syringe ¯Restricted For use in flushing of in-situ vascular access devices only. Inj 0.9%, bag .....................................................................................................1.70 1.71 3.01 2.28 3.60 1.77 1.80 Inj 0.9%, 5 ml syringe ¯Restricted For use in flushing of in-situ vascular access devices only. Inj 0.9%, 10 ml syringe ¯Restricted For use in flushing of in-situ vascular access devices only. Inj 3%, bag ........................................................................................................5.69 Inj 0.9%, 5 ml ampoule ...................................................................................10.85 15.50 Inj 0.9%, 10 ml ampoule .................................................................................11.50 15.50 Inj 0.9%, 20 ml ampoule ...................................................................................8.41 Inj 23.4% (4 mmol/ml), 20 ml – 1% DV Sep-13 to 2016 ................................31.25 Inj 1.8%, 500 ml bottle SODIUM DIHYDROGEN PHOSPHATE [SODIUM ACID PHOSPHATE] Inj 1 mmol per ml, 20 ml ampoule

1,000 ml 1,000 ml 1,000 ml

Baxter Baxter Baxter

1,000 ml

Baxter

1 1 500 ml

Biomed Biomed Baxter

°

¯ ¯ ¯

500 ml 1,000 ml 50 ml 100 ml 250 ml 500 ml 1,000 ml

Freeflex Freeflex Baxter Baxter Baxter Baxter Baxter

1,000 ml 50 50 20 5

Baxter Multichem Pfizer Multichem Pfizer Multichem Biomed

34

Item restricted (see ° above); Item restricted (see ¯ below) e.g. Brand indicates brand example only. It is not a contracted product.

¯


BLOOD AND BLOOD FORMING ORGANS

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

WATER Inj, bag ..............................................................................................................2.75 Inj 5 ml ampoule .............................................................................................10.25 Inj 10 ml ampoule ...........................................................................................11.25 Inj 20 ml ampoule .............................................................................................6.50 Inj 250 ml bag Inj 500 ml bag

1,000 ml 50 50 20

Baxter Multichem Multichem Multichem

Oral Administration

CALCIUM POLYSTYRENE SULPHONATE Powder ..........................................................................................................169.85 COMPOUND ELECTROLYTES Powder for oral soln COMPOUND ELECTROLYTES WITH GLUCOSE Soln with electrolytes PHOSPHORUS Tab eff 500 mg POTASSIUM CHLORIDE Tab eff 548 mg (14 mmol) with chloride 285 mg (8 mmol) Tab long-acting 600 mg (8 mmol) – 1% DV Oct-12 to 2015 ............................7.42 Oral liq 2 mmol per ml SODIUM BICARBONATE Cap 840 mg ......................................................................................................8.52 SODIUM CHLORIDE Tab 600 mg Oral liq 2 mmol/ml SODIUM POLYSTYRENE SULPHONATE Powder 300 g Calcium Resonium

200

Span-K

100

Sodibic

Plasma Volume Expanders

GELATINE, SUCCINYLATED Inj 4%, 500 ml bag ..........................................................................................92.50 108.00 10 Gelafusal Gelofusine

HYDROXYETHYL STARCH 130/0.4 WITH MAGNESIUM CHLORIDE, POTASSIUM CHLORIDE, SODIUM ACETATE AND SODIUM CHLORIDE Inj 6% with magnesium chloride 0.03%, potassium chloride 0.03%, sodium acetate 0.463% and sodium chloride 0.6%, 500 ml bag ........... 198.00 20 Volulyte 6% HYDROXYETHYL STARCH 130/0.4 WITH SODIUM CHLORIDE Inj 6% with sodium chloride 0.9%, 500 ml bag .............................................198.00 20 Voluven

Products with Hospital Supply Status (HSS) are in bold Expiry date of HSS period is 30 June of the year indicated unless otherwise stated.

35


CARDIOVASCULAR SYSTEM

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

Agents Affecting the Renin-Angiotensin System ACE Inhibitors

CAPTOPRIL Oral liq 5 mg per ml ........................................................................................94.99 ¯Restricted Any of the following: 1 For use in children under 12 years of age; or 2 For use in tube-fed patients; or 3 For management of rebound transient hypertension following cardiac surgery. CILAZAPRIL Tab 0.5 mg – 1% DV Sep-13 to 2016 ..............................................................2.00 Tab 2.5 mg – 1% DV Sep-13 to 2016 ..............................................................4.31 Tab 5 mg – 1% DV Sep-13 to 2016 .................................................................6.98 ENALAPRIL MALEATE Tab 5 mg ...........................................................................................................1.19 Tab 10 mg .........................................................................................................1.47 Tab 20 mg .........................................................................................................1.91 LISINOPRIL Tab 5 mg – 1% DV Jan-13 to 2015..................................................................3.58 Tab 10 mg – 1% DV Jan-13 to 2015................................................................4.08 Tab 20 mg – 1% DV Jan-13 to 2015................................................................4.88 PERINDOPRIL Tab 2 mg ...........................................................................................................3.75 Tab 4 mg ...........................................................................................................4.80 QUINAPRIL Tab 5 mg – 1% DV Apr-13 to 2015 ..................................................................3.44 Tab 10 mg – 1% DV Apr-13 to 2015 ................................................................4.64 Tab 20 mg – 1% DV Apr-13 to 2015 ................................................................6.34 TRANDOLAPRIL – Restricted: For continuation only ¬ Cap 1 mg ¬ Cap 2 mg ¯ 95 ml Capoten

90 90 90 100 100 100 90 90 90 30 30 90 90 90

Zapril Zapril Zapril Ethics Enalapril Ethics Enalapril Ethics Enalapril Arrow-Lisinopril Arrow-Lisinopril Arrow-Lisinopril Apo-Perindopril Apo-Perindopril Arrow-Quinapril 5 Arrow-Quinapril 10 Arrow-Quinapril 20

ACE Inhibitors with Diuretics

CILAZAPRIL WITH HYDROCHLOROTHIAZIDE Tab 5 mg with hydrochlorothiazide 12.5 mg – 1% DV Mar-14 to 2016 ..........10.72 100 Apo-Cilazapril/ Hydrochlorothiazide

ENALAPRIL MALEATE WITH HYDROCHLOROTHIAZIDE – Restricted: For continuation only ¬ Tab 20 mg with hydrochlorothiazide 12.5 mg QUINAPRIL WITH HYDROCHLOROTHIAZIDE Tab 10 mg with hydrochlorothiazide 12.5 mg – 1% DV Aug-12 to 2015..........3.37 Tab 20 mg with hydrochlorothiazide 12.5 mg – 1% DV Aug-12 to 2015..........4.57 30 30 Accuretic 10 Accuretic 20

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36

Item restricted (see ° above); Item restricted (see ¯ below) e.g. Brand indicates brand example only. It is not a contracted product.

¯


CARDIOVASCULAR SYSTEM

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

Angiotensin II Antagonists

CANDESARTAN CILEXETIL – Restricted see terms below Tab 4 mg – 1% DV Nov-12 to 2015 .................................................................4.13 Tab 8 mg – 1% DV Nov-12 to 2015 .................................................................6.10 Tab 16 mg – 1% DV Nov-12 to 2015 .............................................................10.18 Tab 32 mg – 1% DV Nov-12 to 2015 .............................................................17.66 ¯¯¯¯ 90 90 90 90 Candestar Candestar Candestar Candestar

¯Restricted ACE inhibitor intolerance Either: 1 Patient has persistent ACE inhibitor induced cough that is not resolved by ACE inhibitor retrial (same or new ACE inhibitor); or 2 Patient has a history of angioedema. Unsatisfactory response to ACE inhibitor Patient is not adequately controlled on maximum tolerated dose of an ACE inhibitor. LOSARTAN POTASSIUM Tab 12.5 mg – 1% DV Dec-11 to 2014 ............................................................2.88 90 Lostaar Tab 25 mg – 1% DV Dec-11 to 2014 ...............................................................3.20 90 Lostaar Tab 50 mg – 1% DV Dec-11 to 2014 ...............................................................5.22 90 Lostaar Tab 100 mg – 1% DV Dec-11 to 2014 .............................................................8.68 90 Lostaar

Angiotensin II Antagonists with Diuretics

LOSARTAN POTASSIUM WITH HYDROCHLOROTHIAZIDE Tab 50 mg with hydrochlorothiazide 12.5 mg – 1% DV Dec-11 to 2014 ..........4.89 30 Arrow-Losartan & Hydrochlorothiazide

Alpha-Adrenoceptor Blockers

DOXAZOSIN Tab 2 mg – 1% DV Jun-11 to 2014..................................................................8.23 Tab 4 mg – 1% DV Jun-11 to 2014................................................................12.40 PHENOXYBENZAMINE HYDROCHLORIDE Cap 10 mg Inj 50 mg per ml, 2 ml ampoule PHENTOLAMINE MESYLATE Inj 10 mg per ml, 1 ml ampoule PRAZOSIN Tab 1 mg ...........................................................................................................5.53 Tab 2 mg ...........................................................................................................7.00 Tab 5 mg .........................................................................................................11.70 TERAZOSIN Tab 1 mg – 1% DV Sep-13 to 2016 .................................................................0.50 Tab 2 mg – 1% DV Sep-13 to 2016 .................................................................0.45 Tab 5 mg – 1% DV Sep-13 to 2016 .................................................................0.68 100 100 100 Apo-Prazo Apo-Prazosin Apo-Prazo Apo-Prazosin Apo-Prazo Apo-Prazosin Arrow Arrow Arrow 500 500 Apo-Doxazosin Apo-Doxazosin

28 28 28

Products with Hospital Supply Status (HSS) are in bold Expiry date of HSS period is 30 June of the year indicated unless otherwise stated.

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CARDIOVASCULAR SYSTEM

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Per

Antiarrhythmics

ADENOSINE Inj 3 mg per ml, 2 ml vial Inj 3 mg per ml, 10 ml vial ¯Restricted For use in cardiac catheterisation, electrophysiology and MRI. AJMALINE – Restricted see terms below Inj 5 mg per ml, 10 ml ampoule ¯Restricted Cardiologist AMIODARONE HYDROCHLORIDE Tab 100 mg Tab 200 mg Inj 50 mg per ml, 3 ml ampoule – 1% DV Aug-13 to 2016.............................22.80

°

¯ ¯

6 50

Cordarone-X AstraZeneca

ATROPINE SULPHATE Inj 600 mcg per ml, 1 ml ampoule – 1% DV Jan-13 to 2015 .........................71.00 DIGOXIN Tab 62.5 mcg Tab 250 mcg Oral liq 50 mcg per ml Inj 250 mcg per ml, 2 ml vial DISOPYRAMIDE PHOSPHATE Cap 100 mg Cap 150 mg FLECAINIDE ACETATE Tab 50 mg .......................................................................................................45.82 Tab 100 mg .....................................................................................................80.92 Cap long-acting 100 mg .................................................................................45.82 Cap long-acting 200 mg .................................................................................80.92 Inj 10 mg per ml, 15 ml ampoule ....................................................................52.45 MEXILETINE HYDROCHLORIDE Cap 150 mg ....................................................................................................65.00 Cap 250 mg ..................................................................................................102.00 PROPAFENONE HYDROCHLORIDE Tab 150 mg

60 60 30 30 5 100 100

Tambocor Tambocor Tambocor CR Tambocor CR Tambocor Mexiletine Hydrochloride USP Mexiletine Hydrochloride USP

Antihypotensives

MIDODRINE – Restricted see terms on the next page Tab 2.5 mg Tab 5 mg ¯¯

38

Item restricted (see ° above); Item restricted (see ¯ below) e.g. Brand indicates brand example only. It is not a contracted product.

¯


CARDIOVASCULAR SYSTEM

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

¯Restricted All of the following: 1 Disabling orthostatic hypotension not due to drugs; and 2 Patient has tried fludrocortisone (unless contra-indicated) with unsatisfactory results; and 3 Patient has tried non-pharmacological treatments such as support hose, increased salt intake, exercise, and elevation of head and trunk at night.

Beta-Adrenoceptor Blockers

ATENOLOL Tab 50 mg – 1% DV Oct-12 to 2015 ................................................................5.56 Tab 100 mg – 1% DV Oct-12 to 2015 ..............................................................9.12 Oral liq 5 mg per ml ........................................................................................21.25 BISOPROLOL Tab 2.5 mg ........................................................................................................3.88 Tab 5 mg ...........................................................................................................4.74 Tab 10 mg .........................................................................................................9.18 CARVEDILOL Tab 6.25 mg ....................................................................................................21.00 Tab 12.5 mg ....................................................................................................27.00 Tab 25 mg .......................................................................................................33.75 CELIPROLOL Tab 200 mg .....................................................................................................19.00 ESMOLOL HYDROCHLORIDE Inj 10 mg per ml, 10 ml vial LABETALOL Tab 50 mg .........................................................................................................8.23 Tab 100 mg .....................................................................................................10.06 Tab 200 mg .....................................................................................................17.55 Tab 400 mg Inj 5 mg per ml, 20 ml ampoule METOPROLOL SUCCINATE Tab long-acting 23.75 mg – 1% DV Sep-12 to 2015........................................0.96 Tab long-acting 47.5 mg – 1% DV Sep-12 to 2015..........................................1.41 Tab long-acting 95 mg – 1% DV Sep-12 to 2015.............................................2.42 Tab long-acting 190 mg – 1% DV Sep-12 to 2015...........................................4.66 METOPROLOL TARTRATE Tab 50 mg – 1% DV Aug-12 to 2015 .............................................................16.00 Tab 100 mg – 1% DV Aug-12 to 2015 ...........................................................21.00 Tab long-acting 200 mg – 1% DV Aug-12 to 2015.........................................18.00 Inj 1 mg per ml, 5 ml vial – 1% DV Dec-12 to 2015 .......................................24.00 NADOLOL Tab 40 mg – 1% DV Apr-13 to 2015 ..............................................................15.57 Tab 80 mg – 1% DV Apr-13 to 2015 ..............................................................23.74 PINDOLOL Tab 5 mg – 1% DV Nov-13 to 2016 .................................................................9.72 Tab 10 mg – 1% DV Nov-13 to 2016 .............................................................15.62 Tab 15 mg – 1% DV Nov-13 to 2016 .............................................................23.46 100 100 100 Hybloc Hybloc Hybloc 500 500 300 ml 30 30 30 30 30 30 180 Mylan Atenolol Mylan Atenolol Atenolol-AFT Bosvate Bosvate Bosvate Dilatrend Dilatrend Dilatrend Celol

30 30 30 30 100 60 28 5 100 100 100 100 100

Metoprolol - AFT CR Metoprolol - AFT CR Metoprolol - AFT CR Metoprolol - AFT CR Lopresor Lopresor Slow-Lopresor Lopresor Apo-Nadolol Apo-Nadolol Apo-Pindolol Apo-Pindolol Apo-Pindolol

Products with Hospital Supply Status (HSS) are in bold Expiry date of HSS period is 30 June of the year indicated unless otherwise stated.

39


CARDIOVASCULAR SYSTEM

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

PROPRANOLOL Tab 10 mg .........................................................................................................3.65 Tab 40 mg .........................................................................................................4.65 Cap long-acting 160 mg .................................................................................16.06 Oral liq 4 mg per ml Inj 1 mg per ml, 1 ml ampoule SOTALOL Tab 80 mg .......................................................................................................27.50 Tab 160 mg .....................................................................................................10.50 Inj 10 mg per ml, 4 ml ampoule ......................................................................65.39 TIMOLOL MALEATE Tab 10 mg

100 100 100

Apo-Propranolol Apo-Propranolol Cardinol LA

500 100 5

Mylan Mylan Sotacor

Calcium Channel Blockers Dihydropyridine Calcium Channel Blockers

AMLODIPINE Tab 2.5 mg – 1% DV Mar-12 to 2014...............................................................2.45 Tab 5 mg – 1% DV Oct-11 to 2014 ..................................................................2.65 Tab 10 mg – 1% DV Oct-11 to 2014 ................................................................4.15 FELODIPINE Tab long-acting 2.5 mg – 1% DV Sep-12 to 2015............................................2.90 Tab long-acting 5 mg – 1% DV Nov-12 to 2015...............................................3.10 Tab long-acting 10 mg – 1% DV Nov-12 to 2015.............................................4.60 ISRADIPINE Tab 2.5 mg Cap long-acting 2.5 mg Cap long-acting 5 mg NIFEDIPINE Tab long-acting 10 mg Tab long-acting 20 mg ......................................................................................9.59 Tab long-acting 30 mg ......................................................................................8.56 Tab long-acting 60 mg ....................................................................................12.28 Cap 5 mg NIMODIPINE Tab 30 mg Inj 200 mcg per ml, 50 ml vial 100 100 100 30 30 30 Apo-Amlodipine Apo-Amlodipine Apo-Amlodipine Plendil ER Plendil ER Plendil ER

100 30 30

Nyefax Retard Adefin XL Arrow-Nifedipine XR Adefin XL Arrow-Nifedipine XR

Other Calcium Channel Blockers

DILTIAZEM HYDROCHLORIDE Tab 30 mg – 5% DV Sep-12 to 2015 ...............................................................4.60 Tab 60 mg – 5% DV Sep-12 to 2015 ...............................................................8.50 Cap long-acting 120 mg ...................................................................................1.91 31.83 Cap long-acting 180 mg – 5% DV Feb-13 to 2015 ........................................47.67 Cap long-acting 240 mg – 5% DV Feb-13 to 2015 ........................................63.58 Inj 5 mg per ml, 5 ml vial 100 100 30 500 500 500 Dilzem Dilzem Cardizem CD Apo-Diltiazem CD Apo-Diltiazem CD Apo-Diltiazem CD

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40

Item restricted (see ° above); Item restricted (see ¯ below) e.g. Brand indicates brand example only. It is not a contracted product.

¯


CARDIOVASCULAR SYSTEM

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

PERHEXILINE MALEATE – Restricted see terms below Tab 100 mg .....................................................................................................62.90

¯

100

Pexsig

¯Restricted Both: 1 Patient has refractory angina; and 2 Patient is on the maximal tolerated dose of a beta-blocker, a calcium channel blocker and a long-acting nitrate. VERAPAMIL HYDROCHLORIDE Tab 40 mg – 1% DV Sep-11 to 2014 ...............................................................7.01 100 Isoptin Tab 80 mg – 1% DV Sep-11 to 2014 .............................................................11.74 100 Isoptin Tab long-acting 120 mg ..................................................................................15.20 250 Verpamil SR Tab long-acting 240 mg ..................................................................................25.00 250 Verpamil SR Inj 2.5 mg per ml, 2 ml ampoule .......................................................................7.54 5 Isoptin

Centrally-Acting Agents

CLONIDINE Patch 2.5 mg, 100 mcg per day ......................................................................23.30 Patch 5 mg, 200 mcg per day .........................................................................32.80 Patch 7.5 mg, 300 mcg per day ......................................................................41.20 CLONIDINE HYDROCHLORIDE Tab 25 mcg – 1% DV Jul-13 to 2015 .............................................................15.09 Tab 150 mcg – 1% DV Feb-13 to 2015..........................................................34.32 Inj 150 mcg per ml, 1 ml ampoule – 1% DV Nov-12 to 2015 .........................16.07 METHYLDOPA Tab 125 mg .....................................................................................................14.25 Tab 250 mg .....................................................................................................15.10 Tab 500 mg .....................................................................................................23.15 4 4 4 112 100 5 100 100 100 Catapres-TTS-1 Catapres-TTS-2 Catapres-TTS-3 Clonidine BNM Catapres Catapres Prodopa Prodopa Prodopa

Diuretics Loop Diuretics

BUMETANIDE Tab 1 mg .........................................................................................................16.36 Inj 500 mcg per ml, 4 ml vial FUROSEMIDE (FRUSEMIDE) Tab 40 mg – 1% DV Sep-12 to 2015 .............................................................10.25 Tab 500 mg – 1% DV Feb-13 to 2015............................................................25.00 Oral liq 10 mg per ml Inj 10 mg per ml, 2 ml ampoule ........................................................................1.30 Inj 10 mg per ml, 25 ml ampoule 100 Burinex

1,000 50 5

Diurin 40 Urex Forte Frusemide-Claris

Osmotic Diuretics

MANNITOL Inj 10%, 1,000 ml bag .....................................................................................14.21 Inj 15%, 500 ml bag ..........................................................................................9.84 Inj 20%, 500 ml bag ........................................................................................10.80 1,000 ml 500 ml 500 ml Baxter Baxter Baxter

Products with Hospital Supply Status (HSS) are in bold Expiry date of HSS period is 30 June of the year indicated unless otherwise stated.

41


CARDIOVASCULAR SYSTEM

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Per

Potassium Sparing Combination Diuretics

AMILORIDE HYDROCHLORIDE WITH FUROSEMIDE Tab 5 mg with furosemide 40 mg AMILORIDE HYDROCHLORIDE WITH HYDROCHLOROTHIAZIDE Tab 5 mg with hydrochlorothiazide 50 mg

Potassium Sparing Diuretics

AMILORIDE HYDROCHLORIDE Tab 5 mg .........................................................................................................17.50 Oral liq 1 mg per ml ........................................................................................30.00 SPIRONOLACTONE Tab 25 mg – 1% DV Feb-14 to 2016................................................................3.65 Tab 100 mg – 1% DV Sep-13 to 2016 ...........................................................11.80 Oral liq 5 mg per ml ........................................................................................30.00 (Spirotone Tab 25 mg to be delisted 1 April 2014) 100 25 ml 100 100 25 ml Apo-Amiloride Biomed Spiractin Spirotone Spiractin Spirotone Biomed

Thiazide and Related Diuretics

BENDROFLUMETHAZIDE [BENDROFLUAZIDE] Tab 2.5 mg – 1% DV Sep-11 to 2014 ..............................................................6.48 Tab 5 mg – 1% DV Sep-11 to 2014 .................................................................9.95 CHLOROTHIAZIDE Oral liq 50 mg per ml ......................................................................................26.00 CHLORTALIDONE [CHLORTHALIDONE] Tab 25 mg .........................................................................................................8.00 INDAPAMIDE Tab 2.5 mg – 1% DV Oct-13 to 2016 ...............................................................2.25 ¯ 500 500 25 ml 50 90 Arrow-Bendrofluazide Arrow-Bendrofluazide Biomed Hygroton Dapa-Tabs

METOLAZONE – Restricted see terms below Tab 5 mg ¯Restricted Either: 1 Patient has refractory heart failure and is intolerant or has not responded to loop diuretics and/or loop-thiazide combination therapy; or 2 Patient has severe refractory nephrotic oedema unresponsive to high dose loop diuretics and concentrated albumin infusions

Lipid-Modifying Agents Fibrates

BEZAFIBRATE Tab 200 mg – 1% DV Mar-13 to 2015..............................................................9.70 Tab long-acting 400 mg – 1% DV Oct-12 to 2015 ...........................................5.70 GEMFIBROZIL Tab 600 mg – 1% DV Nov-13 to 2016 ...........................................................17.60 90 30 60 Bezalip Bezalip Retard Lipazil

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Item restricted (see ° above); Item restricted (see ¯ below) e.g. Brand indicates brand example only. It is not a contracted product.

¯


CARDIOVASCULAR SYSTEM

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

HMG CoA Reductase Inhibitors (Statins)

ATORVASTATIN Tab 10 mg – 1% DV Oct-12 to 2015 ................................................................2.52 Tab 20 mg – 1% DV Oct-12 to 2015 ................................................................4.17 Tab 40 mg – 1% DV Oct-12 to 2015 ................................................................7.32 Tab 80 mg – 1% DV Oct-12 to 2015 ..............................................................16.23 PRAVASTATIN Tab 10 mg Tab 20 mg – 1% DV Nov-11 to 2014 ...............................................................5.44 Tab 40 mg – 1% DV Nov-11 to 2014 ...............................................................9.28 SIMVASTATIN Tab 10 mg Tab 20 mg Tab 40 mg Tab 80 mg – 1% DV Sep-11 to 2014 ...............................................................1.40 – 1% DV Sep-11 to 2014 ...............................................................1.95 – 1% DV Sep-11 to 2014 ...............................................................3.18 – 1% DV Sep-11 to 2014 ...............................................................9.31 90 90 90 90 Zarator Zarator Zarator Zarator

30 30 90 90 90 90

Cholvastin Cholvastin Arrow-Simva Arrow-Simva Arrow-Simva Arrow-Simva

Resins

CHOLESTYRAMINE Powder for oral liq 4 g COLESTIPOL HYDROCHLORIDE Grans for oral liq 5 g

Selective Cholesterol Absorption Inhibitors

EZETIMIBE – Restricted see terms below Tab 10 mg ¯Restricted All of the following: 1 Patient has a calculated absolute risk of cardiovascular disease of at least 15% over 5 years; and 2 Patient’s LDL cholesterol is 2.0 mmol/litre or greater; and 3 Any of the following: 3.1 The patient has rhabdomyolysis (defined as muscle aches and creatine kinase more than 10 × normal) when treated with one statin; or 3.2 The patient is intolerant to both simvastatin and atorvastatin; or 3.3 The patient has not reduced their LDL cholesterol to less than 2.0 mmol/litre with the use of the maximal tolerated dose of atorvastatin. EZETIMIBE WITH SIMVASTATIN – Restricted see terms below Tab 10 mg with simvastatin 10 mg Tab 10 mg with simvastatin 20 mg Tab 10 mg with simvastatin 40 mg Tab 10 mg with simvastatin 80 mg ¯Restricted All of the following: 1 Patient has a calculated absolute risk of cardiovascular disease of at least 15% over 5 years; and 2 Patient’s LDL cholesterol is 2.0 mmol/litre or greater; and 3 The patient has not reduced their LDL cholesterol to less than 2.0 mmol/litre with the use of the maximal tolerated dose of atorvastatin. ¯ ¯¯¯¯

Products with Hospital Supply Status (HSS) are in bold Expiry date of HSS period is 30 June of the year indicated unless otherwise stated.

43


CARDIOVASCULAR SYSTEM

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Per

Other Lipid-Modifying Agents

ACIPIMOX Cap 250 mg NICOTINIC ACID Tab 50 mg Tab 500 mg

Nitrates

GLYCERYL TRINITRATE Tab 600 mcg – 1% DV Sep-11 to 2014............................................................8.00 Inj 1 mg per ml, 5 ml ampoule – 1% DV Dec-12 to 2015...............................22.70 Inj 1 mg per ml, 50 ml vial – 1% DV Dec-12 to 2015 .....................................86.60 Inj 5 mg per ml, 10 ml ampoule ......................................................................40.00 Oral spray, 400 mcg per dose – 1% DV Mar-12 to 2014..................................4.45 Patch 25 mg, 5 mg per day – 1% DV Sep-11 to 2014 ...................................16.56 Patch 50 mg, 10 mg per day – 1% DV Sep-11 to 2014 .................................19.50 ISOSORBIDE MONONITRATE Tab 20 mg – 1% DV Jun-11 to 2014..............................................................17.10 Tab long-acting 40 mg .....................................................................................7.50 Tab long-acting 60 mg ......................................................................................3.94 (Corangin Tab long-acting 40 mg to be delisted 1 August 2014) 100 10 10 5 250 dose 30 30 100 30 90 Lycinate Nitronal Nitronal Mayne Glytrin Nitroderm TTS 5 Nitroderm TTS 10 Ismo-20 Corangin Ismo 40 Retard Duride

Other Cardiac Agents

LEVOSIMENDAN – Restricted see terms below Inj 2.5 mg per ml, 5 ml vial Inj 2.5 mg per ml, 10 ml vial ¯Restricted Heart transplant Either: 1 For use as a bridge to heart transplant, in patients who have been accepted for transplant; or 2 For the treatment of heart failure following heart transplant. Heart failure - cardiologist or intensivist For the treatment of severe acute decompensated heart failure that is non-responsive to dobutamine. ¯¯

Sympathomimetics

ADRENALINE Inj 1 in 1,000, 1 ml ampoule .............................................................................4.98 5.25 Inj 1 in 1,000, 30 ml vial Inj 1 in 10,000, 10 ml ampoule .......................................................................27.00 49.00 Inj 1 in 10,000, 10 ml syringe DOBUTAMINE HYDROCHLORIDE Inj 12.5 mg per ml, 20 ml vial DOPAMINE HYDROCHLORIDE Inj 40 mg per ml, 5 ml ampoule – 1% DV Sep-12 to 2015.............................69.77 10 Martindale 5 Aspen Adrenaline Mayne Mayne Aspen Adrenaline

5 10

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Item restricted (see ° above); Item restricted (see ¯ below) e.g. Brand indicates brand example only. It is not a contracted product.

¯


CARDIOVASCULAR SYSTEM

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

EPHEDRINE Inj 3 mg per ml, 10 ml syringe Inj 30 mg per ml, 1 ml ampoule – 1% DV Nov-12 to 2014.............................66.00 ISOPRENALINE Inj 200 mcg per ml, 1 ml ampoule Inj 200 mcg per ml, 5 ml ampoule METARAMINOL Inj 0.5 mg per ml, 20 ml syringe Inj 1 mg per ml, 1 ml ampoule Inj 1 mg per ml, 10 ml syringe Inj 10 mg per ml, 1 ml ampoule NORADRENALINE Inj 0.06 mg per ml, 100 ml bag Inj 0.06 mg per ml, 50 ml syringe Inj 0.1 mg per ml, 100 ml bag Inj 0.12 mg per ml, 100 ml bag Inj 0.12 mg per ml, 50 ml syringe Inj 0.16 mg per ml, 50 ml syringe Inj 1 mg per ml, 100 ml bag Inj 1 mg per ml, 2 ml ampoule ........................................................................42.00 PHENYLEPHRINE HYDROCHLORIDE Inj 10 mg per ml, 1 ml vial .............................................................................115.50

10

Max Health

6 25

Levophed Neosynephrine HCL

Vasodilators

ALPROSTADIL HYDROCHLORIDE Inj 500 mcg per ml, 1 ml ampoule – 1% DV Oct-12 to 2015.....................1,417.50 AMYL NITRITE Liq 98% in 3 ml capsule DIAZOXIDE Inj 15 mg per ml, 20 ml ampoule HYDRALAZINE HYDROCHLORIDE Tab 25 mg ¯Restricted Either: 1 For the treatment of refractory hypertension; or 2 For the treatment of heart failure, in combination with a nitrate, in patients who are intolerant or have not responded to ACE inhibitors and/or angiotensin receptor blockers. Inj 20 mg ampoule ..........................................................................................25.90 5 Apresoline MILRINONE Inj 1 mg per ml, 10 ml ampoule MINOXIDIL – Restricted see terms below Tab 10 mg .......................................................................................................70.00 100 Loniten ¯Restricted For patients with severe refractory hypertension who have failed to respond to extensive multiple therapies. NICORANDIL – Restricted see terms on the next page Tab 10 mg .......................................................................................................27.95 60 Ikorel Tab 20 mg .......................................................................................................33.28 60 Ikorel ¯ ¯¯ ¯ 5 Prostin VR

Products with Hospital Supply Status (HSS) are in bold Expiry date of HSS period is 30 June of the year indicated unless otherwise stated.

45


CARDIOVASCULAR SYSTEM

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

¯Restricted Both: 1 Patient has refractory angina; and 2 Patient is on the maximal tolerated dose of a beta-blocker, a calcium channel blocker and a long-acting nitrate. PAPAVERINE HYDROCHLORIDE Inj 30 mg per ml, 1 ml vial Inj 12 mg per ml, 10 ml ampoule ....................................................................73.12 5 Mayne PENTOXIFYLLINE [OXPENTIFYLLINE] Tab 400 mg SODIUM NITROPRUSSIDE Inj 50 mg vial

Endothelin Receptor Antagonists

AMBRISENTAN – Restricted see terms below Tab 5 mg ....................................................................................................4,585.00 Tab 10 mg ..................................................................................................4,585.00 ¯Restricted 1 For use in patients with approval by the Pulmonary Arterial Hypertension Panel; or 2 In hospital stabilisations in emergency situations. BOSENTAN – Restricted see terms below Tab 62.5 mg ...............................................................................................1,500.00 4,585.00 Tab 125 mg ................................................................................................1,500.00 4,585.00 ¯Restricted 1 For use in patients with approval by the Pulmonary Arterial Hypertension Panel; or 2 In hospital stabilisation in emergency situations. ¯¯ ¯ ¯ ¯¯¯ 30 30 Volibris Volibris

60 60

pms-Bosentan Tracleer pms-Bosentan Tracleer

Phosphodiesterase Type 5 Inhibitors

SILDENAFIL – Restricted see terms below Tab 25 mg – 1% DV May-13 to 2014 ...............................................................1.85 Tab 50 mg – 1% DV May-13 to 2014 ...............................................................1.85 Tab 100 mg – 1% DV May-13 to 2014 .............................................................7.45 4 4 4 Silagra Silagra Silagra

¯Restricted Any of the following: 1 For use in patients with approval by the Pulmonary Arterial Hypertension Panel; or 2 For use in neonatal units for persistent pulmonary hypertension of the newborn (PPHN); or 3 For use in weaning patients from inhaled nitric oxide; or 4 For perioperative use in cardiac surgery patients; or 5 For use in intensive care as an alternative to nitric oxide; or 6 In-hospital stabilisation in emergency situations; or 7 All of the following: 7.1 Patient has Raynaud’s phenomenon; and 7.2 Patient has severe digital ischaemia (defined as severe pain requiring hospital admission or with a high likelihood of digital ulceration; digital ulcers; or gangrene); and continued. . .

°

46

Item restricted (see ° above); Item restricted (see ¯ below) e.g. Brand indicates brand example only. It is not a contracted product.

¯


CARDIOVASCULAR SYSTEM

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

continued. . . 7.3 Patient is following lifestyle management (proper body insulation, avoidance of cold exposure, smoking cessation support, avoidance of sympathomimetic drugs); and 7.4 Patient has persisting severe symptoms despite treatment with calcium channel blockers and nitrates (unless contraindicated or not tolerated).

Prostacyclin Analogues

ILOPROST Inj 50 mcg in 0.5 ml ampoule – 1% DV Apr-14 to 2016...............................925.00 Nebuliser soln 10 mcg per ml, 2 ml ...........................................................1,185.00 ¯Restricted Any of the following: 1 For use in patients with approval by the Pulmonary Arterial Hypertension Panel; or 2 For diagnostic use in catheter laboratories; or 3 For use following mitral or tricuspid valve surgery; or 4 In hopsital stabilisation in emergency situations. 5 30 Ilomedin Ventavis

¯

Products with Hospital Supply Status (HSS) are in bold Expiry date of HSS period is 30 June of the year indicated unless otherwise stated.

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DERMATOLOGICALS

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

Anti-Infective Preparations Antibacterials

FUSIDATE SODIUM [FUSIDIC ACID] Crm 2% ............................................................................................................3.25 Oint 2% – 1% DV Sep-13 to 2016 ...................................................................3.45 HYDROGEN PEROXIDE Crm 1% ............................................................................................................8.56 Soln 3% (10 vol) MAFENIDE ACETATE – Restricted see terms below Powder 50 g sachet ¯Restricted For the treatment of burns patients. MUPIROCIN Oint 2% SULPHADIAZINE SILVER Crm 1% ..........................................................................................................12.30 50 g Flamazine ¯ 15 g 15 g 15 g Foban Foban Crystaderm

Antifungals

AMOROLFINE – Restricted: For continuation only ¬ Nail soln 5% CICLOPIROX OLAMINE Nail soln 8% ¬ Soln 1% – Restricted: For continuation only CLOTRIMAZOLE Crm 1% – 1% DV Nov-11 to 2014 ...................................................................0.54 ¬ Soln 1% – Restricted: For continuation only ECONAZOLE NITRATE ¬ Crm 1% – Restricted: For continuation only Foaming soln 1% KETOCONAZOLE Shampoo 2% – 1% DV Sep-11 to 2014...........................................................3.08 METRONIDAZOLE Gel 0.75% MICONAZOLE NITRATE Crm 2% – 1% DV Nov-11 to 2014 ...................................................................0.46 ¬ Lotn 2% – Restricted: For continuation only Tinc 2% NYSTATIN Crm 100,000 u per g 15 g Multichem 100 ml Sebizole 20 g Clomazol

Antiparasitics

LINDANE [GAMMA BENZENE HEXACHLORIDE] Crm 1%

°

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Item restricted (see ° above); Item restricted (see ¯ below) e.g. Brand indicates brand example only. It is not a contracted product.

¯


DERMATOLOGICALS

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

MALATHION [MALDISON] Lotn 0.5% Shampoo 1% MALATHION WITH PERMETHRIN AND PIPERONYL BUTOXIDE Spray 0.25% with permethrin 0.5% and piperonyl butoxide 2% Note: Temporary listing to cover out-of-stock. PERMETHRIN Crm 5% – 1% DV Sep-11 to 2014 ...................................................................4.20 Lotn 5% – 1% DV Sep-11 to 2014 ...................................................................3.24

30 g 30 ml

Lyderm A-Scabies

Antiacne Preparations

ADAPALENE Crm 0.1% Gel 0.1% BENZOYL PEROXIDE Soln 5% ISOTRETINOIN Cap 10 mg – 1% DV Jan-13 to 2015 .............................................................18.71 Cap 20 mg – 1% DV Jan-13 to 2015 .............................................................28.91 TRETINOIN Crm 0.05% 120 120 Oratane Oratane

Antipruritic Preparations

CALAMINE Crm, aqueous, BP – 1% DV Mar-13 to 2015 ...................................................1.77 Lotn, BP – 1% DV Nov-12 to 2015 ................................................................13.45 CROTAMITON Crm 10% – 1% DV Sep-12 to 2015 .................................................................3.48 100 g 2,000 ml 20 g Pharmacy Health PSM Itch-Soothe

Barrier Creams and Emollients Barrier Creams

DIMETHICONE Crm 5% tube – 1% DV Apr-14 to 2016............................................................1.65 Crm 5% pump bottle – 1% DV Apr-14 to 2016................................................4.73 ZINC Crm 100 g 500 ml healthE Dimethicone 5% healthE Dimethicone 5% e.g. Zinc Cream (Orion);Zinc Cream (PSM) e.g. Zinc oxide (PSM)

Oint Paste ZINC AND CASTOR OIL Crm – 1% DV Apr-12 to 2014..........................................................................1.63 Oint, BP 20 g

Orion

Products with Hospital Supply Status (HSS) are in bold Expiry date of HSS period is 30 June of the year indicated unless otherwise stated.

49


DERMATOLOGICALS

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

ZINC WITH WOOL FAT Crm zinc 15.25% with wool fat 4%

e.g. Sudocrem

Emollients

AQUEOUS CREAM Crm 100 g – 1% DV Sep-11 to 2014 ...............................................................1.23 Note: DV limit applies to the pack sizes of 100 g or less. Crm 500 g – 1% DV Sep-11 to 2014 ...............................................................1.96 Note: DV limit applies to the pack sizes of greater than 100 g. CETOMACROGOL Crm BP, 500 g ..................................................................................................3.50 Crm BP, 100 g ..................................................................................................1.65 CETOMACROGOL WITH GLYCEROL Crm 90% with glycerol 10%, ............................................................................2.10 2.00 3.20 Crm 90% with glycerol 10% .............................................................................4.50 100 g 500 g AFT AFT

500 g 1 100 g

Pharmacy Health healthE Pharmacy Health Pharmacy Health healthE Pharmacy Health Sorbolene with Glycerin Pharmacy Health Sorbolene with Glycerin healthE Jaychem AFT

500 ml

6.50

1,000 ml

Crm 90% with glycerol 10%, 500 ml, 1 bottle ...................................................5.46 EMULSIFYING OINTMENT Oint BP – 1% DV Nov-11 to 2014....................................................................1.95 Oint BP, 500 g – 1% DV Sep-11 to 2014..........................................................3.04 Note: DV limit applies to pack sizes of greater than 100 g. GLYCEROL WITH PARAFFIN Crm glycerol 10% with white soft paraffin 5% and liquid paraffin 10% OIL IN WATER EMULSION Crm – 1% DV Dec-12 to 2015 .........................................................................2.63 Crm, 100 g ........................................................................................................1.60

1 100 g 500 g

e.g. QV cream 500 g 1 healthE Fatty Cream healthE Fatty Cream

PARAFFIN Oint liquid paraffin 50% with white soft paraffin 50% ........................................3.10 100 g healthE White soft – 1% DV Feb-13 to 2015 ................................................................0.92 10 g healthE Note: DV limit applies to pack sizes of 30 g or less, and to both white soft paraffin and yellow soft paraffin. Yellow soft PARAFFIN WITH WOOL FAT Lotn liquid paraffin 15.9% with wool fat 0.6% Lotn liquid paraffin 91.7% with wool fat 3% UREA Crm 10% WOOL FAT Crm e.g. AlphaKeri;BK ;DP; Hydroderm Lotn e.g. Alpha Keri Bath Oil

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Item restricted (see ° above); Item restricted (see ¯ below) e.g. Brand indicates brand example only. It is not a contracted product.

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DERMATOLOGICALS

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

Corticosteroids

BETAMETHASONE DIPROPIONATE Crm 0.05% Oint 0.05% BETAMETHASONE VALERATE Crm 0.1% Oint 0.1% Lotn 0.1% CLOBETASOL PROPIONATE Crm 0.05% .......................................................................................................3.68 Oint 0.05% ........................................................................................................3.68 CLOBETASONE BUTYRATE Crm 0.05% DIFLUCORTOLONE VALERATE – Restricted: For continuation only ¬ Crm 0.1% ¬ Fatty oint 0.1% HYDROCORTISONE Crm 1%, 100 g .................................................................................................3.75 Crm 1%, 500 g – 1% DV Nov-11 to 2014 ......................................................14.00 Note: DV limit applies to the pack sizes of greater than 100 g. HYDROCORTISONE ACETATE Crm 1% ............................................................................................................2.48 HYDROCORTISONE BUTYRATE Crm 0.1% – 1% DV Mar-13 to 2015 ................................................................2.30 6.85 Oint 0.1% – 1% DV Mar-13 to 2015.................................................................6.85 Milky emul 0.1% – 1% DV Mar-13 to 2015 ......................................................6.85 HYDROCORTISONE WITH PARAFFIN AND WOOL FAT Lotn 1% with paraffin liquid 15.9% and wool fat 0.6% METHYLPREDNISOLONE ACEPONATE Crm 0.1% .........................................................................................................4.95 Oint 0.1% ..........................................................................................................4.95 MOMETASONE FUROATE Crm 0.1% – 1% DV Sep-12 to 2015 ................................................................1.78 3.42 Oint 0.1% – 1% DV Sep-12 to 2015 ................................................................1.78 3.42 Lotn 0.1% TRIAMCINOLONE ACETONIDE Crm 0.02% – 1% DV Sep-11 to 2014 ..............................................................6.63 Oint 0.02% – 1% DV Sep-11 to 2014 ..............................................................6.69 15 g 15 g 15 g 45 g 15 g 45 g Advantan Advantan m-Mometasone m-Mometasone m-Mometasone m-Mometasone 100 g 500 g Pharmacy Health Pharmacy Health 30 g 30 g Dermol Dermol

14.2 g 30 g 100 g 100 g 100 ml

AFT Locoid Lipocream Locoid Lipocream Locoid Locoid Crelo

100 g 100 g

Aristocort Aristocort

Corticosteroids with Anti-Infective Agents

BETAMETHASONE VALERATE WITH CLIOQUINOL – Restricted see terms on the next page Crm 0.1% with clioquiniol 3% Oint 0.1% with clioquiniol 3% ¯¯

Products with Hospital Supply Status (HSS) are in bold Expiry date of HSS period is 30 June of the year indicated unless otherwise stated.

51


DERMATOLOGICALS

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

¯Restricted Either: 1 For the treatment of intertrigo; or 2 For continuation use BETAMETHASONE VALERATE WITH FUSIDIC ACID Crm 0.1% with fusidic acid 2% HYDROCORTISONE WITH MICONAZOLE Crm 1% with miconazole nitrate 2% .................................................................2.20 HYDROCORTISONE WITH NATAMYCIN AND NEOMYCIN Crm 1% with natamycin 1% and neomycin sulphate 0.5% ..............................2.79 Oint 1% with natamycin 1% and neomycin sulphate 0.5% ...............................2.79 15 g 15 g 15 g Micreme H Pimafucort Pimafucort

TRIAMCINOLONE ACETONIDE WITH NEOMYCIN SULPHATE, GRAMICIDIN AND NYSTATIN Crm 1 mg with nystatin 100,000 u, neomycin sulphate 2.5 mg and gramicidin 250 mcg per g

Psoriasis and Eczema Preparations

ACITRETIN Cap 10 mg ......................................................................................................35.95 38.66 Cap 25 mg ......................................................................................................83.11 85.40 BETAMETHASONE DIPROPIONATE WITH CALCIPOTRIOL Gel 500 mcg with calcipotriol 50 mcg per g ....................................................26.12 Oint 500 mcg with calcipotriol 50 mcg per g ...................................................26.12 CALCIPOTRIOL Crm 50 mcg per g ...........................................................................................45.00 Oint 50 mcg per g ...........................................................................................45.00 Soln 50 mcg per ml .........................................................................................16.00 COAL TAR WITH SALICYLIC ACID AND SULPHUR Oint 12% with salicylic acid 2% and sulphur 4% COAL TAR WITH TRIETHANOLAMINE LARYL SULPHATE AND FLUORESCEIN Soln 2.3% with triethanolamine lauryl sulphate and fluorescein sodium – 1% DV Nov-11 to 2014 ........................................................................... 3.05 5.82 METHOXSALEN [8-METHOXYPSORALEN] Cap 10 mg Lotn 1.2% POTASSIUM PERMANGANATE Tab 400 mg Crystals 100 60 60 100 30 g 30 g 100 g 100 g 30 ml Neotigason Novatretin Novatretin Neotigason Daivobet Daivobet Daivonex Daivonex Daivonex

500 ml 1,000 ml

Pinetarsol Pinetarsol

Scalp Preparations

BETAMETHASONE VALERATE Scalp app 0.1% ................................................................................................7.75 CLOBETASOL PROPIONATE Scalp app 0.05% ..............................................................................................6.96 100 ml 30 ml Beta Scalp Dermol

°

52

Item restricted (see ° above); Item restricted (see ¯ below) e.g. Brand indicates brand example only. It is not a contracted product.

¯


DERMATOLOGICALS

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

HYDROCORTISONE BUTYRATE Scalp lotn 0.1% – 1% DV Mar-13 to 2015........................................................3.65

100 ml

Locoid

Wart Preparations

IMIQUIMOD – Restricted see terms below Crm 5%, 250 mg sachet – 1% DV Nov-11 to 2014 .......................................62.00 12 Aldara ¯Restricted Any of the following: 1 The patient has external anogenital warts and podophyllotoxin has been tried and failed (or is contraindicated); or 2 The patient has external anogenital warts and podophyllotoxin is unable to be applied accurately to the site; or 3 The patient has confirmed superficial basal cell carcinoma where other standard treatments, including surgical excision, are contraindicated or inappropriate. Notes: Superficial basal cell carcinoma G Surgical excision remains first-line treatment for superficial basal cell carcinoma as it has a higher cure rate than imiquimod and allows histological assessment of tumour clearance. G Imiquimod has not been evaluated for the treatment of superficial basal cell carcinoma within 1 cm of the hairline, eyes, nose, mouth or ears. G Imiquimod is not indicated for recurrent, invasive, infiltrating, or nodular basal cell carcinoma. G Every effort should be made to biopsy the lesion to confirm that it is a superficial basal cell carcinoma. External anogenital warts G Imiquimod is only indicated for external genital and perianal warts (condyloma acuminata). PODOPHYLLOTOXIN Soln 0.5% .......................................................................................................33.60 3.5 ml Condyline SILVER NITRATE Sticks with applicator ¯

Other Skin Preparations

DIPHEMANIL METILSULFATE Powder 2% SUNSCREEN, PROPRIETARY Crm Lotn .................................................................................................................2.55 5.10 3.30 5.10 (Marine Blue Lotion SPF 30+ Lotn to be delisted 1 May 2014)

100 g 200 g 100 g 200 g

Marine Blue Lotion SPF 30+ Marine Blue Lotion SPF 30+ Marine Blue Lotion SPF 50+ Marine Blue Lotion SPF 50+

Antineoplastics

FLUOROURACIL SODIUM Crm 5% – 1% DV Feb-13 to 2015 .................................................................25.16 METHYL AMINOLEVULINATE HYDROCHLORIDE – Restricted see terms below Crm 16% ¯Restricted Dermatologist or plastic surgeon ¯ 20 g Efudix

Products with Hospital Supply Status (HSS) are in bold Expiry date of HSS period is 30 June of the year indicated unless otherwise stated.

53


DERMATOLOGICALS

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

Wound Management Products

CALCIUM GLUCONATE Gel 2.5% .........................................................................................................21.00 1 healthE

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54

Item restricted (see ° above); Item restricted (see ¯ below) e.g. Brand indicates brand example only. It is not a contracted product.

¯


GENITO-URINARY SYSTEM

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

Anti-Infective Agents

ACETIC ACID Soln 3% Soln 5% ACETIC ACID WITH HYDROXYQUINOLINE, GLYCEROL AND RICINOLEIC ACID Jelly 0.94% with hydroxyquinoline sulphate 0.025%, glycerol 5% and ricinoleic acid 0.75% with applicator CHLORHEXIDINE Crm 1% – 1% DV Oct-12 to 2015....................................................................1.24 CHLORHEXIDINE GLUCONATE Lotn 1%, 200 ml ................................................................................................6.75 CLOTRIMAZOLE Vaginal crm 1% with applicator – 1% DV Dec-13 to 2016 ...............................1.45 Vaginal crm 2% with applicator – 1% DV Dec-13 to 2016 ...............................2.20 MICONAZOLE NITRATE Vaginal crm 2% with applicator NYSTATIN Vaginal crm 100,000 u per 5 g with applicator(s) 50 g 1 35 g 20 g healthE healthE Clomazol Clomazol

Contraceptives Antiandrogen Oral Contraceptives

CYPROTERONE ACETATE WITH ETHINYLOESTRADIOL Tab 2 mg with ethinyloestradiol 35 mcg

Combined Oral Contraceptives

ETHINYLOESTRADIOL WITH DESOGESTREL Tab 20 mcg with desogestrel 150 mcg Tab 30 mcg with desogestrel 150 mcg ETHINYLOESTRADIOL WITH LEVONORGESTREL Tab 20 mcg with levonorgestrel 100 mcg and 7 inert tablets ............................2.65 Tab 30 mcg with levonorgestrel 150 mcg and 7 inert tablets ............................2.30 Tab 20 mcg with levonorgestrel 100 mcg Tab 30 mcg with levonorgestrel 150 mcg Tab 50 mcg with levonorgestrel 125 mcg .........................................................9.45 ETHINYLOESTRADIOL WITH NORETHISTERONE Tab 35 mcg with norethisterone 1 mg Tab 35 mcg with norethisterone 500 mcg NORETHISTERONE WITH MESTRANOL Tab 1 mg with mestranol 50 mcg 84 84 Ava 20 ED Ava 30 ED

84

Microgynon 50 ED

Contraceptive Devices

INTRA-UTERINE DEVICE IUD e.g.Multiload Cu375, Multiload Cu375 SL

Products with Hospital Supply Status (HSS) are in bold Expiry date of HSS period is 30 June of the year indicated unless otherwise stated.

55


GENITO-URINARY SYSTEM

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

Emergency Contraception

LEVONORGESTREL Tab 1.5 mg – 1% DV Jul-13 to 2016 ................................................................3.50 1 Postinor-1

Progestogen-Only Contraceptives

LEVONORGESTREL Tab 30 mcg Implant 75 mg ...............................................................................................133.65 1 Jadelle Intra-uterine system, 20 mcg per day e.g. Mirena ¯Restricted Obstetrician or gynaecologist Initiation – heavy menstrual bleeding All of the following: 1 The patient has a clinical diagnosis of heavy menstrual bleeding; and 2 The patient has failed to respond to or is unable to tolerate other appropriate pharmaceutical therapies as per the Heavy Menstrual Bleeding Guidelines; and 3 Any of the following: 3.1 Serum ferritin level < 16 mcg/l (within the last 12 months); or 3.2 Haemoglobin level < 120 g/l; or 3.3 The patient has had a uterine ultrasound and either a hysteroscopy or endometrial biopsy. Continuation – heavy menstrual bleeding Either: 1 Patient demonstrated clinical improvement of heavy menstrual bleeding; or 2 Previous insertion was removed or expelled within 3 months of insertion. Initiation – endometriosis The patient has a clinical diagnosis of endometriosis confirmed by laparoscopy. Continuation – endometriosis Either: 1 Patient demonstrated satisfactory management of endometriosis; or 2 Previous insertion was removed or expelled within 3 months of insertion. Note:endometriosis is an unregistered indication. MEDROXYPROGESTERONE ACETATE Inj 150 mg per ml, 1 ml syringe – 1% DV Sep-13 to 2016 ...............................7.00 1 Depo-Provera

°

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NORETHISTERONE Tab 350 mcg

Obstetric Preparations Antiprogestogens

MIFEPRISTONE Tab 200 mg

Oxytocics

CARBOPROST TROMETAMOL Inj 250 mcg per ml, 1 ml ampoule

56

Item restricted (see ° above); Item restricted (see ¯ below) e.g. Brand indicates brand example only. It is not a contracted product.

¯


GENITO-URINARY SYSTEM

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

DINOPROSTONE Pessaries 10 mg Gel 1 mg in 2.5 ml ..........................................................................................52.65 Gel 2 mg in 2.5 ml ..........................................................................................64.60 ERGOMETRINE MALEATE Inj 500 mcg per ml, 1 ml ampoule – 1% DV Nov-11 to 2014 .........................31.00 OXYTOCIN Inj 5 iu per ml, 1 ml ampoule – 1% DV Feb-14 to 2015 ...................................4.75 Inj 10 iu per ml, 1 ml ampoule – 1% DV Feb-14 to 2015 .................................5.98 OXYTOCIN WITH ERGOMETRINE MALEATE Inj 5 iu with ergometrine maleate 500 mcg per ml, 1 ml ampoule – 1% DV Oct-12 to 2015 ................................................................................... 11.13

1 1 5 5 5

Prostin E2 Prostin E2 DBL Ergometrine Oxytocin BNM Oxytocin BNM

5

Syntometrine

Tocolytics

PROGESTERONE – Restricted see terms below Cap 100 mg ....................................................................................................16.50 30 Utrogestan ¯Restricted Obstetrician or gynaecologist Both: 1 For the prevention of pre-term labour*; and 2 Either: 2.1 The patient has a short cervix on ultrasound (defined as < 25mm at 16 to 28 weeks) or 2.2 The patient has a history of pre-term birth at less than 28 weeks. Note: Indications marked with * are Unapproved Indications (refer to Section A: General Rules, Part I (Interpretations and Definitions) and Part IV (Miscallaneous Provisions) rule 23.1). TERBUTALINE – Restricted see terms below Inj 500 mcg ampoule ¯Restricted Obstetrician ¯ ¯ ¯

Oestrogens

OESTRIOL Crm 1 mg per g with applicator Pessaries 500 mcg

Urologicals 5-Alpha Reductase Inhibitors

FINASTERIDE – Restricted see terms below Tab 5 mg – 1% DV Nov-11 to 2014 .................................................................5.10 30 ¯Restricted Both: 1 Patient has symptomatic benign prostatic hyperplasia; and 2 Either: 2.1 The patient is intolerant of non-selective alpha blockers or these are contraindicated; or 2.2 Symptoms are not adequately controlled with non-selective alpha blockers. Rex Medical

Products with Hospital Supply Status (HSS) are in bold Expiry date of HSS period is 30 June of the year indicated unless otherwise stated.

57


GENITO-URINARY SYSTEM

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

Alpha-1A Adrenoceptor Blockers

TAMSULOSIN – Restricted see terms below Cap 400 mcg – 1% DV Dec-13 to 2016.........................................................13.51 ¯ ¯ ¯¯ ¯¯ 100 Tamsulosin-Rex

¯Restricted Both: 1 Patient has symptomatic benign prostatic hyperplasia; and 2 The patient is intolerant of non-selective alpha blockers or these are contraindicated.

Urinary Alkalisers

POTASSIUM CITRATE – Restricted see terms below Oral liq 3 mmol per ml ....................................................................................30.00 200 ml ¯Restricted Both: 1 The patient has recurrent calcium oxalate urolithiasis; and 2 The patient has had more than two renal calculi in the two years prior to the application. SODIUM CITRO-TARTRATE Grans eff 4 g sachets .......................................................................................3.93 28 Biomed

Ural

Urinary Antispasmodics

OXYBUTYNIN Tab 5 mg – 1% DV Jun-13 to 2016................................................................11.20 Oral liq 5 mg per 5 ml – 1% DV Jun-13 to 2016 ............................................56.45 500 473 ml Apo-Oxybutynin Apo-Oxybutynin Vesicare Vesicare

SOLIFENACIN SUCCINATE – Restricted see terms below Tab 5 mg .........................................................................................................56.50 30 Tab 10 mg .......................................................................................................56.50 30 ¯Restricted Patient has overactive bladder and a documented intolerance of, or is non-responsive to, oxybutynin. TOLTERODINE TARTRATE – Restricted see terms below Tab 1 mg .........................................................................................................14.56 56 Tab 2 mg .........................................................................................................14.56 56 ¯Restricted Patient has overactive bladder and a documented intolerance of, or is non-responsive to, oxybutynin.

Arrow-Tolterodine Arrow-Tolterodine

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Item restricted (see ° above); Item restricted (see ¯ below) e.g. Brand indicates brand example only. It is not a contracted product.

¯


HORMONE PREPARATIONS - SYSTEMIC EXCLUDING CONTRACEPTIVE HORMONES

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

Anabolic Agents

OXANDROLINE Tab 2.5 mg ¯Restricted For the treatment of burns patients. ¯

Androgen Agonists and Antagonists

CYPROTERONE ACETATE Tab 50 mg – 1% DV Oct-12 to 2015 ..............................................................18.80 Tab 100 mg – 1% DV Oct-12 to 2015 ............................................................34.25 TESTOSTERONE Patch 2.5 mg per day ......................................................................................80.00 TESTOSTERONE CYPIONATE Inj 100 mg per ml, 10 ml vial – 1% DV Feb-12 to 2014 .................................76.50 TESTOSTERONE ESTERS Inj testosterone decanoate 100 mg, testosterone isocarproate 60 mg, testosterone phenylpropionate 60 mg and testosterone propionate 30 mg per ml, 1 ml ampoule TESTOSTERONE UNDECANOATE Cap 40 mg – 1% DV Oct-12 to 2015 .............................................................31.17 Inj 250 mg per ml, 4 ml ampoule ....................................................................86.00 60 1 Andriol Testocaps Reandron 1000 50 50 60 1 Siterone Siterone Androderm Depo-Testosterone

Calcium Homeostasis

CALCITONIN Inj 100 iu per ml, 1 ml ampoule – 1% DV Sep-11 to 2014 ...........................110.00 ZOLEDRONIC ACID Inj 0.8 mg per ml, 5 ml vial ............................................................................550.00 ¯Restricted For hypercalcaemia of malignancy ¯ 5 1 Miacalcic Zometa

Corticosteroids

BETAMETHASONE Tab 500 mcg Inj 4 mg per ml, 1 ml ampoule BETAMETHASONE SODIUM PHOSPHATE WITH BETAMETHASONE ACETATE Inj 3.9 mg with betamethasone acetate 3 mg per ml, 1 ml ampoule DEXAMETHASONE Tab 1 mg – 1% DV Aug-12 to 2015 .................................................................5.87 Tab 4 mg – 1% DV Aug-12 to 2015 .................................................................8.16 Oral liq 1 mg per ml ........................................................................................45.00 100 100 25 ml Douglas Douglas Biomed

Products with Hospital Supply Status (HSS) are in bold Expiry date of HSS period is 30 June of the year indicated unless otherwise stated.

59


HORMONE PREPARATIONS - SYSTEMIC EXCLUDING CONTRACEPTIVE HORMONES

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

DEXAMETHASONE PHOSPHATE Inj 4 mg per ml, 1 ml ampoule – 1% DV Apr-14 to 2016 ..............................21.50 25.80 Inj 4 mg per ml, 2 ml ampoule – 1% DV Apr-14 to 2016 ...............................17.98 Inj 4 mg per ml, 2 ml vial ................................................................................31.00 (Hospira Inj 4 mg per ml, 1 ml ampoule to be delisted 1 April 2014) (Hospira Inj 4 mg per ml, 2 ml vial to be delisted 1 April 2014) FLUDROCORTISONE ACETATE Tab 100 mcg ...................................................................................................14.32 HYDROCORTISONE Tab 5 mg – 1% DV Nov-12 to 2015 .................................................................8.10 Tab 20 mg – 1% DV Nov-12 to 2015 .............................................................20.32 Inj 100 mg vial – 1% DV Oct-13 to 2016..........................................................4.99 METHYLPREDNISOLONE (AS SODIUM SUCCINATE) Tab 4 mg – 1% DV Oct-12 to 2015 ................................................................60.00 Tab 100 mg – 1% DV Oct-12 to 2015 ..........................................................166.52 Inj 40 mg vial – 1% DV Oct-12 to 2015............................................................7.50 Inj 125 mg vial – 1% DV Oct-12 to 2015........................................................18.50 Inj 500 mg vial – 1% DV Oct-12 to 2015........................................................18.00 Inj 1 g vial – 1% DV Oct-12 to 2015...............................................................37.50 METHYLPREDNISOLONE ACETATE Inj 40 mg per ml, 1 ml vial – 1% DV Oct-12 to 2015........................................6.70 METHYLPREDNISOLONE ACETATE WITH LIGNOCAINE Inj 40 mg with lignocaine 10 mg per ml, 1 ml vial – 1% DV Oct-12 to 2015 ....................................................................................................... 7.50 PREDNISOLONE Oral liq 5 mg per ml ........................................................................................10.45 Enema 200 mcg per ml, 100 ml PREDNISONE Tab 1 mg ...........................................................................................................2.13 10.68 Tab 2.5 mg ......................................................................................................12.09 Tab 5 mg .........................................................................................................11.09 Tab 20 mg .......................................................................................................29.03 TRIAMCINOLONE ACETONIDE Inj 10 mg per ml, 1 ml ampoule – 1% DV Jun-12 to 2014 .............................21.90 Inj 40 mg per ml, 1 ml ampoule – 1% DV Jun-12 to 2014 .............................53.79 TRIAMCINOLONE HEXACETONIDE Inj 20 mg per ml, 1 ml vial

5 10 5 5

Hospira Dexamethasonehameln Dexamethasonehameln Hospira

100 100 100 1 100 20 1 1 1 1 1

Florinef Douglas Douglas Solu-Cortef Medrol Medrol Solu-Medrol Solu-Medrol Solu-Medrol Solu-Medrol Depo-Medrol

1

Depo-Medrol with Lidocaine Redipred

30 ml

100 500 500 500 500 5 5

Apo-Prednisone S29 Apo-Prednisone Apo-Prednisone Apo-Prednisone Apo-Prednisone Kenacort-A Kenacort-A40

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Item restricted (see ° above); Item restricted (see ¯ below) e.g. Brand indicates brand example only. It is not a contracted product.

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HORMONE PREPARATIONS - SYSTEMIC EXCLUDING CONTRACEPTIVE HORMONES

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

Hormone Replacement Therapy Oestrogens

OESTRADIOL Tab 1 mg Tab 2 mg Patch 25 mcg per day Patch 50 mcg per day Patch 100 mcg per day OESTRADIOL VALERATE Tab 1 mg Tab 2 mg OESTROGENS (CONJUGATED EQUINE) Tab 300 mcg Tab 625 mcg

Progestogen and Oestrogen Combined Preparations

OESTRADIOL WITH NORETHISTERONE ACETATE Tab 1 mg with 0.5 mg norethisterone acetate Tab 2 mg with 1 mg norethisterone acetate Tab 2 mg with 1 mg norethisterone acetate (10), and tab 2 mg oestradiol (12) and tab 1 mg oestradiol (6) OESTROGENS WITH MEDROXYPROGESTERONE ACETATE Tab 625 mcg conjugated equine with 2.5 mg medroxyprogesterone acetate Tab 625 mcg conjugated equine with 5 mg medroxyprogesterone acetate

Progestogens

MEDROXYPROGESTERONE ACETATE Tab 2.5 mg – 1% DV Sep-13 to 2016 ..............................................................3.09 Tab 5 mg – 1% DV Sep-13 to 2016 ...............................................................13.06 Tab 10 mg – 1% DV Sep-13 to 2016 ...............................................................6.85 30 100 30 Provera Provera Provera

Other Endocrine Agents

CABERGOLINE – Restricted see terms below Tab 0.5 mg – 1% DV Sep-12 to 2015 ..............................................................6.25 25.00 ¯Restricted Any of the following: 1 Inhibition of lactation; or 2 Patient has pathological hyperprolactinemia; or 3 Patient has acromegaly. CLOMIPHENE CITRATE Tab 50 mg – 1% DV Sep-13 to 2016 .............................................................29.84 ¯ 2 8 Dostinex Dostinex

10

Serophene

Products with Hospital Supply Status (HSS) are in bold Expiry date of HSS period is 30 June of the year indicated unless otherwise stated.

61


HORMONE PREPARATIONS - SYSTEMIC EXCLUDING CONTRACEPTIVE HORMONES

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

DANAZOL Cap 100 mg ....................................................................................................68.33 Cap 200 mg ....................................................................................................97.83 GESTRINONE Cap 2.5 mg METYRAPONE Cap 250 mg PENTAGASTRIN Inj 250 mcg per ml, 2 ml ampoule

100 100

Azol Azol

Other Oestrogen Preparations

ETHINYLOESTRADIOL Tab 10 mcg OESTRADIOL Implant 50 mg OESTRIOL Tab 2 mg

Other Progestogen Preparations

MEDROXYPROGESTERONE Tab 100 mg – 1% DV Sep-13 to 2016 ...........................................................96.50 Tab 200 mg .....................................................................................................70.50 NORETHISTERONE Tab 5 mg – 1% DV Nov-11 to 2014 ...............................................................26.50 100 30 100 Provera Provera Primolut N

Pituitary and Hypothalamic Hormones and Analogues

CORTICOTRORELIN (OVINE) Inj 100 mcg vial THYROTROPIN ALFA Inj 900 mcg vial

Adrenocorticotropic Hormones

TETRACOSACTIDE [TETRACOSACTRIN] Inj 250 mcg per ml, 1 ml ampoule – 1% DV Sep-11 to 2014 .......................177.18 Inj 1 mg per ml, 1 ml ampoule – 1% DV Sep-11 to 2014...............................29.56 10 1 Synacthen Synacthen Depot

GnRH Agonists and Antagonists

BUSERELIN Inj 1 mg per ml, 5.5 ml vial GONADORELIN Inj 100 mcg vial GOSERELIN Implant 3.6 mg ..............................................................................................166.20 Implant 10.8 mg ............................................................................................443.76 1 1 Zoladex Zoladex

°

62

Item restricted (see ° above); Item restricted (see ¯ below) e.g. Brand indicates brand example only. It is not a contracted product.

¯


HORMONE PREPARATIONS - SYSTEMIC EXCLUDING CONTRACEPTIVE HORMONES

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

LEUPRORELIN ACETATE Inj 3.75 mg syringe .......................................................................................221.60 Inj 7.5 mg syringe .........................................................................................166.20 Inj 11.25 mg syringe .....................................................................................591.68 Inj 22.5 mg syringe .......................................................................................443.76 Inj 30 mg syringe .......................................................................................1,109.40 Inj 30 mg vial ................................................................................................591.68 Inj 45 mg syringe ..........................................................................................832.05

1 1 1 1 1 1 1

Lucrin Depot PDS Eligard Lucrin Depot PDS Eligard Lucrin Depot PDS Eligard Eligard

Gonadotrophins

CHORIOGONADOTROPIN ALFA Inj 250 mcg in 0.5 ml syringe

Growth Hormone

SOMATROPIN – Restricted see terms below Inj 16 iu (5.3 mg) vial Inj 36 iu (12 mg) vial ¯Restricted Only for use in patients with approval by the New Zealand Growth Hormone Committee or the Adult Growth Hormone Panel ¯¯ ¯ ¯

Thyroid and Antithyroid Preparations

CARBIMAZOLE Tab 5 mg IODINE Soln BP 50 mg per ml LEVOTHYROXINE Tab 25 mcg Tab 50 mcg Tab 100 mcg LIOTHYRONINE SODIUM Tab 20 mcg ¯Restricted For a maximum of 14 days’ treatment in patients with thyroid cancer who are due to receive radioiodine therapy Inj 20 mcg vial POTASSIUM IODATE Tab 170 mg POTASSIUM PERCHLORATE Cap 200 mg PROPYLTHIOURACIL – Restricted see terms below Tab 50 mg .......................................................................................................35.00 100 PTU ¯Restricted Both: 1 The patient has hyperthyroidism; and 2 The patient is intolerant of carbimazole or carbimazole is contraindicated. Note: Propylthiouracil is not recommended for patients under the age of 18 years unless the patient is pregnant and other treatments are contraindicated. PROTIRELIN Inj 100 mcg per ml, 2 ml ampoule

Products with Hospital Supply Status (HSS) are in bold Expiry date of HSS period is 30 June of the year indicated unless otherwise stated.

63


HORMONE PREPARATIONS - SYSTEMIC EXCLUDING CONTRACEPTIVE HORMONES

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

Vasopressin Agents

ARGIPRESSIN [VASOPRESSIN] Inj 20 u per ml, 1 ml ampoule DESMOPRESSIN ACETATE – Some items restricted see terms below Tab 100 mcg ...................................................................................................36.40 Tab 200 mcg ...................................................................................................93.60 Nasal spray 10 mcg per dose – 1% DV Sep-11 to 2014................................27.48 Inj 4 mcg per ml, 1 ml ampoule Inj 15 mcg per ml, 1 ml ampoule Nasal drops 100 mcg per ml ¯Restricted Nocturnal enuresis Either: 1 The nasal forms of desmopressin are contraindicated; or 2 An enuresis alarm is contraindicated. Cranial diabetes insipidus and the nasal forms of desmopressin are contraindicated TERLIPRESSIN Inj 1 mg vial ..................................................................................................450.00 ¯¯ 30 30 6 ml Minirin Minirin Desmopressin-PH&T

5

Glypressin

°

64

Item restricted (see ° above); Item restricted (see ¯ below) e.g. Brand indicates brand example only. It is not a contracted product.

¯


INFECTIONS - AGENTS FOR SYSTEMIC USE

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

Antibacterials Aminoglycosides

AMIKACIN – Restricted see terms below Inj 5 mg per ml, 10 ml syringe Inj 5 mg per ml, 5 ml syringe – 1% DV Nov-12 to 2014...............................176.00 Inj 15 mg per ml, 5 ml syringe Inj 250 mg per ml, 2 ml vial ¯Restricted Infectious disease physician, clinical microbiologist or respiratory physician GENTAMICIN SULPHATE Inj 10 mg per ml, 1 ml ampoule ........................................................................8.56 Inj 10 mg per ml, 2 ml ampoule ....................................................................175.10 Inj 40 mg per ml, 2 ml ampoule – 1% DV Sep-12 to 2015...............................6.50 ¯¯¯¯ ¯ ¯ ¯¯ ¯ ¯ ¯¯

10

Biomed

5 25 10 16

Mayne APP Pharmaceuticals Pfizer Humatin

PAROMOMYCIN – Restricted see terms below Cap 250 mg ..................................................................................................126.00 ¯Restricted Infectious disease physician or clinical microbiologist STREPTOMYCIN SULPHATE – Restricted see terms below Inj 400 mg per ml, 2.5 ml ampoule ¯Restricted Infectious disease physician, clinical microbiologist or respiratory physician TOBRAMYCIN – Restricted see terms below Inj 40 mg per ml, 2 ml vial – 1% DV Sep-11 to 2014 .....................................29.32 Inj 100 mg per ml, 5 ml vial ¯Restricted Infectious disease physician, clinical microbiologist or respiratory physician

5

DBL Tobramycin

Carbapenems

ERTAPENEM – Restricted see terms below Inj 1 g vial .......................................................................................................70.00 ¯Restricted Infectious disease physician or clinical microbiologist IMIPENEM WITH CILASTATIN – Restricted see terms below Inj 500 mg with 500 mg cilastatin vial – 1% DV Dec-12 to 2014....................18.37 ¯Restricted Infectious disease physician or clinical microbiologist MEROPENEM – Restricted see terms below Inj 500 mg vial – 1% DV Mar-12 to 2014 .......................................................10.50 Inj 1 g vial – 1% DV Mar-12 to 2014 ..............................................................21.00 ¯Restricted Infectious disease physician or clinical microbiologist 1 Invanz

1

Primaxin

1 1

Penembact Penembact

Cephalosporins and Cephamycins - 1st Generation

CEFALEXIN Cap 500 mg – 1% DV Oct-13 to 2016 .............................................................5.70 Grans for oral liq 25 mg per ml – 1% DV Oct-13 to 2016 ................................8.50 Grans for oral liq 50 mg per ml – 1% DV Oct-13 to 2016 ..............................11.50 20 100 ml 100 ml Cephalexin ABM Cefalexin Sandoz Cefalexin Sandoz

Products with Hospital Supply Status (HSS) are in bold Expiry date of HSS period is 30 June of the year indicated unless otherwise stated.

65


INFECTIONS - AGENTS FOR SYSTEMIC USE

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

CEFAZOLIN Inj 500 mg vial – 1% DV Mar-12 to 2014 .........................................................3.99 Inj 1 g vial – 1% DV Mar-12 to 2014 ................................................................3.99

5 5

AFT AFT

Cephalosporins and Cephamycins - 2nd Generation

CEFACLOR Cap 250 mg – 1% DV Dec-13 to 2016...........................................................26.00 Grans for oral liq 25 mg per ml – 1% DV Dec-13 to 2016................................3.53 CEFOXITIN Inj 1 g vial .......................................................................................................55.00 CEFUROXIME Tab 250 mg .....................................................................................................29.40 Inj 750 mg vial – 1% DV Mar-12 to 2014 .........................................................6.96 Inj 1.5 g vial – 1% DV Mar-12 to 2014 .............................................................2.65 100 100 ml 5 50 5 1 Ranbaxy-Cefaclor Ranbaxy-Cefaclor Hospira Zinnat m-Cefuroxime Mylan

Cephalosporins and Cephamycins - 3rd Generation

CEFOTAXIME Inj 500 mg vial – 1% DV Oct-11 to 2014..........................................................1.90 Inj 1 g vial – 1% DV Nov-11 to 2014..............................................................15.58 CEFTAZADIME – Restricted see terms below Inj 500 mg vial – 1% DV Oct-11 to 2014..........................................................2.37 Inj 1 g vial .........................................................................................................3.25 Inj 2 g vial .........................................................................................................6.49 ¯Restricted Infectious disease physician, clinical microbiologist or respiratory physician CEFTRIAXONE Inj 500 mg vial – 1% DV Mar-14 to 2016 .........................................................1.50 Inj 1 g vial – 1% DV Mar-14 to 2016 ................................................................5.22 Inj 2 g vial – 1% DV Mar-14 to 2016 ................................................................2.75 ¯¯¯ ¯¯ 1 10 1 1 1 Cefotaxime Sandoz DBL Cefotaxime Fortum DBL Ceftazidime DBL Ceftazidime

1 5 1

Ceftriaxone-AFT Ceftriaxone-AFT Ceftriaxone-AFT

Cephalosporins and Cephamycins - 4th Generation

CEFEPIME – Restricted see terms below Inj 1 g vial – 1% DV Oct-12 to 2015.................................................................8.80 Inj 2 g vial – 1% DV Oct-12 to 2015...............................................................17.60 ¯Restricted Infectious disease physician or clinical microbiologist 1 1 DBL Cefepime DBL Cefepime

Macrolides

AZITHROMYCIN – Restricted see terms below Tab 250 mg .....................................................................................................10.00 30 Apo-Azithromycin Tab 500 mg – 1% DV Feb-13 to 2015..............................................................1.25 2 Apo-Azithromycin Oral liq 40 mg per ml ........................................................................................6.60 15 ml Zithromax ¯Restricted Any of the following: 1 Patient has received a lung transplant and requires treatment or prophylaxis for bronchiolitis obliterans syndrome; or 2 Patient has cystic fibrosis and has chronic infection with Pseudomonas aeruginosa or Pseudomonas related gram negative organisms; or 3 For any other condition for five days’ treatment, with review after five days. ¯¯¯

°

66

Item restricted (see ° above); Item restricted (see ¯ below) e.g. Brand indicates brand example only. It is not a contracted product.

¯


INFECTIONS - AGENTS FOR SYSTEMIC USE

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

CLARITHROMYCIN – Restricted see terms below Tab 250 mg – 1% DV Jan-12 to 2014..............................................................4.19 Tab 500 mg – 1% DV Apr-12 to 2014 ............................................................10.95 Grans for oral liq 25 mg per ml .......................................................................23.12 Inj 500 mg vial – 1% DV Oct-11 to 2014........................................................30.00

¯¯¯¯

14 14 70 ml 1

Apo-Clarithromycin Apo-Clarithromycin Klacid Klacid

¯Restricted Tab 250 mg and oral liquid Tab 250 mg and oral liquid 1 Atypical mycobacterial infection; or 2 Mycobacterium tuberculosis infection where there is drug resistance or intolerance to standard pharmaceutical agents. Tab 500 mg Helicobacter pylori eradication. Infusion Infusion 1 Atypical mycobacterial infection; or 2 Mycobacterium tuberculosis infection where there is drug resistance or intolerance to standard pharmaceutical agents; or 3 Community-acquired pneumonia (clarithromycin is not to be used as the first-line macrolide). ERYTHROMYCIN (AS ETHYLSUCCINATE) Tab 400 mg .....................................................................................................16.95 100 E-Mycin Grans for oral liq 200 mg per 5 ml ....................................................................4.35 100 ml E-Mycin Grans for oral liq 400 mg per 5 ml ....................................................................5.85 100 ml E-Mycin ERYTHROMYCIN (AS LACTOBIONATE) Inj 1 g vial .......................................................................................................16.00 ERYTHROMYCIN (AS STEARATE) – Restricted: For continuation only ¬ Tab 250 mg ¬ Tab 500 mg ROXITHROMYCIN Tab 150 mg – 1% DV Sep-12 to 2015 .............................................................7.48 Tab 300 mg – 1% DV Sep-12 to 2015 ...........................................................14.40 50 50 Arrow-Roxithromycin Arrow-Roxithromycin 1 Erythrocin IV

Penicillins

AMOXYCILLIN Cap 250 mg – 1% DV Mar-14 to 2016...........................................................16.18 Cap 500 mg ....................................................................................................26.50 Grans for oral liq 25 mg per ml .........................................................................1.55 Grans for oral liq 50 mg per ml .........................................................................1.10 Inj 250 mg vial – 1% DV Nov-11 to 2014.......................................................12.96 Inj 500 mg vial – 1% DV Nov-11 to 2014.......................................................15.08 Inj 1 g vial – 1% DV Nov-11 to 2014..............................................................21.94 AMOXYCILLIN WITH CLAVULANIC ACID Tab 500 mg with clavulanic acid 125 mg – 1% DV Aug-12 to 2014 ..............12.55 Grans for oral liq 25 mg with clavulanic acid 6.25 mg per ml – 1% DV Nov-12 to 2015 .......................................................................................... 1.61 Grans for oral liq 50 mg with clavulanic acid 12.5 mg per ml – 1% DV Nov-12 to 2015 .......................................................................................... 2.19 Inj 500 mg with clavulanic acid 100 mg vial – 1% DV Jan-13 to 2015...........10.14 Inj 1,000 mg with clavulanic acid 200 mg vial – 1% DV Jan-13 to 2015 .........14.03 500 500 100 ml 100 ml 10 10 10 100 100 ml 100 ml 10 10 Apo-Amoxi Alphamox Ospamox Ospamox Ibiamox Ibiamox Ibiamox Curam Duo Augmentin Augmentin m-Amoxiclav m-Amoxiclav

Products with Hospital Supply Status (HSS) are in bold Expiry date of HSS period is 30 June of the year indicated unless otherwise stated.

67


INFECTIONS - AGENTS FOR SYSTEMIC USE

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

BENZATHINE BENZYLPENICILLIN Inj 900 mg (1.2 million units) in 2.3 ml syringe – 1% DV Sep-12 to 2015 ................................................................................................... 315.00 BENZYLPENICILLIN SODIUM [PENICILLIN G] Inj 600 mg (1 million units) vial – 1% DV Nov-11 to 2014..............................11.50 FLUCLOXACILLIN Cap 250 mg – 1% DV Oct-12 to 2015 ...........................................................22.00 Cap 500 mg – 1% DV Oct-12 to 2015 ...........................................................74.00 Grans for oral liq 25 mg per ml – 1% DV Sep-12 to 2015................................2.49 Grans for oral liq 50 mg per ml – 1% DV Sep-12 to 2015................................3.25 Inj 250 mg vial – 1% DV Nov-11 to 2014.......................................................10.86 Inj 500 mg vial – 1% DV Nov-11 to 2014.......................................................11.32 Inj 1 g vial – 1% DV Nov-11 to 2014..............................................................14.28 PHENOXYMETHYLPENICILLIN [PENICILLIN V] Cap 250 mg ....................................................................................................11.99 Cap 500 mg ....................................................................................................14.45 Grans for oral liq 125 mg per 5 ml – 1% DV Apr-14 to 2016 ...........................1.64 Grans for oral liq 250 mg per 5 ml – 1% DV Apr-14 to 2016 ...........................1.74 PIPERACILLIN WITH TAZOBACTAM – Restricted see terms below Inj 4 g with tazobactam 0.5 g vial – 1% DV Oct-13 to 2016.............................5.84 ¯Restricted Infectious disease physician, clinical microbiologist or respiratory physician PROCAINE PENICILLIN Inj 1.5 g in 3.4 ml syringe – 1% DV Nov-11 to 2014 ....................................123.50 TICARCILLIN WITH CLAVULANIC ACID – Restricted see terms below Inj 3 g with clavulanic acid 0.1 mg vial ¯Restricted Infectious disease physician, clinical microbiologist or respiratory physician ¯ ¯ ¯¯¯¯¯¯

10 10 250 500 100 ml 100 ml 10 10 10 50 50 100 ml 100 ml 1

Bicillin LA Sandoz Staphlex Staphlex AFT AFT Flucloxin Flucloxin Flucloxin Cilicaine VK Cilicaine VK AFT AFT Tazocin EF

5

Cilicaine

Quinolones

CIPROFLOXACIN – Restricted see terms below Tab 250 mg – 1% DV Dec-11 to 2014 .............................................................2.20 Tab 500 mg – 1% DV Dec-11 to 2014 .............................................................3.00 Tab 750 mg – 1% DV Dec-11 to 2014 .............................................................5.15 Oral liq 50 mg per ml Oral liq 100 mg per ml Inj 2 mg per ml, 100 ml bag ............................................................................41.00 ¯Restricted Infectious disease physician or clinical microbiologist MOXIFLOXACIN – Restricted see terms on the next page Tab 400 mg .....................................................................................................52.00 Inj 1.6 mg per ml, 250 ml bag .........................................................................70.00 28 28 28 Cipflox Cipflox Cipflox

10

Aspen Ciprofloxacin

°

¯¯

5 1

Avelox Avelox IV 400

68

Item restricted (see ° above); Item restricted (see ¯ below) e.g. Brand indicates brand example only. It is not a contracted product.

¯


INFECTIONS - AGENTS FOR SYSTEMIC USE

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

¯Restricted Mycobacterium infection Infectious disease physician, clinical microbiologist or respiratory physician 1 Active tuberculosis, with any of the following: 1.1 Documented resistance to one or more first-line medications; or 1.2 Suspected resistance to one or more first-line medications (tuberculosis assumed to be contracted in an area with known resistance), as part of regimen containing other second-line agents; or 1.3 Impaired visual acuity (considered to preclude ethambutol use); or 1.4 Significant pre-existing liver disease or hepatotoxicity from tuberculosis medications; or 1.5 Significant documented intolerance and/or side effects following a reasonable trial of first-line medications. 2 Mycobacterium avium-intracellulare complex not responding to other therapy or where such therapy is contraindicated Pneumonia Infectious disease physician or clinical microbiologist 1 Immunocompromised patient with pneumonia that is unresponsive to first-line treatment; or 2 Pneumococcal pneumonia or other invasive pneumococcal disease highly resistant to other antibiotics. Penetrating eye injury Ophthalmologist Five days treatment for patients requiring prophylaxis following a penetrating eye injury Mycoplasma genitalium All of the following: 1 Has nucleic acid amplification test (NAAT) confirmed Mycoplasma genitalium; and 2 Has tried and failed to clear infection using azithromycin; and 3 Treatment is only for 7 days. NORFLOXACIN Tab 400 mg – 1% DV Sep-11 to 2014 ...........................................................15.45 100 Arrow-Norfloxacin

Tetracyclines

DEMECLOCYCLINE HYDROCHLORIDE Cap 150 mg DOXYCYCLINE ¬ Tab 50 mg – Restricted: For continuation only Tab 100 mg – 1% DV Sep-11 to 2014 .............................................................7.95 Inj 5 mg per ml, 20 ml vial MINOCYCLINE Tab 50 mg ¬ Cap 100 mg – Restricted: For continuation only TETRACYCLINE Tab 250 mg Cap 500 mg ....................................................................................................46.00 TIGECYCLINE – Restricted see terms below Inj 50 mg vial ¯Restricted Infectious disease physician or clinical microbiologist ¯ ¯

250

Doxine

30

Tetracyclin Wolff

Other Antibacterials

AZTREONAM – Restricted see terms below Inj 1 g vial – 1% DV Sep-11 to 2014 ............................................................131.00 ¯Restricted Infectious disease physician or clinical microbiologist 5 Azactam

Products with Hospital Supply Status (HSS) are in bold Expiry date of HSS period is 30 June of the year indicated unless otherwise stated.

69


INFECTIONS - AGENTS FOR SYSTEMIC USE

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

CHLORAMPHENICOL – Restricted see terms below Inj 1 g vial

°

¯ ¯¯¯ ¯ ¯¯ ¯ ¯ ¯ ¯¯¯ ¯

¯Restricted Infectious disease physician or clinical microbiologist CLINDAMYCIN – Restricted see terms below Cap 150 mg – 1% DV Oct-13 to 2016 .............................................................5.80 Oral liq 15 mg per ml Inj 150 mg per ml, 4 ml ampoule – 1% DV Sep-13 to 2016.........................100.00 ¯Restricted Infectious disease physician or clinical microbiologist COLISTIN SULPHOMETHATE [COLESTIMETHATE] – Restricted see terms below Inj 150 mg per ml, 1 ml vial .............................................................................65.00 ¯Restricted Infectious disease physician, clinical microbiologist or respiratory physician DAPTOMYCIN – Restricted see terms below Inj 350 mg vial Inj 500 mg vial ¯Restricted Infectious disease physician or clinical microbiologist FOSFOMYCIN – Restricted see terms below Powder for oral solution, 3 g sachet ¯Restricted Infectious disease physician or clinical microbiologist FUSIDIC ACID – Restricted see terms below Tab 250 mg .....................................................................................................34.50 ¯Restricted Infectious disease physician or clinical microbiologist HEXAMINE HIPPURATE Tab 1 g LINCOMYCIN – Restricted see terms below Inj 300 mg per ml, 2 ml vial ¯Restricted Infectious disease physician or clinical microbiologist LINEZOLID – Restricted see terms below Tab 600 mg Oral liq 20 mg per ml Inj 2 mg per ml, 300 ml bag ¯Restricted Infectious disease physician or clinical microbiologist NITROFURANTOIN Tab 50 mg Tab 100 mg PIVMECILLINAM – Restricted see terms below Tab 200 mg ¯Restricted Infectious disease physician or clinical microbiologist SULPHADIAZINE – Restricted see terms on the next page Tab 500 mg

16 10

Clindamycin ABM Dalacin C

1

Colistin-Link

12

Fucidin

¯

70

Item restricted (see ° above); Item restricted (see ¯ below) e.g. Brand indicates brand example only. It is not a contracted product.

¯


INFECTIONS - AGENTS FOR SYSTEMIC USE

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

¯Restricted Infectious disease physician, clinical microbiologist or maternal-foetal medicine specialist TEICOPLANIN – Restricted see terms below Inj 400 mg vial ¯Restricted Infectious disease physician or clinical microbiologist TRIMETHOPRIM Tab 100 mg Tab 300 mg .......................................................................................................9.28 TRIMETHOPRIM WITH SULPHAMETHOXAZOLE [CO-TRIMOXAZOLE] Tab 80 mg with sulphamethoxazole 400 mg Oral liq 8 mg with sulphamethoxazole 40 mg per ml ........................................2.15 Inj 16 mg with sulphamethoxazole 80 mg per ml, 5 ml ampoule VANCOMYCIN – Restricted see terms below Inj 500 mg vial – 1% DV Sep-11 to 2014 .........................................................3.58 ¯Restricted Infectious disease physician or clinical microbiologist

¯ ¯

50

TMP

100 ml

Deprim

1

Mylan

Antifungals Imidazoles

KETOCONAZOLE Tab 200 mg ¯Restricted Infectious disease physician, clinical microbiologist, dermatologist, endocrinologist or oncologist ¯ ¯ ¯

Polyene Antimycotics

AMPHOTERICIN B Inj (liposomal) 50 mg vial – 1% DV Oct-12 to 2015 ..................................3,450.00 10 AmBisome ¯Restricted Infectious disease physician, clinical microbiologist, haematologist, oncologist, transplant specialist or respiratory physician Either: 1 Proven or probable invasive fungal infection, to be prescribed under an established protocol; or 2 Both: 2.1 Possible invasive fungal infection; and 2.2 A multidisciplinary team (including an infectious disease physician or a clinical microbiologist) considers the treatment to be appropriate. Inj 50 mg vial ¯Restricted Infectious disease physician, clinical microbiologist, haematologist, oncologist, transplant specialist or respiratory physician NYSTATIN Tab 500,000 u .................................................................................................17.09 50 Nilstat Cap 500,000 u ................................................................................................15.47 50 Nilstat

Products with Hospital Supply Status (HSS) are in bold Expiry date of HSS period is 30 June of the year indicated unless otherwise stated.

71


INFECTIONS - AGENTS FOR SYSTEMIC USE

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

Triazoles

FLUCONAZOLE – Restricted see terms below Cap 50 mg – 1% DV Jan-12 to 2014 ...............................................................4.77 Cap 150 mg – 1% DV Jan-12 to 2014 .............................................................0.91 Cap 200 mg – 1% DV Jan-12 to 2014 ...........................................................13.34 Oral liquid 50 mg per 5 ml ..............................................................................34.56 Inj 2 mg per ml, 50 ml vial – 1% DV Oct-13 to 2016........................................4.95 Inj 2 mg per ml, 100 ml vial – 1% DV Oct-13 to 2016......................................6.47 ¯¯¯¯¯¯ ¯¯ ¯ ¯¯¯¯ 28 1 28 35 ml 1 1 Ozole Ozole Ozole Diflucan Fluconazole-Claris Fluconazole-Claris

¯Restricted Consultant ITRACONAZOLE – Restricted see terms below Cap 100 mg – 1% DV Oct-13 to 2016 .............................................................2.99 15 Itrazole Oral liquid 10 mg per ml ¯Restricted Infectious disease physician, clinical microbiologist, clinical immunologist or dermatologist POSACONAZOLE – Restricted see terms below Oral liq 40 mg per ml ....................................................................................761.13 105 ml Noxafil ¯Restricted Infectious disease physician or haematologist Initiation Re-assessment required after 6 weeks Both: 1 Either: 1.1 Patient has acute myeloid leukaemia; or 1.2 Patient is planned to receive a stem cell transplant and is at high risk for aspergillus infection; and 2 Patient is to be treated with high dose remission induction therapy or re-induction therapy Continuation Re-assessment required after 6 weeks Both: 1 Patient has previously received posaconazole prophylaxis during remission induction therapy; and 2 Any of the following: 2.1 Patient is to be treated with high dose remission re-induction therapy; or 2.2 Patient is to be treated with high dose consolidation therapy; or 2.3 Patient is receiving a high risk stem cell transplant. VORICONAZOLE – Restricted see terms below Tab 50 mg .....................................................................................................730.00 56 Vfend Tab 200 mg ................................................................................................2,930.00 56 Vfend Oral liq 40 mg per ml ....................................................................................730.00 70 ml Vfend Inj 200 mg vial ..............................................................................................185.00 1 Vfend ¯Restricted Infectious disease physician, clinical microbiologist or haematologist Proven or probable aspergillus infection Both: 1 Patient is immunocompromised; and 2 Patient has proven or probable invasive aspergillus infection. Possible aspergillus infection All of the following: continued. . .

°

72

Item restricted (see ° above); Item restricted (see ¯ below) e.g. Brand indicates brand example only. It is not a contracted product.

¯


INFECTIONS - AGENTS FOR SYSTEMIC USE

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

continued. . . 1 Patient is immunocompromised; and 2 Patient has possible invasive aspergillus infection; and 3 A multidisciplinary team (including an infectious disease physician) considers the treatment to be appropriate. Resistant candidiasis infections and other moulds All of the following: 1 Patient is immunocompromised, and 2 Either: 2.1 Patient has fluconazole resistant candidiasis; or 2.2 Patient has mould strain such as Fusarium spp. and Scedosporium spp; and 3 A multidisciplinary team (including an infectious disease physician or clinical microbiologist) considers the treatment to be appropriate.

Other Antifungals

CASPOFUNGIN – Restricted see terms below Inj 50 mg vial – 1% DV Oct-12 to 2015........................................................667.50 1 Cancidas Inj 70 mg vial – 1% DV Oct-12 to 2015........................................................862.50 1 Cancidas ¯Restricted Infectious disease physician, clinical microbiologist, haematologist, oncologist, transplant specialist or respiratory physician Either: 1 Proven or probable invasive fungal infection, to be prescribed under an established protocol; or 2 Both: 2.1 Possible invasive fungal infection; and 2.2 A multidisciplinary team (including an infectious disease physician or a clinical microbiologist) considers the treatment to be appropriate. FLUCYTOSINE – Restricted see terms below Cap 500 mg ¯Restricted Infectious disease physician or clinical microbiologist. TERBINAFINE Tab 250 mg – 1% DV Nov-11 to 2014 .............................................................1.78 14 Dr Reddy’s Terbinafine ¯¯ ¯ ¯ ¯¯ ¯

Antimycobacterials Antileprotics

CLOFAZIMINE – Restricted see terms below Cap 50 mg ¯Restricted Infectious disease physician, clinical microbiologist or dermatologist DAPSONE – Restricted see terms below Tab 25 mg Tab 100 mg ¯Restricted Infectious disease physician, clinical microbiologist or dermatologist

Antituberculotics

CYCLOSERINE – Restricted see terms below Cap 250 mg ¯Restricted Infectious disease physician, clinical microbiologist or respiratory physician

Products with Hospital Supply Status (HSS) are in bold Expiry date of HSS period is 30 June of the year indicated unless otherwise stated.

73


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ETHAMBUTOL HYDROCHLORIDE – Restricted see terms below Tab 100 mg .....................................................................................................48.01 Tab 400 mg .....................................................................................................49.34

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56 56

Myambutol Myambutol

¯Restricted Infectious disease physician, clinical microbiologist or respiratory physician ISONIAZID – Restricted see terms below Tab 100 mg – 1% DV Mar-13 to 2015............................................................20.00 100 PSM ¯Restricted Internal medicine physician, paediatrician, clinical microbiologist, dermatologist or public health physician ISONIAZID WITH RIFAMPICIN – Restricted see terms below Tab 100 mg with rifampicin 150 mg Tab 150 mg with rifampicin 300 mg ¯Restricted Internal medicine physician, paediatrician, clinical microbiologist, dermatologist or public health physician PARA-AMINOSALICYLIC ACID – Restricted see terms below Grans for oral liq 4 g .....................................................................................280.00 30 Paser ¯Restricted Infectious disease physician, clinical microbiologist or respiratory physician PROTIONAMIDE – Restricted see terms below Tab 250 mg ...................................................................................................305.00 100 Peteha ¯Restricted Infectious disease physician, clinical microbiologist or respiratory physician PYRAZINAMIDE – Restricted see terms below Tab 500 mg ¯Restricted Infectious disease physician, clinical microbiologist or respiratory physician RIFABUTIN – Restricted see terms below Cap 150 mg – 1% DV Sep-13 to 2016.........................................................213.19 30 Mycobutin ¯Restricted Infectious disease physician, clinical microbiologist, respiratory physician or gastroenterologist RIFAMPICIN – Restricted see terms below Tab 600 mg Cap 150 mg Cap 300 mg Oral liq 100 mg per 5 ml Inj 600 mg vial ¯Restricted Internal medicine physician, clinical microbiologist, dermatologist, paediatrician or public health physician

Antiparasitics Anthelmintics

ALBENDAZOLE – Restricted see terms below Tab 200 mg Tab 400 mg ¯Restricted Infectious disease physician or clinical microbiologist

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IVERMECTIN – Restricted see terms below Tab 3 mg .........................................................................................................17.20 ¯Restricted Infectious disease physician, clinical microbiologist or dermatologist. MEBENDAZOLE Tab 100 mg – 1% DV Nov-11 to 2014 ...........................................................24.19 Oral liq 100 mg per 5 ml

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Stromectol

24

De-Worm

PRAZIQUANTEL Tab 600 mg

Antiprotozoals

ARTEMETHER WITH LUMEFANTRINE – Restricted see terms below Tab 20 mg with lumefantrine 120 mg ¯Restricted Infectious disease physician or clinical microbiologist ARTESUNATE – Restricted see terms below Inj 60 mg vial ¯Restricted Infectious disease physician or clinical microbiologist ATOVAQUONE WITH PROGUANIL HYDROCHLORIDE – Restricted see terms below Tab 62.5 mg with proguanil hydrochloride 25 mg Tab 250 mg with proguanil hydrochloride 100 mg ¯Restricted Infectious disease physician or clinical microbiologist CHLOROQUINE PHOSPHATE – Restricted see terms below Tab 250 mg ¯Restricted Infectious disease physician, clinical microbiologist, dermatologist or rheumatologist MEFLOQUINE HYDROCHLORIDE – Restricted see terms below Tab 250 mg ¯Restricted Infectious disease physician, clinical microbiologist, dermatologist or rheumatologist METRONIDAZOLE Tab 200 mg .....................................................................................................10.45 Tab 400 mg .....................................................................................................18.15 Oral liq benzoate 200 mg per 5 ml .................................................................25.00 Inj 5 mg per ml, 100 ml bag ..............................................................................2.46 12.30 Suppos 500 mg ..............................................................................................24.48 NITAZOXANIDE – Restricted see terms below Tab 500 mg ................................................................................................1,680.00 Oral liq 100 mg per 5 ml ¯Restricted Infectious disease physician or clinical microbiologist ORNIDAZOLE Tab 500 mg .....................................................................................................16.50 PENTAMIDINE ISETHIONATE – Restricted see terms on the next page Inj 300 mg vial

100 100 100 ml 1 5 10 30

Trichozole Trichozole Flagyl-S Baxter AFT Flagyl Alinia

10

Arrow-Ornidazole

Products with Hospital Supply Status (HSS) are in bold Expiry date of HSS period is 30 June of the year indicated unless otherwise stated.

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¯Restricted Infectious disease physician or clinical microbiologist PRIMAQUINE PHOSPHATE – Restricted see terms below Tab 7.5 mg ¯Restricted Infectious disease physician or clinical microbiologist PYRIMETHAMINE – Restricted see terms below Tab 25 mg ¯Restricted Infectious disease physician, clinical microbiologist or maternal-foetal medicine specialist QUININE DIHYDROCHLORIDE – Restricted see terms below Inj 60 mg per ml, 10 ml ampoule Inj 300 mg per ml, 2 ml vial ¯Restricted Infectious disease physician or clinical microbiologist QUININE SULPHATE Tab 300 mg .....................................................................................................54.06 SODIUM STIBOGLUCONATE – Restricted see terms below Inj 100 mg per ml, 1 ml vial ¯Restricted Infectious disease physician or clinical microbiologist SPIRAMYCIN – Restricted see terms below Tab 500 mg ¯Restricted Maternal-foetal medicine specialist

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500

Q 300

Antiretrovirals HIV Fusion Inhibitors

ENFUVIRTIDE – Restricted see terms below Inj 108 mg vial × 60 ...................................................................................2,380.00 1 Fuzeon ¯Restricted Initiation Re-assessment required after 12 months All of the following: 1 Confirmed HIV infection; and 2 Enfuvirtide to be given in combination with optimized background therapy (including at least 1 other antiretroviral drug that the patient has never previously been exposed to) for treatment failure; and 3 Either: 3.1 Patient has evidence of HIV replication, despite ongoing therapy; or 3.2 Patient has treatment-limiting toxicity to previous antiretroviral agents; and 4 Previous treatment with 3 different antiretroviral regimens has failed; and 5 All of the following: 5.1 Previous treatment with a non-nucleoside reverse transcriptase inhibitor has failed; and 5.2 Previous treatment with a nucleoside reverse transcriptase inhibitor has failed; and 5.3 Previous treatment with a protease inhibitor has failed. Continuation Patient has had at least a 10-fold reduction in viral load at 12 months

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Non-Nucleoside Reverse Transcriptase Inhibitors

°Restricted Confirmed HIV Both: 1 Confirmed HIV infection; and 2 Any of the following: 2.1 Symptomatic patient; or 2.2 Patient aged 12 months and under; or 2.3 Both: 2.3.1 Patient aged 1 to 5 years; and 2.3.2 Any of the following: 2.3.2.1 CD4 counts < 1000 cells/mm3 ; or 2.3.2.2 CD4 counts < 0.25 × total lymphocyte count; or 2.3.2.3 Viral load counts > 100000 copies per ml; or 2.4 Both: 2.4.1 Patient aged 6 years and over; and 2.4.2 CD4 counts < 500 cells/mm3 Prevention of maternal transmission Either: 1 Prevention of maternal foetal transmission; or 2 Treatment of the newborn for up to eight weeks. Post-exposure prophylaxis following non-occupational exposure to HIV Both: 1 Treatment course to be initiated within 72 hours post exposure; and 2 Any of the following: 2.1 Patient has had unprotected receptive anal intercourse with a known HIV positive person; or 2.2 Patient has shared intravenous injecting equipment with a known HIV positive person; or 2.3 Patient has had non-consensual intercourse and the clinician considers that the risk assessment indicates prophylaxis is required. Percutaneous exposure Patient has percutaneous exposure to blood known to be HIV positive. EFAVIRENZ – Restricted see terms above Tab 50 mg .....................................................................................................158.33 30 Stocrin Tab 200 mg ...................................................................................................474.99 90 Stocrin Tab 600 mg ...................................................................................................474.99 30 Stocrin Oral liq 30 mg per ml ETRAVIRINE – Restricted see terms above Tab 200 mg ...................................................................................................770.00 NEVIRAPINE – Restricted see terms above Tab 200 mg – 1% DV Jan-13 to 2015............................................................95.94 Oral suspension 10 mg per ml ......................................................................134.55 60 60 240 ml Intelence Nevirapine Alphapharm Viramune Suspension

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Nucleoside Reverse Transcriptase Inhibitors

°Restricted Confirmed HIV Both: 1 Confirmed HIV infection; and 2 Any of the following: continued. . .

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continued. . . 2.1 Symptomatic patient; or 2.2 Patient aged 12 months and under; or 2.3 Both: 2.3.1 Patient aged 1 to 5 years; and 2.3.2 Any of the following: 2.3.2.1 CD4 counts < 1000 cells/mm3 ; or 2.3.2.2 CD4 counts < 0.25 × total lymphocyte count; or 2.3.2.3 Viral load counts > 100000 copies per ml; or 2.4 Both: 2.4.1 Patient aged 6 years and over; and 2.4.2 CD4 counts < 500 cells/mm3 Prevention of maternal transmission Either: 1 Prevention of maternal foetal transmission; or 2 Treatment of the newborn for up to eight weeks. Post-exposure prophylaxis following non-occupational exposure to HIV Both: 1 Treatment course to be initiated within 72 hours post exposure; and 2 Any of the following: 2.1 Patient has had unprotected receptive anal intercourse with a known HIV positive person; or 2.2 Patient has shared intravenous injecting equipment with a known HIV positive person; or 2.3 Patient has had non-consensual intercourse and the clinician considers that the risk assessment indicates prophylaxis is required. Percutaneous exposure Patient has percutaneous exposure to blood known to be HIV positive. ABACAVIR SULPHATE – Restricted see terms on the preceding page Tab 300 mg – 1% DV Jul-11 to 2014 ...........................................................229.00 60 Ziagen Oral liq 20 mg per ml – 1% DV Jul-11 to 2014 ..............................................50.00 240 ml Ziagen ABACAVIR SULPHATE WITH LAMIVUDINE – Restricted see terms on the preceding page Tab 600 mg with lamivudine 300 mg ............................................................630.00 30 DIDANOSINE [DDI] – Restricted see terms on the preceding page Cap 125 mg Cap 200 mg Cap 250 mg Cap 400 mg EFAVIRENZ WITH EMTRICITABINE AND TENOFOVIR DISOPROXIL FUMARATE – Restricted see terms on the preceding page Tab 600 mg with emtricitabine 200 mg and tenofovir disoproxil fumarate 300 mg ................................................................................... 1,313.19 30 Atripla EMTRICITABINE – Restricted see terms on the preceding page Cap 200 mg ..................................................................................................307.20 30 Emtriva Kivexa

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EMTRICITABINE WITH TENOFOVIR DISOPROXIL FUMARATE – Restricted see terms on the preceding page Tab 200 mg with tenofovir disoproxil fumarate 300 mg ................................838.20 30 Truvada LAMIVUDINE – Restricted see terms on the preceding page Tab 150 mg Oral liq 10 mg per ml

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78

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STAVUDINE – Restricted see terms on page 77 Cap 30 mg Cap 40 mg Powder for oral soln 1 mg per ml ZIDOVUDINE [AZT] – Restricted see terms on page 77 Cap 100 mg – 1% DV Oct-13 to 2016 .........................................................152.25 Oral liq 10 mg per ml – 1% DV Oct-13 to 2016..............................................30.45 Inj 10 mg per ml, 20 ml vial ZIDOVUDINE [AZT] WITH LAMIVUDINE – Restricted see terms on page 77 Tab 300 mg with lamivudine 150 mg – 1% DV Dec-12 to 2014.....................63.50 100 200 ml Retrovir Retrovir

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60

Alphapharm

Protease Inhibitors

°Restricted Confirmed HIV Both: 1 Confirmed HIV infection; and 2 Any of the following: 2.1 Symptomatic patient; or 2.2 Patient aged 12 months and under; or 2.3 Both: 2.3.1 Patient aged 1 to 5 years; and 2.3.2 Any of the following: 2.3.2.1 CD4 counts < 1000 cells/mm3 ; or 2.3.2.2 CD4 counts < 0.25 × total lymphocyte count; or 2.3.2.3 Viral load counts > 100000 copies per ml; or 2.4 Both: 2.4.1 Patient aged 6 years and over; and 2.4.2 CD4 counts < 500 cells/mm3 Prevention of maternal transmission Either: 1 Prevention of maternal foetal transmission; or 2 Treatment of the newborn for up to eight weeks. Post-exposure prophylaxis following non-occupational exposure to HIV Both: 1 Treatment course to be initiated within 72 hours post exposure; and 2 Any of the following: 2.1 Patient has had unprotected receptive anal intercourse with a known HIV positive person; or 2.2 Patient has shared intravenous injecting equipment with a known HIV positive person; or 2.3 Patient has had non-consensual intercourse and the clinician considers that the risk assessment indicates prophylaxis is required. Percutaneous exposure Patient has percutaneous exposure to blood known to be HIV positive. ATAZANAVIR SULPHATE – Restricted see terms above Cap 150 mg ..................................................................................................568.34 60 Reyataz Cap 200 mg ..................................................................................................757.79 60 Reyataz DARUNAVIR – Restricted see terms above Tab 400 mg ...................................................................................................837.50 Tab 600 mg ................................................................................................1,190.00 60 60 Prezista Prezista

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INDINAVIR – Restricted see terms on the preceding page Cap 200 mg Cap 400 mg LOPINAVIR WITH RITONAVIR – Restricted see terms on the preceding page Tab 100 mg with ritonavir 25 mg ...................................................................183.75 Tab 200 mg with ritonavir 50 mg ...................................................................735.00 Oral liq 80 mg with ritonavir 20 mg per ml ....................................................735.00 RITONAVIR – Restricted see terms on the preceding page Tab 100 mg – 1% DV Oct-12 to 2015 ............................................................43.31 Oral liq 80 mg per ml 60 120 300 ml 30 Kaletra Kaletra Kaletra Norvir

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Strand Transfer Inhibitors

°Restricted Confirmed HIV Both: 1 Confirmed HIV infection; and 2 Any of the following: 2.1 Symptomatic patient; or 2.2 Patient aged 12 months and under; or 2.3 Both: 2.3.1 Patient aged 1 to 5 years; and 2.3.2 Any of the following: 2.3.2.1 CD4 counts < 1000 cells/mm3 ; or 2.3.2.2 CD4 counts < 0.25 × total lymphocyte count; or 2.3.2.3 Viral load counts > 100000 copies per ml; or 2.4 Both: 2.4.1 Patient aged 6 years and over; and 2.4.2 CD4 counts < 500 cells/mm3 Prevention of maternal transmission Either: 1 Prevention of maternal foetal transmission; or 2 Treatment of the newborn for up to eight weeks. Post-exposure prophylaxis following non-occupational exposure to HIV Both: 1 Treatment course to be initiated within 72 hours post exposure; and 2 Any of the following: 2.1 Patient has had unprotected receptive anal intercourse with a known HIV positive person; or 2.2 Patient has shared intravenous injecting equipment with a known HIV positive person; or 2.3 Patient has had non-consensual intercourse and the clinician considers that the risk assessment indicates prophylaxis is required. Percutaneous exposure Patient has percutaneous exposure to blood known to be HIV positive. RALTEGRAVIR POTASSIUM – Restricted see terms above Tab 400 mg ................................................................................................1,090.00 60 Isentress

Antivirals Hepatitis B

ADEFOVIR DIPIVOXIL – Restricted see terms on the next page Tab 10 mg .....................................................................................................670.00 30 Hepsera

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80

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¯Restricted Gastroenterologist or infectious disease physician All of the following: 1 Patient has confirmed Hepatitis B infection (HBsAg+); and Documented resistance to lamivudine, defined as: 1 Patient has raised serum ALT (> 1 × ULN); and 2 Patient has HBV DNA greater than 100,000 copies per mL, or viral load ≥ 10-fold over nadir; and 3 Detection of M204I or M204V mutation; and 4 Either: 4.1 Both: 4.1.1 Patient is cirrhotic; and 4.1.2 Adefovir dipivoxil to be used in combination with lamivudine; or 4.2 Both: 4.2.1 Patient is not cirrhotic; and 4.2.2 Adefovir dipivoxil to be used as monotherapy. ENTECAVIR – Restricted see terms below Tab 0.5 mg ....................................................................................................400.00 30 Baraclude ¯Restricted Gastroenterologist or infectious disease physician All of the following: 1 Patient has confirmed Hepatitis B infection (HBsAg positive for more than 6 months); and 2 Patient is Hepatitis B nucleoside analogue treatment-naive; and 3 Entecavir dose 0.5 mg/day; and 4 Either: 4.1 ALT greater than upper limit of normal; or 4.2 Bridging fibrosis or cirrhosis (Metavir stage 3 or greater or moderate fibrosis) on liver histology; and 5 Either: 5.1 HBeAg positive; or 5.2 Patient has ≥ 2,000 IU HBV DNA units per ml and fibrosis (Metavir stage 2 or greater) on liver histology; and 6 No continuing alcohol abuse or intravenous drug use; and 7 Not co-infected with HCV, HIV or HDV; and 8 Neither ALT nor AST greater than 10 times upper limit of normal; and 9 No history of hypersensitivity to entecavir; and 10 No previous documented lamivudine resistance (either clinical or genotypic). LAMIVUDINE – Restricted see terms below Tab 100 mg – 1% DV Dec-12 to 2014 ...........................................................32.50 28 Zetlam Oral liq 5 mg per ml ¯Restricted Gastroenterologist, infectious disease specialist, paediatrician or general physician Initiation Re-assessment required after 12 months Any of the following: 1 HBV DNA positive cirrhosis prior to liver transplantation; or 2 HBsAg positive and have had a liver, kidney, heart, lung or bone marrow transplant; or 3 Hepatitis B virus naive patient who has received a liver transplant from an anti-HBc (Hepatitis B core antibody) positive donor; or 4 Hepatitis B surface antigen positive (HbsAg) patient who is receiving chemotherapy for a malignancy, or who has received such treatment within the previous two months; and 5 Hepatitis B surface antigen positive patient who is receiving anti tumour necrosis factor treatment; or continued. . .

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continued. . . 6 Hepatitis B core antibody (anti-HBc) positive patient who is receiving rituximab plus high dose steroids (e.g. R-CHOP). Continuation - patients who have maintained continuous treatment and response to lamivudine Re-assessment required after 2 years All of the following: 1 Have maintained continuous treatment with lamivudine; and 2 Most recent test result shows continuing biochemical response (normal ALT); and 3 HBV DNA <100,00 copies per ml by quantitative PCR at a reference laboratory; or Continuation - when given in combination with adefovir dipivoxil for patients with cirrhosis and resistance to lamivudine Re-assessment required after 2 years All of the following: 1 Lamivudine to be used in combination with adefovir dipivoxil; and 2 Patient is cirrhotic; and Documented resistance to lamivudine, defined as: 1 Patient has raised serum ALT (> 1 × ULN); and 2 Patient has HBV DNA greater than 100,000 copies per mL, or viral load ≥ 10-fold over nadir; and 3 Detection of M204I or M204V mutation; or Continuation - when given in combination with adefovir dipivoxil for patients with resistance to adefovir dipivoxil Re-assessment required after 2 years All of the following: 1 Lamivudine to be used in combination with adefovir dipivoxil; and Documented resistance to adefovir, defined as: 1 Patient has raised serum ALT (> 1 × ULN); and 2 Patient has HBV DNA greater than 100,000 copies per mL, or viral load ≥ 10-fold over nadir; and 3 Detection of N236T or A181T/V mutation. TENOFOVIR DISOPROXIL FUMARATE – Restricted see terms below Tab 300 mg ...................................................................................................531.00 30 Viread ¯Restricted Confirmed hepatitis B Either: 1 All of the following: 1.1 Patient has confirmed Hepatitis B infection (HBsAg positive for more than 6 months); and 1.2 Patient has had previous lamivudine, adefovir or entecavir therapy; and 1.3 HBV DNA greater than 20,000 IU/mL or increased ≤ 10-fold over nadir; and 1.4 Any of the following: 1.4.1 Lamivudine resistance - detection of M204I/V mutation; or 1.4.2 Adefovir resistance - detection of A181T/V or N236T mutation; or 1.4.3 Entecavir resistance - detection of relevant mutations including I169T, L180M T184S/A/I/L/G/C/M, S202C/G/I,M204V or M250I/V mutation; or 2 Patient is either listed or has undergone liver transplantation for HBV; or 3 Patient has a decompensated cirrhosis with a Mayo score > 20. Pregnant or Breastfeeding, Active hepatitis B Limited to twelve months’ treatment Both: 1 Patient is HBsAg positive and pregnant; and 2 HBV DNA > 20,000 IU/mL and ALT > ULN. Pregnant, prevention of vertical transmission Limited to six months’ treatment Both: continued. . .

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continued. . . 1 Patient is HBsAg positive and pregnant; and 2 HBV DNA > 20 million IU/mL and ALT normal. Confirmed HIV Both: 1 Confirmed HIV infection; and 2 Any of the following: 2.1 Symptomatic patient; or 2.2 Patient aged 12 months and under; or 2.3 Both: 2.3.1 Patient aged 1 to 5 years; and 2.3.2 Any of the following: 2.3.2.1 CD4 counts < 1000 cells/mm3 ; or 2.3.2.2 CD4 counts < 0.25 × total lymphocyte count; or 2.3.2.3 Viral load counts > 100000 copies per ml; or 2.4 Both: 2.4.1 Patient aged 6 years and over; and 2.4.2 CD4 counts < 500 cells/mm3 Prevention of maternal transmission Either: 1 Prevention of maternal foetal transmission; or 2 Treatment of the newborn for up to eight weeks. Post-exposure prophylaxis following non-occupational exposure to HIV Both: 1 Treatment course to be initiated within 72 hours post exposure; and 2 Any of the following: 2.1 Patient has had unprotected receptive anal intercourse with a known HIV positive person; or 2.2 Patient has shared intravenous injecting equipment with a known HIV positive person; or 2.3 Patient has had non-consensual intercourse and the clinician considers that the risk assessment indicates prophylaxis is required. Percutaneous exposure Patient has percutaneous exposure to blood known to be HIV positive.

Hepatitis C

BOCEPREVIR – Restricted see terms below Cap 200 mg ...............................................................................................5,015.00 ¯ 336 Victrelis

¯Restricted Chronic hepatitis C - genotype 1, first-line from gastroenterologist, infectious disease physician or general physician All of the following: 1 Patient has chronic hepatitis C, genotype 1; and 2 Patient has not received prior pegylated interferon treatment; and 3 Patient has IL-28B genotype CT or TT; and 4 Patient is to be treated in combination with pegylated interferon and ribavirin; and 5 Patient is hepatitis C protease inhibitor treatment-naive; and 6 Maximum of 44 weeks therapy. Chronic hepatitis C - genotype 1, second-line from gastroenterologist, infectious disease physician or general physician. All of the following: 1 Patient has chronic hepatitis C, genotype 1; and 2 Patient has received pegylated interferon treatment; and continued. . .

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continued. . . 3 Any one of: 3.1 Patient was a responder relapser; or 3.2 Patient was a partial responder; or 3.3 Patient received pegylated interferon prior to 2004; and 4 Patient is to be treated in combination with pegylated interferon and ribavirin; and 5 Maximum of 44 weeks therapy. Note: Due to risk of severe sepsis boceprevir should not be initiated if either Platelet count <100 x109 /l or Albumin <35 g/l.

Herpesviridae

ACICLOVIR Tab dispersible 200 mg – 1% DV Sep-13 to 2016 ...........................................1.78 Tab dispersible 400 mg – 1% DV Sep-13 to 2016 ...........................................5.98 Tab dispersible 800 mg – 1% DV Sep-13 to 2016 ...........................................6.64 Inj 250 mg vial – 1% DV Mar-13 to 2015 .......................................................14.09 ¯ ¯ ¯ ¯ 25 56 35 5 Lovir Lovir Lovir Zovirax IV

CIDOFOVIR – Restricted see terms below Inj 75 mg per ml, 5 ml vial ¯Restricted Infectious disease physician, clinical microbiologist, otolaryngologist or oral surgeon FOSCARNET SODIUM – Restricted see terms below Inj 24 mg per ml, 250 ml bottle ¯Restricted Infectious disease physician or clinical microbiologist GANCICLOVIR – Restricted see terms below Inj 500 mg vial ..............................................................................................380.00 5 Cymevene ¯Restricted Infectious disease physician or clinical microbiologist VALACICLOVIR – Restricted see terms below Tab 500 mg ...................................................................................................102.72 30 Valtrex ¯Restricted Any of the following: 1 Patient has genital herpes with 2 or more breakthrough episodes in any 6 month period while treated with aciclovir 400 mg twice daily. 2 Patient has previous history of ophthalmic zoster and the patient is at risk of vision impairment. 3 Patient has undergone organ transplantation. Immunocompromised patients Limited to 7 days treatment Both: 1 Patient is immunocompromised; and 2 Patient has herpes zoster. VALGANCICLOVIR – Restricted see terms on the next page Tab 450 mg ................................................................................................3,000.00 60 Valcyte

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¯Restricted Transplant cytomegalovirus prophylaxis Limited to three months’ treatment Patient has undergone a solid organ transplant and requires valganciclovir for CMV prophylaxis. Lung transplant cytomegalovirus prophylaxis Limited to six months’ treatment Both: 1 Patient has undergone a lung transplant; and 2 Either: 2.1 The donor was cytomegalovirus positive and the patient is cytomegalovirus negative; or 2.2 The recipient is cytomegalovirus positive. Cytomegalovirus in immunocompromised patients Both: 1 Patient is immunocompromised; and 2 Any of the following: 2.1 Patient has cytomegalovirus syndrome or tissue invasive disease; or 2.2 Patient has rapidly rising plasma CMV DNA in absence of disease; or 2.3 Patient has cytomegalovirus retinitis.

Influenza

OSELTAMIVIR – Restricted see terms below Tab 75 mg Powder for oral suspension 6 mg per ml ¯Restricted Either: 1 Only for hospitalised patient with known or suspected influenza; or 2 For prophylaxis of influenza in hospitalised patients as part of a DHB hospital approved infections control plan. ZANAMIVIR Powder for inhalation 5 mg .............................................................................37.38 20 dose Relenza Rotadisk ¯Restricted Either: 1 Only for hospitalised patient with known or suspected influenza; or 2 For prophylaxis of influenza in hospitalised patients as part of a DHB hospital approved infections control plan. ¯¯

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Immune Modulators

INTERFERON ALFA-2A Inj 3 m iu prefilled syringe Inj 6 m iu prefilled syringe Inj 9 m iu prefilled syringe INTERFERON ALFA-2B Inj 18 m iu, 1.2 ml multidose pen Inj 30 m iu, 1.2 ml multidose pen Inj 60 m iu, 1.2 ml multidose pen INTERFERON GAMMA – Restricted see terms below Inj 100 mcg in 0.5 ml vial ¯Restricted Patient has chronic granulomatous disease and requires interferon gamma.

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PEGYLATED INTERFERON ALFA-2A – Restricted see terms below Inj 135 mcg prefilled syringe Inj 135 mcg prefilled syringe (4) with ribavirin tab 200 mg (112) Inj 135 mcg prefilled syringe (4) with ribavirin tab 200 mg (168) Inj 180 mcg prefilled syringe .........................................................................900.00 Inj 180 mcg prefilled syringe (4) with ribavirin tab 200 mg (112) ...............1,159.84 Inj 180 mcg prefilled syringe (4) with ribavirin tab 200 mg (168) ...............1,290.00

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4 1 1

Pegasys Pegasus RBV Combination Pack Pegasus RBV Combination Pack

¯Restricted Initiation – Chronic hepatitis C - genotype 1, 4, 5 or 6 infection or co-infection with HIV or genotype 2 or 3 post liver transplant Both: 1 Any of the following: 1.1 Patient has chronic hepatitis C, genotype 1, 4, 5 or 6 infection; or 1.2 Patient has chronic hepatitis C and is co-infected with HIV; or 1.3 Patient has chronic hepatitis C genotype 2 or 3 and has received a liver transplant. 2 Maximum of 48 weeks therapy. Notes: Consider stopping treatment if there is absence of a virological response (defined as at least a 2-log reduction in viral load) following 12 weeks of treatment since this is predictive of treatment failure. Consider reducing treatment to 24 weeks if serum HCV RNA level at Week 4 is undetectable by sensitive PCR assay (less than 50IU/ml) AND Baseline serum HCV RNA is less than 400,000IU/ml. Continuation – (Chronic hepatitis C - genotype 1 infection) - gastroenterologist, infectious disease physician or general physician All of the following: 1 Patient has chronic hepatitis C, genotype 1; and 2 Patient has had previous treatment with pegylated interferon and ribavirin; and 3 Either: 3.1 Patient has responder relapsed; or 3.2 Patient was a partial responder; and 4 Patient is to be treated in combination with boceprevir; and 5 Maximum of 48 weeks therapy. Initiation (Chronic Hepatitis C - genotype 1 infection treatment more than 4 years prior) - Gastroenterologist, infectious disease physician or general physician All of the following: 1 Patient has chronic hepatitis C, genotype 1; and 2 Patient has had previous treatment with pegylated interferon and ribavirin; and 3 Any of the following: 3.1 Patient has responder relapsed; or 3.2 Patient was a partial responder; or 3.3 Patient received interferon treatment prior to 2004; and 4 Patient is to be treated in combination with boceprevir; and 5 Maximum of 48 weeks therapy. Initiation – Chronic hepatitis C - genotype 2 or 3 infection without co-infection with HIV Both: 1 Patient has chronic hepatitis C, genotype 2 or 3 infection; and 2 Maximum of 6 months therapy. Initiation – Hepatitis B continued. . .

86

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INFECTIONS - AGENTS FOR SYSTEMIC USE

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continued. . . Gastroenterologist, infectious disease specialist or general physician All of the following: 1 Patient has confirmed Hepatitis B infection (HBsAg positive for more than 6 months); and 2 Patient is Hepatitis B treatment-naive; and 3 ALT > 2 times Upper Limit of Normal; and 4 HBV DNA < 10 log10 IU/ml; and 5 Either: 5.1 HBeAg positive; or 5.2 Serum HBV DNA ≥ 2,000 units/ml and significant fibrosis (≥ Metavir Stage F2 or moderate fibrosis); and 6 Compensated liver disease; and 7 No continuing alcohol abuse or intravenous drug use; and 8 Not co-infected with HCV, HIV or HDV; and 9 Neither ALT nor AST > 10 times upper limit of normal; and 10 No history of hypersensitivity or contraindications to pegylated interferon; and 11 Maximum of 48 weeks therapy. Notes: Approved dose is 180 mcg once weekly. The recommended dose of Pegylated Interferon alfa-2a is 180 mcg once weekly. In patients with renal insufficiency (calculated creatinine clearance less than 50ml/min), Pegylated Interferon alfa-2a dose should be reduced to 135 mcg once weekly. In patients with neutropaenia and thrombocytopaenia, dose should be reduced in accordance with the datasheet guidelines. Pegylated Interferon alfa-2a is not approved for use in children.

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Anticholinesterases

EDROPHONIUM CHLORIDE – Restricted see terms below Inj 10 mg per ml, 15 ml vial Inj 10 mg per ml, 1 ml ampoule ¯Restricted For the diagnosis of myasthenia gravis NEOSTIGMINE METILSULFATE Inj 2.5 mg per ml, 1 ml ampoule – 1% DV Sep-11 to 2014..........................140.00 ¯¯ ¯

50

AstraZeneca

NEOSTIGMINE METILSULFATE WITH GLYCOPYRRONIUM BROMIDE Inj 2.5 mg with glycopyrronium bromide 0.5 mg per ml, 1 ml ampoule – 1% DV Nov-13 to 2016 ......................................................................... 27.86 PYRIDOSTIGMINE BROMIDE Tab 60 mg – 1% DV Sep-11 to 2014 .............................................................38.90

10 100

Max Health Mestinon

Antirheumatoid Agents

AURANOFIN Tab 3 mg HYDROXYCHLOROQUINE Tab 200 mg – 1% DV Nov-12 to 2015 ...........................................................18.00 LEFLUNOMIDE Tab 10 mg .......................................................................................................55.00 Tab 20 mg .......................................................................................................76.00 Tab 100 mg .....................................................................................................54.44 PENICILLAMINE Tab 125 mg .....................................................................................................61.93 Tab 250 mg .....................................................................................................98.98 SODIUM AUROTHIOMALATE Inj 10 mg in 0.5 ml ampoule Inj 20 mg in 0.5 ml ampoule Inj 50 mg in 0.5 ml ampoule 100 30 30 3 100 100 Plaquenil Arava Arava Arava D-Penamine D-Penamine

Drugs Affecting Bone Metabolism Bisphosphonates

ALENDRONATE SODIUM Tab 40 mg .....................................................................................................133.00 30 Fosamax ¯Restricted Both: 1 Paget’s disease; and 2 Any of the following: 2.1 Bone or articular pain; or 2.2 Bone deformity; or 2.3 Bone, articular or neurological complications; or 2.4 Asymptomatic disease, but risk of complications due to site (base of skull, spine, long bones of lower limbs); or 2.5 Preparation for orthopaedic surgery. Tab 70 mg .......................................................................................................22.90 4 Fosamax

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MUSCULOSKELETAL SYSTEM

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¯Restricted Osteoporosis Any of the following: 1 History of one significant osteoporotic fracture demonstrated radiologically and documented bone mineral density (BMD) ≥ 2.5 standard deviations below the mean normal value in young adults (i.e. T-Score ≤ -2.5) (see Note); or 2 History of one significant osteoporotic fracture demonstrated radiologically, and either the patient is elderly, or densitometry scanning cannot be performed because of major logistical, technical or pathophysiological reasons. It is unlikely that this provision would apply to many patients under 75 years of age; or 3 History of two significant osteoporotic fractures demonstrated radiologically; or 4 Documented T-Score ≤ -3.0 (see Note); or 5 A 10-year risk of hip fracture ≥ 3%, calculated using a published risk assessment algorithm (e.g. FRAX or Garvan) which incorporates BMD measurements (see Note); or 6 Patient has had a Special Authority approval for zoledronic acid (osteoporosis) or raloxifene. Initiation - glucocorticosteroid therapy Re-assessment required after 12 months Both: 1 The patient is receiving systemic glucocorticosteroid therapy (≥ 5 mg per day prednisone equivalents) and has already received or is expected to receive therapy for at least three months; and 2 Any of the following: 2.1 The patient has documented BMD ≥ 1.5 standard deviations below the mean normal value in young adults (i.e. T-Score ≤ -1.5) (see Note); or 2.2 The patient has a history of one significant osteoporotic fracture demonstrated radiologically; or 2.3 The patient has had a Special Authority approval for zoledronic acid (glucocorticosteroid therapy) or raloxifene. Continuation - glucocorticosteroid therapy Re-assessment required after 12 months The patient is continuing systemic glucocorticosteriod therapy (≥ 5 mg per day prednisone equivalents) Notes: 1 BMD (including BMD used to derive T-Score) must be measured using dual-energy x-ray absorptiometry (DXA). Quantitative ultrasound and quantitative computed tomography (QCT) are not acceptable. 2 Evidence suggests that patients aged 75 years and over who have a history of significant osteoporotic fracture demonstrated radiologically are very likely to have a T-Score ≤ -2.5 and, therefore, do not require BMD measurement for treatment with bisphosphonates. 3 Osteoporotic fractures are the incident events for severe (established) osteoporosis, and can be defined using the WHO definitions of osteoporosis and fragility fracture. The WHO defines severe (established) osteoporosis as a T-score below -2.5 with one or more associated fragility fractures. Fragility fractures are fractures that occur as a result of mechanical forces that would not ordinarily cause fracture (minimal trauma). The WHO has quantified this as forces equivalent to a fall from a standing height or less. 4 A vertebral fracture is defined as a 20% or greater reduction in height of the anterior or mid portion of a vertebral body relative to the posterior height of that body, or a 20% or greater reduction in any of these heights compared to the vertebral body above or below the affected vertebral body. ALENDRONATE SODIUM WITH CHOLECALCIFEROL – Restricted see terms below Tab 70 mg with cholecalciferol 5,600 iu ..........................................................22.90 4 Fosamax Plus ¯Restricted Osteoporosis Any of the following: 1 History of one significant osteoporotic fracture demonstrated radiologically and documented bone mineral density (BMD) ≥ 2.5 standard deviations below the mean normal value in young adults (i.e. T-Score ≤ -2.5) (see Note); or 2 History of one significant osteoporotic fracture demonstrated radiologically, and either the patient is elderly, or densitometry scanning cannot be performed because of major logistical, technical or pathophysiological reasons. It is unlikely that this provision would apply to many patients under 75 years of age; or continued. . .

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continued. . . 3 History of two significant osteoporotic fractures demonstrated radiologically; or 4 Documented T-Score ≤ -3.0 (see Note); or 5 A 10-year risk of hip fracture ≥ 3%, calculated using a published risk assessment algorithm (e.g. FRAX or Garvan) which incorporates BMD measurements (see Note); or 6 Patient has had a Special Authority approval for zoledronic acid (osteoporosis) or raloxifene. Initiation - glucocorticosteroid therapy Re-assessment required after 12 months Both: 1 The patient is receiving systemic glucocorticosteroid therapy (≥ 5 mg per day prednisone equivalents) and has already received or is expected to receive therapy for at least three months; and 2 Any of the following: 2.1 The patient has documented BMD ≥ 1.5 standard deviations below the mean normal value in young adults (i.e. T-Score ≤ -1.5) (see Note); or 2.2 The patient has a history of one significant osteoporotic fracture demonstrated radiologically; or 2.3 The patient has had a Special Authority approval for zoledronic acid (glucocorticosteroid therapy) or raloxifene. Continuation - glucocorticosteroid therapy Re-assessment required after 12 months The patient is continuing systemic glucocorticosteriod therapy (≥ 5 mg per day prednisone equivalents) Notes: 1 BMD (including BMD used to derive T-Score) must be measured using dual-energy x-ray absorptiometry (DXA). Quantitative ultrasound and quantitative computed tomography (QCT) are not acceptable. 2 Evidence suggests that patients aged 75 years and over who have a history of significant osteoporotic fracture demonstrated radiologically are very likely to have a T-Score ≥ -2.5 and, therefore, do not require BMD measurement for treatment with bisphosphonates. 3 Osteoporotic fractures are the incident events for severe (established) osteoporosis, and can be defined using the WHO definitions of osteoporosis and fragility fracture. The WHO defines severe (established) osteoporosis as a T-score below -2.5 with one or more associated fragility fractures. Fragility fractures are fractures that occur as a result of mechanical forces that would not ordinarily cause fracture (minimal trauma). The WHO has quantified this as forces equivalent to a fall from a standing height or less. 4 A vertebral fracture is defined as a 20% or greater reduction in height of the anterior or mid portion of a vertebral body relative to the posterior height of that body, or a 20% or greater reduction in any of these heights compared to the vertebral body above or below the affected vertebral body. ETIDRONATE DISODIUM Tab 200 mg – 1% DV Sep-12 to 2015 ...........................................................15.80 100 Arrow-Etidronate PAMIDRONATE DISODIUM Inj 3 mg per ml, 5 ml vial .................................................................................18.75 Inj 3 mg per ml, 10 ml vial – 1% DV Feb-13 to 2014 .....................................16.00 Inj 6 mg per ml, 10 ml vial – 1% DV Feb-13 to 2014 .....................................32.00 Inj 9 mg per ml, 10 ml vial – 1% DV Feb-13 to 2014 .....................................48.00 ZOLEDRONIC ACID – Restricted see terms on the next page Inj 0.05 mg per ml, 100 ml vial ......................................................................600.00 ¯ 1 1 1 1 100 ml Pamisol Pamidronate BNM Pamidronate BNM Pamidronate BNM Aclasta

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MUSCULOSKELETAL SYSTEM

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¯Restricted Osteogenesis imperfecta Patient has been diagnosed with clinical or genetic osteogenesis imperfecta. Osteoporosis Both: 1 Any of the following: 1.1 History of one significant osteoporotic fracture demonstrated radiologically and documented bone mineral density (BMD) ≥ 2.5 standard deviations below the mean normal value in young adults (i.e. T-Score ≤ -2.5) (see Note); or 1.2 History of one significant osteoporotic fracture demonstrated radiologically, and either the patient is elderly, or densitometry scanning cannot be performed because of major logistical, technical or pathophysiological reasons. It is unlikely that this provision would apply to many patients under 75 years of age; or 1.3 History of two significant osteoporotic fractures demonstrated radiologically; or 1.4 Documented T-Score ≥ -3.0 (see Note); or 1.5 A 10-year risk of hip fracture ≥ 3%, calculated using a published risk assessment algorithm (e.g. FRAX or Garvan) which incorporates BMD measurements (see Note); or 1.6 Patient has had a Special Authority approval for alendronate (Underlying cause - Osteoporosis) or raloxifene; and 2 The patient will not be prescribed more than one infusion in a 12-month period. Initiation - glucocorticosteroid therapy Re-assessment required after 12 months All of the following: 1 The patient is receiving systemic glucocorticosteroid therapy (≥ 5 mg per day prednisone equivalents) and has already received or is expected to receive therapy for at least three months; and 2 Any of the following: 2.1 The patient has documented BMD ≥ 1.5 standard deviations below the mean normal value in young adults (i.e. T-Score ≤ -1.5) (see Note); or 2.2 The patient has a history of one significant osteoporotic fracture demonstrated radiologically; or 2.3 The patient has had a Special Authority approval for alendronate (Underlying cause - glucocorticosteroid therapy) or raloxifene; and 3 The patient will not be prescribed more than one infusion in the 12-month approval period. Continuation - glucocorticosteroid therapy Re-assessment required after 12 months Both: 1 The patient is continuing systemic glucocorticosteriod therapy (≥ 5 mg per day prednisone equivalents); and 2 The patient will not be prescribed more than one infusion in the 12-month approval period. Initiation - Paget’s disease Re-assessment required after 12 months All of the following: 1 Paget’s disease; and 2 Any of the following: 2.1 Bone or articular pain; or 2.2 Bone deformity; or 2.3 Bone, articular or neurological complications; or 2.4 Asymptomatic disease, but risk of complications; or 2.5 Preparation for orthopaedic surgery; and 3 The patient will not be prescribed more than one infusion in the 12-month approval period. Continuation - Paget’s disease Re-assessment required after 12 months Both: 1 Any of the following: 1.1 The patient has relapsed (based on increases in serum alkaline phosphatase); or continued. . .

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continued. . . 1.2 The patient’s serum alkaline phosphatase has not normalised following previous treatment with zoledronic acid; or 1.3 Symptomatic disease (prescriber determined); and 2 The patient will not be prescribed more than one infusion in the 12-month approval period. Notes: 1 BMD (including BMD used to derive T-Score) must be measured using dual-energy x-ray absorptiometry (DXA). Quantitative ultrasound and quantitative computed tomography (QCT) are not acceptable. 2 Evidence suggests that patients aged 75 years and over who have a history of significant osteoporotic fracture demonstrated radiologically are very likely to have a T-Score ≤ -2.5 and, therefore, do not require BMD measurement for treatment with bisphosphonates. 3 Osteoporotic fractures are the incident events for severe (established) osteoporosis and can be defined using the WHO definitions of osteoporosis and fragility fracture. The WHO defines severe (established) osteoporosis as a T-score below -2.5 with one or more associated fragility fractures. Fragility fractures are fractures that occur as a result of mechanical forces that would not ordinarily cause fracture (minimal trauma). The WHO has quantified this as forces equivalent to a fall from a standing height or less. 4 A vertebral fracture is defined as a 20% or greater reduction in height of the anterior or mid portion of a vertebral body relative to the posterior height of that body, or a 20% or greater reduction in any of these heights compared to the vertebral body above or below the affected vertebral body.

Other Drugs Affecting Bone Metabolism

RALOXIFENE – Restricted see terms below Tab 60 mg .......................................................................................................53.76 28 Evista ¯Restricted Any of the following: 1 History of one significant osteoporotic fracture demonstrated radiologically and documented bone mineral density (BMD) ≥ 2.5 standard deviations below the mean normal value in young adults (i.e. T-Score ≤ -2.5) (see Notes); or 2 History of one significant osteoporotic fracture demonstrated radiologically, and either the patient is elderly, or densitometry scanning cannot be performed because of major logistical, technical or pathophysiological reasons. It is unlikely that this provision would apply to many patients under 75 years of age; or 3 History of two significant osteoporotic fractures demonstrated radiologically; or 4 Documented T-Score ≥ -3.0 (see Notes); or 5 A 10-year risk of hip fracture ≥ 3%, calculated using a published risk assessment algorithm (e.g. FRAX or Garvan) which incorporates BMD measurements (see Notes); or 6 Patient has had a prior Special Authority approval for zoledronic acid (Underlying cause - Osteoporosis) or alendronate (Underlying cause - Osteoporosis). Notes: 1 BMD (including BMD used to derive T-Score) must be measured using dual-energy x-ray absorptiometry (DXA). Quantitative ultrasound and quantitative computed tomography (QCT) are not acceptable. 2 Evidence suggests that patients aged 75 years and over who have a history of significant osteoporotic fracture demonstrated radiologically are very likely to have a T-Score ≤ -2.5 and, therefore, do not require BMD measurement for raloxifene funding. 3 Osteoporotic fractures are the incident events for severe (established) osteoporosis, and can be defined using the WHO definitions of osteoporosis and fragility fracture. The WHO defines severe (established) osteoporosis as a T-score below -2.5 with one or more associated fragility fractures. Fragility fractures are fractures that occur as a result of mechanical forces that would not ordinarily cause fracture (minimal trauma). The WHO has quantified this as forces equivalent to a fall from a standing height or less. 4 A vertebral fracture is defined as a 20% or greater reduction in height of the anterior or mid portion of a vertebral body relative to the posterior height of that body, or a 20% or greater reduction in any of these heights compared to the vertebral body above or below the affected vertebral body. RISEDRONATE SODIUM Tab 35 mg .........................................................................................................4.00 4 Risedronate Sandoz ¯

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MUSCULOSKELETAL SYSTEM

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TERIPARATIDE – Restricted see terms below Inj 250 mcg per ml, 2.4 ml cartridge .............................................................490.00

¯ ¯

1

Forteo

¯Restricted Limited to 18 months’ treatment All of the following: 1 The patient has severe, established osteoporosis; and 2 The patient has a documented T-score less than or equal to -3.0 (see Notes); and 3 The patient has had two or more fractures due to minimal trauma; and 4 The patient has experienced at least one symptomatic new fracture after at least 12 months’ continuous therapy with a funded antiresorptive agent at adequate doses (see Notes). Notes: 1 The bone mineral density (BMD) measurement used to derive the T-score must be made using dual-energy x-ray absorptiometry (DXA). Quantitative ultrasound and quantitative computed tomography (QCT) are not acceptable 2 Antiresorptive agents and their adequate doses for the purposes of this Special Authority are defined as: alendronate sodium tab 70 mg or tab 70 mg with cholecalciferol 5,600 iu once weekly; raloxifene hydrochloride tab 60 mg once daily; zoledronic acid 5 mg per year. If an intolerance of a severity necessitating permanent treatment withdrawal develops during the use of one antiresorptive agent, an alternate antiresorptive agent must be trialled so that the patient achieves the minimum requirement of 12 months’ continuous therapy. 3 A vertebral fracture is defined as a 20% or greater reduction in height of the anterior or mid portion of a vertebral body relative to the posterior height of that body, or a 20% or greater reduction in any of these heights compared to the vertebral body above or below the affected vertebral body.

Enzymes

HYALURONIDASE Inj 1,500 iu ampoule

Hyperuricaemia and Antigout

ALLOPURINOL Tab 100 mg – 1% DV Dec-11 to 2014 ...........................................................15.90 Tab 300 mg – 1% DV Dec-11 to 2014 ...........................................................16.75 BENZBROMARONE – Restricted see terms below Tab 100 mg .....................................................................................................45.00 1,000 500 100 Apo-Allopurinol Apo-Allopurinol Benzbromaron AL 100

¯Restricted Both: 1 Any of the following: 1.1 The patient has a serum urate level greater than 0.36 mmol/l despite treatment with allopurinol at doses of at least 600 mg/day and appropriate doses of probenecid: or 1.2 The patient has experienced intolerable side effects from allopurinol such that treatment discontinuation is required and serum urate remains greater than 0.36 mmol/l despite appropriate doses of probenecid; or 1.3 Both: 1.3.1 The patient has renal impairment and serum urate remains greater than 0.36 mmol/l despite optimal treatment with allopurinol (see Note); and 1.3.2 The patient has a rate of creatinine clearance greater than or equal to 20 ml/min; or 1.4 All of the following: 1.4.1 The patient is taking azathioprine and requires urate-lowering therapy; and 1.4.2 Allopurinol is contraindicated; and 1.4.3 Appropriate doses of probenecid are ineffective or probenecid cannot be used due to reduced renal function; and continued. . .

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continued. . . 2 The patient is receiving monthly liver function tests. Notes: Benzbromarone has been associated with potentially fatal hepatotoxicity. Optimal treatment with allopurinol in patients with renal impairment is defined as treatment to the creatinine clearance-adjusted dose of allopurinol then, if serum urate remains greater than 0.36 mmol/l, a gradual increase of the dose of allopurinol to 600 mg or the maximum tolerated dose. The New Zealand Rheumatology Association has developed information for prescribers which can be accessed from its website at http://www.rheumatology.org.nz/benzbromarone_prescriber_information.cfm COLCHICINE Tab 500 mcg – 1% DV Oct-13 to 2016 ..........................................................10.08 PROBENECID Tab 500 mg RASBURICASE – Restricted see terms below Inj 1.5 mg vial ¯Restricted Haematologist ¯ 100 Colgout

Muscle Relaxants and Related Agents

ATRACURIUM BESYLATE Inj 10 mg per ml, 2.5 ml ampoule – 1% DV Sep-12 to 2015............................6.13 Inj 10 mg per ml, 5 ml ampoule – 1% DV Sep-12 to 2015...............................9.19 BACLOFEN Tab 10 mg – 1% DV Jun-13 to 2016................................................................3.85 Oral liq 1 mg per ml Inj 0.05 mg per ml, 1 ml ampoule – 1% DV Oct-12 to 2015 ..........................11.55 Inj 2 mg per ml, 5 ml ampoule – 1% DV Oct-12 to 2015 .............................209.29 CLOSTRIDIUM BOTULINUM TYPE A TOXIN Inj 100 u vial .................................................................................................467.50 Inj 500 u vial ..............................................................................................1,295.00 DANTROLENE Cap 25 mg ......................................................................................................65.00 Cap 50 mg ......................................................................................................77.00 Inj 20 mg vial MIVACURIUM CHLORIDE Inj 2 mg per ml, 5 ml ampoule ........................................................................33.92 Inj 2 mg per ml, 10 ml ampoule ......................................................................67.17 ORPHENADRINE CITRATE Tab 100 mg PANCURONIUM BROMIDE Inj 2 mg per ml, 2 ml ampoule – 1% DV Jan-13 to 2015 .............................260.00 ROCURONIUM BROMIDE Inj 10 mg per ml, 5 ml vial – 1% DV Sep-12 to 2015 .....................................38.25 SUXAMETHONIUM CHLORIDE Inj 50 mg per ml, 2 ml ampoule ....................................................................130.00 VECURONIUM BROMIDE Inj 4 mg ampoule Inj 10 mg vial 50 10 AstraZeneca DBL Rocuronium Bromide AstraZeneca 5 5 100 1 1 1 2 100 100 Tracrium Tracrium Pacifen Lioresal Intrathecal Lioresal Intrathecal Botox Dysport Dantrium Dantrium e.g. Dantrium IV Mivacron Mivacron

5 5

50

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MUSCULOSKELETAL SYSTEM

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Reversers of Neuromuscular Blockade

SUGAMMADEX – Restricted see terms below Inj 100 mg per ml, 2 ml vial ........................................................................1,200.00 Inj 100 mg per ml, 5 ml vial ........................................................................3,000.00 ¯¯ 10 10 Bridion Bridion

¯Restricted Any of the following: 1 Patient requires reversal of profound neuromuscular blockade following rapid sequence induction that has been undertaken using rocuronium (i.e. suxamethonium is contraindicated or undesirable); or 2 Severe neuromuscular degenerative disease where the use of neuromuscular blockade is required; or 3 Patient has an unexpectedly difficult airway that cannot be intubated and requires a rapid reversal of anaesthesia and neuromuscular blockade; or 4 The duration of the patient’s surgery is unexpectedly short; or 5 Neostigmine or a neostigmine/anticholinergic combination is contraindicated (for example the patient has ischaemic heart disease, morbid obesity or COPD); or 6 Patient has a partial residual block after conventional reversal.

Non-Steroidal Anti-Inflammatory Drugs

CELECOXIB – Restricted see terms below Cap 100 mg Cap 200 mg Cap 400 mg ¯Restricted For preoperative and/or postoperative use for a total of up to 8 days’ use. DICLOFENAC SODIUM Tab EC 25 mg – 1% DV Mar-13 to 2015..........................................................4.00 Tab 50 mg dispersible Tab EC 50 mg – 1% DV Mar-13 to 2015........................................................16.00 Tab long-acting 75 mg – 1% DV Dec-12 to 2015.............................................3.10 24.52 Tab long-acting 100 mg – 1% DV Dec-12 to 2015.........................................42.25 Inj 25 mg per ml, 3 ml ampoule – 1% DV Sep-11 to 2014.............................12.00 Suppos 12.5 mg – 1% DV Sep-11 to 2014 ......................................................1.85 Suppos 25 mg – 1% DV Sep-11 to 2014 .........................................................2.22 Suppos 50 mg – 1% DV Sep-11 to 2014 .........................................................3.84 Suppos 100 mg – 1% DV Sep-11 to 2014 .......................................................6.36 ETORICOXIB – Restricted see terms below Tab 30 mg Tab 60 mg Tab 90 mg Tab 120 mg ¯Restricted For preoperative and/or postoperative use for a total of up to 8 days’ use. IBUPROFEN Tab 200 mg ¬ Tab 400 mg – Restricted: For continuation only ¬ Tab 600 mg – Restricted: For continuation only Tab long-acting 800 mg – 1% DV Oct-11 to 2014 ...........................................8.12 Oral liq 20 mg per ml – 1% DV Mar-14 to 2016 ...............................................1.89 Inj 5 mg per ml, 2 ml ampoule ¯¯¯ ¯¯¯¯

100 500 30 500 500 5 10 10 10 10

Apo-Diclo Apo-Diclo Diclax SR Diclax SR Diclax SR Voltaren Voltaren Voltaren Voltaren Voltaren

30 200 ml

Brufen SR Fenpaed

Products with Hospital Supply Status (HSS) are in bold Expiry date of HSS period is 30 June of the year indicated unless otherwise stated.

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MUSCULOSKELETAL SYSTEM

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INDOMETHACIN Cap 25 mg Cap 50 mg Cap long-acting 75 mg Inj 1 mg vial Suppos 100 mg KETOPROFEN Cap long-acting 100 mg ................................................................................21.56 Cap long-acting 200 mg .................................................................................12.07 (Oruvail SR Cap long-acting 100 mg to be delisted 1 September 2014) MEFENAMIC ACID – Restricted: For continuation only ¬ Cap 250 mg MELOXICAM – Restricted see terms below Tab 7.5 mg ¯Restricted Either: 1 Haemophilic arthropathy, with both of the following: 1.1 The patient has moderate to severe haemophilia with less than or equal to 5% of normal circulating functional clotting factor; and 1.2 Pain and inflammation associated with haemophilic arthropathy is inadequately controlled by alternative funded treatment options, or alternative funded treatment options are contraindicated; or 2 For preoperative and/or postoperative use for a total of up to 8 days’ use. NAPROXEN Tab 250 mg – 1% DV Jan-13 to 2015............................................................21.25 500 Noflam 250 Tab 500 mg – 1% DV Jan-13 to 2015............................................................22.25 250 Noflam 500 Tab long-acting 750 mg Tab long-acting 1 g PARECOXIB Inj 40 mg vial ................................................................................................100.00 SULINDAC – Restricted: For continuation only ¬ Tab 100 mg ¬ Tab 200 mg TENOXICAM Tab 20 mg Inj 20 mg vial ....................................................................................................9.95 TIAPROFENIC ACID Tab 300 mg .....................................................................................................19.26 10 Dynastat ¯ 100 28 Oruvail SR Oruvail SR

1 60

AFT Surgam

Topical Products for Joint and Muscular Pain

CAPSAICIN – Restricted see terms below Crm 0.025% .....................................................................................................9.95 45 g Zostrix ¯Restricted Patient has osteoarthritis that is not responsive to paracetamol and oral non-steroidal anti-inflammatories are contraindicated. ¯

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NERVOUS SYSTEM

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Agents for Parkinsonism and Related Disorders Agents for Essential Tremor, Chorea and Related Disorders

RILUZOLE – Restricted see terms below Tab 50 mg .....................................................................................................400.00 56 Rilutek ¯Restricted Initiation Neurologist or respiratory specialist Re-assessment required after 6 months All of the following: 1 The patient has amyotrophic lateral sclerosis with disease duration of 5 years or less; and 2 The patient has at least 60 percent of predicted forced vital capacity within 2 months prior to the initial application; and 3 The patient has not undergone a tracheostomy; and 4 The patient has not experienced respiratory failure; and 5 Any of the following: 5.1 The patient is ambulatory; or 5.2 The patient is able to use upper limbs; or 5.3 The patient is able to swallow. Continuation Re-assessment required after 18 months All of the following: 1 The patient has not undergone a tracheostomy; and 2 The patient has not experienced respiratory failure; and 3 Any of the following: 3.1 The patient is ambulatory; or 3.2 The patient is able to use upper limb; or 3.3 The patient is able to swallow. TETRABENAZINE Tab 25 mg – 1% DV Sep-13 to 2016 ...........................................................118.00 112 Motetis ¯

Anticholinergics

BENZTROPINE MESYLATE Tab 2 mg ...........................................................................................................7.99 Inj 1 mg per ml, 2 ml ampoule ........................................................................95.00 ORPHENADRINE HYDROCHLORIDE Tab 50 mg PROCYCLIDINE HYDROCHLORIDE Tab 5 mg 60 5 Benztrop Cogentin

Dopamine Agonists and Related Agents

AMANTADINE HYDROCHLORIDE Cap 100 mg – 1% DV Sep-11 to 2014...........................................................38.24 APOMORPHINE HYDROCHLORIDE Inj 10 mg per ml, 1 ml ampoule Inj 10 mg per ml, 2 ml ampoule ....................................................................110.00 BROMOCRIPTINE Tab 2.5 mg Cap 5 mg 60 Symmetrel

5

Apomine

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Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

ENTACAPONE Tab 200 mg – 1% DV Dec-12 to 2015 ...........................................................47.92 LEVODOPA WITH BENSERAZIDE Tab dispersible 50 mg with benserazide 12.5 mg ...........................................10.00 Cap 50 mg with benserazide 12.5 mg ..............................................................8.00 Cap 100 mg with benserazide 25 mg .............................................................12.50 Cap long-acting 100 mg with benserazide 25 mg ..........................................17.00 Cap 200 mg with benserazide 50 mg .............................................................25.00 LEVODOPA WITH CARBIDOPA Tab 100 mg with carbidopa 25 mg ..................................................................20.00 Tab long-acting 200 mg with carbidopa 50 mg ...............................................47.50 Tab 250 mg with carbidopa 25 mg ..................................................................40.00 LISURIDE HYDROGEN MALEATE Tab 200 mcg ...................................................................................................25.00 PERGOLIDE Tab 0.25 mg – 1% DV Sep-11 to 2014 ..........................................................48.00 Tab 1 mg – 1% DV Sep-11 to 2014 .............................................................170.00 PRAMIPEXOLE HYDROCHLORIDE Tab 0.125 mg ....................................................................................................1.95 Tab 0.25 mg ......................................................................................................2.40 7.20 Tab 0.5 mg ........................................................................................................4.20 Tab 1 mg ...........................................................................................................7.20 24.39 ROPINIROLE HYDROCHLORIDE Tab 0.25 mg – 1% DV Mar-14 to 2016.............................................................2.36 Tab 1 mg – 1% DV Mar-14 to 2016..................................................................5.32 Tab 2 mg – 1% DV Mar-14 to 2016..................................................................7.72 Tab 5 mg – 1% DV Mar-14 to 2016................................................................14.48 SELEGILINE HYDROCHLORIDE Tab 5 mg TOLCAPONE Tab 100 mg – 1% DV Sep-11 to 2014 .........................................................126.20

100 100 100 100 100 100 100 100 100

Entapone Madopar Rapid Madopar 62.5 Madopar 125 Madopar HBS Madopar 250 Sinemet e.g. Sindopa Sinemet CR Sinemet e.g. Sindopa Dopergin Permax Permax Dr Reddy’s Pramipexole Dr Reddy’s Pramipexole Ramipex Dr Reddy’s Pramipexole Dr Reddy’s Pramipexole Ramipex Apo-Ropinirole Apo-Ropinirole Apo-Ropinirole Apo-Ropinirole

30 100 100 30 30 100 30 30 100 100 100 100 100

100

Tasmar

Anaesthetics General Anaesthetics

DESFLURANE Soln for inhalation 100%, 240 ml bottle – 1% DV Dec-12 to 2015............1,230.00 DEXMEDETOMIDINE HYDROCHLORIDE Inj 100 mcg per ml, 2 ml vial ETOMIDATE Inj 2 mg per ml, 10 ml ampoule ISOFLURANE Soln for inhalation 100%, 250 ml bottle – 1% DV Dec-12 to 2015............1,020.00 6 Aerrane 6 Suprane

°

98

Item restricted (see ° above); Item restricted (see ¯ below) e.g. Brand indicates brand example only. It is not a contracted product.

¯


NERVOUS SYSTEM

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

KETAMINE HYDROCHLORIDE Inj 1 mg per ml, 100 ml bag Inj 4 mg per ml, 50 ml syringe Inj 10 mg per ml, 10 ml syringe Inj 100 mg per ml, 2 ml vial METHOHEXITAL SODIUM Inj 10 mg per ml, 50 ml vial PROPOFOL Inj 10 mg per ml, 20 ml ampoule ......................................................................7.60 Inj 10 mg per ml, 20 ml vial ...............................................................................7.60 42.00 Inj 10 mg per ml, 50 ml syringe ......................................................................47.00 Inj 10 mg per ml, 50 ml vial ...............................................................................4.00 25.00 Inj 10 mg per ml, 100 ml vial .............................................................................7.60 30.00 SEVOFLURANE Soln for inhalation 100%, 250 ml bottle – 1% DV Dec-12 to 2015............1,230.00 THIOPENTAL [THIOPENTONE] SODIUM Inj 500 mg ampoule 6 5 5 1 1 Fresofol 1% Provive MCT-LCT 1% Diprivan Diprivan Fresofol 1% Provive MCT-LCT 1% Diprivan Fresofol 1% Provive MCT-LCT 1% Diprivan Baxter

1

Local Anaesthetics

ARTICAINE HYDROCHLORIDE WITH ADRENALINE Inj 4% with adrenaline 1:100,000, 1.7 ml dental cartridge Inj 4% with adrenaline 1:100,000, 2.2 ml dental cartridge Inj 4% with adrenaline 1:200,000, 1.7 ml dental cartridge Inj 4% with adrenaline 1:200,000, 2.2 ml dental cartridge BENZOCAINE Gel 20% BUPIVACAINE HYDROCHLORIDE Inj 5 mg per ml, 4 ml ampoule ........................................................................50.00 Inj 2.5 mg per ml, 20 ml ampoule Inj 2.5 mg per ml, 20 ml ampoule sterile pack – 1% DV Oct-12 to 2015 .........35.00 Inj 5 mg per ml, 10 ml ampoule ......................................................................35.00 Inj 5 mg per ml, 10 ml ampoule sterile pack – 1% DV Oct-12 to 2015 ..........28.00 Inj 5 mg per ml, 20 ml ampoule Inj 5 mg per ml, 20 ml ampoule sterile pack – 1% DV Oct-12 to 2015 ..........28.00 Inj 1.25 mg per ml, 100 ml bag Inj 1.25 mg per ml, 200 ml bag Inj 2.5 mg per ml, 100 ml bag .......................................................................150.00 Inj 2.5 mg per ml, 200 ml bag Inj 1.25 mg per ml, 500 ml bag 5 5 50 5 5 Marcain Isobaric Marcain Marcain Marcain Marcain

5

Marcain

Products with Hospital Supply Status (HSS) are in bold Expiry date of HSS period is 30 June of the year indicated unless otherwise stated.

99


NERVOUS SYSTEM

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

BUPIVACAINE HYDROCHLORIDE WITH ADRENALINE Inj 2.5 mg per ml with adrenaline 1:400,000, 20 ml vial – 1% DV Nov11 to 2014 .............................................................................................. 135.00 Inj 5 mg per ml with adrenaline 1:200,000, 20 ml vial – 1% DV Nov-11 to 2014 ................................................................................................... 115.00 BUPIVACAINE HYDROCHLORIDE WITH FENTANYL Inj 0.625 mg with fentanyl 2 mcg per ml, 100 ml bag Inj 1.25 mg with fentanyl 2 mcg per ml, 100 ml syringe Inj 1.25 mg with fentanyl 2 mcg per ml, 100 ml bag – 1% DV Nov-11 to 2014 ................................................................................................... 210.00 Inj 1.25 mg with fentanyl 2 mcg per ml, 200 ml bag – 1% DV Nov-11 to 2014 ................................................................................................... 210.00 Inj 1.25 mg with fentanyl 2 mcg per ml, 50 ml syringe Inj 1.25 mg with fentanyl 2 mcg per ml, 15 ml syringe – 1% DV Nov-11 to 2014 ..................................................................................................... 72.00 Inj 1.25 mg with fentanyl 2 mcg per ml, 20 ml syringe – 1% DV Nov-11 to 2014 ..................................................................................................... 92.00 BUPIVACAINE HYDROCHLORIDE WITH GLUCOSE Inj 0.5% with glucose 8%, 4 ml ampoule ........................................................38.00 COCAINE HYDROCHLORIDE Paste 5% Soln 15%, 2 ml syringe Soln 4%, 2 ml syringe .....................................................................................25.46 COCAINE HYDROCHLORIDE WITH ADRENALINE Paste 15% with adrenaline 0.06% Paste 25% with adrenaline 0.06% ETHYL CHLORIDE Spray 100% LIDOCAINE [LIGNOCAINE] HYDROCHLORIDE Gel 2% – 1% DV Oct-12 to 2015 .....................................................................3.40 Soln 4% Spray 10% – 1% DV Sep-13 to 2016.............................................................75.00 Oral (viscous) soln 2% – 1% DV Sep-11 to 2014 ..........................................55.00 Inj 1%, 20 ml ampoule, sterile pack Inj 2%, 20 ml ampoule, sterile pack Inj 1%, 5 ml ampoule – 1% DV Jul-13 to 2015 ................................................8.75 Inj 1%, 20 ml ampoule – 1% DV Jul-13 to 2015 ..............................................2.40 Inj 2%, 5 ml ampoule – 1% DV Jul-13 to 2015 ................................................6.90 Inj 2%, 20 ml ampoule – 1% DV Jul-13 to 2015 ..............................................2.40 Gel 2%, 10 ml urethral syringe .......................................................................43.26

5

Marcain with Adrenaline Marcain with Adrenaline

5

10 10

Bupafen Bupafen

10 10 5

Biomed Biomed Marcain Heavy

1

Biomed

20 ml 50 ml 200 ml

Orion Xylocaine Xylocaine Viscous

25 1 25 1 10

Lidocaine-Claris Lidocaine-Claris Lidocaine-Claris Lidocaine-Claris Pfizer

°

100

Item restricted (see ° above); Item restricted (see ¯ below) e.g. Brand indicates brand example only. It is not a contracted product.

¯


NERVOUS SYSTEM

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

LIDOCAINE [LIGNOCAINE] HYDROCHLORIDE WITH ADRENALINE Inj 1% with adrenaline 1:100,000, 5 ml ampoule ............................................27.00 Inj 1% with adrenaline 1:200,000, 20 ml vial ..................................................50.00 Inj 2% with adrenaline 1:80,000, 1.7 ml dental cartridge Inj 2% with adrenaline 1:80,000, 1.8 ml dental cartridge Inj 2% with adrenaline 1:80,000, 2.2 ml dental cartridge Inj 2% with adrenaline 1:200,000, 20 ml vial ..................................................60.00

10 5

Xylocaine Xylocaine

5

Xylocaine

LIDOCAINE [LIGNOCAINE] HYDROCHLORIDE WITH ADRENALINE AND TETRACAINE HYDROCHLORIDE Soln 4% with adrenaline 0.1% and tetracaine hydrochloride 0.5%, 5 ml syringe LIDOCAINE [LIGNOCAINE] HYDROCHLORIDE WITH CHLORHEXIDINE Gel 2% with chlorhexidine 0.05%, 10 ml urethral syringe ..............................43.26 10 Pfizer

LIDOCAINE [LIGNOCAINE] HYDROCHLORIDE WITH PHENYLEPHRINE HYDROCHLORIDE Nasal spray 5% with phenylephrine hydrochloride 0.5% LIDOCAINE [LIGNOCAINE] WITH PRILOCAINE Crm 2.5% with prilocaine 2.5% ......................................................................45.00 Patch 25 mcg with prilocaine 25 mcg ...........................................................115.00 Crm 2.5% with prilocaine 2.5%, 5 g ...............................................................45.00 MEPIVACAINE HYDROCHLORIDE Inj 3%, 1.8 ml dental cartridge Inj 3%, 2.2 ml dental cartridge PRILOCAINE HYDROCHLORIDE Inj 0.5%, 50 ml vial .......................................................................................100.00 Inj 2%, 5 ml ampoule ......................................................................................55.00 PRILOCAINE HYDROCHLORIDE WITH FELYPRESSIN Inj 3% with felypressin 0.03 iu per ml, 1.8 ml dental cartridge Inj 3% with felypressin 0.03 iu per ml, 2.2 ml dental cartridge ROPIVACAINE HYDROCHLORIDE Inj 2 mg per ml, 10 ml ampoule Inj 2 mg per ml, 20 ml ampoule ......................................................................75.00 Inj 2 mg per ml, 100 ml bag ..........................................................................200.00 Inj 2 mg per ml, 200 ml bag ..........................................................................265.00 Inj 7.5 mg per ml, 10 ml ampoule ...................................................................45.00 Inj 7.5 mg per ml, 20 ml ampoule ...................................................................84.00 Inj 10 mg per ml, 10 ml ampoule ....................................................................54.00 Inj 10 mg per ml, 20 ml ampoule ROPIVACAINE HYDROCHLORIDE WITH FENTANYL Inj 2 mg with fentanyl 2 mcg per ml, 100 ml bag ..........................................198.50 Inj 2 mg with fentanyl 2 mcg per ml, 200 ml bag ..........................................270.00 TETRACAINE [AMETHOCAINE] HYDROCHLORIDE Gel 4% 5 10 Citanest Citanest 30 g 20 5 EMLA EMLA EMLA

5 5 5 5 5 5

Naropin Naropin Naropin Naropin Naropin Naropin

5 5

Naropin Naropin

Products with Hospital Supply Status (HSS) are in bold Expiry date of HSS period is 30 June of the year indicated unless otherwise stated.

101


NERVOUS SYSTEM

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

Analgesics Non-Opioid Analgesics

ASPIRIN Tab EC 300 mg Tab dispersible 300 mg CAPSAICIN – Restricted see terms below Crm 0.075% ...................................................................................................12.50 45 g Zostrix HP ¯Restricted For post-herpetic neuralgia or diabetic peripheral neuropathy METHOXYFLURANE – Restricted see terms below Soln for inhalation 99.9%, 3 ml bottle ¯Restricted Both: 1 Patient is undergoing a painful procedure with an expected duration of less than one hour; and 2 Only to be used under supervision by a medical practitioner or nurse who is trained in the use of methoxyflurane. NEFOPAM HYDROCHLORIDE Tab 30 mg PARACETAMOL – Some items restricted see terms below Tab soluble 500 mg Tab 500 mg Oral liq 120 mg per 5 ml – 20% DV Dec-11 to 2014........................................2.21 Oral liq 250 mg per 5 ml – 20% DV Sep-11 to 2014........................................6.70 ¯¯ ¯ ¯

500 ml 1,000 ml

Inj 10 mg per ml, 50 ml vial – 1% DV Dec-13 to 2014 ...................................22.50 10 Inj 10 mg per ml, 100 ml vial – 1% DV Apr-13 to 2014..................................22.50 10 Suppos 25 mg ................................................................................................56.35 20 Suppos 50 mg ................................................................................................56.35 20 Suppos 125 mg ................................................................................................7.49 20 Suppos 250 mg ..............................................................................................14.40 20 Suppos 500 mg – 1% DV Jan-13 to 2015 .....................................................20.70 50 ¯Restricted Intravenous paracetamol is only to be used where other routes are unavailable or impractical, or where there is reduced absorption. The need for IV paracetamol must be re-assessed every 24 hours. SUCROSE Oral liq 25%

Ethics Paracetamol Paracare Double Strength Paracetamol-AFT Paracetamol-AFT Biomed Biomed Panadol Panadol Paracare

Opioid Analgesics

ALFENTANIL HYDROCHLORIDE Inj 0.5 mg per ml, 2 ml ampoule CODEINE PHOSPHATE Tab 15 mg – 1% DV Jul-13 to 2016 .................................................................4.75 Tab 30 mg – 1% DV Jul-13 to 2016 .................................................................5.80 Tab 60 mg – 1% DV Jul-13 to 2016 ...............................................................12.50 DIHYDROCODEINE TARTRATE Tab long-acting 60 mg – 1% DV Sep-13 to 2016...........................................13.64 100 100 100 60 PSM PSM PSM DHC Continus

°

102

Item restricted (see ° above); Item restricted (see ¯ below) e.g. Brand indicates brand example only. It is not a contracted product.

¯


NERVOUS SYSTEM

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

FENTANYL Inj 10 mcg per ml, 10 ml syringe Inj 50 mcg per ml, 2 ml ampoule – 1% DV Sep-12 to 2015 .............................4.50 Inj 10 mcg per ml, 50 ml bag – 1% DV Dec-11 to 2014...............................210.00 Inj 10 mcg per ml, 50 ml syringe – 1% DV Dec-11 to 2014 .........................165.00 Inj 50 mcg per ml, 10 ml ampoule – 1% DV Sep-12 to 2015 .........................11.77 Inj 10 mcg per ml, 100 ml bag – 1% DV Dec-11 to 2014.............................210.00 Inj 20 mcg per ml, 50 ml syringe – 1% DV Dec-11 to 2014 .........................185.00 Inj 20 mcg per ml, 100 ml bag Patch 12.5 mcg per hour ..................................................................................8.90 Patch 25 mcg per hour .....................................................................................9.15 Patch 50 mcg per hour ...................................................................................11.50 Patch 75 mcg per hour ...................................................................................13.60 Patch 100 mcg per hour .................................................................................14.50 METHADONE HYDROCHLORIDE Tab 5 mg ...........................................................................................................1.85 Oral liq 2 mg per ml – 1% DV Sep-12 to 2015.................................................5.55 Oral liq 5 mg per ml – 1% DV Sep-12 to 2015.................................................5.55 Oral liq 10 mg per ml – 1% DV Sep-12 to 2015...............................................6.55 Inj 10 mg per ml, 1 ml vial ...............................................................................61.00 MORPHINE HYDROCHLORIDE Oral liq 1 mg per ml – 1% DV Oct-12 to 2015..................................................8.84 Oral liq 2 mg per ml – 1% DV Oct-12 to 2015................................................11.62 Oral liq 5 mg per ml – 1% DV Oct-12 to 2015................................................14.65 Oral liq 10 mg per ml – 1% DV Oct-12 to 2015..............................................21.55

10 10 10 10 10 10 5 5 5 5 5 10 200 ml 200 ml 200 ml 10 200 ml 200 ml 200 ml 200 ml

Boucher and Muir Biomed Biomed Boucher and Muir Biomed Biomed Mylan Fentanyl Patch Mylan Fentanyl Patch Mylan Fentanyl Patch Mylan Fentanyl Patch Mylan Fentanyl Patch Methatabs Biodone Biodone Forte Biodone Extra Forte AFT RA-Morph RA-Morph RA-Morph RA-Morph

Products with Hospital Supply Status (HSS) are in bold Expiry date of HSS period is 30 June of the year indicated unless otherwise stated.

103


NERVOUS SYSTEM

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

MORPHINE SULPHATE Tab long-acting 10 mg – 1% DV Sep-13 to 2016.............................................1.95 Tab immediate-release 10 mg ..........................................................................2.80 Tab immediate-release 20 mg ..........................................................................5.52 Tab long-acting 30 mg – 1% DV Sep-13 to 2016.............................................2.98 Tab long-acting 60 mg – 1% DV Sep-13 to 2016.............................................5.75 Tab long-acting 100 mg – 1% DV Sep-13 to 2016...........................................6.45 Cap long-acting 10 mg – 1% DV Feb-14 to 2016 ............................................1.70 Cap long-acting 30 mg – 1% DV Feb-14 to 2016 ............................................2.50 Cap long-acting 60 mg – 1% DV Feb-14 to 2016 ............................................5.40 Cap long-acting 100 mg – 1% DV Feb-14 to 2016 ..........................................6.38 Inj 1 mg per ml, 100 ml bag – 1% DV Dec-11 to 2014.................................165.00 Inj 1 mg per ml, 10 ml syringe – 1% DV Dec-11 to 2014 ...............................39.50 Inj 1 mg per ml, 50 ml syringe – 1% DV Dec-11 to 2014 ...............................79.50 Inj 1 mg per ml, 2 ml syringe Inj 2 mg per ml, 30 ml syringe – 1% DV Dec-11 to 2014 .............................135.00 Inj 5 mg per ml, 1 ml ampoule – 1% DV Nov-11 to 2014.................................5.51 Inj 10 mg per ml, 1 ml ampoule – 1% DV Nov-11 to 2014...............................4.79 Inj 10 mg per ml, 100 mg cassette Inj 10 mg per ml, 100 ml bag Inj 15 mg per ml, 1 ml ampoule – 1% DV Nov-11 to 2014...............................5.01 Inj 30 mg per ml, 1 ml ampoule – 1% DV Nov-11 to 2014...............................5.30 Inj 200 mcg in 0.4 ml syringe Inj 300 mcg in 0.3 ml syringe MORPHINE TARTRATE Inj 80 mg per ml, 1.5 ml ampoule – 1% DV Sep-13 to 2016..........................35.60 Inj 80 mg per ml, 5 ml ampoule – 1% DV Sep-13 to 2016...........................107.67 OXYCODONE HYDROCHLORIDE Tab controlled-release 5 mg .............................................................................7.51 Tab controlled-release 10 mg – 1% DV Oct-13 to 2015...................................6.75 Tab controlled-release 20 mg – 1% DV Oct-13 to 2015.................................11.50 Tab controlled-release 40 mg – 1% DV Oct-13 to 2015.................................18.50 Tab controlled-release 80 mg – 1% DV Oct-13 to 2015.................................34.00 Cap immediate-release 5 mg ...........................................................................2.83 Cap immediate-release 10 mg .........................................................................5.58 Cap immediate-release 20 mg .........................................................................9.77 Oral liq 5 mg per 5 ml .....................................................................................11.20 Inj 1 mg per ml, 100 ml bag Inj 10 mg per ml, 1 ml ampoule – 1% DV Dec-12 to 2015.............................10.08 Inj 10 mg per ml, 2 ml ampoule – 1% DV Dec-12 to 2015.............................19.87 Inj 50 mg per ml, 1 ml ampoule – 1% DV May-13 to 2015.............................60.00 PARACETAMOL WITH CODEINE Tab paracetamol 500 mg with codeine phosphate 8 mg – 1% DV Nov11 to 2014 .................................................................................................. 2.70

10 10 10 10 10 10 10 10 10 10 10 10 10 10 5 5

Arrow-Morphine LA Sevredol Sevredol Arrow-Morphine LA Arrow-Morphine LA Arrow-Morphine LA m-Eslon m-Eslon m-Eslon m-Eslon Biomed Biomed Biomed Biomed DBL Morphine Sulphate DBL Morphine Sulphate

5 5

DBL Morphine Sulphate DBL Morphine Sulphate

5 5 20 20 20 20 20 20 20 20 250 ml 5 5 5

Hospira Hospira OxyContin Oxydone BNM Oxydone BNM Oxydone BNM Oxydone BNM OxyNorm OxyNorm OxyNorm OxyNorm Oxycodone Orion Oxycodone Orion OxyNorm

100

Paracetamol + Codeine (Relieve)

°

104

Item restricted (see ° above); Item restricted (see ¯ below) e.g. Brand indicates brand example only. It is not a contracted product.

¯


NERVOUS SYSTEM

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

PETHIDINE HYDROCHLORIDE Tab 50 mg – 1% DV Mar-13 to 2015................................................................3.95 Tab 100 mg – 1% DV Mar-13 to 2015..............................................................5.80 Inj 5 mg per ml, 10 ml syringe Inj 5 mg per ml, 100 ml bag Inj 10 mg per ml, 100 ml bag Inj 10 mg per ml, 50 ml syringe Inj 50 mg per ml, 1 ml ampoule – 1% DV Nov-11 to 2014...............................5.51 Inj 50 mg per ml, 2 ml ampoule – 1% DV Nov-11 to 2014...............................5.83 REMIFENTANIL HYDROCHLORIDE Inj 1 mg vial – 1% DV Feb-12 to 2014 ...........................................................27.95 Inj 2 mg vial – 1% DV Feb-12 to 2014 ...........................................................41.80 TRAMADOL HYDROCHLORIDE Tab sustained-release 100 mg .........................................................................2.14 Tab sustained-release 150 mg .........................................................................3.21 Tab sustained-release 200 mg .........................................................................4.28 Cap 50 mg – 1% DV Sep-11 to 2014...............................................................4.95 Oral drops 100 mg per ml Inj 10 mg per ml, 100 ml bag Inj 50 mg per ml, 1 ml ampoule ........................................................................4.50 Inj 50 mg per ml, 2 ml ampoule ........................................................................4.50

10 10

PSM PSM

5 5

DBL Pethidine Hydrochloride DBL Pethidine Hydrochloride Remifentanil-AFT Remifentanil-AFT Tramal SR 100 Tramal SR 150 Tramal SR 200 Arrow-Tramadol

5 5 20 20 20 100

5 5

Tramal 50 Tramal 100

Antidepressants Cyclic and Related Agents

AMITRIPTYLINE Tab 10 mg – 1% DV Jan-13 to 2014................................................................3.32 Tab 25 mg – 1% DV Jun-11 to 2014................................................................1.85 Tab 50 mg – 1% DV Jun-11 to 2014................................................................3.60 CLOMIPRAMINE HYDROCHLORIDE Tab 10 mg – 1% DV Jan-13 to 2015..............................................................12.60 Tab 25 mg – 1% DV Jan-13 to 2015................................................................8.68 DOTHIEPIN HYDROCHLORIDE Tab 75 mg .......................................................................................................10.50 Cap 25 mg ........................................................................................................6.17 DOXEPIN HYDROCHLORIDE Cap 10 mg Cap 25 mg Cap 50 mg IMIPRAMINE HYDROCHLORIDE Tab 10 mg .........................................................................................................5.48 6.58 Tab 25 mg .........................................................................................................8.80 MAPROTILINE HYDROCHLORIDE Tab 25 mg Tab 75 mg 50 60 50 Tofranil Tofranil Tofranil 100 100 100 100 100 100 100 Arrow-Amitriptyline Amitrip Amitrip Apo-Clomipramine Apo-Clomipramine Dopress Dopress

Products with Hospital Supply Status (HSS) are in bold Expiry date of HSS period is 30 June of the year indicated unless otherwise stated.

105


NERVOUS SYSTEM

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

MIANSERIN HYDROCHLORIDE Tab 30 mg NORTRIPTYLINE HYDROCHLORIDE Tab 10 mg – 1% DV Jun-13 to 2016................................................................4.00 Tab 25 mg – 1% DV Jun-13 to 2016................................................................9.00 100 180 Norpress Norpress

Monoamine-Oxidase Inhibitors - Non-Selective

PHENELZINE SULPHATE Tab 15 mg TRANYLCYPROMINE SULPHATE Tab 10 mg

Monoamine-Oxidase Type A Inhibitors

MOCLOBEMIDE Tab 150 mg – 1% DV Apr-13 to 2015 ............................................................81.83 Tab 300 mg – 1% DV Apr-13 to 2015 ............................................................29.51 500 100 Apo-Moclobemide Apo-Moclobemide

Other Antidepressants

MIRTAZAPINE – Restricted see terms below Tab 30 mg – 1% DV Sep-12 to 2015 ...............................................................8.78 30 Avanza Tab 45 mg – 1% DV Sep-12 to 2015 .............................................................13.95 30 Avanza ¯Restricted Initiation Re-assessment required after two years Both: 1 The patient has a severe major depressive episode; and 2 Either: 2.1 The patient must have had a trial of two different antidepressants and was unable to tolerate the treatments or failed to respond to an adequate dose over an adequate period of time (usually at least four weeks); or 2.2 Both: 2.2.1 The patient is currently a hospital in-patient as a result of an acute depressive episode; and 2.2.2 The patient must have had a trial of one other antidepressant and either could not tolerate it or failed to respond to an adequate dose over an adequate period of time. Continuation Re-assessment required after two years The patient has a high risk of relapse (prescriber determined) VENLAFAXINE – Some items restricted see terms on the next page Tab modified release 37.5 mg ..........................................................................5.06 28 Arrow-Venlafaxine XR Tab modified release 75 mg .............................................................................6.44 28 Arrow-Venlafaxine XR Tab modified release 150 mg ...........................................................................8.86 28 Arrow-Venlafaxine XR Tab modified release 225 mg .........................................................................14.34 28 Arrow-Venlafaxine XR Cap modified release 37.5 mg ..........................................................................8.71 28 Efexor XR Cap modified release 75 mg ...........................................................................17.42 28 Efexor XR Cap modified release 150 mg .........................................................................21.35 28 Efexor XR ¯¯

°

¯¯¯

106

Item restricted (see ° above); Item restricted (see ¯ below) e.g. Brand indicates brand example only. It is not a contracted product.

¯


NERVOUS SYSTEM

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

¯Restricted Initiation Re-assessment required after two years Both: 1 The patient has ’treatment-resistant’ depression; and 2 Either: 2.1 The patient must have had a trial of two different antidepressants and have had an inadequate response from an adequate dose over an adequate period of time (usually at least four weeks); or 2.2 Both: 2.2.1 The patient is currently a hospital in-patient as a result of an acute depressive episode; and. 2.2.2 The patient must have had a trial of one other antidepressant and have had an inadequate response from an adequate dose over an adequate period of time.Continuation. Continuation Re-assessment required after two years The patient has a high risk of relapse (prescriber determined)

Selective Serotonin Reuptake Inhibitors

CITALOPRAM HYDROBROMIDE Tab 20 mg – 1% DV Sep-11 to 2014 ...............................................................2.34 ESCITALOPRAM Tab 10 mg .........................................................................................................2.65 Tab 20 mg .........................................................................................................4.20 FLUOXETINE HYDROCHLORIDE Tab dispersible 20 mg, scored – 1% DV Apr-14 to 2016 .................................2.50 Cap 20 mg – 1% DV Apr-14 to 2016 ...............................................................1.74 2.70 (Fluox Tab dispersible 20 mg, scored to be delisted 1 April 2014) (Fluox Cap 20 mg to be delisted 1 April 2014) PAROXETINE HYDROCHLORIDE Tab 20 mg .........................................................................................................4.32 SERTRALINE Tab 50 mg – 1% DV Sep-13 to 2016 ...............................................................3.64 Tab 100 mg – 1% DV Sep-13 to 2016 .............................................................6.28 84 28 28 30 90 84 Arrow-Citalopram Loxalate Loxalate Arrow-Fluoxetine Fluox Arrow-Fluoxetine Fluox

90 90 90

Loxamine Arrow-Sertraline Arrow-Sertraline

Antiepilepsy Drugs Agents for the Control of Status Epilepticus

CLONAZEPAM Inj 1 mg per ml, 1 ml ampoule ........................................................................19.00 DIAZEPAM Inj 5 mg per ml, 2 ml ampoule ..........................................................................9.24 Rectal tubes 5 mg ...........................................................................................25.05 Rectal tubes 10 mg .........................................................................................30.50 LORAZEPAM Inj 2 mg vial Inj 4 mg per ml, 1 ml vial PARALDEHYDE Inj 5 ml ampoule 5 5 5 5 Rivotril Mayne Stesolid Stesolid

Products with Hospital Supply Status (HSS) are in bold Expiry date of HSS period is 30 June of the year indicated unless otherwise stated.

107


NERVOUS SYSTEM

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

PHENYTOIN SODIUM Inj 50 mg per ml, 2 ml ampoule Inj 50 mg per ml, 5 ml ampoule

Control of Epilepsy

CARBAMAZEPINE Tab 200 mg Tab long-acting 200 mg Tab 400 mg Tab long-acting 400 mg Oral liq 20 mg per ml CLOBAZAM Tab 10 mg CLONAZEPAM Oral drops 2.5 mg per ml ETHOSUXIMIDE Cap 250 mg Oral liq 50 mg per ml GABAPENTIN – Restricted see terms below Tab 600 mg Cap 100 mg ......................................................................................................7.16 Cap 300 mg ....................................................................................................11.00 Cap 400 mg ....................................................................................................13.75 ¯¯ ¯ ¯

100 100 100

Arrow-Gabapentin Nupentin Arrow-Gabapentin Nupentin Arrow-Gabapentin Nupentin

¯Restricted 1 For preoperative and/or postoperative use for up to a total of 8 days’ use; or 2 For the pain management of burns patients with monthly review. Initiation - epilepsy Re-assessment required after 15 months Either: 1 Seizures are not adequately controlled with optimal treatment with other antiepilepsy agents; or 2 Seizures are controlled adequately but the patient has experienced unacceptable side effects from optimal treatment with other antiepilepsy agents. Note: "Optimal treatment with other antiepilepsy agents" is defined as treatment with other antiepilepsy agents which are indicated and clinically appropriate for the patient, given in adequate doses for the patient’s age, weight, and other features affecting the pharmacokinetics of the drug with good evidence of compliance. Continuation - epilepsy Patient has demonstrated a significant and sustained improvement in seizure rate or severity and/or quality of life. Note: As a guideline, clinical trials have referred to a notional 50% reduction in seizure frequency as an indicator of success with anticonvulsant therapy and have assessed quality of life from the patient’s perspective. Initiation - neuropathic pain Re-assessment required after 3 months Patient has tried and failed, or has been unable to tolerate, treatment with a tricyclic antidepressant. Continuation - neuropathic pain Either: continued. . .

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Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

continued. . . 1 The patient has demonstrated a marked improvement in their control of pain (prescriber determined); or 2 The patient has previously demonstrated clinical responsiveness to gabapentin and has now developed neuropathic pain in a new site. LACOSAMIDE – Restricted see terms below Tab 50 mg .......................................................................................................25.04 14 Vimpat Tab 100 mg .....................................................................................................50.06 14 Vimpat 200.24 56 Vimpat Tab 150 mg .....................................................................................................75.10 14 Vimpat 300.40 56 Vimpat Tab 200 mg ...................................................................................................400.55 56 Vimpat Inj 10 mg per ml, 20 ml vial ¯Restricted Initiation Re-assessment required after 15 months Both: 1 Patient has partial-onset epilepsy; and 2 Seizures are not adequately controlled by, or patient has experienced unacceptable side effects from, optimal treatment with all of the following: sodium valproate, topiramate, levetiracetam and any two of carbamazepine, lamotrigine and phenytoin sodium (see Note). Note: "Optimal treatment" is defined as treatment which is indicated and clinically appropriate for the patient, given in adequate doses for the patient’s age, weight and other features affecting the pharmacokinetics of the drug with good evidence of compliance. Women of childbearing age are not required to have a trial of sodium valproate. Continuation Patient has demonstrated a significant and sustained improvement in seizure rate or severity and/or quality of life compared with that prior to starting lacosamide treatment (see Note). Note: As a guideline, clinical trials have referred to a notional 50% reduction in seizure frequency as an indicator of success with anticonvulsant therapy and have assessed quality of life from the patient’s perspective. LAMOTRIGINE Tab dispersible 2 mg .........................................................................................6.74 30 Lamictal Tab dispersible 5 mg .........................................................................................9.64 30 Lamictal 15.00 56 Arrow-Lamotrigine Tab dispersible 25 mg .....................................................................................19.38 56 Logem 20.40 Arrow-Lamotrigine Mogine 29.09 Lamictal Tab dispersible 50 mg .....................................................................................32.97 56 Logem 34.70 Arrow-Lamotrigine Mogine 47.89 Lamictal Tab dispersible 100 mg ...................................................................................56.91 56 Logem 59.90 Arrow-Lamotrigine Mogine 79.16 Lamictal LEVETIRACETAM Tab 250 mg .....................................................................................................24.03 Tab 500 mg .....................................................................................................28.71 Tab 750 mg .....................................................................................................45.23 Inj 100 mg per ml, 5 ml vial 60 60 60 Levetiracetam-Rex Levetiracetam-Rex Levetiracetam-Rex

¯¯ ¯ ¯¯

Products with Hospital Supply Status (HSS) are in bold Expiry date of HSS period is 30 June of the year indicated unless otherwise stated.

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Per

PHENOBARBITONE Tab 15 mg – 1% DV Mar-13 to 2015..............................................................28.00 Tab 30 mg – 1% DV Mar-13 to 2015..............................................................29.00 PHENYTOIN Tab 50 mg PHENYTOIN SODIUM Cap 30 mg Cap 100 mg Oral liq 6 mg per ml PRIMIDONE Tab 250 mg SODIUM VALPROATE Tab 100 mg Tab EC 200 mg Tab EC 500 mg Oral liq 40 mg per ml Inj 100 mg per ml, 4 ml vial

500 500

PSM PSM

STIRIPENTOL – Restricted see terms below Cap 250 mg ..................................................................................................509.29 60 Diacomit Powder for oral liq 250 mg sachet ................................................................509.29 60 Diacomit ¯Restricted Paediatric neurologist Initiation Re-assessment required after 6 months Both: 1 Patient has confirmed diagnosis of Dravet syndrome; and 2 Seizures have been inadequately controlled by appropriate courses of sodium valproate, clobazam and at least two of the following: topiramate, levetiracetam, ketogenic diet. Continuation Patient continues to benefit from treatment as measured by reduced seizure frequency from baseline. TOPIRAMATE Tab 25 mg .......................................................................................................11.07 60 Arrow-Topiramate 26.04 Topamax Tab 50 mg .......................................................................................................18.81 60 Arrow-Topiramate 44.26 Topamax Tab 100 mg .....................................................................................................31.99 60 Arrow-Topiramate 75.25 Topamax Tab 200 mg .....................................................................................................55.19 60 Arrow-Topiramate 129.85 Topamax Cap sprinkle 15 mg ........................................................................................20.84 60 Topamax Cap sprinkle 25 mg ........................................................................................26.04 60 Topamax VIGABATRIN – Restricted see terms on the next page Tab 500 mg

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¯

110

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Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

¯Restricted Both: 1 Either: 1.1 Patient has infantile spasms; or 1.2 Both: 1.2.1 Patient has epilepsy; and 1.2.2 Either: 1.2.2.1 Seizures are not adequately controlled with optimal treatment with other antiepilepsy agents; or 1.2.2.2 Seizures are controlled adequately but the patient has experienced unacceptable side effects from optimal treatment with other antiepilepsy agents; and 2 Either: 2.1 Patient is, or will be, receiving regular automated visual field testing (ideally before starting therapy and on a 6-monthly basis thereafter); or 2.2 It is impractical or impossible (due to comorbid conditions) to monitor the patient’s visual fields. Notes: "Optimal treatment with other antiepilepsy agents" is defined as treatment with other antiepilepsy agents which are indicated and clinically appropriate for the patient, given in adequate doses for the patient’s age, weight, and other features affecting the pharmacokinetics of the drug with good evidence of compliance. Vigabatrin is associated with a risk of irreversible visual field defects, which may be asymptomatic in the early stages.

Antimigraine Preparations Acute Migraine Treatment

DIHYDROERGOTAMINE MESYLATE Inj 1 mg per ml, 1 ml ampoule ERGOTAMINE TARTRATE WITH CAFFEINE Tab 1 mg with caffeine 100 mg METOCLOPRAMIDE HYDROCHLORIDE WITH PARACETAMOL Tab 5 mg with paracetamol 500 mg RIZATRIPTAN BENZOATE Tab orodispersible 10 mg – 1% DV May-12 to 2014......................................18.00 SUMATRIPTAN Tab 50 mg – 1% DV Sep-13 to 2016 .............................................................29.80 Tab 100 mg – 1% DV Sep-13 to 2016 ...........................................................54.80 Inj 12 mg per ml, 0.5 ml cartridge – 1% DV Sep-13 to 2016 .........................13.80 30 100 100 2 Rizamelt Arrow-Sumatriptan Arrow-Sumatriptan Arrow-Sumatriptan

Prophylaxis of Migraine

PIZOTIFEN Tab 500 mcg – 1% DV Mar-13 to 2015 ..........................................................23.21 100 Sandomigran

Antinausea and Vertigo Agents

APREPITANT – Restricted see terms below Cap 2 × 80 mg and 1 × 125 mg ..................................................................116.00 3 Emend Tri-Pack ¯Restricted Patient is undergoing highly emetogenic chemotherapy and/or anthracycline-based chemotherapy for the treatment of malignancy. BETAHISTINE DIHYDROCHLORIDE Tab 16 mg .......................................................................................................10.00 84 Vergo 16 CYCLIZINE HYDROCHLORIDE Tab 50 mg – 1% DV Sep-12 to 2015 ...............................................................0.59 10 Nausicalm ¯

Products with Hospital Supply Status (HSS) are in bold Expiry date of HSS period is 30 June of the year indicated unless otherwise stated.

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NERVOUS SYSTEM

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Per

CYCLIZINE LACTATE Inj 50 mg per ml, 1 ml ampoule ......................................................................14.95 DOMPERIDONE Tab 10 mg – 1% DV Mar-13 to 2015................................................................3.25 DROPERIDOL Inj 2.5 mg per ml, 1 ml ampoule HYOSCINE HYDROBROMIDE Inj 400 mcg per ml, 1 ml ampoule ....................................................................6.66 Patch 1.5 mg – 1% DV Dec-13 to 2016 .........................................................11.95

5 100

Nausicalm Prokinex

5 2

Mayne Scopoderm TTS

°

¯

¯Restricted Any of the following: 1 Control of intractable nausea, vomiting, or inability to swallow saliva in the treatment of malignancy or chronic disease where the patient cannot tolerate or does not adequately respond to oral anti-nausea agents; or 2 Control of clozapine-induced hypersalivation where trials of at least two other alternative treatments have proven ineffective; or 3 For treatment of post-operative nausea and vomiting where cyclizine, droperidol and a 5HT3 antagonist have proven ineffective, are not tolerated or are contraindicated. METOCLOPRAMIDE HYDROCHLORIDE Tab 10 mg – 1% DV Jun-11 to 2014................................................................3.95 100 Metamide Oral liq 5 mg per 5 ml Inj 5 mg per ml, 2 ml ampoule – 1% DV Sep-11 to 2014.................................4.50 10 Pfizer ONDANSETRON Tab 4 mg – 1% DV Jan-14 to 2016..................................................................5.51 Tab dispersible 4 mg .........................................................................................1.70 17.18 Tab 8 mg – 1% DV Jan-14 to 2016..................................................................6.19 Tab dispersible 8 mg .........................................................................................2.00 Inj 2 mg per ml, 2 ml ampoule – 1% DV Sep-13 to 2016.................................1.82 Inj 2 mg per ml, 4 ml ampoule – 1% DV Sep-13 to 2016.................................2.18 PROCHLORPERAZINE Tab buccal 3 mg Tab 5 mg .........................................................................................................16.85 Inj 12.5 mg per ml, 1 ml ampoule Suppos 25 mg PROMETHAZINE THEOCLATE – Restricted: For continuation only ¬ Tab 25 mg TROPISETRON Cap 5 mg ........................................................................................................77.41 Inj 1 mg per ml, 2 ml ampoule – 1% DV May-14 to 2015.................................8.95 19.20 Inj 1 mg per ml, 5 ml ampoule – 1% DV May-14 to 2015...............................13.95 38.40 (Navoban Inj 1 mg per ml, 2 ml ampoule to be delisted 1 May 2014) (Navoban Inj 1 mg per ml, 5 ml ampoule to be delisted 1 May 2014) 5 1 1 Navoban Tropisetron-AFT Navoban Tropisetron-AFT Navoban 50 10 50 10 5 5 Onrex Dr Reddy’s Ondansetron Zofran Zydis Onrex Dr Reddy’s Ondansetron Ondanaccord Ondanaccord

500

Antinaus

112

Item restricted (see ° above); Item restricted (see ¯ below) e.g. Brand indicates brand example only. It is not a contracted product.

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NERVOUS SYSTEM

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

Antipsychotic Agents General

AMISULPRIDE Tab 100 mg – 1% DV Jul-13 to 2016 ...............................................................6.22 Tab 200 mg – 1% DV Jul-13 to 2016 .............................................................21.92 Tab 400 mg – 1% DV Jul-13 to 2016 .............................................................44.52 Oral liq 100 mg per ml – 1% DV Jul-13 to 2016 ............................................52.50 ¯¯¯¯ 30 60 60 60 ml Solian Solian Solian Solian

ARIPIPRAZOLE – Restricted see terms below Tab 10 mg .....................................................................................................123.54 30 Abilify Tab 15 mg .....................................................................................................175.28 30 Abilify Tab 20 mg .....................................................................................................213.42 30 Abilify Tab 30 mg .....................................................................................................260.07 30 Abilify ¯Restricted Both: 1 Patient is suffering from schizophrenia or related psychoses; and 2 Either: 2.1 An effective dose of risperidone or quetiapine has been trialled and has been discontinued, or is in the process of being discontinued, because of unacceptable side effects; or 2.2 An effective dose of risperidone or quetiapine has been trialled and has been discontinued, or is in the process of being discontinued, because of inadequate clinical response. CHLORPROMAZINE HYDROCHLORIDE Tab 10 mg Tab 25 mg Tab 100 mg Oral liq 10 mg per ml Inj 25 mg per ml, 2 ml ampoule CLOZAPINE Tab 25 mg .......................................................................................................13.37 26.74 6.69 13.37 Tab 50 mg .........................................................................................................8.67 17.33 Tab 100 mg .....................................................................................................34.65 69.30 17.33 34.65 Tab 200 mg .....................................................................................................34.65 69.30 Oral liq 50 mg per ml ......................................................................................17.33 HALOPERIDOL Tab 500 mcg – 1% DV Oct-13 to 2016 ............................................................6.23 Tab 1.5 mg – 1% DV Oct-13 to 2016 ...............................................................9.43 Tab 5 mg – 1% DV Oct-13 to 2016 ................................................................29.72 Oral liq 2 mg per ml – 1% DV Oct-13 to 2016................................................23.84 Inj 5 mg per ml, 1ml ampoule – 1% DV Oct-13 to 2016 ................................21.55 50 100 50 100 50 100 50 100 50 100 50 100 100 ml 100 100 100 100 ml 10 Clozaril Clozaril Clopine Clopine Clopine Clopine Clozaril Clozaril Clopine Clopine Clopine Clopine Clopine Serenace Serenace Serenace Serenace Serenace

Products with Hospital Supply Status (HSS) are in bold Expiry date of HSS period is 30 June of the year indicated unless otherwise stated.

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Per

LEVOMEPROMAZINE Tab 25 mg Tab 100 mg Inj 25 mg per ml, 1 ml ampoule LITHIUM CARBONATE Tab long-acting 400 mg Tab 250 mg – 1% DV Sep-12 to 2015 ...........................................................34.30 Tab 400 mg – 1% DV Sep-12 to 2015 ...........................................................12.83 Cap 250 mg – 1% DV Nov-11 to 2014.............................................................9.42 OLANZAPINE Tab 2.5 mg .......................................................................................................2.00 Tab 5 mg ...........................................................................................................3.85 Tab orodispersible 5 mg ...................................................................................6.36 Tab 10 mg .........................................................................................................6.35 Tab orodispersible 10 mg .................................................................................8.76 Inj 10 mg vial (Olanzine Tab 2.5 mg to be delisted 1 April 2014) PERICYAZINE Tab 2.5 mg Tab 10 mg QUETIAPINE Tab 25 mg .........................................................................................................7.00 10.50 Tab 100 mg .....................................................................................................14.00 21.00 Tab 200 mg .....................................................................................................24.00 36.00 Tab 300 mg .....................................................................................................40.00 60.00 60 90 60 90 60 90 60 90 Dr Reddy’s Quetiapine Seroquel Quetapel Seroquel Dr Reddy’s Quetiapine Quetapel Dr Reddy’s Quetiapine Seroquel Quetapel Dr Reddy’s Quetiapine Seroquel Quetapel

500 100 100 28 28 28 28 28

Lithicarb FC Lithicarb FC Douglas Olanzine Zypine Olanzine Zypine Olanzine-D Zypine ODT Olanzine Zypine Olanzine-D Zypine ODT

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NERVOUS SYSTEM

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

RISPERIDONE – Some items restricted see terms below Tab 0.5 mg ........................................................................................................2.86 3.51

20 60

Tab orodispersible 0.5 mg ..............................................................................21.42 Tab 1 mg ...........................................................................................................6.00

28 60

16.92 Tab orodispersible 1 mg .................................................................................42.84 Tab 2 mg .........................................................................................................11.00

28 60

33.84 Tab orodispersible 2 mg .................................................................................85.71 Tab 3 mg .........................................................................................................15.00

28 60

50.78 Tab 4 mg .........................................................................................................20.00

60

67.68 Oral liq 1 mg per ml ........................................................................................18.35 25.26

30 ml

Risperdal Apo-Risperidone Dr Reddy’s Risperidone Ridal Risperdal Quicklet Apo-Risperidone Dr Reddy’s Risperidone Ridal Risperdal Risperdal Quicklet Apo-Risperidone Dr Reddy’s Risperidone Ridal Risperdal Risperdal Quicklet Apo-Risperidone Dr Reddy’s Risperidone Ridal Risperdal Apo-Risperidone Dr Reddy’s Risperidone Ridal Risperdal Apo-Risperidone Risperon Risperdal

¯ ¯ ¯ ¯¯¯¯

¯Restricted Acute situations Both: 1 For a non-adherent patient on oral therapy with standard risperidone tablets or risperidone oral liquid; and 2 The patient is under direct supervision for administration of medicine. Chronic situations Both: 1 The patient is unable to take standard risperidone tablets or oral liquid, or once stabilized refuses to take risperidone tablets or oral liquid; and 2 The patient is under direct supervision for administration of medicine. TRIFLUOPERAZINE HYDROCHLORIDE Tab 1 mg Tab 2 mg Tab 5 mg ZIPRASIDONE – Some items restricted see terms on the next page Cap 20 mg ......................................................................................................87.88 Cap 40 mg ....................................................................................................164.78 Cap 60 mg ....................................................................................................247.17 Cap 80 mg ....................................................................................................329.56 Inj 20 mg Inj 100 mg 60 60 60 60 Zeldox Zeldox Zeldox Zeldox

Products with Hospital Supply Status (HSS) are in bold Expiry date of HSS period is 30 June of the year indicated unless otherwise stated.

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Per

¯Restricted 1 Patient is suffering from schizophrenia or related psychoses; and 2 Either: 2.1 An effective dose of risperidone or quetiapine has been trialled and has been discontinued, or is in the process of being discontinued, because of unacceptable side effects; or 2.2 An effective dose of risperidone or quetiapine has been trialled and has been discontinued, or is in the process of being discontinued, because of inadequate clinical response. ZUCLOPENTHIXOL ACETATE Inj 50 mg per ml, 1 ml ampoule Inj 50 mg per ml, 2 ml ampoule ZUCLOPENTHIXOL HYDROCHLORIDE Tab 10 mg .......................................................................................................31.45 100 Clopixol

Depot Injections

FLUPENTHIXOL DECANOATE Inj 20 mg per ml, 1 ml ampoule ......................................................................13.14 Inj 20 mg per ml, 2 ml ampoule ......................................................................20.90 Inj 100 mg per ml, 1 ml ampoule ....................................................................40.87 FLUPHENAZINE DECANOATE Inj 12.5 mg per 0.5 ml ampoule ......................................................................17.60 Inj 25 mg per ml, 1 ml ampoule ......................................................................27.90 Inj 100 mg per ml, 1 ml ampoule ..................................................................154.50 HALOPERIDOL DECANOATE Inj 50 mg per ml, 1 ml ampoule ......................................................................28.39 Inj 100 mg per ml, 1 ml ampoule ....................................................................55.90 ¯¯¯ 5 5 5 5 5 5 5 5 Fluanxol Fluanxol Fluanxol Modecate Modecate Modecate Haldol Haldol Concentrate

OLANZAPINE – Restricted see terms below Inj 210 mg vial ..............................................................................................280.00 1 Zyprexa Relprevv Inj 300 mg vial ..............................................................................................460.00 1 Zyprexa Relprevv Inj 405 mg vial ..............................................................................................560.00 1 Zyprexa Relprevv ¯Restricted Initiation Re-assessment required after 12 months All of the following: 1 The patient has schizophrenia; and 2 The patient has tried but failed to comply with treatment using oral atypical antipsychotic agents; and 3 The patient has been admitted to hospital or treated in respite care, or intensive outpatient or home-based treatment for 30 days or more in the last 12 months. Continuation Re-assessment required after 12 months Either: 1 The patient has had less than 12 months’ treatment with olanzapine depot injection and there is no clinical reason to discontinue treatment; or 2 The initiation of olanzapine depot injection has been associated with fewer days of intensive intervention than was the case during a corresponding period of time prior to the initiation of olanzapine depot injection. PIPOTHIAZINE PALMITATE Inj 50 mg per ml, 1 ml ampoule Inj 50 mg per ml, 2 ml ampoule

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NERVOUS SYSTEM

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

RISPERIDONE – Restricted see terms below Inj 25 mg vial ................................................................................................175.00 Inj 37.5 mg vial .............................................................................................230.00 Inj 50 mg vial ................................................................................................280.00

¯¯¯ ¯

1 1 1

Risperdal Consta Risperdal Consta Risperdal Consta

¯Restricted Initiation Re-assessment required after 6 months All of the following: 1 The patient has schizophrenia or other psychotic disorder; and 2 The patient has tried but failed to comply with treatment using oral atypical antipsychotic agents; and 3 The patient has been admitted to hospital or treated in respite care, or intensive outpatient or home-based treatment for 30 days or more in the last 12 months. Continuation Re-assessment required after 12 months Either: 1 The patient has had less than 12 months’ treatment with risperidone depot injection and there is no clinical reason to discontinue treatment; or 2 The initiation of risperidone depot injection has been associated with fewer days of intensive intervention than was the case during a corresponding period of time prior to the initiation of risperidone depot injection. ZUCLOPENTHIXOL DECANOATE Inj 200 mg per ml, 1 ml ampoule ....................................................................19.80 5 Clopixol

Anxiolytics

ALPRAZOLAM Tab 1 mg Tab 250 mcg Tab 500 mcg BUSPIRONE HYDROCHLORIDE Tab 5 mg .........................................................................................................28.00 Tab 10 mg .......................................................................................................17.00 CLONAZEPAM Tab 500 mcg .....................................................................................................6.68 Tab 2 mg .........................................................................................................12.75 DIAZEPAM Tab 2 mg .........................................................................................................11.44 Tab 5 mg .........................................................................................................13.71 LORAZEPAM Tab 1 mg .........................................................................................................19.82 Tab 2.5 mg ......................................................................................................13.49 OXAZEPAM Tab 10 mg Tab 15 mg 100 100 100 100 500 500 250 100 Pacific Buspirone Pacific Buspirone Paxam Paxam Arrow-Diazepam Arrow-Diazepam Ativan Ativan

Multiple Sclerosis Treatments

GLATIRAMER ACETATE – Restricted see terms below Inj 20 mg per ml, 1 ml syringe ¯Restricted Only for use in patients with approval by the Multiple Sclerosis Treatment Assessments Committee

Products with Hospital Supply Status (HSS) are in bold Expiry date of HSS period is 30 June of the year indicated unless otherwise stated.

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Per

INTERFERON BETA-1-ALPHA – Restricted see terms below Inj 6 million iu in 0.5 ml pen Inj 6 million iu in 0.5 ml syringe Inj 6 million iu vial ¯Restricted Only for use in patients with approval by the Multiple Sclerosis Treatment Assessments Committee INTERFERON BETA-1-BETA – Restricted see terms below Inj 8 million iu per ml, 1 ml vial ¯Restricted Only for use in patients with approval by the Multiple Sclerosis Treatment Assessments Committee

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Sedatives and Hypnotics

CHLORAL HYDRATE Oral liq 100 mg per ml Oral liq 200 mg per ml LORMETAZEPAM – Restricted: For continuation only ¬ Tab 1 mg MELATONIN – Restricted see terms below Tab modified-release 2 mg e.g. Circadin Tab 1 mg Tab 2 mg Tab 3 mg Cap 2 mg Cap 3 mg ¯Restricted For in hospital use only. For the treatment of insomnia where benzodiazepines and zopiclone are contraindicated. MIDAZOLAM Tab 7.5 mg ......................................................................................................40.00 100 Hypnovel Oral liq 2 mg per ml Inj 1 mg per ml, 5 ml ampoule ........................................................................10.00 10 Pfizer 10.75 Hypnovel Inj 5 mg per ml, 3 ml ampoule ........................................................................11.90 5 Hypnovel Pfizer NITRAZEPAM Tab 5 mg PHENOBARBITONE Inj 200 mg per ml, 1 ml ampoule TEMAZEPAM Tab 10 mg – 1% DV Nov-11 to 2014 ...............................................................1.27 TRIAZOLAM – Restricted: For continuation only ¬ Tab 125 mcg ¬ Tab 250 mcg ZOPICLONE Tab 7.5 mg – 1% DV Jan-12 to 2014...............................................................1.90 30 Apo-Zopiclone 25 Normison

118

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Per

Stimulants / ADHD Treatments

ATOMOXETINE – Restricted see terms below Cap 10 mg ....................................................................................................107.03 Cap 18 mg ....................................................................................................107.03 Cap 25 mg ....................................................................................................107.03 Cap 40 mg ....................................................................................................107.03 Cap 60 mg ....................................................................................................107.03 Cap 80 mg ....................................................................................................139.11 Cap 100 mg ..................................................................................................139.11 ¯¯¯¯¯¯¯ ¯ 28 28 28 28 28 28 28 Strattera Strattera Strattera Strattera Strattera Strattera Strattera

¯Restricted All of the following: 1 Patient has ADHD (Attention Deficit and Hyperactivity Disorder) diagnosed according to DSM-IV or ICD 10 criteria; and 2 Once-daily dosing; and 3 Any of the following: 3.1 Treatment with a subsidised formulation of a stimulant has resulted in the development or worsening of serious adverse reactions or where the combination of subsidised stimulant treatment with another agent would pose an unacceptable medical risk; or 3.2 Treatment with a subsidised formulation of a stimulant has resulted in worsening of co-morbid substance abuse or there is a significant risk of diversion with subsidised stimulant therapy; or 3.3 An effective dose of a subsidised formulation of a stimulant has been trialled and has been discontinued because of inadequate clinical response; or 3.4 Treatment with a subsidised formulation of a stimulant is considered inappropriate because the patient has a history of psychoses or has a first-degree relative with schizophrenia; and 4 The patient will not be receiving treatment with atomoxetine in combination with a subsidised formulation of a stimulant, except for the purposes of transitioning from subsidised stimulant therapy to atomoxetine. Note: A "subsidised formulation of a stimulant" refers to currently listed methylphenidate hydrochloride tablet formulations (immediaterelease, sustained-release and extended-release) or dexamphetamine sulphate tablets. CAFFEINE Tab 100 mg DEXAMPHETAMINE SULPHATE – Restricted see terms below Tab 5 mg – 1% DV Mar-13 to 2015................................................................16.50 100 PSM ¯Restricted ADHD Paediatrician or psychiatrist Patient has ADHD (Attention Deficit and Hyperactivity Disorder), diagnosed according to DSM-IV or ICD 10 criteria Narcolepsy Neurologist or respiratory specialist Patient suffers from narcolepsy

Products with Hospital Supply Status (HSS) are in bold Expiry date of HSS period is 30 June of the year indicated unless otherwise stated.

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NERVOUS SYSTEM

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Per

METHYLPHENIDATE HYDROCHLORIDE – Restricted see terms below Tab extended-release 18 mg ..........................................................................58.96 Tab extended-release 27 mg ..........................................................................65.44 Tab extended-release 36 mg ..........................................................................71.93 Tab extended-release 54 mg ..........................................................................86.24 Tab immediate-release 5 mg ............................................................................3.20 Tab immediate-release 10 mg ..........................................................................3.00 Tab immediate-release 20 mg ..........................................................................7.85 Tab sustained-release 20 mg .........................................................................10.95 50.00 Cap modified-release 10 mg ..........................................................................19.50 Cap modified-release 20 mg ..........................................................................25.50 Cap modified-release 30 mg ..........................................................................31.90 Cap modified-release 40 mg ..........................................................................38.25

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30 30 30 30 30 30 30 30 100 30 30 30 30

Concerta Concerta Concerta Concerta Rubifen Ritalin Rubifen Rubifen Rubifen SR Ritalin SR Ritalin LA Ritalin LA Ritalin LA Ritalin LA

¯Restricted ADHD (immediate-release and sustained-release formulations) Paediatrician or psychiatrist Patient has ADHD (Attention Deficit and Hyperactivity Disorder), diagnosed according to DSM-IV or ICD 10 criteria Narcolepsy (immediate-release and sustained-release formulations) Neurologist or respiratory specialist Patient suffers from narcolepsy Extended-release and modified-release formulations Paediatrician or psychiatrist Both: 1 Patient has ADHD (Attention Deficit and Hyperactivity Disorder), diagnosed according to DSM-IV or ICD 10 criteria; and 2 Either: 2.1 Patient is taking a currently listed formulation of methylphenidate hydrochloride (immediate-release or sustainedrelease) which has not been effective due to significant administration and/or compliance difficulties; or 2.2 There is significant concern regarding the risk of diversion or abuse of immediate-release methylphenidate hydrochloride. MODAFINIL – Restricted see terms below Tab 100 mg ¯Restricted Neurologist or respiratory specialist All of the following: 1 The patient has a diagnosis of narcolepsy and has excessive daytime sleepiness associated with narcolepsy occurring almost daily for three months or more; and 2 Either: 2.1 The patient has a multiple sleep latency test with a mean sleep latency of less than or equal to 10 minutes and 2 or more sleep onset rapid eye movement periods; or 2.2 The patient has at least one of: cataplexy, sleep paralysis or hypnagogic hallucinations; and 3 Either: 3.1 An effective dose of a listed formulation of methylphenidate or dexamphetamine has been trialled and discontinued because of intolerable side effects; or 3.2 Methylphenidate and dexamphetamine are contraindicated.

120

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Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

Treatments for Dementia

DONEPEZIL HYDROCHLORIDE Tab 5 mg ...........................................................................................................7.71 Tab 10 mg .......................................................................................................14.06 90 90 Donepezil-Rex Donepezil-Rex

Treatments for Substance Dependence

BUPRENORPHINE WITH NALOXONE – Restricted see terms below Tab 2 mg with naloxone 0.5 mg ......................................................................57.40 28 Suboxone Tab 8 mg with naloxone 2 mg .......................................................................166.00 28 Suboxone ¯Restricted Detoxification All of the following: 1 Patient is opioid dependent; and 2 Patient is currently engaged with an opioid treatment service approved by the Ministry of Health; and 3 Prescriber works in an opioid treatment service approved by the Ministry of Health. Maintenance treatment All of the following: 1 Patient is opioid dependent; and 2 Patient will not be receiving methadone; and 3 Patient is currently enrolled in an opioid substitution treatment program in a service approved by the Ministry of Health; and 4 Prescriber works in an opioid treatment service approved by the Ministry of Health. BUPROPION HYDROCHLORIDE Tab modified-release 150 mg – 1% DV Oct-13 to 2016...................................4.97 30 Zyban 100 Antabuse ¯¯ ¯ ¯

DISULFIRAM Tab 200 mg .....................................................................................................24.30

NALTREXONE HYDROCHLORIDE – Restricted see terms below Tab 50 mg – 1% DV Sep-13 to 2016 .............................................................76.00 30 Naltraccord ¯Restricted Alcohol dependence Both: 1 Patient is currently enrolled, or is planned to be enrolled, in a recognised comprehensive treatment programme for alcohol dependence; and 2 Naltrexone is to be prescribed by, or on the recommendation of, a physician working in an Alcohol and Drug Service. Constipation For the treatment of opioid-induced constipation NICOTINE – Some items restricted see terms on the next page Gum 2 mg – 5% DV Oct-11 to 2014 ..............................................................36.47 384 Habitrol (Classic) Habitrol (Fruit) Habitrol (Mint) Gum 4 mg – 5% DV Oct-11 to 2014 ..............................................................42.04 384 Habitrol (Classic) Habitrol (Fruit) Habitrol (Mint) Patch 7 mg per 24 hours – 5% DV Jul-11 to 2014 ........................................18.13 28 Habitrol Patch 14 mg per 24 hours – 5% DV Jul-11 to 2014 ......................................18.81 28 Habitrol Patch 21 mg per 24 hours – 5% DV Jul-11 to 2014 ......................................19.14 28 Habitrol Lozenge 1 mg – 5% DV Jul-11 to 2014 .........................................................19.94 216 Habitrol Lozenge 2 mg – 5% DV Jul-11 to 2014 .........................................................24.27 216 Habitrol Soln for inhalation 15 mg cartridge e.g. Nicorette Inhalator

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NERVOUS SYSTEM

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Per

¯Restricted Any of the following: 1 For perioperative use in patients who have a ’nil by mouth’ instruction; or 2 For use within mental health inpatient units; or 3 For acute use in agitated patients who are unable to leave the hospital facilities. VARENICLINE – Restricted see terms below Tab 0.5 mg × 11 and 1 mg × 14 ....................................................................60.48 25 Champix Tab 1 mg .........................................................................................................67.74 28 Champix 135.48 56 Champix ¯Restricted All of the following: 1 Short-term therapy as an aid to achieving abstinence in a patient who has indicated that they are ready to cease smoking; and 2 The patient is part of, or is about to enrol in, a comprehensive support and counselling smoking cessation programme, which includes prescriber or nurse monitoring; and 3 Either: 3.1 The patient has tried but failed to quit smoking after at least two separate trials of nicotine replacement therapy, at least one of which included the patient receiving comprehensive advice on the optimal use of nicotine replacement therapy; or 3.2 The patient has tried but failed to quit smoking using bupropion or nortriptyline; and 4 The patient has not used funded varenicline in the last 12 months; and 5 Varenicline is not to be used in combination with other pharmacological smoking cessation treatments and the patient has agreed to this; and 6 The patient is not pregnant; and 7 The patient will not be prescribed more than 3 months’ funded varenicline in a 12 month period.

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ONCOLOGY AGENTS AND IMMUNOSUPPRESSANTS

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Per

Chemotherapeutic Agents Alkylating Agents

BUSULFAN Tab 2 mg .........................................................................................................59.50 Inj 6 mg per ml, 10 ml ampoule CARMUSTINE Inj 100 mg vial CHLORAMBUCIL Tab 2 mg CYCLOPHOSPHAMIDE Tab 50 mg .......................................................................................................79.00 158.00 Inj 1 g vial – 1% DV Nov-11 to 2014..............................................................26.70 Inj 2 g vial – 1% DV Nov-11 to 2014..............................................................56.90 IFOSFAMIDE Inj 1 g vial .......................................................................................................96.00 Inj 2 g vial .....................................................................................................180.00 LOMUSTINE Cap 10 mg – 1% DV Sep-11 to 2014...........................................................132.59 Cap 40 mg – 1% DV Sep-11 to 2014...........................................................399.15 MELPHALAN Tab 2 mg Inj 50 mg vial THIOTEPA Inj 15 mg vial 50 100 1 1 1 1 20 20 Endoxan Procytox Endoxan Endoxan Holoxan Holoxan Ceenu Ceenu 100 Myleran

Anthracyclines and Other Cytotoxic Antibiotics

BLEOMYCIN SULPHATE Inj 15,000 iu (10 mg) vial DACTINOMYCIN [ACTINOMYCIN D] Inj 0.5 mg vial DAUNORUBICIN Inj 2 mg per ml, 10 ml vial – 1% DV Aug-13 to 2016 ...................................118.72 DOXORUBICIN HYDROCHLORIDE Note: DV limit applies to all 50 mg presentations of doxorubicin hydrochloride. Inj 2 mg per ml, 5 ml vial Inj 2 mg per ml, 25 ml vial – 1% DV Mar-13 to 2015......................................17.00 Inj 50 mg vial Inj 2 mg per ml, 50 ml vial Inj 2 mg per ml, 100 ml vial – 1% DV Mar-13 to 2015....................................65.00 1 Pfizer

1

Arrow-Doxorubicin

1

Arrow-Doxorubicin

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Per

EPIRUBICIN HYDROCHLORIDE Inj 2 mg per ml, 5 ml vial .................................................................................25.00 Inj 2 mg per ml, 25 ml vial – 1% DV Aug-12 to 2015 .....................................39.38 Inj 2 mg per ml, 50 ml vial – 1% DV Aug-12 to 2015 .....................................58.20 Inj 2 mg per ml, 100 ml vial – 1% DV Aug-12 to 2015 ...................................94.50 IDARUBICIN HYDROCHLORIDE Cap 5 mg ......................................................................................................115.00 Cap 10 mg ....................................................................................................144.50 Inj 5 mg vial – 1% DV Sep-12 to 2015 .........................................................100.00 Inj 10 mg vial – 1% DV Sep-12 to 2015 .......................................................200.00 MITOMYCIN C Inj 5 mg vial – 1% DV Oct-13 to 2016............................................................79.75 MITOZANTRONE Inj 2 mg per ml, 5 ml vial ...............................................................................110.00 Inj 2 mg per ml, 10 ml vial .............................................................................100.00 Inj 2 mg per ml, 12.5 ml vial ..........................................................................407.50

1 1 1 1

Epirubicin Ebewe DBL Epirubicin Hydrochloride DBL Epirubicin Hydrochloride DBL Epirubicin Hydrochloride Zavedos Zavedos Zavedos Zavedos Arrow Mitozantrone Ebewe Mitozantrone Ebewe Onkotrone

1 1 1 1 1 1 1 1

Antimetabolites

CAPECITABINE Tab 150 mg ...................................................................................................115.00 Tab 500 mg ...................................................................................................705.00 CLADRIBINE Inj 2 mg per ml, 5 ml vial Inj 1 mg per ml, 10 ml vial ..........................................................................5,249.72 CYTARABINE Inj 20 mg per ml, 5 ml vial – 1% DV Nov-13 to 2016 .....................................55.00 Inj 20 mg per ml, 25 ml vial .............................................................................18.15 Inj 100 mg per ml, 10 ml vial – 1% DV Nov-13 to 2016 ...................................8.83 Inj 100 mg per ml, 20 ml vial – 1% DV Nov-13 to 2016 .................................17.65 FLUDARABINE PHOSPHATE Tab 10 mg – 1% DV Jun-12 to 2015............................................................433.50 Inj 50 mg vial – 1% DV Sep-11 to 2014 .......................................................525.00 FLUOROURACIL Inj 25 mg per ml, 100 ml vial ...........................................................................13.55 Inj 50 mg per ml, 10 ml vial .............................................................................26.25 Inj 50 mg per ml, 20 ml vial ...............................................................................7.50 Inj 50 mg per ml, 50 ml vial .............................................................................18.00 Inj 50 mg per ml, 100 ml vial ...........................................................................34.50 GEMCITABINE Inj 10 mg per ml, 100 ml vial ...........................................................................62.50 Inj 10 mg per ml, 20 ml vial .............................................................................12.50 Inj 200 mg vial ................................................................................................12.50 Inj 1 g vial .......................................................................................................62.50 60 120 Xeloda Xeloda

7 5 1 1 1 20 5 1 5 1 1 1 1 1 1 1

Leustatin Pfizer Pfizer Pfizer Pfizer Fludara Oral Fludarabine Ebewe Mayne Fluorouracil Ebewe Fluorouracil Ebewe Fluorouracil Ebewe Fluorouracil Ebewe Gemcitabine Ebewe Gemcitabine Ebewe Gemcitabine Actavis 200 DBL Gemcitabine Gemcitabine Actavis 1000

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ONCOLOGY AGENTS AND IMMUNOSUPPRESSANTS

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Per

MERCAPTOPURINE Tab 50 mg – 1% DV Oct-13 to 2016 ..............................................................49.41 METHOTREXATE Tab 2.5 mg ........................................................................................................5.22 Tab 10 mg .......................................................................................................40.93 Inj 2.5 mg per ml, 2 ml vial Inj 7.5 mg prefilled syringe – 1% DV Jan-14 to 2016.....................................17.19 Inj 10 mg prefilled syringe – 1% DV Jan-14 to 2016......................................17.25 Inj 15 mg prefilled syringe – 1% DV Jan-14 to 2016......................................17.38 Inj 20 mg prefilled syringe – 1% DV Jan-14 to 2016......................................17.50 Inj 25 mg prefilled syringe – 1% DV Jan-14 to 2016......................................17.63 Inj 30 mg prefilled syringe – 1% DV Jan-14 to 2016......................................17.75 Inj 25 mg per ml, 2 ml vial – 1% DV Sep-13 to 2016 .....................................20.20 Inj 25 mg per ml, 20 ml vial – 1% DV Sep-13 to 2016 ...................................27.78 Inj 100 mg per ml, 10 ml vial – 1% DV Nov-08 to 2014 .................................25.00 Inj 100 mg per ml, 50 ml vial – 1% DV Nov-08 to 2014 ...............................125.00 THIOGUANINE Tab 40 mg

25 30 50 1 1 1 1 1 1 5 1 1 1

Puri-nethol Methoblastin Methoblastin Methotrexate Sandoz Methotrexate Sandoz Methotrexate Sandoz Methotrexate Sandoz Methotrexate Sandoz Methotrexate Sandoz Hospira Hospira Methotrexate Ebewe Methotrexate Ebewe

Other Cytotoxic Agents

AMSACRINE Inj 50 mg per ml, 1.5 ml ampoule ANAGRELIDE HYDROCHLORIDE Cap 0.5 mg ARSENIC TRIOXIDE Inj 1 mg per ml, 10 ml vial ..........................................................................4,817.00 ¯¯ 10 AFT

BORTEZOMIB – Restricted see terms below Inj 1 mg vial ..................................................................................................540.70 1 Velcade Inj 3.5 mg vial ............................................................................................1,892.50 1 Velcade ¯Restricted Initiation - treatment naive multiple myeloma/amyloidosis Both: 1 Either: 1.1 The patient has treatment-naive symptomatic multiple myeloma; or 1.2 The patient has treatment-naive symptomatic systemic AL amyloidosis *; and 2 Maximum of 9 treatment cycles. Note: Indications marked with * are Unapproved Indications. Initiation - relapsed/refractory multiple myeloma/amyloidosis All of the following: 1 Either: 1.1 The patient has relapsed or refractory multiple myeloma; or 1.2 The patient has relapsed or refractory systemic AL amyloidosis *; and 2 The patient has received only one prior front line chemotherapy for multiple myeloma or amyloidosis; and 3 The patient has not had prior publicly funded treatment with bortezomib; and 4 Maximum of 4 treatment cycles. Note: Indications marked with * are Unapproved Indications. Continuation - relapsed/refractory multiple myeloma/amyloidosis Both: continued. . .

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ONCOLOGY AGENTS AND IMMUNOSUPPRESSANTS

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Per

continued. . . 1 The patient’s disease obtained at least a partial response from treatment with bortezomib at the completion of cycle 4; and 2 Maximum of 4 further treatment cycles (making a total maximum of 8 consecutive treatment cycles). Notes: Responding relapsed/refractory multiple myeloma patients should receive no more than 2 additional cycles of treatment beyond the cycle at which a confirmed complete response was first achieved. A line of therapy is considered to comprise either: 1 A known therapeutic chemotherapy regimen and supportive treatments; or 2 A transplant induction chemotherapy regimen, stem cell transplantation and supportive treatments. Refer to datasheet for recommended dosage and number of doses of bortezomib per treatment cycle. COLASPASE [L-ASPARAGINASE] Inj 10,000 iu vial ............................................................................................102.32 1 Leunase DACARBAZINE Inj 200 mg vial – 1% DV Oct-13 to 2016........................................................51.84 ETOPOSIDE Cap 50 mg ....................................................................................................340.73 Cap 100 mg ..................................................................................................340.73 Inj 20 mg per ml, 5 ml vial ...............................................................................25.00 ETOPOSIDE (AS PHOSPHATE) Inj 100 mg vial – 1% DV Sep-11 to 2014 .......................................................40.00 HYDROXYUREA Cap 500 mg ....................................................................................................31.76 IRINOTECAN HYDROCHLORIDE Inj 20 mg per ml, 2 ml vial – 1% DV Nov-12 to 2015 .......................................9.34 Inj 20 mg per ml, 5 ml vial – 1% DV Nov-12 to 2015 .....................................23.34 ¯ 1 20 10 1 1 100 1 1 Hospira Vepesid Vepesid Mayne Etopophos Hydrea Irinotecan Actavis 40 Irinotecan Actavis 100

PEGASPARGASE – Restricted see terms below Inj 750 iu per ml, 5 ml vial ..........................................................................3,005.00 1 Oncaspar ¯Restricted Newly diagnosed ALL Limited to 12 months’ treatment All of the following: 1 The patient has newly diagnosed acute lymphoblastic leukaemia; and 2 Pegaspargase to be used with a contemporary intensive multi-agent chemotherapy treatment protocol; and 3 Treatment is with curative intent. Relapsed ALL Limited to 12 months’ treatment All of the following: 1 The patient has relapsed acute lymphoblastic leukaemia; and 2 Pegaspargase to be used with a contemporary intensive multi-agent chemotherapy treatment protocol; and 3 Treatment is with curative intent. PENTOSTATIN [DEOXYCOFORMYCIN] Inj 10 mg vial PROCARBAZINE HYDROCHLORIDE Cap 50 mg ....................................................................................................225.00 TEMOZOLOMIDE – Restricted see terms on the next page Cap 5 mg – 1% DV Sep-13 to 2016.................................................................8.00 Cap 20 mg – 1% DV Sep-13 to 2016.............................................................36.00 Cap 100 mg – 1% DV Sep-13 to 2016.........................................................175.00 Cap 250 mg – 1% DV Sep-13 to 2016.........................................................410.00 50 5 5 5 5 Natulan Temaccord Temaccord Temaccord Temaccord

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ONCOLOGY AGENTS AND IMMUNOSUPPRESSANTS

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Per

¯Restricted All of the following: 1 Either: 1.1 Patient has newly diagnosed glioblastoma multiforme; or 1.2 Patient has newly diagnosed anaplastic astrocytoma*; and 2 Temozolomide is to be (or has been) given concomitantly with radiotherapy; and 3 Following concomitant treatment temozolomide is to be used for a maximum of six cycles of 5 days treatment, at a maximum dose of 200 mg/m2 . Notes: Indication marked with a * is an Unapproved Indication. Studies of temozolomide show that its benefit is predominantly in those patients with a good performance status (WHO grade 0 or 1 or Karnofsky score >80), and in patients who have had at least a partial resection of the tumour. THALIDOMIDE – Restricted see terms below Cap 50 mg ....................................................................................................504.00 28 Thalomid Cap 100 mg ...............................................................................................1,008.00 28 Thalomid ¯Restricted Initiation Either: 1 The patient has multiple myeloma; or 2 The patient has systemic AL amyloidosis*; or 3 The patient has erythema nodosum leprosum. Continuation Patient has obtained a response from treatment during the initial approval period. Notes: Prescription must be written by a registered prescriber in the thalidomide risk management programme operated by the supplier. Maximum dose of 400 mg daily as monotherapy or in a combination therapy regimen. Indication marked with * is an Unapproved Indication TRETINOIN Cap 10 mg ....................................................................................................435.90 100 Vesanoid

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Platinum Compounds

CARBOPLATIN Inj 10 mg per ml, 5 ml vial ...............................................................................20.00 Inj 10 mg per ml, 15 ml vial – 1% DV Jan-13 to 2015....................................19.50 Inj 10 mg per ml, 45 ml vial – 1% DV Jan-13 to 2015....................................48.50 Inj 10 mg per ml, 100 ml vial .........................................................................105.00 CISPLATIN Inj 1 mg per ml, 50 ml vial ...............................................................................15.00 Inj 1 mg per ml, 100 ml vial .............................................................................21.00 OXALIPLATIN Inj 50 mg vial – 1% DV Aug-12 to 2015.........................................................15.32 Inj 100 mg vial – 1% DV Aug-12 to 2015.......................................................25.01 1 1 1 1 1 1 1 1 Carboplatin Ebewe Carbaccord Carbaccord Carboplatin Ebewe Cisplatin Ebewe Cisplatin Ebewe Oxaliplatin Actavis 50 Oxaliplatin Actavis 100

Protein-Tyrosine Kinase Inhibitors

DASATINIB – Restricted see terms below Tab 20 mg ..................................................................................................3,774.06 Tab 50 mg ..................................................................................................6,214.20 Tab 70 mg ..................................................................................................7,692.58 Tab 100 mg ................................................................................................6,214.20 ¯Restricted For use in patients with approval from the CML/GIST Co-ordinator ¯¯¯¯ 60 60 60 30 Sprycel Sprycel Sprycel Sprycel

Products with Hospital Supply Status (HSS) are in bold Expiry date of HSS period is 30 June of the year indicated unless otherwise stated.

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ONCOLOGY AGENTS AND IMMUNOSUPPRESSANTS

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Per

ERLOTINIB – Restricted see terms below Tab 100 mg ................................................................................................1,133.00 Tab 150 mg ................................................................................................1,700.00

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30 30

Tarceva Tarceva

¯Restricted Initiation Re-assessment required after 3 months Either: 1 All of the following: 1.1 Patient has locally advanced or metastatic, unresectable, non-squamous Non Small Cell Lung Cancer (NSCLC); and 1.2 There is documentation confirming that the disease expresses activating mutations of EGFR tyrosine kinase; and 1.3 Either: 1.3.1 Patient is treatment naive; or 1.3.2 Both: 1.3.2.1 Patient has documented disease progression following treatment with first line platinum based chemotherapy; and 1.3.2.2 Patient has not received prior treatment with gefitinib; and 1.4 Erlotinib is to be given for a maximum of 3 months, or 2 The patient received funded erlotinib prior to 31 December 2013 and radiological assessment (preferably including CT scan) indicates NSCLC has not progressed. Continuation Re-assessment required after 6 months Radiological assessment (preferably including CT scan) indicates NSCLC has not progressed. GEFITINIB – Restricted see terms below Tab 250 mg ................................................................................................1,700.00 30 Iressa ¯Restricted Initiation Re-assessment required after 3 months Both 1 Patient has treatment naive locally advanced, or metastatic, unresectable, non-squamous Non Small Cell Lung Cancer (NSCLC); and 2 There is documentation confirming that disease expresses activating mutations of EGFR tyrosine kinase. Continuation Re-assessment required after 6 months Radiological assessment (preferably including CT scan) indicates NSCLC has not progressed. IMATINIB MESILATE – Restricted see terms below Tab 100 mg ................................................................................................2,400.00 60 Glivec ¯Restricted For use in patients with approval from the CML/GIST Co-ordinator LAPATINIB – Restricted see terms below Tab 250 mg ................................................................................................1,899.00 70 Tykerb ¯Restricted Initiation Re-assessment required after 12 months Either: 1 All of the following: 1.1 The patient has metastatic breast cancer expressing HER-2 IHC 3+ or ISH+ (including FISH or other current technology); and 1.2 The patient has not previously received trastuzumab treatment for HER 2 positive metastatic breast cancer; and continued. . .

128

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Per

continued. . . 1.3 Lapatinib not to be given in combination with trastuzumab; and 1.4 Lapatinib to be discontinued at disease progression; or 2 All of the following: 2.1 The patient has metastatic breast cancer expressing HER-2 IHC 3+ or ISH+ (including FISH or other current technology); and 2.2 The patient started trastuzumab for metastatic breast cancer but discontinued trastuzumab within 3 months of starting treatment due to intolerance; and 2.3 The cancer did not progress whilst on trastuzumab; and 2.4 Lapatinib not to be given in combination with trastuzumab; and 2.5 Lapatinib to be discontinued at disease progression. Continuation Re-assessment required after 12 months All of the following: 1 The patient has metastatic breast cancer expressing HER-2 IHC 3+ or ISH+ (including FISH or other current technology); and 2 The cancer has not progressed at any time point during the previous 12 months whilst on lapatinib; and 3 Lapatinib not to be given in combination with trastuzumab; and 4 Lapatinib to be discontinued at disease progression. PAZOPANIB – Restricted see terms below Tab 200 mg ................................................................................................1,334.70 30 Votrient Tab 400 mg ................................................................................................2,669.40 30 Votrient ¯Restricted Initiation Re-assessment required after 3 months All of the following: 1 The patient has metastatic renal cell carcinoma; and 2 Any of the following: 2.1 The patient is treatment naive; or 2.2 The patient has only received prior cytokine treatment; or 2.3 Both: 2.3.1 The patient has discontinued sunitinib within 3 months of starting treatment due to intolerance; and 2.3.2 The cancer did not progress whilst on sunitinib; and 3 The patient has good performance status (WHO/ECOG grade 0-2); and 4 The disease is of predominant clear cell histology; and 5 The patient has intermediate or poor prognosis defined as any of the following: 5.1 Lactate dehydrogenase level > 1.5 times upper limit of normal; or 5.2 Haemoglobin level < lower limit of normal; or 5.3 Corrected serum calcium level > 10 mg/dL (2.5 mmol/L); or 5.4 Interval of < 1 year from original diagnosis to the start of systemic therapy; or 5.5 Karnofsky performance score of ≤ 70; or 5.6 ≥ 2 sites of organ metastasis. Continuation Re-assessment required after 3 months Both: 1 No evidence of disease progression; and 2 The treatment remains appropriate and the patient is benefiting from treatment. Notes: Pazopanib treatment should be stopped if disease progresses. Poor prognosis patients are defined as having at least 3 of criteria 5.1-5.6. Intermediate prognosis patients are defined as having 1 or 2 of criteria 5.1-5.6.

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ONCOLOGY AGENTS AND IMMUNOSUPPRESSANTS

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Per

SUNITINIB – Restricted see terms below Cap 12.5 mg ..............................................................................................2,315.38 Cap 25 mg .................................................................................................4,630.77 Cap 50 mg .................................................................................................9,261.54

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28 28 28

Sutent Sutent Sutent

¯Restricted Re-assessment required after 3 months Initiation - RCC 1 The patient has metastatic renal cell carcinoma; and 2 Any of the following: 2.1 The patient is treatment naive; or 2.2 The patient has only received prior cytokine treatment; or 2.3 The patient has only received prior treatment with an investigational agent within the confines of a bona fide clinical trial which has Ethics Committee approval; or 2.4 Both: 2.4.1 The patient has discontinued pazopanib within 3 months of starting treatment due to intolerance; and 2.4.2 The cancer did not progress whilst on pazopanib; and 3 The patient has good performance status (WHO/ECOG grade 0-2); and 4 The disease is of predominant clear cell histology; and 5 The patient has intermediate or poor prognosis defined as any of the following: 5.1 Lactate dehydrogenase level > 1.5 times upper limit of normal; or 5.2 Haemoglobin level < lower limit of normal; or 5.3 Corrected serum calcium level > 10 mg/dL (2.5 mmol/L); or 5.4 Interval of < 1 year from original diagnosis to the start of systemic therapy; or 5.5 Karnofsky performance score of ≤ 70; or 5.6 ≥ 2 sites of organ metastasis; and 6 Sunitinib to be used for a maximum of 2 cycles. Continuation - RCC Re-assessment required after 3 months Both: 1 No evidence of disease progression; and 2 The treatment remains appropriate and the patient is benefiting from treatment. Initiation - GIST Re-assessment required after 3 months Both: 1 The patient has unresectable or metastatic malignant gastrointestinal stromal tumour (GIST); and 2 Either: 2.1 The patient’s disease has progressed following treatment with imatinib; or 2.2 The patient has documented treatment-limiting intolerance, or toxicity to, imatinib. Continuation - GIST Re-assessment required after 6 months Both: The patient has responded to treatment or has stable disease as determined by Choi’s modified CT response evaluation criteria as follows: 1 Any of the following: 1.1 The patient has had a complete response (disappearance of all lesions and no new lesions); or 1.2 The patient has had a partial response (a decrease in size of ≥ 10% or decrease in tumour density in Hounsfield Units (HU) of ≥ 15% on CT and no new lesions and no obvious progression of non-measurable disease); or 1.3 The patient has stable disease (does not meet criteria the two above) and does not have progressive disease and no symptomatic deterioration attributed to tumour progression; and continued. . .

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Per

continued. . . 2 The treatment remains appropriate and the patient is benefiting from treatment. Notes: RCC - Sunitinib treatment should be stopped if disease progresses. Poor prognosis patients are defined as having at least 3 of criteria 5.1-5.6. Intermediate prognosis patients are defined as having 1 or 2 of criteria 5.1-5.6. GIST - It is recommended that response to treatment be assessed using Choi’s modified CT response evaluation criteria (J Clin Oncol, 2007, 25:1753-1759). Progressive disease is defined as either: an increase in tumour size of ≥ 10% and not meeting criteria of partial response (PR) by tumour density (HU) on CT; or: new lesions, or new intratumoral nodules, or increase in the size of the existing intratumoral nodules.

Taxanes

DOCETAXEL Inj 10 mg per ml, 2 ml vial – 1% DV May-13 to 2014 .....................................48.75 Inj 10 mg per ml, 8 ml vial – 1% DV May-13 to 2014 ...................................195.00 PACLITAXEL Inj 6 mg per ml, 5 ml vial – 1% DV Oct-08 to 2014......................................137.50 Inj 6 mg per ml, 16.7 ml vial – 1% DV Oct-08 to 2014...................................91.67 Inj 6 mg per ml, 25 ml vial – 1% DV Oct-08 to 2014....................................137.50 1 1 5 1 1 Docetaxel Sandoz Docetaxel Sandoz Paclitaxel Ebewe Paclitaxel Actavis Paclitaxel Ebewe Anzatax Paclitaxel Actavis Paclitaxel Ebewe Anzatax Paclitaxel Actavis Paclitaxel Ebewe Paclitaxel Ebewe

Inj 6 mg per ml, 50 ml vial – 1% DV Oct-08 to 2014....................................275.00

1

Inj 6 mg per ml, 100 ml vial – 1% DV Oct-08 to 2014..................................550.00

1

Treatment of Cytotoxic-Induced Side Effects

CALCIUM FOLINATE Tab 15 mg – 1% DV Nov-11 to 2014 .............................................................82.45 Inj 3 mg per ml, 1 ml ampoule Inj 10 mg per ml, 5 ml ampoule – 1% DV Sep-08 to 2014.............................24.50 Inj 10 mg per ml, 10 ml vial – 1% DV Sep-08 to 2014 .....................................9.75 Inj 10 mg per ml, 30 ml vial – 1% DV Sep-08 to 2014 ...................................30.00 Inj 10 mg per ml, 100 ml vial – 1% DV Sep-08 to 2014 .................................90.00 MESNA Tab 400 mg – 1% DV Oct-13 to 2016 ..........................................................227.50 Tab 600 mg – 1% DV Oct-13 to 2016 ..........................................................339.50 Inj 100 mg per ml, 4 ml ampoule – 1% DV Oct-13 to 2016 .........................148.05 Inj 100 mg per ml, 10 ml ampoule – 1% DV Oct-13 to 2016 .......................339.90 10 DBL Leucovorin Calcium Calcium Folinate Ebewe Calcium Folinate Ebewe Calcium Folinate Ebewe Calcium Folinate Ebewe Uromitexan Uromitexan Uromitexan Uromitexan

5 1 1 1

50 50 15 15

Vinca Alkaloids

VINBLASTINE SULPHATE Inj 1 mg per ml, 10 ml vial .............................................................................137.50 5 Mayne

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ONCOLOGY AGENTS AND IMMUNOSUPPRESSANTS

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Per

VINCRISTINE SULPHATE Inj 1 mg per ml, 1 ml vial – 1% DV Sep-13 to 2016 .......................................64.80 Inj 1 mg per ml, 2 ml vial – 1% DV Sep-13 to 2016 .......................................69.60 VINORELBINE Inj 10 mg per ml, 1 ml vial – 1% DV Sep-12 to 2015 .....................................12.85 Inj 10 mg per ml, 5 ml vial – 1% DV Sep-12 to 2015 .....................................64.25

5 5 1 1

Hospira Hospira Navelbine Navelbine

Endocrine Therapy

BICALUTAMIDE – Restricted see terms below Tab 50 mg – 1% DV Nov-11 to 2014 .............................................................10.00 ¯Restricted For the treatment of advanced prostate cancer FLUTAMIDE Tab 250 mg .....................................................................................................55.00 MEGESTROL ACETATE Tab 160 mg – 1% DV Jan-13 to 2015............................................................51.55 OCTREOTIDE – Some items restricted see terms below Inj 50 mcg per ml, 1 ml ampoule – 1% DV May-12 to 2014...........................19.24 Inj 100 mcg per ml, 1 ml ampoule – 1% DV May-12 to 2014.........................36.38 Inj 500 mcg per ml, 1 ml ampoule – 1% DV May-12 to 2014.......................131.25 Inj 10 mg vial .............................................................................................1,772.50 Inj 20 mg vial .............................................................................................2,358.75 Inj 30 mg vial .............................................................................................2,951.25 ¯ ¯¯¯ 28 Bicalaccord

100 30 5 5 5 1 1 1

Flutamin Apo-Megestrol Octreotide MaxRx Octreotide MaxRx Octreotide MaxRx Sandostatin LAR Sandostatin LAR Sandostatin LAR

¯Restricted Note: restriction applies only to the long-acting formulations of octreotide Malignant bowel obstruction All of the following: 1 The patient has nausea* and vomiting* due to malignant bowel obstruction*; and 2 Treatment with antiemetics, rehydration, antimuscarinic agents, corticosteroids and analgesics for at least 48 hours has failed; and 3 Octreotide to be given at a maximum dose 1500 mcg daily for up to 4 weeks. Note: Indications marked with * are Unapproved Indications Initiation - acromegaly Re-assessment required after 3 months Both: 1 The patient has acromegaly; and 2 Any of the following: 2.1 Treatment with surgery, radiotherapy and a dopamine agonist has failed; or 2.2 Treatment with octreotide is for an interim period while awaiting the effects of radiotherapy and a dopamine agonist has failed; or 2.3 The patient is unwilling, or unable, to undergo surgery and/or radiotherapy. Continuation - acromegaly Both: 1 IGF1 levels have decreased since starting octreotide; and 2 The treatment remains appropriate and the patient is benefiting from treatment. Note: In patients with acromegaly octreotide treatment should be discontinued if IGF1 levels have not decreased after 3 months treatment. In patients treated with radiotherapy octreotide treatment should be withdrawn every 2 years, for 1 month, for assessment continued. . .

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continued. . . of remission. Octreotide treatment should be stopped where there is biochemical evidence of remission (normal IGF1 levels) following octreotide treatment withdrawal for at least 4 weeks. Other indications Any of the following: 1 VIPomas and glucagonomas - for patients who are seriously ill in order to improve their clinical state prior to definitive surgery; or 2 Both: 2.1 Gastrinoma; and 2.2 Either: 2.2.1 Patient has failed surgery; or 2.2.2 Patient in metastatic disease after H2 antagonists (or proton pump inhibitors) have failed; or 3 Both: 3.1 Insulinomas; and 3.2 Surgery is contraindicated or has failed; or 4 For pre-operative control of hypoglycaemia and for maintenance therapy; or 5 Both: 5.1 Carcinoid syndrome (diagnosed by tissue pathology and/or urinary 5HIAA analysis); and 5.2 Disabling symptoms not controlled by maximal medical therapy. TAMOXIFEN CITRATE Tab 10 mg .........................................................................................................2.63 60 Genox 17.50 100 Genox Tab 20 mg – 1% DV Jun-11 to 2014................................................................2.63 30 Genox 8.75 100 Genox

Aromatase Inhibitors

ANASTROZOLE Tab 1 mg .........................................................................................................26.55 EXEMESTANE Tab 25 mg – 1% DV Jun-11 to 2014..............................................................22.57 LETROZOLE Tab 2.5 mg – 1% DV Oct-12 to 2015 ...............................................................4.85 30 Aremed DP-Anastrozole Aromasin Letraccord

30 30

Immunosuppressants Calcineurin Inhibitors

CICLOSPORIN Cap 25 mg ......................................................................................................44.63 Cap 50 mg ......................................................................................................88.91 Cap 100 mg ..................................................................................................177.81 Oral liq 100 mg per ml – 1% DV Oct-12 to 2015..........................................198.13 Inj 50 mg per ml, 5 ml ampoule – 1% DV Oct-12 to 2015 ...........................276.30 TACROLIMUS – Restricted see terms on the next page Cap 0.5 mg ...................................................................................................214.00 Cap 1 mg ......................................................................................................428.00 Cap 5 mg ...................................................................................................1,070.00 Inj 5 mg per ml, 1 ml ampoule ¯¯¯¯ 50 50 50 50 ml 10 100 100 50 Neoral Neoral Neoral Neoral Sandimmun Prograf Prograf Prograf

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¯Restricted For use in organ transplant recipients

Fusion Proteins

ETANERCEPT – Restricted see terms below Inj 25 mg vial ................................................................................................949.96 Inj 50 mg autoinjector ................................................................................1,899.92 Inj 50 mg syringe .......................................................................................1,899.92 ¯¯¯ 4 4 4 Enbrel Enbrel Enbrel

¯Restricted Initiation - juvenile idiopathic arthritis Rheumatologist or named specialist Re-assessment required after 4 months Either: 1 Both: 1.1 The patient has had an initial Special Authority approval for adalimumab for juvenile idiopathic arthritis (JIA); and 1.2 Either: 1.2.1 The patient has experienced intolerable side effects from adalimumab; or 1.2.2 The patient has received insufficient benefit from adalimumab to meet the renewal criteria for adalimumab for JIA; or 2 All of the following: 2.1 Patient diagnosed with Juvenile Idiopathic Arthritis (JIA); and 2.2 To be used as an adjunct to methotrexate therapy or monotherapy where use of methotrexate is limited by toxicity or intolerance; and 2.3 Patient has had severe active polyarticular course JIA for 6 months duration or longer; and 2.4 Patient has tried and not responded to at least three months of oral or parenteral methotrexate (at a dose of 1020 mg/m2 weekly or at the maximum tolerated dose) in combination with either oral corticosteroids (prednisone 0.25 mg/kg or at the maximum tolerated dose) or a full trial of serial intra-articular corticosteroid injections; and 2.5 Both: 2.5.1 Either: 2.5.1.1 Patient has persistent symptoms of poorly-controlled and active disease in at least 20 swollen, tender joints; or 2.5.1.2 Patient has persistent symptoms of poorly-controlled and active disease in at least four joints from the following: wrist, elbow, knee, ankle, shoulder, cervical spine, hip; and 2.5.2 Physician’s global assessment indicating severe disease. Continuation - juvenile idiopathic arthritis Rheumatologist or named specialist Re-assessment required after 6 months All of the following: 1 Treatment is to be used as an adjunct to methotrexate therapy or monotherapy where use of methotrexate is limited by toxicity or intolerance; and 2 Either: 2.1 Following 3 to 4 months’ initial treatment, the patient has at least a 50% decrease in active joint count and an improvement in physician’s global assessment from baseline; or 2.2 On subsequent reapplications, the patient demonstrates at least a continuing 30% improvement in active joint count and continued improvement in physician’s global assessment from baseline. Initiation - rheumatoid arthritis Rheumatologist Re-assessment required after 6 months Either: 1 Both: continued. . .

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continued. . . 1.1 The patient has had an initial Special Authority approval for adalimumab for rheumatoid arthritis; and 1.2 Either: 1.2.1 The patient has experienced intolerable side effects from adalimumab; or 1.2.2 The patient has received insufficient benefit from adalimumab to meet the renewal criteria for adalimumab for rheumatoid arthritis; or 2 All of the following: 2.1 Patient has had severe and active erosive rheumatoid arthritis for six months duration or longer; and 2.2 Treatment is to be used as an adjunct to methotrexate therapy or monotherapy where use of methotrexate is limited by toxicity or intolerance; and 2.3 Patient has tried and not responded to at least three months of oral or parenteral methotrexate at a dose of at least 20 mg weekly or a maximum tolerated dose; and 2.4 Patient has tried and not responded to at least three months of oral or parenteral methotrexate in combination with sulphasalazine and hydroxychloroquine sulphate (at maximum tolerated doses); and 2.5 Any of the following: 2.5.1 Patient has tried and not responded to at least three months of oral or parenteral methotrexate in combination with the maximum tolerated dose of cyclosporin; or 2.5.2 Patient has tried and not responded to at least three months of oral or parenteral methotrexate in combination with intramuscular gold; or 2.5.3 Patient has tried and not responded to at least three months of therapy at the maximum tolerated dose of leflunomide alone or in combination with oral or parenteral methotrexate; and 2.6 Either: 2.6.1 Patient has persistent symptoms of poorly controlled and active disease in at least 20 swollen, tender joints; or 2.6.2 Patient has persistent symptoms of poorly controlled and active disease in at least four joints from the following: wrist, elbow, knee, ankle, and either shoulder or hip; and 2.7 Either: 2.7.1 Patient has a C-reactive protein level greater than 15 mg/L measured no more than one month prior to the date of this application; or 2.7.2 C-reactive protein levels not measured as patient is currently receiving prednisone therapy at a dose of greater than 5 mg per day and has done so for more than three months. Continuation - rheumatoid arthritis Rheumatologist Re-assessment required after 6 months All of the following: 1 Treatment is to be used as an adjunct to methotrexate therapy or monotherapy where use of methotrexate is limited by toxicity or intolerance; and 2 Either: 2.1 Following 3 to 4 months’ initial treatment, the patient has at least a 50% decrease in active joint count from baseline and a clinically significant response to treatment in the opinion of the physician; or 2.2 On subsequent reapplications, the patient demonstrates at least a continuing 30% improvement in active joint count from baseline and a clinically significant response to treatment in the opinion of the physician; and 3 Etanercept to be administered at doses no greater than 50 mg every 7 days. Initiation - ankylosing spondylitis Rheumatologist Re-assessment required after 6 months Either: 1 Both: 1.1 The patient has had an initial Special Authority approval for adalimumab for ankylosing spondylitis; and 1.2 Either: continued. . .

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continued. . . 1.2.1 The patient has experienced intolerable side effects from adalimumab; or 1.2.2 The patient has received insufficient benefit from adalimumab to meet the renewal criteria for adalimumab for ankylosing spondylitis; or 2 All of the following: 2.1 Patient has a confirmed diagnosis of ankylosing spondylitis present for more than six months; and 2.2 Patient has low back pain and stiffness that is relieved by exercise but not by rest; and 2.3 Patient has bilateral sacroiliitis demonstrated by plain radiographs, CT or MRI scan; and 2.4 Patient’s ankylosing spondylitis has not responded adequately to treatment with two or more non-steroidal antiinflammatory drugs (NSAIDs), in combination with anti-ulcer therapy if indicated, while patient was undergoing at least 3 months of an exercise regime supervised by a physiotherapist; and 2.5 Either: 2.5.1 Patient has limitation of motion of the lumbar spine in the sagittal and the frontal planes as determined by the following Bath Ankylosing Spondylitis Metrology Index (BASMI) measures: a modified Schober’s test of less than or equal to 4 cm and lumbar side flexion measurement of less than or equal to 10 cm (mean of left and right); or 2.5.2 Patient has limitation of chest expansion by at least 2.5 cm below the average normal values corrected for age and gender (see Notes); and 2.6 Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) of at least 6 on a 0-10 scale. Notes: The BASDAI must have been determined at the completion of the 3 month exercise trial, but prior to ceasing NSAID treatment. The BASDAI measure must be no more than 1 month old at the time of starting treatment. Average normal chest expansion corrected for age and gender: Age Male Female 18-24 7.0 cm 5.5 cm 25-34 7.5 cm 5.5 cm 35-44 6.5 cm 4.5 cm 45-54 6.0 cm 5.0 cm 55-64 5.5 cm 4.0 cm 65-74 4.0 cm 4.0 cm 75+ 3.0 cm 2.5 cm Continuation - ankylosing spondylitis Rheumatologist Re-assessment required after 6 months All of the following: 1 Following 12 weeks of etanercept treatment, BASDAI has improved by 4 or more points from pre-treatment baseline on a 10 point scale, or by 50%, whichever is less; and 2 Physician considers that the patient has benefited from treatment and that continued treatment is appropriate; and 3 Etanercept to be administered at doses no greater than 50 mg every 7 days. Initiation - psoriatic arthritis Rheumatologist Re-assessment required after 6 months Either: 1 Both: 1.1 The patient has had an initial Special Authority approval for adalimumab for psoriatic arthritis; and 1.2 Either: 1.2.1 The patient has experienced intolerable side effects from adalimumab; or 1.2.2 The patient has received insufficient benefit from adalimumab to meet the renewal criteria for adalimumab for psoriatic arthritis; or 2 All of the following: continued. . .

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continued. . .

2.1 Patient has had severe active psoriatic arthritis for six months duration or longer; and 2.2 Patient has tried and not responded to at least three months of oral or parenteral methotrexate at a dose of at least 20 mg weekly or a maximum tolerated dose; and 2.3 Patient has tried and not responded to at least three months of sulphasalazine at a dose of at least 2 g per day or leflunomide at a dose of up to 20 mg daily (or maximum tolerated doses); and 2.4 Either: 2.4.1 Patient has persistent symptoms of poorly controlled and active disease in at least 15 swollen, tender joints; or 2.4.2 Patient has persistent symptoms of poorly controlled and active disease in at least four joints from the following: wrist, elbow, knee, ankle, and either shoulder or hip; and 2.5 Any of the following: 2.5.1 Patient has a C-reactive protein level greater than 15 mg/L measured no more than one month prior to the date of this application; or 2.5.2 Patient has an elevated erythrocyte sedimentation rate (ESR) greater than 25 mm per hour; or 2.5.3 ESR and CRP not measured as patient is currently receiving prednisone therapy at a dose of greater than 5 mg per day and has done so for more than three months. Continuation - psoriatic arthritis Rheumatologist Re-assessment required after 6 months All of the following: 1 Either: 1.1 Following 3 to 4 months’ initial treatment, the patient has at least a 50% decrease in active joint count from baseline and a clinically significant response to treatment in the opinion of the physician; or 1.2 The patient demonstrates at least a continuing 30% improvement in active joint count from baseline and a clinically significant response to prior etanercept treatment in the opinion of the treating physician; and 2 Etanercept to be administered at doses no greater than 50 mg every 7 days. Initiation - plaque psoriasis, prior TNF use Dermatologist Re-assessment required after 4 months Both: 1 The patient has had an initial Special Authority approval for adalimumab for severe chronic plaque psoriasis; and Either: 1.1 The patient has experienced intolerable side effects from adalimumab; or 1.2 The patient has received insufficient benefit from adalimumab to meet the renewal criteria for adalimumab for severe chronic plaque psoriasis; and 2 Patient must be reassessed for continuation after 3 doses. Initiation - plaque psoriasis, treatment-naive Dermatologist Re-assessment required after 4 months All of the following: 1 Either: 1.1 Patient has "whole body" severe chronic plaque psoriasis with a Psoriasis Area and Severity Index (PASI) score of greater than 15, where lesions have been present for at least 6 months from the time of initial diagnosis; or 1.2 Patient has severe chronic plaque psoriasis of the face, or palm of a hand or sole of a foot, where the plaque or plaques have been present for at least 6 months from the time of initial diagnosis; and 2 Patient has tried, but had an inadequate response (see Note) to, or has experienced intolerable side effects from, at least three of the following (at maximum tolerated doses unless contraindicated): phototherapy, methotrexate, cyclosporin, or acitretin; and continued. . .

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continued. . . 3 A PASI assessment has been completed for at least the most recent prior treatment course (but preferably all prior treatment courses), preferably while still on treatment but no longer than 1 month following cessation of each prior treatment course; and 4 The most recent PASI assessment is no more than 1 month old at the time of initiation. Note: "Inadequate response" is defined as: for whole body severe chronic plaque psoriasis, a PASI score of greater than 15, as assessed preferably while still on treatment but no longer than 1 month following cessation of the most recent prior treatment; for severe chronic plaque psoriasis of the face, hand or foot, at least 2 of the 3 PASI symptom subscores for erythema, thickness and scaling are rated as severe or very severe, and the skin area affected is 30% or more of the face, palm of a hand or sole of a foot, as assessed preferably while still on treatment but no longer than 1 month following cessation of the most recent prior treatment. Continuation - plaque psoriasis Dermatologist Re-assessment required after 6 months Both: 1 Either: 1.1 Both: 1.1.1 Patient had "whole body" severe chronic plaque psoriasis at the start of treatment; and 1.1.2 Following each prior etanercept treatment course the patient has a PASI score which is reduced by 75% or more, or is sustained at this level, when compared with the pre-etanercept treatment baseline value; or 1.2 Both: 1.2.1 Patient had severe chronic plaque psoriasis of the face, or palm of a hand or sole of a foot at the start of treatment; and 1.2.2 Either: 1.2.2.1 Following each prior etanercept treatment course the patient has a reduction in the PASI symptom subscores for all 3 of erythema, thickness and scaling, to slight or better, or sustained at this level, as compared to the treatment course baseline values; or 1.2.2.2 Following each prior etanercept treatment course the patient has a reduction of 75% or more in the skin area affected, or sustained at this level, as compared to the pre-etanercept treatment baseline value; and 2 Etanercept to be administered at doses no greater than 50 mg every 7 days.

Monoclonal Antibodies

ABCIXIMAB – Restricted see terms below Inj 2 mg per ml, 5 ml vial ...............................................................................579.53 1 ReoPro ¯Restricted Either: 1 For use in patients with acute coronary syndromes undergoing percutaneous coronary intervention; or 2 For use in patients undergoing intra-cranial intervention. ADALIMUMAB – Restricted see terms below Inj 20 mg per 0.4 ml syringe ......................................................................1,799.92 2 Humira Inj 40 mg per 0.8 ml pen ............................................................................1,799.92 2 HumiraPen Inj 40 mg per 0.8 ml syringe ......................................................................1,799.92 2 Humira ¯Restricted Initiation - juvenile idiopathic arthritis Rheumatologist or named specialist Re-assessment required after 4 months Either: 1 Either: 1.1 Both: continued. . . ¯ ¯¯¯

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continued. . . 1.1.1 The patient has had an initial Special Authority approval for etanercept for juvenile idiopathic arthritis (JIA); and 1.1.2 Either: 1.1.2.1 The patient has experienced intolerable side effects from etanercept; or 1.1.2.2 The patient has received insufficient benefit from etanercept to meet the renewal criteria for etanercept for JIA; or 2 All of the following: 2.1 Patient diagnosed with Juvenile Idiopathic Arthritis (JIA); and 2.2 To be used as an adjunct to methotrexate therapy or monotherapy where use of methotrexate is limited by toxicity or intolerance; and 2.3 Patient has had severe active polyarticular course JIA for 6 months duration or longer; and 2.4 Patient has tried and not responded to at least three months of oral or parenteral methotrexate (at a dose of 1020 mg/m2 weekly or at the maximum tolerated dose) in combination with either oral corticosteroids (prednisone 0.25 mg/kg or at the maximum tolerated dose) or a full trial of serial intra-articular corticosteroid injections; and 2.5 Both: 2.5.1 Either: 2.5.1.1 Patient has persistent symptoms of poorly-controlled and active disease in at least 20 swollen, tender joints; or 2.5.1.2 Patient has persistent symptoms of poorly-controlled and active disease in at least four joints from the following: wrist, elbow, knee, ankle, shoulder, cervical spine, hip; and 2.5.2 Physician’s global assessment indicating severe disease. Continuation - juvenile idiopathic arthritis Rheumatologist or named specialist Re-assessment required after 6 months All of the following: 1 Treatment is to be used as an adjunct to methotrexate therapy or monotherapy where use of methotrexate is limited by toxicity or intolerance; and 2 Either: 2.1 Following 3 to 4 months’ initial treatment, the patient has at least a 50% decrease in active joint count and an improvement in physician’s global assessment from baseline; or 2.2 On subsequent reapplications, the patient demonstrates at least a continuing 30% improvement in active joint count and continued improvement in physician’s global assessment from baseline. Initiation - fistulising Crohn’s disease Gastroenterologist Re-assessment required after 4 months All of the following 1 Patient has confirmed Crohn’s disease; and 2 Either: 2.1 Patient has one or more complex externally draining enterocutaneous fistula(e); or 2.2 Patient has one or more rectovaginal fistula(e); and 3 A Baseline Fistula Assessment (a copy of which is available at www.pharmac.govt.nz/latest/BaselineFistulaAssessment.pdf) has been completed and is no more than 1 month old at the time of application. Continuation - fistulising Crohn’s disease Gastroenterologist Re-assessment required after 6 months Either: 1 The number of open draining fistulae have decreased from baseline by at least 50%; or 2 There has been a marked reduction in drainage of all fistula(e) from baseline as demonstrated by a reduction in the Fistula Assessment score, together with less induration and patient-reported pain. Initiation - Crohn’s disease continued. . .

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continued. . .

Gastroenterologist Re-assessment required after 3 months All of the following: 1 Patient has severe active Crohn’s disease; and 2 Any of the following: 2.1 Patient has a Crohn’s Disease Activity Index (CDAI) score of greater than or equal to 300; or 2.2 Patient has extensive small intestine disease affecting more than 50 cm of the small intestine; or 2.3 Patient has evidence of short gut syndrome or would be at risk of short gut syndrome with further bowel resection; or 2.4 Patient has an ileostomy or colostomy, and has intestinal inflammation; and 3 Patient has tried but had an inadequate response to, or has experienced intolerable side effects from, prior systemic therapy with immunomodulators at maximum tolerated doses (unless contraindicated) and corticosteroids; and 4 Surgery (or further surgery) is considered to be clinically inappropriate. Continuation - Crohn’s disease Gastroenterologist Re-assessment required after 3 months Both: 1 Either: 1.1 Either: 1.1.1 CDAI score has reduced by 100 points from the CDAI score when the patient was initiated on adalimumab; or 1.1.2 CDAI score is 150 or less; or 1.2 Both: 1.2.1 The patient has demonstrated an adequate response to treatment but CDAI score cannot be assessed; and 1.2.2 Applicant to indicate the reason that CDAI score cannot be assessed; and 2 Adalimumab to be administered at doses no greater than 40 mg every 14 days. Initiation - rheumatoid arthritis Rheumatologist Re-assessment required after 6 months Either: 1 Both: 1.1 The patient has had an initial Special Authority approval for etanercept for rheumatoid arthritis; and 1.2 Either: 1.2.1 The patient has experienced intolerable side effects from etanercept; or 1.2.2 The patient has received insufficient benefit from etanercept to meet the renewal criteria for etanercept for rheumatoid arthritis; or 2 All of the following: 2.1 Patient has had severe and active erosive rheumatoid arthritis for six months duration or longer; and 2.2 Treatment is to be used as an adjunct to methotrexate therapy or monotherapy where use of methotrexate is limited by toxicity or intolerance; and 2.3 Patient has tried and not responded to at least three months of oral or parenteral methotrexate at a dose of at least 20 mg weekly or a maximum tolerated dose; and 2.4 Patient has tried and not responded to at least three months of oral or parenteral methotrexate in combination with sulphasalazine and hydroxychloroquine sulphate (at maximum tolerated doses); and 2.5 Any of the following: 2.5.1 Patient has tried and not responded to at least three months of oral or parenteral methotrexate in combination with the maximum tolerated dose of cyclosporin; or 2.5.2 Patient has tried and not responded to at least three months of oral or parenteral methotrexate in combination with intramuscular gold; or continued. . .

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continued. . . 2.5.3 Patient has tried and not responded to at least three months of therapy at the maximum tolerated dose of leflunomide alone or in combination with oral or parenteral methotrexate; and 2.6 Either: 2.6.1 Patient has persistent symptoms of poorly controlled and active disease in at least 20 swollen, tender joints; or 2.6.2 Patient has persistent symptoms of poorly controlled and active disease in at least four joints from the following: wrist, elbow, knee, ankle, and either shoulder or hip; and 2.7 Either: 2.7.1 Patient has a C-reactive protein level greater than 15 mg/L measured no more than one month prior to the date of this application; or 2.7.2 C-reactive protein levels not measured as patient is currently receiving prednisone therapy at a dose of greater than 5 mg per day and has done so for more than three months. Continuation - rheumatoid arthritis Rheumatologist Re-assessment required after 6 months All of the following: 1 Treatment is to be used as an adjunct to methotrexate therapy or monotherapy where use of methotrexate is limited by toxicity or intolerance; and 2 Either: 2.1 Following 3 to 4 months’ initial treatment, the patient has at least a 50% decrease in active joint count from baseline and a clinically significant response to treatment in the opinion of the physician; or 2.2 On subsequent reapplications, the patient demonstrates at least a continuing 30% improvement in active joint count from baseline and a clinically significant response to treatment in the opinion of the physician; and 3 Adalimumab to be administered at doses no greater than 50 mg every 7 days. Initiation - ankylosing spondylitis Rheumatologist Re-assessment required after 6 months Either: 1 Both: 1.1 The patient has had an initial Special Authority approval for etanercept for ankylosing spondylitis; and 1.2 Either: 1.2.1 The patient has experienced intolerable side effects from etanercept; or 1.2.2 The patient has received insufficient benefit from etanercept to meet the renewal criteria for etanercept for ankylosing spondylitis; or 2 All of the following: 2.1 Patient has a confirmed diagnosis of ankylosing spondylitis present for more than six months; and 2.2 Patient has low back pain and stiffness that is relieved by exercise but not by rest; and 2.3 Patient has bilateral sacroiliitis demonstrated by plain radiographs, CT or MRI scan; and 2.4 Patient’s ankylosing spondylitis has not responded adequately to treatment with two or more non-steroidal antiinflammatory drugs (NSAIDs), in combination with anti-ulcer therapy if indicated, while patient was undergoing at least 3 months of an exercise regime supervised by a physiotherapist; and 2.5 Either: 2.5.1 Patient has limitation of motion of the lumbar spine in the sagittal and the frontal planes as determined by the following Bath Ankylosing Spondylitis Metrology Index (BASMI) measures: a modified Schober’s test of less than or equal to 4 cm and lumbar side flexion measurement of less than or equal to 10 cm (mean of left and right); or 2.5.2 Patient has limitation of chest expansion by at least 2.5 cm below the average normal values corrected for age and gender (see Notes); and 2.6 Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) of at least 6 on a 0-10 scale. continued. . .

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continued. . . Notes: The BASDAI must have been determined at the completion of the 3 month exercise trial, but prior to ceasing NSAID treatment. The BASDAI measure must be no more than 1 month old at the time of starting treatment. Average normal chest expansion corrected for age and gender: Age Male Female 18-24 7.0 cm 5.5 cm 25-34 7.5 cm 5.5 cm 35-44 6.5 cm 4.5 cm 45-54 6.0 cm 5.0 cm 55-64 5.5 cm 4.0 cm 65-74 4.0 cm 4.0 cm 75+ 3.0 cm 2.5 cm Continuation - ankylosing spondylitis Rheumatologist Re-assessment required after 6 months All of the following: 1 Following 12 weeks of adalimumab treatment, BASDAI has improved by 4 or more points from pre-treatment baseline on a 10 point scale, or by 50%, whichever is less; and 2 Physician considers that the patient has benefited from treatment and that continued treatment is appropriate; and 3 Adalimumab to be administered at doses no greater than 40 mg every 14 days. Initiation - psoriatic arthritis Rheumatologist Re-assessment required after 6 months Either: 1 Both: 1.1 The patient has had an initial Special Authority approval for etanercept for psoriatic arthritis; and 1.2 Either: 1.2.1 The patient has experienced intolerable side effects from etanercept; or 1.2.2 The patient has received insufficient benefit from etanercept to meet the renewal criteria for etanercept for psoriatic arthritis; or 2 All of the following: 2.1 Patient has had severe active psoriatic arthritis for six months duration or longer; and 2.2 Patient has tried and not responded to at least three months of oral or parenteral methotrexate at a dose of at least 20 mg weekly or a maximum tolerated dose; and 2.3 Patient has tried and not responded to at least three months of sulphasalazine at a dose of at least 2 g per day or leflunomide at a dose of up to 20 mg daily (or maximum tolerated doses); and 2.4 Either: 2.4.1 Patient has persistent symptoms of poorly controlled and active disease in at least 15 swollen, tender joints; or 2.4.2 Patient has persistent symptoms of poorly controlled and active disease in at least four joints from the following: wrist, elbow, knee, ankle, and either shoulder or hip; and 2.5 Any of the following: 2.5.1 Patient has a C-reactive protein level greater than 15 mg/L measured no more than one month prior to the date of this application; or 2.5.2 Patient has an elevated erythrocyte sedimentation rate (ESR) greater than 25 mm per hour; or 2.5.3 ESR and CRP not measured as patient is currently receiving prednisone therapy at a dose of greater than 5 mg per day and has done so for more than three months. Continuation - psoriatic arthritis Rheumatologist Re-assessment required after 6 months Both: continued. . .

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continued. . . 1 Either: 1.1 Following 3 to 4 months’ initial treatment, the patient has at least a 50% decrease in active joint count from baseline and a clinically significant response to treatment in the opinion of the physician; or 1.2 The patient demonstrates at least a continuing 30% improvement in active joint count from baseline and a clinically significant response to prior adalimumab treatment in the opinion of the treating physician; and 2 Adalimumab to be administered at doses no greater than 40 mg every 14 days. Initiation - plaque psoriasis, prior TNF use Dermatologist Re-assessment required after 4 months Both: 1 The patient has had an initial Special Authority approval for etanercept for severe chronic plaque psoriasis; and 2 Either: 2.1 The patient has experienced intolerable side effects from etanercept; or 2.2 The patient has received insufficient benefit from etanercept to meet the renewal criteria for etanercept for severe chronic plaque psoriasis; and Initiation - plaque psoriasis, treatment-naive Dermatologist Re-assessment required after 4 months All of the following: 1 Either: 1.1 Patient has "whole body" severe chronic plaque psoriasis with a Psoriasis Area and Severity Index (PASI) score of greater than 15, where lesions have been present for at least 6 months from the time of initial diagnosis; or 1.2 Patient has severe chronic plaque psoriasis of the face, or palm of a hand or sole of a foot, where the plaque or plaques have been present for at least 6 months from the time of initial diagnosis; and 2 Patient has tried, but had an inadequate response (see Note) to, or has experienced intolerable side effects from, at least three of the following (at maximum tolerated doses unless contraindicated): phototherapy, methotrexate, cyclosporin, or acitretin; and 3 A PASI assessment has been completed for at least the most recent prior treatment course (but preferably all prior treatment courses), preferably while still on treatment but no longer than 1 month following cessation of each prior treatment course; and 4 The most recent PASI assessment is no more than 1 month old at the time of initiation. Note: "Inadequate response" is defined as: for whole body severe chronic plaque psoriasis, a PASI score of greater than 15, as assessed preferably while still on treatment but no longer than 1 month following cessation of the most recent prior treatment; for severe chronic plaque psoriasis of the face, hand or foot, at least 2 of the 3 PASI symptom subscores for erythema, thickness and scaling are rated as severe or very severe, and the skin area affected is 30% or more of the face, palm of a hand or sole of a foot, as assessed preferably while still on treatment but no longer than 1 month following cessation of the most recent prior treatment. Continuation - plaque psoriasis Dermatologist Re-assessment required after 6 months Both: 1 Either: 1.1 Both: 1.1.1 Patient had "whole body" severe chronic plaque psoriasis at the start of treatment; and 1.1.2 Following each prior adalimumab treatment course the patient has a PASI score which is reduced by 75% or more, or is sustained at this level, when compared with the pre-adalimumab treatment baseline value; or 1.2 Both: 1.2.1 Patient had severe chronic plaque psoriasis of the face, or palm of a hand or sole of a foot at the start of treatment; and 1.2.2 Either: continued. . .

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continued. . . 1.2.2.1 Following each prior adalimumab treatment course the patient has a reduction in the PASI symptom subscores for all 3 of erythema, thickness and scaling, to slight or better, or sustained at this level, as compared to the treatment course baseline values; or 1.2.2.2 Following each prior adalimumab treatment course the patient has a reduction of 75% or more in the skin area affected, or sustained at this level, as compared to the pre-etanercept treatment baseline value; and 2 Adalimumab to be administered at doses no greater than 40 mg every 14 days. BASILIXIMAB – Restricted see terms below Inj 20 mg vial .............................................................................................3,200.00 1 Simulect ¯Restricted For use in solid organ transplants BEVACIZUMAB – Restricted see terms below Inj 25 mg per ml, 16 ml vial Inj 25 mg per ml, 4 ml vial ¯Restricted Either: 1 Ocular neovascularisation; or 2 Exudative ocular angiopathy. INFLIXIMAB – Restricted see terms below Inj 100 mg ..................................................................................................1,227.00 1 Remicade ¯Restricted Graft vs host disease Patient has steroid-refractory acute graft vs. host disease of the gut Initiation - rheumatoid arthritis Rheumatologist Re-assessment required after 3-4 months All of the following: 1 The patient has had an initial Special Authority approval for adalimumab and/or etanercept for rheumatoid arthritis; and 2 Either: 2.1 The patient has experienced intolerable side effects from a reasonable trial of adalimumab and/or etanercept; or 2.2 Following at least a four month trial of adalimumab and/or etanercept, the patient did not meet the renewal criteria for adalimumab and/or etanercept; and 3 Treatment is to be used as an adjunct to methotrexate therapy or monotherapy where use of methotrexate is limited by toxicity or intolerance Continuation - rheumatoid arthritis Rheumatologist Re-assessment required after 6 months All of the following: 1 Treatment is to be used as an adjunct to methotrexate therapy or monotherapy where use of methotrexate is limited by toxicity or intolerance; and 2 Either: 2.1 Following 3 to 4 months’ initial treatment, the patient has at least a 50% decrease in active joint count from baseline and a clinically significant response to treatment in the opinion of the physician; or 2.2 The patient demonstrates at least a continuing 30% improvement in active joint count from baseline and a clinically significant response to treatment in the opinion of the physician; and 3 Infliximab to be administered at doses no greater than 3 mg/kg every 8 weeks. Initiation - ankylosing spondylitis Rheumatologist continued. . .

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continued. . . Re-assessment required after 3 months Both: 1 The patient has had an initial Special Authority approval for adalimumab and/or etanercept for ankylosing spondylitis; and 2 Either: 2.1 The patient has experienced intolerable side effects from a reasonable trial of adalimumab and/or etanercept; or 2.2 Following 12 weeks of adalimumab and/or etanercept treatment, the patient did not meet the renewal criteria for adalimumab and/or etanercept for ankylosing spondylitis. Continuation - ankylosing spondylitis Rheumatologist Re-assessment required after 6 months All of the following: 1 Following 12 weeks of infliximab treatment, BASDAI has improved by 4 or more points from pre-infliximab baseline on a 10 point scale, or by 50%, whichever is less; and 2 Physician considers that the patient has benefited from treatment and that continued treatment is appropriate; and 3 Infliximab to be administered at doses no greater than 5 mg/kg every 6-8 weeks. Initiation - psoriatic arthritis Rheumatologist Re-assessment required after 3-4 months Both: 1 The patient has had an initial Special Authority approval for adalimumab and/or etanercept for psoriatic arthritis; and 2 Either: 2.1 The patient has experienced intolerable side effects from a reasonable trial of adalimumab and/or etanercept; or 2.2 Following 3-4 months’ initial treatment with adalimumab and/or etanercept, the patient did not meet the renewal criteria for adalimumab and/or etanercept for psoriatic arthritis. Continuation - psoriatic arthritis Rheumatologist Re-assessment required after 6 months Both: 1 Either: 1.1 Following 3 to 4 months’ initial treatment, the patient has at least a 50% decrease in active joint count from baseline and a clinically significant response to treatment in the opinion of the physician; or 1.2 The patient demonstrates at least a continuing 30% improvement in active joint count from baseline and a clinically significant response to prior infliximab treatment in the opinion of the treating physician; and 2 Infliximab to be administered at doses no greater than 5 mg/kg every 8 weeks. Initiation - severe ocular inflammation Re-assessment required after 3 doses Both: 1 Patient has severe, vision-threatening ocular inflammation requiring rapid control; and 2 Either: 2.1 Patient has failed to achieve control of severe vision-threatening ocular inflammation following high-dose steroids (intravenous methylprednisolone) followed by high dose oral steroids; or 2.2 Patient developed new inflammatory symptoms while receiving high dose steroids. Initiation - chronic ocular inflammation Re-assessment required after 3 doses Both: 1 Patient has severe uveitis uncontrolled with treatment of steroids and other immunosuppressants with a severe risk of vision loss; and 2 Patient has tried at least two other immunomodulatory agents. Continuation - ocular inflammation continued. . .

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continued. . . Both: 1 Patient had a good clinical response to initial treatment; and 2 Either: 2.1 A withdrawal of infliximab has been trialled and patient has relapsed after trial withdrawal; or 2.2 Patient has Behcet’s disease. Pulmonary sarcoidosis Both: 1 Patient has life-threatening pulmonary sarcoidosis that is refractory to other treatments; and 2 Treatment is to be prescribed by, or has been recommended by, a physician with expertise in the treatment of pulmonary sarcoidosis. Initiation - Crohn’s disease (adults) Gastroenterologist Re-assessment required after 3 months All of the following: 1 Patient has severe active Crohn’s disease; and 2 Any of the following: 2.1 Patient has a Crohn’s Disease Activity Index (CDAI) score of greater than or equal to 300; or 2.2 Patient has extensive small intestine disease affecting more than 50 cm of the small intestine; or 2.3 Patient has evidence of short gut syndrome or would be at risk of short gut syndrome with further bowel resection; or 2.4 Patient has an ileostomy or colostomy, and has intestinal inflammation; and 3 Patient has tried but had an inadequate response to, or has experienced intolerable side effects from, prior systemic therapy with immunomodulators at maximum tolerated doses (unless contraindicated) and corticosteroids; and 4 Surgery (or further surgery) is considered to be clinically inappropriate; and 5 Patient must be reassessed for continuation after 3 months of therapy. Continuation - Crohn’s disease (adults) Gastroenterologist Re-assessment required after 6 months All of the following: 1 One of the following: 1.1 CDAI score has reduced by 100 points from the CDAI score when the patient was initiated on adalimumab; or 1.2 CDAI score is 150 or less; or 1.3 The patient has demonstrated an adequate response to treatment but CDAI score cannot be assessed; and 2 Infliximab to be administered at doses up to 5 mg/kg every 8 weeks. Up to 10 mg/kg every 8 weeks (or equivalent) can be used for up to 3 doses if required for secondary non-response to treatment for re-induction. Another re-induction may be considered sixteen weeks after completing the last re-induction cycle; and 3 Patient must be reassessed for continuation after further 6 months. Initiation - Crohn’s disease (children) Gastroenterologist Re-assessment required after 3 months All of the following: 1 Paediatric patient has severe active Crohn’s disease; and 2 Any of the following: 2.1 Patient has a Paediatric Crohn’s Disease Activity Index (PCDAI) score of greater than or equal to 30; or 2.2 Patient has extensive small intestine disease; and 3 Patient has tried but had an inadequate response to, or has experienced intolerable side effects from, prior systemic therapy with immunomodulators at maximum tolerated doses (unless contraindicated) and corticosteroids; and 4 Surgery (or further surgery) is considered to be clinically inappropriate; and 5 Patient must be reassessed for continuation after 3 months of therapy. Continuation - Crohn’s disease (children) continued. . .

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continued. . . Gastroenterologist Re-assessment required after 6 months All of the following: 1 One of the following: 1.1 PCDAI score has reduced by 10 points from the PCDAI score when the patient was initiated on infliximab; or 1.2 PCDAI score is 15 or less; or 1.3 The patient has demonstrated an adequate response to treatment but PCDAI score cannot be assessed; and 2 Infliximab to be administered at doses up to 5 mg/kg every 8 weeks. Up to 10 mg/kg every 8 weeks (or equivalent) can be used for up to 3 doses if required for secondary non-response to treatment for re-induction. Another re-induction may be considered sixteen weeks after completing the last re-induction cycle; and 3 Patient must be reassessed for continuation after further 6 months. Initiation - fistulising Crohn’s disease Gastroenterologist All of the following: 1 Patient has confirmed Crohn’s disease; and 2 Either: 2.1 Patient has one or more complex externally draining enterocutaneous fistula(e); or 2.2 Patient has one or more rectovaginal fistula(e); and 3 Patient must be reassessed for continuation after 4 months of therapy. Continuation - fistulising Crohn’s disease Gastroenterologist All of the following: 1 Either: 1.1 The number of open draining fistulae have decreased from baseline by at least 50%; or 1.2 There has been a marked reduction in drainage of all fistula(e) from baseline (in the case of adult patients, as demonstrated by a reduction in the Fistula Assessment score), together with less induration and patient reported pain; and 2 Infliximab to be administered at doses up to 5 mg/kg every 8 weeks. Up to 10 mg/kg every 8 weeks (or equivalent) can be used for up to 3 doses if required for secondary non-response to treatment for re-induction. Another re-induction may be considered sixteen weeks after completing the last re-induction cycle; and 3 Patient must be reassessed for continuation after further 6 months. Initiation - acute severe fulminant ulcerative colitis Gastroenterologist All of the following: 1 Patient has acute, severe fulminant ulcerative colitis; and 2 Treatment with intravenous or high dose oral corticosteroids has not been successful; and 3 Patient must be reassessed for continuation after 6 weeks of therapy. Continuation - severe fulminant ulcerative colitis Gastroenterologist All of the following: 1 Where maintenance treatment is considered appropriate, infliximab should be used in combination with immunomodulators and reassessed every 6 months; and 2 Infliximab to be administered at doses up to 5 mg/kg every 8 weeks. Up to 10 mg/kg every 8 weeks (or equivalent) can be used for up to 3 doses if required for secondary non-response to treatment for re-induction. Another re-induction may be considered sixteen weeks after completing the last re-induction cycle; and 3 Patient must be reassessed for continuation after further 6 months. Initiation - severe ulcerative colitis Gastroenterologist continued. . .

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continued. . . All of the following: 1 Patient has histologically confirmed ulcerative colitis; and 2 The Simple Clinical Colitis Activity Index (SCCAI) is ≥ 4 3 Patient has tried but had an inadequate response to, or has experienced intolerable side effects from, prior systemic therapy with immunomodulators at maximum tolerated doses for an adequate duration (unless contraindicated) and corticosteroids; and 4 Surgery (or further surgery) is considered to be clinically inappropriate; and 5 Patient must be reassessed for continuation after 3 months of therapy. Continuation - severe ulcerative colitis Gastroenterologist All of the following: 1 Patient is continuing to maintain remission and the benefit of continuing infliximab outweighs the risks; and 2 SCCAI score has reduced by ≥ 2 points from the SCCAI score when the patient was initiated on infliximab; and 3 Infliximab to be administered at doses up to 5 mg/kg every 8 weeks. Up to 10 mg/kg every 8 weeks (or equivalent) can be used for up to 3 doses if required for secondary non-response to treatment for re-induction. Another re-induction may be considered sixteen weeks after completing the last re-induction cycle. Initiation - plaque psoriasis, prior TNF use Dermatologist Re-assessment required after 3 doses Both: 1 The patient has had an initial Special Authority approval for adalimumab or etanercept for severe chronic plaque psoriasis; and 2 Either: 2.1 The patient has experienced intolerable side effects from adalimumab or etanercept; or 2.2 The patient has received insufficient benefit from adalimumab or etanercept to meet the renewal criteria for adalimumab or etanercept for severe chronic plaque psoriasis. Initiation - plaque psoriasis, treatment-naive Dermatologist Re-assessment required after 3 doses All of the following: 1 Either: 1.1 Patient has "whole body" severe chronic plaque psoriasis with a Psoriasis Area and Severity Index (PASI) score of greater than 15, where lesions have been present for at least 6 months from the time of initial diagnosis; or 1.2 Patient has severe chronic plaque psoriasis of the face, or palm of a hand or sole of a foot, where the plaque or plaques have been present for at least 6 months from the time of initial diagnosis; and 2 Patient has tried, but had an inadequate response (see Note) to, or has experienced intolerable side effects from, at least three of the following (at maximum tolerated doses unless contraindicated): phototherapy, thotrexate, cyclosporin, or acitretin; and 3 A PASI assessment has been completed for at least the most recent prior treatment course (but preferably all prior treatment courses), preferably while still on treatment but no longer than 1 month following cessation of each prior treatment course; and 4 The most recent PASI assessment is no more than 1 month old at the time of initiation. Note: "Inadequate response" is defined as: for whole body severe chronic plaque psoriasis, a PASI score of greater than 15, as assessed preferably while still on treatment but no longer than 1 month following cessation of the most recent prior treatment; for severe chronic plaque psoriasis of the face, hand or foot, at least 2 of the 3 PASI symptom subscores for erythema, thickness and scaling are rated as severe or very severe, and the skin area affected is 30% or more of the face, palm of a hand or sole of a foot, as assessed preferably while still on treatment but no longer than 1 month following cessation of the most recent prior treatment. Continuation - plaque psoriasis continued. . .

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continued. . . Dermatologist Re-assessment required after 3 doses Both: 1 Either: 1.1 Both: 1.1.1 Patient had "whole body" severe chronic plaque psoriasis at the start of treatment; and 1.1.2 Following each prior infliximab treatment course the patient has a PASI score which is reduced by 75% or more, or is sustained at this level, when compared with the pre-infliximab treatment baseline value; or 1.2 Both: 1.2.1 Patient had severe chronic plaque psoriasis of the face, or palm of a hand or sole of a foot at the start of treatment; and 1.2.2 Either: 1.2.2.1 Following each prior infliximab treatment course the patient has a reduction in the PASI symptom subscores for all 3 of erythema, thickness and scaling, to slight or better, or sustained at this level, as compared to the treatment course baseline values; or 1.2.2.2 Following each prior infliximab treatment course the patient has a reduction of 75% or more in the skin area affected, or sustained at this level, as compared to the pre-infliximab treatment baseline value; and 2 Infliximab to be administered at doses no greater than 5 mg/kg every 8 weeks. RANIBIZUMAB – Restricted see terms below Inj 10 mg per ml, 0.23 ml vial Inj 10 mg per ml, 0.3 ml vial ¯Restricted Initiation Re-assessment required after 3 doses Both: 1 Either 1.1 Age-related macular degeneration; or 1.2 Chorodial neovascular membrane; and 2 Any of the following: 2.1 The patient has had a severe ophthalmic inflammatory response following bevacizumab; or 2.2 The patient has had a myocardial infarction or stroke within the last three months; or 2.3 The patient has failed to respond to bevacizumab following three intraocular injections; or 2.4 The patient is of child-bearing potential and has not completed a family. Continuation Both: 1 Documented benefit after three doses must be demonstrated to continue; and 2 In the case of but previous non-response to bevacizumab, a retrial of bevacizumab is required to confirm non-response before continuing with ranibizumab. RITUXIMAB – Restricted see terms below Inj 10 mg per ml, 10 ml vial ........................................................................1,075.50 2 Mabthera Inj 10 mg per ml, 50 ml vial ........................................................................2,688.30 1 Mabthera ¯Restricted Initiation - haemophilia with inhibitors Haematologist Any of the following: 1 Patient has mild congenital haemophilia complicated by inhibitors; or 2 Patient has severe congenital haemophilia complicated by inhibitors and has failed immune tolerance therapy; or 3 Patient has acquired haemophilia. continued. . .

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continued. . . Continuation - haemophilia with inhibitors Haematologist All of the following: 1 Patient was previously treated with rituximab for haemophilia with inhibitors; and 2 An initial response lasting at least 12 months was demonstrated; and 3 Patient now requires repeat treatment. Initiation - post-transplant Both: 1 The patient has B-cell post-transplant lymphoproliferative disorder*; and 2 To be used for a maximum of 8 treatment cycles. Note: Indications marked with * are Unapproved Indications. Continuation - post-transplant All of the following: 1 The patient has had a rituximab treatment-free interval of 12 months or more; and 2 The patient has B-cell post-transplant lymphoproliferative disorder*; and 3 To be used for no more than 6 treatment cycles. Note: Indications marked with * are Unapproved Indications Initiation - indolent, low-grade lymphomas Either: 1 Both: 1.1 The patient has indolent low grade NHL with relapsed disease following prior chemotherapy; and 1.2 To be used for a maximum of 6 treatment cycles; or 1.3 Both: 1.3.1 The patient has indolent, low grade lymphoma requiring first-line systemic chemotherapy; and 1.3.2 To be used for a maximum of 6 treatment cycles. Note: ’Indolent, low-grade lymphomas’ includes follicular, mantle, marginal zone and lymphoplasmacytic/Waldenstrom macroglobulinaemia. Continuation - indolent, low-grade lymphomas All of the following: 1 The patient has had a rituximab treatment-free interval of 12 months or more; and 2 The patient has indolent, low-grade NHL with relapsed disease following prior chemotherapy; and 3 To be used for no more than 6 treatment cycles. Note: ’Indolent, low-grade lymphomas’ includes follicular, mantle, marginal zone and lymphoplasmacytic/Waldenstrom macroglobulinaemia. Initiation - aggressive CD20 positive NHL Either: 1 All of the following: 1.1 The patient has treatment naive aggressive CD20 positive NHL; and 1.2 To be used with a multi-agent chemotherapy regimen given with curative intent; and 1.3 To be used for a maximum of 8 treatment cycles; or 2 Both: 2.1 The patient has aggressive CD20 positive NHL with relapsed disease following prior chemotherapy; and 2.2 To be used for a maximum of 6 treatment cycles. Note: ’Aggressive CD20 positive NHL’ includes large B-cell lymphoma and Burkitt’s lymphoma/leukaemia. Continuation - aggressive CD20 positive NHL All of the following: 1 The patient has had a rituximab treatment-free interval of 12 months or more; and 2 The patient has relapsed refractory/aggressive CD20 positive NHL; and continued. . .

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continued. . . 3 To be used with a multi-agent chemotherapy regimen given with curative intent; and 4 To be used for a maximum of 4 treatment cycles. Note: ’Aggressive CD20 positive NHL’ includes large B-cell lymphoma and Burkitt’s lymphoma/leukaemia. Chronic lymphocytic leukaemia All of the following: 1 The patient has progressive Binet stage A, B or C chronic lymphocytic leukaemia (CLL) requiring treatment; and 2 The patient is rituximab treatment naive; and 3 Either: 3.1 The patient is chemotherapy treatment naive; or 3.2 Both: 3.2.1 The patient’s disease has relapsed following no more than three prior lines of chemotherapy treatment; and 3.2.2 The patient has had a treatment-free interval of 12 months or more if previously treated with fludarabine and cyclophosphamide chemotherapy; and 4 The patient has good performance status; and 5 The patient has good renal function (creatinine clearance ≥ 30 ml/min); and 6 The patient does not have chromosome 17p deletion CLL; and 7 Rituximab to be administered in combination with fludarabine and cyclophosphamide for a maximum of 6 treatment cycles; and 8 It is planned that the patient receives full dose fludarabine and cyclophosphamide (orally or dose equivalent intravenous administration). Note: ’Chronic lymphocytic leukaemia (CLL)’ includes small lymphocytic lymphoma. A line of chemotherapy treatment is considered to comprise a known standard therapeutic chemotherapy regimen and supportive treatments. ’Good performance status’ means ECOG score of 0-1, however, in patients temporarily debilitated by their CLL disease symptoms a higher ECOG (2 or 3) is acceptable where treatment with rituximab is expected to improve symptoms and improve ECOG score to <2. Initiation - rheumatoid arthritis - prior TNF inhibitor use Rheumatologist Re-assessment required after 2 doses All of the following: 1 Both: 1.1 The patient has had an initial community Special Authority approval for at least one of etanercept and/or adalimumab for rheumatoid arthritis; and 1.2 Either: 1.2.1 The patient has experienced intolerable side effects from a reasonable trial of adalimumab and/or etanercept; or 1.2.2 Following at least a four month trial of adalimumab and/or etanercept, the patient did not meet the renewal criteria for adalimumab and/or etanercept for rheumatoid arthritis; and 2 Either: 2.1 Rituximab to be used as an adjunct to methotrexate or leflunomide therapy; or 2.2 Patient is contraindicated to both methotrexate and leflunomide, requiring rituximab monotherapy to be used; and 3 Maximum of two 1,000 mg infusions of rituximab given two weeks apart. Initiation - rheumatoid arthritis - TNF inhibitors contraindicated Rheumatologist Re-assessment required after 2 doses All of the following: 1 Treatment with a Tumour Necrosis Factor alpha inhibitor is contraindicated; and 2 Patient has had severe and active erosive rheumatoid arthritis for six months duration or longer; and 3 Patient has tried and not responded to at least three months of oral or parenteral methotrexate at a dose of at least 20 mg weekly or a maximum tolerated dose; and continued. . .

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continued. . .

4 Patient has tried and not responded to at least three months of oral or parenteral methotrexate in combination with sulphasalazine and hydroxychloroquine sulphate (at maximum tolerated doses); and 5 Any of the following: 5.1 Patient has tried and not responded to at least three months of oral or parenteral methotrexate in combination with the maximum tolerated dose of cyclosporin; or 5.2 Patient has tried and not responded to at least three months of oral or parenteral methotrexate in combination with intramuscular gold; or 5.3 Patient has tried and not responded to at least three months of therapy at the maximum tolerated dose of leflunomide alone or in combination with oral or parenteral methotrexate; and 6 Either: 6.1 Patient has persistent symptoms of poorly controlled and active disease in at least 20 swollen, tender joints; or 6.2 Patient has persistent symptoms of poorly controlled and active disease in at least four joints from the following: wrist, elbow, knee, ankle, and either shoulder or hip; and 7 Either: 7.1 Patient has a C-reactive protein level greater than 15 mg/L measured no more than one month prior to the date of this application; or 7.2 C-reactive protein levels not measured as patient is currently receiving prednisone therapy at a dose of greater than 5 mg per day and has done so for more than three months; and 8 Either: 8.1 Rituximab to be used as an adjunct to methotrexate or leflunomide therapy; or 8.2 Patient is contraindicated to both methotrexate and leflunomide, requiring rituximab monotherapy to be used; and 9 Maximum of two 1,000 mg infusions of rituximab given two weeks apart. Continuation - rheumatoid arthritis - re-treatment in ’partial responders’ to rituximab Rheumatologist Re-assessment required after 2 doses All of the following: 1 Either: 1.1 At 4 months following the initial course of rituximab infusions the patient had between a 30% and 50% decrease in active joint count from baseline and a clinically significant response to treatment in the opinion of the physician; or 1.2 At 4 months following the second course of rituximab infusions the patient had at least a 50% decrease in active joint count from baseline and a clinically significant response to treatment in the opinion of the physician; or 1.3 At 4 months following the third and subsequent courses of rituximab infusions, the patient demonstrates at least a continuing 30% improvement in active joint count from baseline and a clinically significant response to treatment in the opinion of the physician; and 2 Rituximab re-treatment not to be given within 6 months of the previous course of treatment; and 3 Either: 3.1 Rituximab to be used as an adjunct to methotrexate or leflunomide therapy; or 3.2 Patient is contraindicated to both methotrexate and leflunomide, requiring rituximab monotherapy to be used; and 4 Maximum of two 1,000 mg infusions of rituximab given two weeks apart. Continuation - rheumatoid arthritis - re-treatment in ’responders’ to rituximab Rheumatologist Re-assessment required after 2 doses All of the following: 1 Either: 1.1 At 4 months following the initial course of rituximab infusions the patient had at least a 50% decrease in active joint count from baseline and a clinically significant response to treatment in the opinion of the physician; or continued. . .

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continued. . . 1.2 At 4 months following the second and subsequent courses of rituximab infusions, the patient demonstrates at least a continuing 30% improvement in active joint count from baseline and a clinically significant response to treatment in the opinion of the physician; and 2 Rituximab re-treatment not to be given within 6 months of the previous course of treatment; and 3 Either: 3.1 Rituximab to be used as an adjunct to methotrexate or leflunomide therapy; or 3.2 Patient is contraindicated to both methotrexate and leflunomide, requiring rituximab monotherapy to be used; and 4 Maximum of two 1,000 mg infusions of rituximab given two weeks apart. Initiation – severe cold haemagglutinin disease (CHAD) Haematologist Limited to 4 weeks’ treatment Both: 1 Patient has cold haemagglutinin disease*; and 2 Patient has severe disease which is characterized by symptomatic anaemia, transfusion dependence or disabling circulatory symptoms. Note: Indications marked with * are Unapproved Indications. Continuation – severe cold haemagglutinin disease (CHAD) Haematologist Limited to 4 weeks’ treatment Either: 1 Previous treatment with lower doses of rituximab (100 mg weekly for 4 weeks) have proven ineffective and treatment with higher doses (375 mg/m2 weekly for 4 weeks) is now planned; or 2 All of the following: 2.1 Patient was previously treated with rituximab for severe cold haemagglutinin disease*; and 2.2 An initial response lasting at least 12 months was demonstrated; and 2.3 Patient now requires repeat treatment. Note: Indications marked with * are Unapproved Indications. Initiation – warm autoimmune haemolytic anaemia (warm AIHA) Haematologist Limited to 4 weeks’ treatment Both: 1 Patient has warm autoimmune haemolytic anaemia*; and 2 One of the following treatments has been ineffective: steroids (including if patient requires ongoing steroids at doses equivalent to >5 mg prednisone daily), cytotoxic agents (e.g. cyclophosphamide monotherapy or in combination), intravenous immunoglobulin. Note: Indications marked with * are Unapproved Indications. Continuation – warm autoimmune haemolytic anaemia (warm AIHA) Haematologist Limited to 4 weeks’ treatment Either: 1 Previous treatment with lower doses of rituximab (100 mg weekly for 4 weeks) have proven ineffective and treatment with higher doses (375 mg/m2 weekly for 4 weeks) is now planned; or 2 All of the following: 2.1 Patient was previously treated with rituximab for warm autoimmune haemolytic anaemia*; and 2.2 An initial response lasting at least 12 months was demonstrated; and 2.3 Patient now requires repeat treatment. Note: Indications marked with * are Unapproved Indications. Initiation – immune thrombocytopenic purpura (ITP) continued. . .

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continued. . . Haematologist Limited to 4 weeks’ treatment Both: 1 Either: 1.1 Patient has immune thrombocytopenic purpura* with a platelet count of ≤ 20,000 platelets per microlitre; or 1.2 Patient has immune thrombocytopenic purpura* with a platelet count of 20,000 to 30,000 platelets per microlitre and significant mucocutaneous bleeding; and 2 Any of the following: 2.1 Treatment with steroids and splenectomy have been ineffective; or 2.2 Treatment with steroids has been ineffective and splenectomy is an absolute contraindication; or 2.3 Other treatments including steroids have been ineffective and patient is being prepared for elective surgery (e.g. splenectomy). Note: Indications marked with * are Unapproved Indications. Continuation – immune thrombocytopenic purpura (ITP) Haematologist Limited to 4 weeks’ treatment Either: 1 Previous treatment with lower doses of rituximab (100 mg weekly for 4 weeks) have proven ineffective and treatment with higher doses (375 mg/m2 weekly for 4 weeks) is now planned; or 2 All of the following: 2.1 Patient was previously treated with rituximab for immune thrombocytopenic purpura*; and 2.2 An initial response lasting at least 12 months was demonstrated; and 2.3 Patient now requires repeat treatment. Note: Indications marked with * are Unapproved Indications. Initiation – thrombotic thrombocytopenic purpura (TTP) Haematologist Limited to 4 weeks’ treatment Either: 1 Patient has thrombotic thrombocytopenic purpura* and has experienced progression of clinical symptoms or persistent thrombocytopenia despite plasma exchange; or 2 Patient has acute idiopathic thrombotic thrombocytopenic purpura* with neurological or cardiovascular pathology. Note: Indications marked with * are Unapproved Indications. Continuation – thrombotic thrombocytopenic purpura (TTP) Haematologist Limited to 4 weeks’ treatment All of the following: 1 Patient was previously treated with rituximab for thrombotic thrombocytopenic purpura*; and 2 An initial response lasting at least 12 months was demonstrated; and 3 Patient now requires repeat treatment. Note: Indications marked with * are Unapproved Indications. Initiation – pure red cell aplasia (PRCA) Haematologist Limited to 6 weeks’ treatment Patient has autoimmune pure red cell aplasia* associated with a demonstrable B-cell lymphoproliferative disorder. Note: Indications marked with * are Unapproved Indications. Continuation – pure red cell aplasia (PRCA) Haematologist Limited to 6 weeks’ treatment continued. . .

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continued. . . Patient was previously treated with rituximab for pure red cell aplasia* associated with a demonstrable B-cell lymphoproliferative disorder and demonstrated an initial response lasting at least 12 months. Note: Indications marked with * are Unapproved Indications. Initiation – ANCA associated vasculitis Rheumatologist or nephrologist Limited to 4 weeks’ treatment All of the following: 1 Patient has been diagnosed with ANCA associated vasculitis*; and 2 Either: 2.1 Patient does not have MPO-ANCA positive vasculitis*; or 2.2 Mycophenolate mofetil has not been effective in those patients who have MPO-ANCA positive vasculitis*; and 3 The total rituximab dose would not exceed the equivalent of 375 mg/m2 of body-surface area per week for a total of 4 weeks; and 4 Any of the following: 4.1 Induction therapy with daily oral or pulse intravenous cyclophosphamide has failed to achieve complete absence of disease after at least 3 months; or 4.2 Patient has previously had a cumulative dose of cyclophosphamide >15 g or a further repeat 3 month induction course of cyclophosphamide would result in a cumulative dose >15 g; or 4.3 Cyclophosphamide and methotrexate are contraindicated; or 4.4 Patient is a female of child-bearing potential; or 4.5 Patient has a previous history of haemorrhagic cystitis, urological malignancy or haematological malignancy. Note: Indications marked with * are Unapproved Indications. Continuation – ANCA associated vasculitis Rheumatologist or nephrologist Limited to 4 weeks’ treatment All of the following: 1 Patient has been diagnosed with ANCA associated vasculitis*; and 2 Patient has previously responded to treatment with rituximab but is now experiencing an acute flare of vasculitis; and 3 The total rituximab dose would not exceed the equivalent of 375 mg/m2 of body-surface area per week for a total of 4 weeks. Note: Indications marked with * are Unapproved Indications. Initiation – treatment refractory systemic lupus erythematosus (SLE) Rheumatologist or nephrologist All of the following: 1 The patient has severe, immediately life- or organ-threatening SLE*; and 2 The disease has proved refractory to treatment with steroids at a dose of at least 1 mg/kg; and 3 The disease has relapsed following prior treatment for at least 6 months with maximal tolerated doses of azathioprine, mycophenolate mofetil and high dose cyclophosphamide, or cyclophosphamide is contraindicated; and 4 Maximum of four 1000 mg infusions of rituximab. Note: Indications marked with * are Unapproved Indications. Continuation – treatment refractory systemic lupus erythematosus (SLE) Rheumatologist or nephrologist All of the following: 1 Patient’s SLE* achieved at least a partial response to the previous round of prior rituximab treatment; and 2 The disease has subsequently relapsed; and 3 Maximum of two 1000 mg infusions of rituximab. Note: Indications marked with * are Unapproved Indications. Antibody-mediated renal transplant rejection Nephrologist continued. . .

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continued. . . Patient has been diagnosed with antibody-mediated renal transplant rejection*. Note: Indications marked with * are Unapproved Indications. ABO-incompatible renal transplant Nephrologist Patient is to undergo an ABO-incompatible renal transplant*. Note: Indications marked with * are Unapproved Indications. TOCILIZUMAB – Restricted see terms below Inj 20 mg per ml, 4 ml vial .............................................................................220.00 1 Actemra Inj 20 mg per ml, 10 ml vial ...........................................................................550.00 1 Actemra Inj 20 mg per ml, 20 ml vial ........................................................................1,100.00 1 Actemra ¯Restricted Initiation - systemic juvenile idiopathic arthritis Paediatric rheumatologist Re-assessment required after 6 months Both: 1 Patient diagnosed with systemic juvenile idiopathic arthritis; and 2 Patient has tried and not responded to a reasonable trial of all of the following, either alone or in combination: oral or parenteral methotrexate; non-steroidal anti-inflammatory drugs (NSAIDs); and systemic corticosteroids. Continuation - systemic juvenile idiopathic arthritis Paediatric rheumatologist Re-assessment required after 6 months Either: 1 Following up to 6 months initial treatment, the patient has achieved at least an American College of Rheumatology paediatric 30% improvement criteria (ACR Pedi 30) response from baseline; or 2 On subsequent reapplications, the patient demonstrates at least a continuing ACR Pedi 30 response from baseline. TRASTUZUMAB – Restricted see terms below Inj 150 mg vial ...........................................................................................1,350.00 1 Herceptin Inj 440 mg vial ...........................................................................................3,875.00 1 Herceptin ¯Restricted Early breast cancer Limited to 12 months’ treatment All of the following: 1 The patient has early breast cancer expressing HER 2 IHC 3+ or ISH+ (including FISH or other current technology); and 2 Maximum cumulative dose of 106 mg/kg (12 months’ treatment); and 3 Any of the following: 3.1 9 weeks’ concurrent treatment with adjuvant chemotherapy is planned; or 3.2 12 months’ concurrent treatment with adjuvant chemotherapy is planned; or 3.3 12 months’ sequential treatment following adjuvant chemotherapy is planned; or 3.4 Other treatment regimen, in association with adjuvant chemotherapy, is planned. Initiation - metastatic breast cancer (trastuzumab-naive patients) Re-assessment required after 12 months Either: 1 All of the following: 1.1 The patient has metastatic breast cancer expressing HER-2 IHC 3+ or ISH+ (including FISH or other current technology); and 1.2 The patient has not previously received lapatinib treatment for HER 2 positive metastatic breast cancer; and 1.3 Trastuzumab not to be given in combination with lapatinib; and 1.4 Trastuzumab to be discontinued at disease progression; or continued. . .

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continued. . . 2 All of the following: 2.1 The patient has metastatic breast cancer expressing HER-2 IHC 3+ or ISH+ (including FISH or other current technology); and 2.2 The patient started lapatinib treatment for metastatic breast cancer but discontinued lapatinib within 3 months of starting treatment due to intolerance; and 2.3 The cancer did not progress whilst on lapatinib; and 2.4 Trastuzumab not to be given in combination with lapatinib; and 2.5 Trastuzumab to be discontinued at disease progression. Initiation - metastatic breast cancer (patients previously treated with trastuzumab) Re-assessment required after 12 months All of the following: 1 The patient has metastatic breast cancer expressing HER-2 IHC 3+ or ISH+ (including FISH or other current technology); and 2 The patient received prior adjuvant trastuzumab treatment for early breast cancer; and 3 Any of the following: 3.1 All of the following: 3.1.1 The patient has not previously received lapatinib treatment for metastatic breast cancer; and 3.1.2 Trastuzumab not to be given in combination with lapatinib; and 3.1.3 Trastuzumab to be discontinued at disease progression; or 3.2 All of the following: 3.2.1 The patient started lapatinib treatment for metastatic breast cancer but discontinued lapatinib within 3 months of starting treatment due to intolerance; and 3.2.2 The cancer did not progress whilst on lapatinib; and 3.2.3 Trastuzumab not to be given in combination with lapatinib; and 3.2.4 Trastuzumab to be discontinued at disease progression; or 3.3 All of the following: 3.3.1 The cancer has not progressed at any time point during the previous 12 months whilst on trastuzumab; and 3.3.2 Trastuzumab not to be given in combination with lapatinib; and 3.3.3 Trastuzumab to be discontinued at disease progression. Continuation - metastatic breast cancer Re-assessment required after 12 months 1 The patient has metastatic breast cancer expressing HER-2 IHC 3+ or ISH+ (including FISH or other current technology); and 2 The cancer has not progressed at any time point during the previous 12 months whilst on trastuzumab; and 3 Trastuzumab not to be given in combination with lapatinib; and 4 Trastuzumab to be discontinued at disease progression.

Other Immunosuppressants

ANTITHYMOCYTE GLOBULIN (EQUINE) Inj 50 mg per ml, 5 ml ampoule .................................................................2,137.50 ANTITHYMOCYTE GLOBULIN (RABBIT) Inj 25 mg vial AZATHIOPRINE Tab 50 mg .......................................................................................................18.45 Inj 50 mg vial ................................................................................................126.00 BACILLUS CALMETTE-GUERIN (BCG) – Restricted see terms below Inj 2-8 × 10ˆ8 CFU vial – 1% DV Sep-13 to 2016 .......................................149.37 ¯Restricted For use in bladder cancer ¯ 100 1 1 Imuprine Imuran OncoTICE 5 ATGAM

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Per

MYCOPHENOLATE MOFETIL – Restricted see terms below Tab 500 mg – 1% DV Nov-13 to 2016 ...........................................................25.00 Cap 250 mg – 1% DV Nov-13 to 2016...........................................................25.00 Powder for oral liq 1 g per 5 ml – 1% DV Nov-13 to 2016............................187.25 Inj 500 mg vial – 1% DV Nov-13 to 2016.....................................................133.33

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50 100 165 ml 4

CellCept CellCept CellCept CellCept

¯Restricted Either: 1 Transplant recipient; or 2 Patients with diseases where both: 2.1 Steroids and azathioprine have been trialled and discontinued because of unacceptable side effects or inadequate clinical response; and 2.2 Either: 2.2.1 Cyclophosphamide has been trialled and discontinued because of unacceptable side effects or inadequate clinical response; or 2.2.2 Cyclophosphamide treatment is contraindicated. PICIBANIL Inj 100 mg vial SIROLIMUS – Restricted see terms below Tab 1 mg .......................................................................................................813.00 100 Rapamune Tab 2 mg ....................................................................................................1,626.00 100 Rapamune Oral liq 1 mg per ml ......................................................................................487.80 60 ml Rapamune ¯Restricted For rescue therapy for an organ transplant recipient Notes: Rescue therapy defined as unresponsive to calcineurin inhibitor treatment as defined by refractory rejection; or intolerant to calcineurin inhibitor treatment due to any of the following: G GFR < 30 ml/min; or G Rapidly progressive transplant vasculopathy; or G Rapidly progressive obstructive bronchiolitis; or G HUS or TTP; or G Leukoencepthalopathy; or G Significant malignant disease

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Antiallergy Preparations Allergy Desensitisation

BEE VENOM – Restricted see terms below Inj 120 mcg vial with diluent, 6 vial Inj 550 mcg vial with diluent ¯Restricted Both: 1 RAST or skin test positive; and 2 Patient has had severe generalised reaction to the sensitising agent. PAPER WASP VENOM – Restricted see terms below Inj 550 mcg vial with diluent ¯Restricted Both: 1 RAST or skin test positive; and 2 Patient has had severe generalised reaction to the sensitising agent. YELLOW JACKET WASP VENOM – Restricted see terms below Inj 550 mcg vial with diluent ¯Restricted Both: 1 RAST or skin test positive; and 2 Patient has had severe generalised reaction to the sensitising agent. ¯¯ ¯ ¯

Allergy Prophylactics

BECLOMETHASONE DIPROPIONATE Nasal spray 50 mcg per dose ...........................................................................4.85 Nasal spray 100 mcg per dose .........................................................................5.75 BUDESONIDE Nasal spray 50 mcg per dose ...........................................................................4.85 Nasal spray 100 mcg per dose .........................................................................5.75 FLUTICASONE PROPIONATE Nasal spray 50 mcg per dose – 1% DV Apr-13 to 2015 ..................................2.30 IPRATROPIUM BROMIDE Nasal spray 0.03% SODIUM CROMOGLYCATE Nasal spray 4% 200 dose 200 dose 200 dose 200 dose 120 dose Alanase Alanase Butacort Aqueous Butacort Aqueous Flixonase Hayfever & Allergy

Antihistamines

CETIRIZINE HYDROCHLORIDE Tab 10 mg – 1% DV Sep-11 to 2014 ...............................................................1.59 Oral liq 1 mg per ml – 1% DV Nov-11 to 2014.................................................3.52 CHLORPHENIRAMINE MALEATE Oral liq 0.4 mg per ml Inj 10 mg per ml, 1 ml ampoule CYPROHEPTADINE HYDROCHLORIDE Tab 4 mg 100 200 ml Zetop Cetirizine - AFT

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Per

FEXOFENADINE HYDROCHLORIDE Tab 60 mg Tab 120 mg Tab 180 mg LORATADINE Tab 10 mg – 1% DV Dec-13 to 2016 ...............................................................1.30 Oral liq 1 mg per ml ..........................................................................................3.10 PROMETHAZINE HYDROCHLORIDE Tab 10 mg – 1% DV Sep-12 to 2015 ...............................................................1.99 Tab 25 mg – 1% DV Sep-12 to 2015 ...............................................................2.99 Oral liq 1 mg per ml – 1% DV Feb-13 to 2015 .................................................2.79 Inj 25 mg per ml, 2 ml ampoule ......................................................................11.00 TRIMEPRAZINE TARTRATE Oral liq 6 mg per ml 100 100 ml 50 50 100 ml 5 Lorafix Lorapaed Allersoothe Allersoothe Allersoothe Mayne

Anticholinergic Agents

IPRATROPIUM BROMIDE Aerosol inhaler 20 mcg per dose Nebuliser soln 250 mcg per ml, 1 ml ampoule – 1% DV Sep-13 to 2016 .........3.26 Nebuliser soln 250 mcg per ml, 2 ml ampoule – 1% DV Sep-13 to 2016 .........3.37 ¯

20 20

Univent Univent

TIOTROPIUM BROMIDE – Restricted see terms below Powder for inhalation 18 mcg per dose ..........................................................70.00 30 dose Spiriva ¯Restricted All of the following: 1 To be used for the long-term maintenance treatment of bronchospasm and dyspnoea associated with COPD; and 2 In addition to standard treatment, the patient has trialled a short acting bronchodilator of at least 40 mcg ipratropium q.i.d for one month; and 3 The patient’s breathlessness according to the Medical Research Council (UK) dyspnoea scale is either: 3.1 Grade 4 (stops for breath after walking about 100 metres or after a few minutes on the level); or 3.2 Grade 5 (too breathless to leave the house, or breathless when dressing or undressing); and 4 Actual FEV1 as a % of predicted, must be below 60%. 5 Either: 5.1 Patient is not a smoker; or 5.2 Patient is a smoker and has been offered smoking cessation counselling; and 6 The patient has been offered annual influenza immunisation.

Anticholinergic Agents with Beta-Adrenoceptor Agonists

SALBUTAMOL WITH IPRATROPIUM BROMIDE Aerosol inhaler 100 mcg with ipratropium bromide 20 mcg per dose Nebuliser soln 2.5 mg with ipratropium bromide 0.5 mg per 2.5 ml ampoule – 1% DV Nov-12 to 2015 ................................................................ 3.75

20

Duolin

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Beta-Adrenoceptor Agonists

SALBUTAMOL Oral liq 400 mcg per ml – 1% DV Jan-14 to 2016............................................2.06 Inj 500 mcg per ml, 1 ml ampoule Inj 1 mg per ml, 5 ml ampoule Aerosol inhaler, 100 mcg per dose ...................................................................4.00 6.00 Nebuliser soln 1 mg per ml, 2.5 ml ampoule – 1% DV Nov-12 to 2015...........3.25 Nebuliser soln 2 mg per ml, 2.5 ml ampoule – 1% DV Nov-12 to 2015...........3.44 TERBUTALINE SULPHATE Powder for inhalation 250 mcg per dose Inj 0.5 mg per ml, 1 ml ampoule 150 ml Ventolin

200 dose 20 20

Salamol Ventolin Asthalin Asthalin

Cough Suppressants

PHOLCODINE Oral liq 1 mg per ml

Decongestants

OXYMETAZOLINE HYDROCHLORIDE Aqueous nasal spray 0.25 mg per ml Aqueous nasal spray 0.5 mg per ml PSEUDOEPHEDRINE HYDROCHLORIDE Tab 60 mg SODIUM CHLORIDE Aqueous nasal spray 7.4 mg per ml SODIUM CHLORIDE WITH SODIUM BICARBONATE Soln for nasal irrigation XYLOMETAZOLINE HYDROCHLORIDE Aqueous nasal spray 0.05% Aqueous nasal spray 0.1% Nasal drops 0.05% Nasal drops 0.1%

Inhaled Corticosteroids

BECLOMETHASONE DIPROPIONATE Aerosol inhaler 50 mcg per dose ......................................................................8.54 Aerosol inhaler 100 mcg per dose ..................................................................12.50 Aerosol inhaler 250 mcg per dose ..................................................................22.67 BUDESONIDE Nebuliser soln 250 mcg per ml, 2 ml ampoule Nebuliser soln 500 mcg per ml, 2 ml ampoule Powder for inhalation 100 mcg per dose Powder for inhalation 200 mcg per dose Powder for inhalation 400 mcg per dose 200 dose 200 dose 200 dose Beclazone 50 Beclazone 100 Beclazone 250

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FLUTICASONE Aerosol inhaler 50 mcg per dose ......................................................................7.50 Powder for inhalation 50 mcg per dose ............................................................8.67 Powder for inhalation 100 mcg per dose ........................................................13.87 Aerosol inhaler 125 mcg per dose ..................................................................13.60 Aerosol inhaler 250 mcg per dose ..................................................................27.20 Powder for inhalation 250 mcg per dose ........................................................24.51

120 dose 60 dose 60 dose 120 dose 120 dose 60 dose

Flixotide Flixotide Accuhaler Flixotide Accuhaler Flixotide Flixotide Flixotide Accuhaler

Leukotriene Receptor Antagonists

MONTELUKAST – Restricted see terms below Tab 4 mg .........................................................................................................18.48 28 Singulair Tab 5 mg .........................................................................................................18.48 28 Singulair Tab 10 mg .......................................................................................................18.48 28 Singulair ¯Restricted Pre-school wheeze Both: 1 To be used for the treatment of intermittent severe wheezing (possibly viral); and 2 The patient has had at least three episodes in the previous 12 months of acute wheeze severe enough to seek medical attention. Exercise-induced asthma Both: 1 Patient has been trialed with maximal asthma therapy, including inhaled corticosteroids and long-acting beta-adrenoceptor agonists; and 2 Patient continues to receive optimal inhaled corticosteroid therapy; and 3 Patient continues to experience frequent episodes of exercise-induced bronchoconstriction. Aspirin desensitisation Clinical immunologist or allergist All of the following: 1 Patient is undergoing aspirin desensitisation therapy under the supervision of a clinical immunologist or allergist; and 2 Patient has moderate to severe aspirin-exacerbated respiratory disease or Samter’s triad; and 3 Nasal polyposis, confirmed radiologically or surgically; and 4 Documented aspirin or NSAID allergy confirmed by aspirin challenge or a clinical history of severe reaction to aspirin or NSAID where challenge would be considered dangerous. ¯¯¯

Long-Acting Beta-Adrenoceptor Agonists

EFORMOTEROL FUMARATE Powder for inhalation 6 mcg per dose Powder for inhalation 12 mcg per dose SALMETEROL Aerosol inhaler 25 mcg per dose ....................................................................26.46 Powder for inhalation 50 mcg per dose ..........................................................26.46 120 dose 60 dose Serevent Serevent Accuhaler

Inhaled Corticosteroids with Long-Acting Beta-Adrenoceptor Agonists

BUDESONIDE WITH EFORMOTEROL – Restricted see terms on the next page Powder for inhalation 100 mcg with eformoterol fumarate 6 mcg Powder for inhalation 200 mcg with eformoterol fumarate 6 mcg Powder for inhalation 400 mcg with eformoterol fumarate 12 mcg Aerosol inhaler 100 mcg with eformoterol fumarate 6 mcg Aerosol inhaler 200 mcg with eformoterol fumarate 6 mcg ¯¯¯¯¯

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RESPIRATORY SYSTEM AND ALLERGIES

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Per

¯Restricted Either: 1 All of the following: 1.1 Patient is a child under the age of 12; and 1.2 Has been treated with inhaled corticosteroids of at least 400 mcg per day beclomethasone or budesonide, or 200 mcg per day fluticasone; and 1.3 The prescriber considers that the patient would receive additional clinical benefit from switching to a combination product; or 2 All of the following: 2.1 Patient is over the age of 12; and 2.2 Has been treated with inhaled corticosteroids of at least 800 mcg per day beclomethasone or budesonide, or 500 mcg per day fluticasone; and 2.3 The prescriber considers that the patient would receive additional clinical benefit from switching to a combination product. FLUTICASONE WITH SALMETEROL Aerosol inhaler 50 mcg with salmeterol 25 mcg .............................................37.48 120 dose Seretide Powder for inhalation 100 mcg with salmeterol 50 mcg .................................37.48 60 dose Seretide Accuhaler Aerosol inhaler 125 mcg with salmeterol 25 mcg ...........................................49.69 120 dose Seretide Powder for inhalation 250 mcg with salmeterol 50 mcg .................................49.69 60 dose Seretide Accuhaler

Mast Cell Stabilisers

NEDOCROMIL Aerosol inhaler 2 mg per dose SODIUM CROMOGLYCATE Powder for inhalation 20 mg per dose Aerosol inhaler 5 mg per dose

Methylxanthines

AMINOPHYLLINE Inj 25 mg per ml, 10 ml ampoule – 1% DV Nov-11 to 2014...........................53.75 CAFFEINE CITRATE Oral liq 20 mg per ml (caffeine 10 mg per ml) ................................................14.85 Inj 20 mg per ml (caffeine 10 mg per ml), 2.5 ml ampoule .............................55.75 THEOPHYLLINE Tab long-acting 250 mg Oral liq 80 mg per 15 ml 5 25 ml 5 DBL Aminophylline Biomed Biomed

Mucolytics and Expectorants

DORNASE ALFA – Restricted see terms below Nebuliser soln 2.5 mg per 2.5 ml ampoule ...................................................250.00 6 ¯Restricted Any of the following: 1 Cystic fibrosis and the patient has been approved by the Cystic Fibrosis Panel; and/or 2 Significant mucus production and meets the following criteria 3 Treatment for up to four weeks for patients meeting the following: 3.1 Patient is an in-patient; and 3.2 The mucus production cannot be cleared by first line chest techniques; or 4 Treatment for up to three days for patients diagnosed with empyema. ¯ Pulmozyme

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RESPIRATORY SYSTEM AND ALLERGIES

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

SODIUM CHLORIDE Nebuliser soln 7%, 90 ml bottle ......................................................................23.50

90 ml

Biomed

Pulmonary Surfactants

BERACTANT Soln 200 mg per 8 ml vial .............................................................................550.00 PORACTANT ALFA Soln 120 mg per 1.5 ml vial ..........................................................................425.00 Soln 240 mg per 3 ml vial .............................................................................695.00 1 1 1 Survanta Curosurf Curosurf

Respiratory Stimulants

DOXAPRAM Inj 20 mg per ml, 5 ml vial

Sclerosing Agents

TALC Powder Soln (slurry) 100 mg per ml, 50 ml

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SENSORY ORGANS

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

Anti-Infective Preparations Antibacterials

CHLORAMPHENICOL Eye oint 1% – 1% DV Jan-13 to 2015..............................................................2.76 Ear drops 0.5% Eye drops 0.5% – 1% DV Sep-12 to 2015.......................................................1.20 Eye drops 0.5%, single dose CIPROFLOXACIN Eye drops 0.3% FRAMYCETIN SULPHATE Ear/eye drops 0.5% FUSIDIC ACID Eye drops 1% ...................................................................................................4.50 GENTAMICIN SULPHATE Eye drops 0.3% ..............................................................................................11.40 PROPAMIDINE ISETHIONATE Eye drops 0.1% SULPHACETAMIDE SODIUM Eye drops 10% TOBRAMYCIN Eye oint 0.3% – 1% DV Sep-11 to 2014 ........................................................10.45 Eye drops 0.3% – 1% DV Sep-11 to 2014.....................................................11.48 3.5 g 5 ml Tobrex Tobrex 5g 5 ml Fucithalmic Genoptic 4g 10 ml Chlorsig Chlorafast

Antifungals

NATAMYCIN Eye drops 5%

Antivirals

ACICLOVIR Eye oint 3%

Combination Preparations

DEXAMETHASONE WITH FRAMYCETIN AND GRAMICIDIN Ear/eye drops 500 mcg with framycetin sulphate 5 mg and gramicidin 50 mcg per ml DEXAMETHASONE WITH NEOMYCIN SULPHATE AND POLYMYXIN B SULPHATE Eye oint 0.1% with neomycin sulphate 0.35% and polymyxin B sulphate 6,000 u per g Eye drops 0.1% with neomycin sulphate 0.35% and polymyxin B sulphate 6,000 u per ml DEXAMETHASONE WITH TOBRAMYCIN Eye drops 0.1% with tobramycin 0.3% FLUMETASONE PIVALATE WITH CLIOQUINOL Ear drops 0.02% with clioquinol 1%

Products with Hospital Supply Status (HSS) are in bold Expiry date of HSS period is 30 June of the year indicated unless otherwise stated.

165


SENSORY ORGANS

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

HYDROCORTISONE WITH CIPROFLOXACIN Ear drops 1% with ciprofloxacin 0.2% TRIAMCINOLONE ACETONIDE WITH GRAMICIDIN, NEOMYCIN AND NYSTATIN Ear drops 1 mg with nystatin 100,000 u, neomycin sulphate 2.5 mg and gramicidin 250 mcg per g ................................................................... 5.16

7.5 ml

Kenacomb

Anti-Inflammatory Preparations Corticosteroids

DEXAMETHASONE Eye oint 0.1% – 1% DV Sep-11 to 2014 ..........................................................5.86 Eye drops 0.1% ................................................................................................4.50 FLUOROMETHOLONE Eye drops 0.1% – 1% DV Dec-12 to 2015.......................................................3.80 PREDNISOLONE ACETATE Eye drops 0.12% Eye drops 1% PREDNISOLONE SODIUM PHOSPHATE Eye drops 0.5%, single dose 3.5 g 5 ml 5 ml Maxidex Maxidex Flucon

Non-Steroidal Anti-Inflammatory Drugs

DICLOFENAC SODIUM Eye drops 0.1% – 1% DV Sep-11 to 2014.....................................................13.80 Eye drops 0.1%, single dose KETOROLAC TROMETAMOL Eye drops 0.5% 5 ml Voltaren Ophtha

Decongestants and Antiallergics Antiallergic Preparations

LEVOCABASTINE Eye drops 0.05% LODOXAMIDE Eye drops 0.1% OLOPATADINE Eye drops 0.1% SODIUM CROMOGLYCATE Eye drops 2%

Decongestants

NAPHAZOLINE HYDROCHLORIDE Eye drops 0.1% – 1% DV Sep-11 to 2014.......................................................4.15 15 ml Naphcon Forte

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SENSORY ORGANS

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Per

Diagnostic and Surgical Preparations Diagnostic Dyes

FLUORESCEIN SODIUM Eye drops 2%, single dose Inj 10%, 5 ml vial ..........................................................................................125.00 Ophthalmic strips 1 mg FLUORESCEIN SODIUM WITH LIGNOCAINE HYDROCHLORIDE Eye drops 0.25% with lignocaine hydrochloride 4%, single dose LISSAMINE GREEN Ophthalmic strips 1.5 mg ROSE BENGAL SODIUM Ophthalmic strips 1%

12

Fluorescite

Irrigation Solutions

CALCIUM CHLORIDE WITH MAGNESIUM CHLORIDE, POTASSIUM CHLORIDE, SODIUM ACETATE, SODIUM CHLORIDE AND SODIUM CITRATE Eye drops 0.048% with magnesium chloride 0.03%, potassium chloride 0.075%, sodium acetate 0.39%, sodium chloride 0.64% and sodium citrate 0.17%, 15 ml e.g. Balanced Salt Solution Eye drops 0.048% with magnesium chloride 0.03%, potassium chloride 0.075%, sodium acetate 0.39%, sodium chloride 0.64% and sodium citrate 0.17%, 250 ml e.g. Balanced Salt Solution Eye drops 0.048% with magnesium chloride 0.03%, potassium chloride 0.075%, sodium acetate 0.39%, sodium chloride 0.64% and sodium citrate 0.17%, 500 ml e.g. Balanced Salt Solution

Ocular Anaesthetics

OXYBUPROCAINE HYDROCHLORIDE Eye drops 0.4%, single dose PROXYMETACAINE HYDROCHLORIDE Eye drops 0.5% TETRACAINE [AMETHOCAINE] HYDROCHLORIDE Eye drops 0.5%, single dose Eye drops 1%, single dose

Viscoelastic Substances

HYPROMELLOSE Inj 2%, 1 ml syringe Inj 2%, 2 ml syringe

Products with Hospital Supply Status (HSS) are in bold Expiry date of HSS period is 30 June of the year indicated unless otherwise stated.

167


SENSORY ORGANS

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

SODIUM HYALURONATE Inj 14 mg per ml, 0.85 ml syringe – 1% DV Oct-12 to 2015...........................50.00 Inj 14 mg per ml, 0.55 ml syringe – 1% DV Oct-12 to 2015...........................50.00 Inj 23 mg per ml, 0.6 ml syringe Inj 10 mg per ml, 0.85 ml syringe – 1% DV Oct-12 to 2015...........................30.00 SODIUM HYALURONATE WITH CHONDROITIN SULPHATE Inj 30 mg per ml with chondroitin sulphate 40 mg per ml, 0.35 ml syringe and inj 10 mg sodium hyaluronate per ml, 0.4 ml syringe .............. 64.00 Inj 30 mg per ml with chondroitin sulphate 40 mg per ml, 0.5 ml syringe and inj 10 mg sodium hyaluronate per ml, 0.55 ml syringe – 1% DV Sep-11 to 2014 .................................................................................. 74.00 Inj 30 mg with chondroitin sulphate 40 mg per ml, 0.75 ml syringe

1 1 1

Healon GV Healon GV Provisc

1

Duovisc

1

Duovisc

Other

RIBOFLAVIN 5-PHOSPHATE Soln trans epithelial riboflavin Inj 0.1% Inj 0.1% plus 20% dextran T500

Glaucoma Preparations Beta Blockers

BETAXOLOL Eye drops 0.25% Eye drops 0.5% LEVOBUNOLOL HYDROCHLORIDE Eye drops 0.25% ..............................................................................................7.00 Eye drops 0.5% ................................................................................................7.00 TIMOLOL Eye drops 0.25% Eye drops 0.25%, gel forming – 1% DV Mar-14 to 2016 .................................3.30 Eye drops 0.5% Eye drops 0.5%, gel forming – 1% DV Mar-14 to 2016 ...................................3.78 5 ml 5 ml Betagan Betagan

2.5 ml 2.5 ml

Timoptol XE Timoptol XE

Carbonic Anhydrase Inhibitors

ACETAZOLAMIDE Tab 250 mg – 1% DV Nov-11 to 2014 ...........................................................17.03 Inj 500 mg BRINZOLAMIDE Eye drops 1% DORZOLAMIDE Eye drops 2% DORZOLAMIDE WITH TIMOLOL Eye drops 2% with timolol 0.5% .....................................................................15.50 5 ml Cosopt 100 Diamox

Miotics

ACETYLCHOLINE CHLORIDE Inj 20 mg vial with diluent

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SENSORY ORGANS

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

PILOCARPINE HYDROCHLORIDE Eye drops 1% Eye drops 2% Eye drops 2%, single dose Eye drops 4%

Prostaglandin Analogues

BIMATOPROST Eye drops 0.03% LATANOPROST Eye drops 0.005% – 1% DV Sep-12 to 2015...................................................1.99 TRAVOPROST Eye drops 0.004% 2.5 ml Hysite

Sympathomimetics

APRACLONIDINE Eye drops 0.5% BRIMONIDINE TARTRATE Eye drops 0.2% – 1% DV Jul-12 to 2014 ........................................................6.45 BRIMONIDINE TARTRATE WITH TIMOLOL Eye drops 0.2% with timolol 0.5% 5 ml Arrow-Brimonidine

Mydriatics and Cycloplegics Anticholinergic Agents

ATROPINE SULPHATE Eye drops 0.5% Eye drops 1%, single dose Eye drops 1% .................................................................................................17.36 CYCLOPENTOLATE HYDROCHLORIDE Eye drops 0.5%, single dose Eye drops 1% Eye drops 1%, single dose TROPICAMIDE Eye drops 0.5% – 1% DV Sep-11 to 2014.......................................................7.15 Eye drops 0.5%, single dose Eye drops 1% – 1% DV Sep-11 to 2014..........................................................8.66 Eye drops 1%, single dose 15 ml 15 ml Mydriacyl Mydriacyl

15 ml

Atropt

Sympathomimetics

PHENYLEPHRINE HYDROCHLORIDE Eye drops 2.5%, single dose Eye drops 10%, single dose

Ocular Lubricants

CARBOMER Ophthalmic gel 0.3%, single dose ....................................................................8.25 Ophthalmic gel 0.2% 30 Poly Gel

Products with Hospital Supply Status (HSS) are in bold Expiry date of HSS period is 30 June of the year indicated unless otherwise stated.

169


SENSORY ORGANS

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

CARMELLOSE SODIUM Eye drops 0.5% Eye drops 0.5%, single dose Eye drops 1% Eye drops 1%, single dose HYPROMELLOSE Eye drops 0.5% ................................................................................................3.92 HYPROMELLOSE WITH DEXTRAN Eye drops 0.3% with dextran 0.1% ...................................................................2.30 Eye drops 0.3% with dextran 0.1%, single dose MACROGOL 400 AND PROPYLENE GLYCOL Eye drops 0.4% with propylene glycol 0.3% preservative free, single dose ........................................................................................................... 4.30 PARAFFIN LIQUID WITH SOFT WHITE PARAFFIN Eye oint 42.5% with soft white paraffin 57.3% PARAFFIN LIQUID WITH WOOL FAT Eye oint 3% with wool fat 3% POLYVINYL ALCOHOL Eye drops 1.4% ................................................................................................2.95 3.62 Eye drops 3% ...................................................................................................3.80 3.88 POLYVINYL ALCOHOL WITH POVIDONE Eye drops 1.4% with povidone 0.6%, single dose RETINOL PALMITATE Oint 138 mcg per g ...........................................................................................3.80 SODIUM HYALURONATE Eye drops 1 mg per ml ...................................................................................22.00 5g 10 ml VitA-POS Hylo-Fresh 15 ml 15 ml Vistil Liquifilm Tears Vistil Forte Liquifilm Forte 15 ml 15 ml Methopt Poly-Tears

24

Systane Unit Dose

Other Otological Preparations

ACETIC ACID WITH PROPYLENE GLYCOL Ear drops 2.3% with propylene glycol 2.8% DOCUSATE SODIUM Ear drops 0.5%

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170

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VARIOUS

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

Agents Used in the Treatment of Poisonings Antidotes

ACETYLCYSTEINE Tab eff 200 mg Inj 200 mg per ml, 10 ml ampoule – 1% DV Jul-12 to 2015 ........................178.00 Inj 200 mg per ml, 30 ml vial .........................................................................219.00 DIGOXIN IMMUNE FAB Inj 38 mg vial Inj 40 mg vial ETHANOL Liq 96% ETHANOL WITH GLUCOSE Inj 10% with glucose 5%, 500 ml bottle ETHANOL, DEHYDRATED Inj 100%, 5 ml ampoule FLUMAZENIL Inj 0.1 mg per ml, 5 ml ampoule ...................................................................170.10 HYDROXOCOBALAMIN Inj 5 g vial Inj 2.5 g vial NALOXONE HYDROCHLORIDE Inj 400 mcg per ml, 1 ml ampoule ..................................................................33.00 PRALIDOXIME IODIDE Inj 25 mg per ml, 20 ml ampoule SODIUM NITRITE Inj 30 mg per ml, 10 ml ampoule SODIUM THIOSULFATE Inj 500 mg per ml, 20 ml ampoule Inj 250 mg per ml, 10 ml vial Inj 500 mg per ml, 10 ml vial SOYA OIL Inj 20%, 500 ml bag Inj 20%, 500 ml bottle 5 Mayne 5 Anexate

10 4

Martindale Acetylcysteine Acetadote

Antitoxins

BOTULISM ANTITOXIN Inj 250 ml vial DIPHTHERIA ANTITOXIN Inj 10,000 iu vial

Antivenoms

RED BACK SPIDER ANTIVENOM Inj 500 u vial

Products with Hospital Supply Status (HSS) are in bold Expiry date of HSS period is 30 June of the year indicated unless otherwise stated.

171


VARIOUS

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

SNAKE ANTIVENOM Inj 50 ml vial

Removal and Elimination

CHARCOAL Oral liq 200 mg per ml ....................................................................................43.50 DEFERIPRONE Tab 500 mg ...................................................................................................533.17 Oral liq 100 mg per ml ..................................................................................266.59 DESFERRIOXAMINE MESILATE Inj 500 mg vial ................................................................................................99.00 DICOBALT EDETATE Inj 15 mg per ml, 20 ml ampoule DIMERCAPROL Inj 50 mg per ml, 2 ml ampoule DIMERCAPTOSUCCINIC ACID Cap 100 mg DISODIUM EDETATE Inj 150 mg per ml, 20 ml ampoule Inj 150 mg per ml, 20 ml vial Inj 150 mg per ml, 100 ml vial SODIUM CALCIUM EDETATE Inj 200 mg per ml, 2.5 ml ampoule Inj 200 mg per ml, 5 ml ampoule 250 ml 100 250 ml 10 Carbasorb-X Ferriprox Ferriprox Hospira

Antiseptics and Disinfectants

CHLORHEXIDINE Soln 4% ............................................................................................................1.86 Soln 5% ..........................................................................................................15.50 CHLORHEXIDINE WITH CETRIMIDE Crm 0.1% with cetrimide 0.5% Foaming soln 0.5% with cetrimide 0.5% CHLORHEXIDINE WITH ETHANOL Soln 0.5% with ethanol 70%, non-staining (pink) 100 ml .................................2.65 Soln 2% with ethanol 70%, non-staining (pink) 100 ml ....................................3.54 Soln 0.5% with ethanol 70%, non-staining (pink) 25 ml ...................................1.55 Soln 0.5% with ethanol 70%, staining (red) 100 ml ..........................................2.90 Soln 2% with ethanol 70%, staining (red) 100 ml .............................................3.86 Soln 0.5% with ethanol 70%, non-staining (pink) 500 ml .................................5.45 Soln 0.5% with ethanol 70%, staining (red) 500 ml ..........................................5.90 Soln 2% with ethanol 70%, staining (red) 500 ml .............................................9.56 IODINE WITH ETHANOL Soln 1% with ethanol 70%, 100 ml ...................................................................9.30 ISOPROPYL ALCOHOL Soln 70%, 500 ml .............................................................................................5.00 5.65 1 1 1 1 1 1 1 1 1 1 healthE healthE healthE healthE healthE healthE healthE healthE healthE PSM healthE 50 ml 500 ml healthE healthE

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172

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VARIOUS

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

POVIDONE-IODINE Vaginal tab 200 mg ¯Restricted Rectal administration pre-prostate biopsy. Oint 10% ...........................................................................................................3.27 Soln 10% ..........................................................................................................2.95 6.20 Soln 5% Soln 7.5% Pad 10% Swab set 10% POVIDONE-IODINE WITH ETHANOL Soln 10% with ethanol 30% ............................................................................10.00 Soln 10% with ethanol 70% SODIUM HYPOCHLORITE Soln 500 ml Betadine Skin Prep

¯

25 g 100 ml 500 ml

Betadine Riodine Riodine Betadine

Contrast Media Iodinated X-ray Contrast Media

DIATRIZOATE MEGLUMINE WITH DIATRIZOATE SODIUM Oral liq 660 mg per ml with diatrizoate sodium 100 mg per ml, 100 ml ..........21.00 Inj 370 mg with sodium amidotrizoate 100 mg per ml, 50 ml bottle Inj 146 mg with sodium amidotrizoate 40 mg per ml, 250 ml bottle ..............210.00 DIATRIZOATE SODIUM Oral liq 370 mg per ml, 10 ml sachet ............................................................156.12 IODISED OIL Inj 480 mg per ml, 10 ml ampoule IODIXANOL Inj 270 mg per ml, 20 ml vial Inj 270 mg per ml, 50 ml bottle .....................................................................223.50 Inj 270 mg per ml, 100 ml bottle ...................................................................447.00 Inj 320 mg per ml, 20 ml vial Inj 320 mg per ml, 50 ml bottle .....................................................................223.50 Inj 320 mg per ml, 100 ml bottle ...................................................................447.00 Inj 320 mg per ml, 150 ml bottle ...................................................................670.50 Inj 320 mg per ml, 200 ml bottle ...................................................................565.56 894.00 100 ml 10 50 Gastrografin Gastrografin Ioscan

10 10 10 10 10 6 10

Visipaque Visipaque Visipaque Visipaque Visipaque Visipaque Visipaque

Products with Hospital Supply Status (HSS) are in bold Expiry date of HSS period is 30 June of the year indicated unless otherwise stated.

173


VARIOUS

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

IOHEXOL Inj 240 mg per ml, 50 ml bottle .......................................................................77.80 Inj 300 mg per ml, 20 ml bottle .......................................................................24.00 Inj 300 mg per ml, 50 ml bottle .......................................................................77.80 Inj 300 mg per ml, 100 ml bottle ...................................................................155.60 Inj 300 mg per ml, 500 ml bottle ...................................................................468.00 Inj 350 mg per ml, 20 ml bottle .......................................................................24.00 Inj 350 mg per ml, 50 ml bottle .......................................................................77.80 Inj 350 mg per ml, 75 ml bottle .....................................................................116.70 Inj 350 mg per ml, 100 ml bottle ...................................................................155.60 Inj 350 mg per ml, 200 ml bottle ...................................................................311.16 IOMEPROL Inj 150 mg per ml, 50 ml bottle Inj 300 mg per ml, 20 ml vial Inj 300 mg per ml, 50 ml bottle Inj 300 mg per ml, 100 ml bottle Inj 350 mg per ml, 20 ml vial Inj 350 mg per ml, 50 ml bottle Inj 350 mg per ml, 75 ml bottle Inj 350 mg per ml, 100 ml bottle Inj 400 mg per ml, 50 ml bottle IOPROMIDE Inj 240 per ml, 50 ml bottle Inj 300 per ml, 20 ml vial Inj 300 per ml, 50 ml bottle Inj 370 per ml, 30 ml vial Inj 370 per ml, 50 ml bottle Inj 370 per ml, 100 ml bottle Inj 370 per ml, 200 ml bottle Inj 300 per ml, 100 ml bottle IOTROLAN Inj 240 mg per ml, 10 ml vial

10 6 10 10 6 6 10 10 10 10

Omnipaque Omnipaque Omnipaque Omnipaque Omnipaque Omnipaque Omnipaque Omnipaque Omnipaque Omnipaque

°

174

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VARIOUS

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

Non-iodinated X-ray Contrast Media

BARIUM SULPHATE Powder for enema 397 g Powder for oral liq 10,000 g Powder for oral liq 100 g Powder for oral liq 148 g Powder for oral liq 22.1 g Powder for oral liq 300 g Powder for oral liq 340 g Eosophogeal cream 30 mg per g Eosophogeal cream 600 mg per g Liq 1,000 mg per ml Oral liq 1 mg per ml Oral liq 1,250 mg per ml Oral liq 13 mg per ml Oral liq 130 mg per ml Oral liq 21 mg per ml Oral liq 400 mg per ml Eosophogeal paste 400 mg per ml Oral liq 22 mg per g, 250 ml .........................................................................175.00 Oral liq 22 mg per g, 450 ml .........................................................................220.00 Enema 1,250 mg per ml CITRIC ACID WITH SODIUM BICARBONATE Powder 382.2 mg per g with sodium bicarbonate 551.3 mg per g, 4 g sachet

24 24

CT Plus+ CT Plus+

e.g. E-Z-GAS II

Paramagnetic Contrast Media

GADOBENIC ACID Inj 334 mg per ml, 10 ml vial .........................................................................324.74 Inj 334 mg per ml, 20 ml vial .........................................................................636.28 GADOBUTROL Inj 1 mmol per ml, 15 ml vial Inj 1 mmol per ml, 7.5 ml syringe .................................................................253.10 GADODIAMIDE Inj 287 mg per ml, 10 ml syringe ..................................................................220.00 Inj 287 mg per ml, 10 ml vial .........................................................................180.00 Inj 287 mg per ml, 5 ml vial Inj 287 mg per ml, 15 ml syringe ..................................................................330.00 Inj 287 mg per ml, 15 ml vial .........................................................................270.00 Inj 287 mg per ml, 20 ml syringe ..................................................................440.00 Inj 287 mg per ml, 20 ml vial GADOTERIC ACID Inj 0.5 mmol per ml, 10 ml syringe Inj 0.5 mmol per ml, 20 ml syringe Inj 0.5 mmol per ml, 10 ml bottle Inj 0.5 mmol per ml, 20 ml bottle Inj 0.5 mmol per ml, 5 ml bottle 10 10 Multihance Multihance

5 10 10 10 10 10

Gadovist Omniscan Omniscan Omniscan Omniscan Omniscan

Products with Hospital Supply Status (HSS) are in bold Expiry date of HSS period is 30 June of the year indicated unless otherwise stated.

175


VARIOUS

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

GADOXETATE DISODIUM Inj 181 mg per ml, 10 ml syringe MEGLUMINE GADOPENTETATE Inj 469 mg per ml, 10 ml syringe ....................................................................92.00 Inj 469 mg per ml, 10 ml vial .........................................................................184.00 Inj 469 mg per ml, 15 ml vial Inj 469 mg per ml, 20 ml vial 5 10 Magnevist Magnevist

Ultrasound Contrast Media

PLERFUTREN Inj 1.1 mg per ml, 2 ml

Diagnostic Agents

ARGININE Inj 50 mg per ml, 500 ml bottle Inj 100 mg per ml, 300 ml bottle HISTAMINE ACID PHOSPHATE Nebuliser soln 0.6%, 10 ml vial Nebuliser soln 2.5%, 10 ml vial Nebuliser soln 5%, 10 ml vial METHACHOLINE CHLORIDE Powder 100 mg SECRETIN PENTAHYDROCHLORIDE Inj 100 u ampoule SINCALIDE Inj 5 mcg per vial TUBERCULIN, PURIFIED PROTEIN DERIVATIVE Inj 5 TU per 0.1 ml, 1 ml vial

Diagnostic Dyes

BONNEY’S BLUE DYE Soln INDIGO CARMINE Inj 4 mg per ml, 5 ml ampoule Inj 8 mg per ml, 5 ml ampoule INDOCYANINE GREEN Inj 25 mg vial METHYLTHIONINIUM CHLORIDE [METHYLENE BLUE] Inj 10 mg per ml, 10 ml ampoule Inj 10 mg per ml, 5 ml ampoule PATENT BLUE V Inj 2.5%, 2 ml ampoule

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176

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VARIOUS

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

Irrigation Solutions

CHLORHEXIDINE Irrigation soln 0.02%, bottle ..............................................................................2.92 Irrigation soln 0.05%, bottle ..............................................................................3.02 3.63 Irrigation soln 0.1%, bottle ................................................................................3.10 Irrigation soln 0.5%, bottle ................................................................................4.69 Irrigation soln 0.02%, 500 ml bottle Irrigation soln 0.1%, 30 ml ampoule CHLORHEXIDINE WITH CETRIMIDE Irrigation soln 0.015% with cetrimide 0.15%, 30 ml ampoule Irrigation soln 0.015% with cetrimide 0.15%, bottle ..........................................3.21 3.47 4.17 Irrigation soln 0.05% with cetrimide 0.5%, bottle ..............................................4.20 3.87 Irrigation soln 0.1% with cetrimide 1%, bottle ...................................................4.38 5.81 GLYCINE Irrigation soln 1.5%, bottle ..............................................................................11.38 14.44 SODIUM CHLORIDE Irrigation soln 0.9%, 30 ml ampoule – 1% DV Nov-11 to 2014......................19.50 Irrigation soln 0.9%, bottle ................................................................................2.49 2.88 2.96 10.00 12.67 WATER Irrigation soln, bottle .........................................................................................2.68 2.61 2.75 9.71 15.80 100 ml 100 ml 500 ml 100 ml 500 ml Baxter Baxter Baxter Baxter Baxter

100 ml 500 ml 1,000 ml 100 ml 500 ml 100 ml 500 ml 2,000 ml 3,000 ml 30 ml 100 ml 500 ml 1,000 ml 2,000 ml 3,000 ml 100 ml 500 ml 1,000 ml 2,000 ml 3,000 ml

Baxter Baxter Baxter Baxter Baxter Baxter Baxter Baxter Baxter Pfizer Baxter Baxter Baxter Baxter Baxter Baxter Baxter Baxter Baxter Baxter

Surgical Preparations

BISMUTH SUBNITRATE AND IODOFORM PARAFFIN Paste DIMETHYL SULFOXIDE Soln 50% Soln 99% PHENOL Inj 6%, 10 ml ampoule PHENOL WITH IOXAGLIC ACID Inj 12%, 10 ml ampoule TROMETAMOL Inj 36 mg per ml, 500 ml bottle

Products with Hospital Supply Status (HSS) are in bold Expiry date of HSS period is 30 June of the year indicated unless otherwise stated.

177


VARIOUS

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

Cardioplegia Solutions

ELECTROLYTES Inj aspartic acid 10.43 mg per ml, citric acid 0.22476 mg per ml, glutamic acid 11.53 mg per ml, sodium phosphate 0.1725 mg per ml, potassium chloride 2.15211 mg per ml, sodium citrate 1.80768 mg per ml, sodium hydroxide 6.31 mg per ml and trometamol 11.2369 mg per ml, 364 ml bag

e.g. Cardioplegia Enriched Paed. Soln.

Inj aspartic acid 8.481 mg per ml, citric acid 0.8188 mg per ml, glutamic acid 9.375 mg per ml, sodium phosphate 0.6285 mg per ml, potassium chloride 2.5 mg per ml, sodium citrate 6.585 mg per ml, sodium hydroxide 5.133 mg per ml and trometamol 9.097 mg per ml, 527 ml bag Inj citric acid 0.07973 mg per ml, sodium phosphate 0.06119 mg per ml, potassium chloride 2.181 mg per ml, sodium chloride 1.788 mg ml, sodium citrate 0.6412 mg per ml and trometamol 5.9 mg per ml, 523 ml bag Inj 110 mmol/l sodium, 16 mmol/l potassium, 1.2 mmol/l calcium, 16 mmol/l magnesium and 160 mmol/l chloride, 1,000 ml bag Inj 143 mmol/l sodium, 16 mmol/l potassium, 16 mmol/l magnesium and 1.2 mmol/l calcium, 1,000 ml bag MONOSODIUM GLUTAMATE WITH SODIUM ASPARTATE Inj 42.68 mg with sodium aspartate 39.48 mg per ml, 250 ml bottle MONOSODIUM L-ASPARTATE Inj 14 mmol per 10 ml, 10 ml

e.g. Cardioplegia Enriched Solution

e.g. Cardioplegia Base Solution e.g. Cardioplegia Solution AHB7832 e.g. Cardioplegia Electrolyte Solution

Cold Storage Solutions

SODIUM WITH POTASSIUM Inj 29 mmol/l with potassium 125 mmol/l, 1,000 ml bag

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178

Item restricted (see ° above); Item restricted (see ¯ below) e.g. Brand indicates brand example only. It is not a contracted product.

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EXTEMPORANEOUSLY COMPOUNDED PREPARATIONS AND GALENICALS

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Per

Extemporaneously Compounded Preparations

ACETIC ACID Liq ALUM Powder BP ARACHIS OIL [PEANUT OIL] Liq ASCORBIC ACID Powder BENZOIN Tincture compound BP BISMUTH SUBGALLATE Powder BORIC ACID Powder CARBOXYMETHYLCELLULOSE Soln 1.5% CETRIMIDE Soln 40% CHLORHEXIDINE GLUCONATE Soln 20 % CHLOROFORM Liq BP CITRIC ACID Powder BP CLOVE OIL Liq COAL TAR Soln BP CODEINE PHOSPHATE Powder COLLODION FLEXIBLE Liq COMPOUND HYDROXYBENZOATE Soln CYSTEAMINE HYDROCHLORIDE Powder DISODIUM HYDROGEN PHOSPHATE WITH SODIUM DIHYDROGEN PHOSPHATE Inj 37.46 mg with sodium dihydrogen phosphate 47.7 mg in 1.5 ml ampoule DITHRANOL Powder

Products with Hospital Supply Status (HSS) are in bold Expiry date of HSS period is 30 June of the year indicated unless otherwise stated.

179


EXTEMPORANEOUSLY COMPOUNDED PREPARATIONS AND GALENICALS

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

GLUCOSE Powder GLYCERIN WITH SODIUM SACCHARIN Suspension .....................................................................................................35.50 GLYCERIN WITH SUCROSE Suspension .....................................................................................................35.50 GLYCEROL Liq ...................................................................................................................19.80 HYDROCORTISONE Powder – 1% DV Nov-11 to 2014 ..................................................................44.00 LACTOSE Powder MAGNESIUM HYDROXIDE Paste MENTHOL Crystals METHADONE HYDROCHLORIDE Powder METHYL HYDROXYBENZOATE Powder METHYLCELLULOSE Powder Suspension .....................................................................................................35.50 METHYLCELLULOSE WITH GLYCERIN AND SODIUM SACCHARIN Suspension .....................................................................................................35.50 METHYLCELLULOSE WITH GLYCERIN AND SUCROSE Suspension .....................................................................................................35.50 OLIVE OIL Liq PARAFFIN Liq PHENOBARBITONE SODIUM Powder PHENOL Liq PILOCARPINE NITRATE Powder POLYHEXAMETHYLENE BIGUANIDE Liq POVIDONE K30 Powder PROPYLENE GLYCOL Liq ...................................................................................................................12.00 500 ml ABM 473 ml 473 ml 2,000 ml 25 g Ora-Sweet SF Ora-Sweet ABM ABM

473 ml 473 ml 473 ml

Ora-Plus Ora-Blend SF Ora-Blend

°

180

Item restricted (see ° above); Item restricted (see ¯ below) e.g. Brand indicates brand example only. It is not a contracted product.

¯


EXTEMPORANEOUSLY COMPOUNDED PREPARATIONS AND GALENICALS

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

SALICYLIC ACID Powder SILVER NITRATE Crystals SODIUM BICARBONATE Powder BP SODIUM CITRATE Powder SODIUM METABISULFITE Powder STARCH Powder SULPHUR Precipitated Sublimed SYRUP Liq (pharmaceutical grade) .............................................................................21.75 TRI-SODIUM CITRATE Crystals TRICHLORACETIC ACID Grans UREA Powder BP WOOL FAT Oint, anhydrous XANTHAN Gum 1% ZINC OXIDE Powder 2,000 ml Midwest

Products with Hospital Supply Status (HSS) are in bold Expiry date of HSS period is 30 June of the year indicated unless otherwise stated.

181


SPECIAL FOODS

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

Food Modules Carbohydrate

°Restricted Use as an additive Any of the following: 1 Cystic fibrosis; or 2 Chronic kidney disease; or 3 Cancer in children; or 4 Cancers affecting alimentary tract where there are malabsorption problems in patients over the age of 20 years; or 5 Faltering growth in an infant/child; or 6 Bronchopulmonary dysplasia; or 7 Premature and post premature infant; or 8 Inborn errors of metabolism. Use as a module For use as a component in a modular formula CARBOHYDRATE SUPPLEMENT – Restricted see terms above Powder 95 g carbohydrate per 100 g, 368 g can Powder 96 g carbohydrate per 100 g, 400 g can e.g. Polycal

°°

°°

°°

Fat

°Restricted Use as an additive Any of the following: 1 Patient has inborn errors of metabolism; or 2 Faltering growth in an infant/child; or 3 Bronchopulmonary dysplasia; or 4 Fat malabsorption; or 5 Lymphangiectasia; or 6 Short bowel syndrome; or 7 Infants with necrotising enterocolitis; or 8 Biliary atresia; or 9 For use in a ketogenic diet; or 10 Chyle leak; or 11 Ascites; or 12 Patient has increased energy requirements, and for whom dietary measures have not been successful. Use as a module For use as a component in a modular formula LONG-CHAIN TRIGLYCERIDE SUPPLEMENT – Restricted see terms above Liquid 50 g fat per 100 ml, 200 ml bottle e.g. Calogen Liquid 50 g fat per 100 ml, 500 ml bottle e.g. Calogen e.g. Liquigen e.g. MCT Oil

MEDIUM-CHAIN TRIGLYCERIDE SUPPLEMENT – Restricted see terms above Liquid 50 g fat per 100 ml, 250 ml bottle Liquid 95 g fat per 100 ml, 500 ml bottle WALNUT OIL – Restricted see terms above Liq

°

°

182

Item restricted (see ° above); Item restricted (see ¯ below) e.g. Brand indicates brand example only. It is not a contracted product.

¯


SPECIAL FOODS

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

Protein

°Restricted Use as an additive Either: 1 Protein losing enteropathy; or 2 High protein needs. Use as a module For use as a component in a modular formula PROTEIN SUPPLEMENT – Restricted see terms above Powder 5 g protein, 0.67 g carbohydrate and 0.6 g fat per 6.6 g, 275 g can Powder 6 g protein per 7 g, can ........................................................................8.95 Powder 89 g protein, <1.5 g carbohydrate and 2 g fat per 100 g, 225 g can

°

°°

227 g

e.g. Promod Resource Beneprotein e.g. Protifar

Other Supplements

BREAST MILK FORTIFIER Powder 0.2 g protein, 0.7 g carbohydrate and 0.02 g fat per 1 g sachet Powder 0.5 g protein, 1.2 g carbohydrate and 0.08 g fat per 2 g sachet Powder 0.6 g protein and 1.4 g carbohydrate per 2.2 g sachet CARBOHYDRATE AND FAT SUPPLEMENT – Restricted see terms below Powder 72.7 g carbohydrate and 22.3 g fat per 100 g, 400 g can ¯Restricted Both: 1 Infant or child aged four years or under; and 2 Any of the following: 2.1 Cystic fibrosis; or 2.2 Cancer in children; or 2.3 Faltering growth; or 2.4 Bronchopulmonary dysplasia; or 2.5 Premature and post premature infants. e.g. FM 85 e.g. S26 Human Milk Fortifier e.g. Nutricia Breast Milk Fortifer e.g. Super Soluble Duocal

¯

Food/Fluid Thickeners

NOTE: While pre-thickened drinks and supplements have not been included in Section H, DHB hospitals may continue to use such products for patients with dysphagia, provided that: G use was established prior to 1 July 2013; and G the product has not been specifically considered and excluded by PHARMAC; and G use of the product conforms to any applicable indication restrictions for similar products that are listed in Section H (for example, use of thickened high protein products should be in line with the restriction for high protein oral feed in Section H). PHARMAC intends to make a further decision in relation to pre-thickened drinks and supplements in the future, and will notify of any change to this situation. CAROB BEAN GUM WITH MAIZE STARCH AND MALTODEXTRIN Powder e.g. Feed Thickener Karicare Aptamil

Products with Hospital Supply Status (HSS) are in bold Expiry date of HSS period is 30 June of the year indicated unless otherwise stated.

183


SPECIAL FOODS

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

GUAR GUM Powder MAIZE STARCH Powder MALTODEXTRIN WITH XANTHAN GUM Powder MALTODEXTRIN WITH XANTHAN GUM AND ASCORBIC ACID Powder

e.g. Guarcol e.g. Resource Thicken Up; Nutilis e.g. Instant Thick e.g. Easy Thick

Metabolic Products

°Restricted Any of the following: 1 For the dietary management of homocystinuria, maple syrup urine disease, phenylketonuria (PKU), glutaric aciduria, isovaleric acidaemia, propionic acidaemia, methylmalonic acidaemia, tyrosinaemia or urea cycle disorders; or 2 Patient has adrenoleukodystrophy; or 3 For use as a supplement to the Ketogenic diet in patients diagnosed with epilepsy.

Glutaric Aciduria Type 1 Products

AMINO ACID FORMULA (WITHOUT LYSINE AND LOW TRYPTOPHAN) – Restricted see terms above Powder 13.1 g protein, 49.5 g carbohydrate, 23 g fat and 5.3 g fibre per 100 g, 400 g can e.g. GA1 Anamix Infant Powder 25 g protein and 51 g carbohydrate per 100 g, 500 g can e.g. XLYS Low TRY Maxamaid ° ° °

Homocystinuria Products

AMINO ACID FORMULA (WITHOUT METHIONINE) – Restricted see terms above Powder 13.1 g protein, 49.5 g carbohydrate, 23 g fat and 5.3 g fibre per 100 g, 400 g can Powder 25 g protein and 51 g carbohydrate per 100 g, 500 g can Powder 39 g protein and 34 g carbohydrate per 100 g, 500 g can Liquid 8 g protein, 7 g carbohydrate, 3.8 g fat and 0.25 g fibre per 100 ml, 125 ml bottle

° °°

e.g. HCU Anamix Infant e.g. XMET Maxamaid e.g. XMET Maxamum e.g. HCU Anamix Junior LQ

Isovaleric Acidaemia Products

AMINO ACID FORMULA (WITHOUT LEUCINE) – Restricted see terms above Powder 13.1 g protein, 49.5 g carbohydrate, 23 g fat and 5.3 g fibre per 100 g, 400 g can Powder 25 g protein and 51 g carbohydrate per 100 g, 500 g can Powder 39 g protein and 34 g carbohydrate per 100 g, 500 g can °

e.g. IVA Anamix Infant e.g. XLEU Maxamaid e.g. XLEU Maxamum

°°

°

184

Item restricted (see ° above); Item restricted (see ¯ below) e.g. Brand indicates brand example only. It is not a contracted product.

¯


SPECIAL FOODS

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

Maple Syrup Urine Disease Products

AMINO ACID FORMULA (WITHOUT ISOLEUCINE, LEUCINE AND VALINE) – Restricted see terms on the preceding page Powder 13.1 g protein, 49.5 g carbohydrate, 23 g fat and 5.3 g fibre per 100 g, 400 g can e.g. MSUD Anamix Infant Powder 25 g protein and 51 g carbohydrate per 100 g, 500 g can e.g. MSUD Maxamaid Powder 39 g protein and 34 g carbohydrate per 100 g, 500 g can e.g. MSUD Maxamum Liquid 8 g protein, 7 g carbohydrate, 3.8 g fat and 0.25 g fibre per 100 ml, 125 ml bottle e.g. MSUD Anamix Junior LQ ° ° ° ° ° ° ° ° ° °°° ° °° ° °°

Phenylketonuria Products

AMINO ACID FORMULA (WITHOUT PHENYLALANINE) – Restricted see terms on the preceding page Tab 8.33 mg e.g. Phlexy-10 Powder 29 g protein, 38 g carbohydrate and 13.5 g fibre per 100 g, 29 g sachet e.g. PKU Anamix Junior Powder 13.1 g protein, 49.5 g carbohydrate, 23 g fat and 5.3 g fibre per 100 g, 400 g can e.g. PKU Anamix Infant Powder 25 g protein and 51 g carbohydrate per 100 g, 500 g can e.g. XP Maxamaid Powder 39 g protein and 34 g carbohydrate per 100 g, 500 g can e.g. XP Maxamum Powder 8.33 g protein and 8.8 g carbohydrate per 20 g sachet e.g. Phlexy-10 Liquid 10 g protein, 4.4 g carbohydrate and 0.25 g fibre per 100 ml, 62.5 ml bottle e.g. PKU Lophlex LQ 10 Liquid 20 g protein, 8.8 g carbohydrate and 0.34 g fibre per 100 ml, 125 ml bottle e.g. PKU Lophlex LQ 20 Liquid 8 g protein, 7 g carbohydrate, 3.8 g fat and 0.25 g fibre per 100 ml, bottle ........................................................................................... 13.10 125 ml PKU Anamix Junior LQ (Berry) PKU Anamix Junior LQ (Orange) PKU Anamix Junior LQ (Unflavoured) Liquid 16 g protein, 7 g carbohydrate and 0.27 g fibre per 100 ml, 125 ml bottle e.g. PKU Lophlex LQ 20 Liquid 16 g protein, 7 g carbohydrate and 0.27 g fibre per 100 ml, 62.5 ml bottle e.g. PKU Lophlex LQ 10 Liquid 16 g protein, 7 g carbohydrate and 0.4 g fibre per 100 ml, 125 ml bottle e.g. PKU Lophlex LQ 20 Liquid 16 g protein, 7 g carbohydrate and 0.4 g fibre per 100 ml, 62.5 ml bottle e.g. PKU Lophlex LQ 10 Liquid 6.7 g protein, 5.1 g carbohydrate and 2 g fat per 100 ml, 250 ml carton e.g. Easiphen

Products with Hospital Supply Status (HSS) are in bold Expiry date of HSS period is 30 June of the year indicated unless otherwise stated.

185


SPECIAL FOODS

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

Propionic Acidaemia and Methylmalonic Acidaemia Products

AMINO ACID FORMULA (WITHOUT ISOLEUCINE, METHIONINE, THREONINE AND VALINE) – Restricted see terms on page 184 Powder 13.1 g protein, 49.5 g carbohydrate, 23 g fat and 5.3 g fibre per 100 g, 400 g can e.g. MMA/PA Anamix Infant Powder 25 g protein and 51 g carbohydrate per 100 g, 500 g can e.g. XMTVI Maxamaid Powder 39 g protein and 34 g carbohydrate per 100 g, 500 g can e.g. XMTVI Maxamum °

°

°°

Protein Free Supplements

PROTEIN FREE SUPPLEMENT – Restricted see terms on page 184 Powder nil added protein and 67 g carbohydrate per 100 g, 400 g can e.g.Energivit

Tyrosinaemia Products

AMINO ACID FORMULA (WITHOUT PHENYLALANINE AND TYROSINE) – Restricted see terms on page 184 Powder 13.1 g protein, 49.5 g carbohydrate, 23 g fat and 5.3 g fibre per 100 g, 400 g can e.g. TYR Anamix Infant Powder 25 g protein and 51 g carbohydrate per 100 g, 400 g can e.g. XPHEN, TYR Maxamaid Powder 29 g protein, 38 g carbohydrate and 13.5 g fat per 100 g, 29 g sachet e.g. TYR Anamix Junior Liquid 8 g protein, 7 g carbohydrate, 3.8 g fat and 0.25 g fibre per 100 ml, 125 ml bottle e.g. TYR Anamix Junior LQ ° °° ° ° °

Urea Cycle Disorders Products

AMINO ACID SUPPLEMENT – Restricted see terms on page 184 Powder 25 g protein and 65 g carbohydrate per 100 g, 200 g can Powder 79 g protein per 100 g, 200 g can e.g. Dialamine e.g. Essential Amino Acid Mix

X-Linked Adrenoleukodystrophy Products

GLYCEROL TRIERUCATE – Restricted see terms on page 184 Liquid, 1,000 ml bottle GLYCEROL TRIOLEATE – Restricted see terms on page 184 Liquid, 500 ml bottle ° °

Specialised Formulas Diabetic Products

°Restricted Any of the following: 1 For patients with type I or type II diabetes suffering weight loss and malnutrition that requires nutritional support; or 2 For patients with pancreatic insufficiency; or 3 For patients who have, or are expected to, eat little or nothing for 5 days; 4 For patients who have a poor absorptive capacity and/or high nutrient losses and/or increased nutritional needs from causes such as catabolism; or continued. . .

°

186

Item restricted (see ° above); Item restricted (see ¯ below) e.g. Brand indicates brand example only. It is not a contracted product.

¯


SPECIAL FOODS

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

continued. . . 5 For use pre- and post-surgery; or 6 For patients being tube-fed; or 7 For tube-feeding as a transition from intravenous nutrition. LOW-GI ENTERAL FEED 1 KCAL/ML – Restricted see terms on the preceding page Liquid 5 g protein, 9.6 g carbohydrate and 5.4 g fat per 100 ml, 1,000 ml bottle .......................................................................................................... 7.50 Liquid 4.3 g protein, 11.3 g carbohydrate and 4.2 g fat per 100 ml, 1,000 ml bag

°

1,000 ml

Glucerna Select RTH (Vanilla) e.g. Nutrison Advanced Diason

°

°

LOW-GI ORAL FEED 1 KCAL/ML – Restricted see terms on the preceding page Liquid 4.5 g protein, 9.8 g carbohydrate, 4.4 g fat and 1.9 g fibre per 100 ml, can ................................................................................................ 2.10 Liquid 5 g protein, 9.6 g carbohydrate and 5.4 g fat per 100 ml, 250 ml bottle .......................................................................................................... 1.88 Liquid 6 g protein, 9.5 g carbohydrate, 4.7 g fat and 2.6 g fibre per 100 ml, can ................................................................................................ 2.10 Liquid 4.9 g protein, 11.7 g carbohydrate, 3.8 g fat and 2 g fibre per 100 ml, 200 ml bottle

237 ml

Sustagen Diabetic (Vanilla) Glucerna Select (Vanilla) Resource Diabetic (Vanilla) e.g. Diasip

°

250 ml 237 ml

°

°

°

Elemental and Semi-Elemental Products

°Restricted Any of the following: 1 Malabsorption; or 2 Short bowel syndrome; or 3 Enterocutaneous fistulas; or 4 Eosinophilic enteritis (including oesophagitis); or 5 Inflammatory bowel disease; or 6 Acute pancreatitis where standard feeds are not tolerated; or 7 Patients with multiple food allergies requiring enteral feeding. AMINO ACID ORAL FEED – Restricted see terms above Powder 11.5 g protein, 61.7 g carbohydrate and 0.8 g fat per sachet ..............4.50 AMINO ACID ORAL FEED 0.8 KCAL/ML – Restricted see terms above Liquid 2.5 g protein, 11 g carbohydrate and 3.5 g fat per 100 ml, 250 ml carton PEPTIDE-BASED ENTERAL FEED 1 KCAL/ML – Restricted see terms above Liquid 4 g protein, 17.6 g carbohydrate and 1.7 g fat per 100 ml, 1,000 ml bag

80.4 g

Vivonex TEN

°

e.g. Elemental 028 Extra

°

e.g. Nutrison Advanced Peptisorb

Products with Hospital Supply Status (HSS) are in bold Expiry date of HSS period is 30 June of the year indicated unless otherwise stated.

187


SPECIAL FOODS

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

PEPTIDE-BASED ORAL FEED – Restricted see terms on the preceding page Powder 12.5 g protein, 55.4 g carbohydrate and 3.25 g fat per sachet ............4.40 Powder 13.7 g protein, 62.9 g carbohydrate and 17.5 g fat per 100 g, 400 g can Powder 13.8 g protein, 59 g carbohydrate and 18 g fat per 100 g, 400 g can Powder 15.8 g protein, 49.5 g carbohydrate and 4.65 g fat per 76 g sachet ........................................................................................................ 7.50

°°

79 g

Vital HN e.g. Peptamen Junior e.g. MCT Pepdite; MCT Pepdite 1+

°

°

76 g

Alitraq Peptamen OS 1.0 (Vanilla)

PEPTIDE-BASED ORAL FEED 1 KCAL/ML – Restricted see terms on the preceding page Liquid 5 g protein, 16 g carbohydrate and 1.69 g fat per 100 ml, carton ..........4.95 237 ml

° ¯

Fat Modified Products

FAT-MODIFIED FEED – Restricted see terms below Powder 11.4 g protein, 68 g carbohydrate and 11.8 g fat per 100 g, 400 g can ¯Restricted Any of the following: 1 Patient has metabolic disorders of fat metabolism; or 2 Patient has a chyle leak; or 3 Modified as a modular feed for adults.

e.g. Monogen

Hepatic Products

°Restricted For children (up to 18 years) who require a liver transplant HEPATIC ORAL FEED – Restricted see terms above Powder 11 g protein, 64 g carbohydrate and 20 g fat per 100 g, can .............78.97

°

400 g

Heparon Junior

High Calorie Products

°Restricted Any of the following: 1 Patient is fluid volume or rate restricted; or 2 Patient requires low electrolyte; or 3 Both: 3.1 Any of the following: 3.1.1 Cystic fibrosis; or 3.1.2 Any condition causing malabsorption; or 3.1.3 Faltering growth in an infant/child; or 3.1.4 Increased nutritional requirements; and 3.2 Patient has substantially increased metabolic requirements. ENTERAL FEED 2 KCAL/ML – Restricted see terms above Liquid 7.5 g protein, 20 g carbohydrate and 10 g fat per 100 ml, bottle ...........5.50 Liquid 8.4 g protein, 21.9 g carbohydrate, 9.1 g fat and 0.5 g fibre per 100 ml, bottle ........................................................................................... 11.00 ORAL FEED 2 KCAL/ML – Restricted see terms above Liquid 8.4 g protein, 22.4 g carbohydrate, 8.9 g fat and 0.8 g fibre per 100 ml, bottle ............................................................................................. 1.90

°°

500 ml 1,000 ml

Nutrison Concentrated TwoCal HN RTH (Vanilla)

°

200 ml

Two Cal HN

°

188

Item restricted (see ° above); Item restricted (see ¯ below) e.g. Brand indicates brand example only. It is not a contracted product.

¯


SPECIAL FOODS

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

High Protein Products

HIGH PROTEIN ENTERAL FEED 1.25 KCAL/ML – Restricted see terms below Liquid 6.3 g protein, 14.2 g carbohydrate and 4.9 g fat per 100 ml, 1,000 ml bag ¯Restricted Both: 1 The patient has a high protein requirement; and 2 Any of the following: 2.1 Patient has liver disease; or 2.2 Patient is obese (BMI > 30) and is undergoing surgery; or 2.3 Patient is fluid restricted; or 2.4 Patient’s needs cannot be more appropriately met using high calorie product. HIGH PROTEIN ENTERAL FEED 1.28 KCAL/ML – Restricted see terms below Liquid 6.3 g protein, 14.1 g carbohydrate, 4.9 g fat and 1.5 g fibre per 100 ml, 1,000 ml bag ¯Restricted Both: 1 The patient has a high protein requirement; and 2 Any of the following: 2.1 Patient has liver disease; or 2.2 Patient is obese (BMI > 30) and is undergoing surgery; or 2.3 Patient is fluid restricted; or 2.4 Patient’s needs cannot be more appropriately met using high calorie product. HIGH PROTEIN ORAL FEED 1 KCAL/ML – Restricted see terms below Liquid 10 g protein, 10.3 g carbohydrate and 2.1 g fat per 100 ml, 200 ml bottle ¯Restricted Any of the following: 1 Decompensating liver disease without encephalopathy; or 2 Protein losing gastro-enteropathy; or 3 Patient has increased protein requirements without increased energy requirements. ¯

e.g. Nutrison Protein Plus

¯ ¯

e.g. Nutrison Protein Plus Multi Fibre

e.g. Fortimel Regular

Products with Hospital Supply Status (HSS) are in bold Expiry date of HSS period is 30 June of the year indicated unless otherwise stated.

189


SPECIAL FOODS

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

Infant Formulas

AMINO ACID FORMULA – Restricted see terms below Powder 1.95 g protein, 8.1 g carbohydrate and 3.5 g fat per 100 ml, 400 g can Powder 13 g protein, 52.5 g carbohydrate and 24.5 g fat per 100 g, 400 g can Powder 13.5 g protein, 52 g carbohydrate and 24.5 g fat per 100 g, can .........53.00 Powder 14 g protein, 50 g carbohydrate and 24.3 g fat per 100 g, 400 g can Powder 16 g protein, 51.4 g carbohydrate and 21 g fat per 100 g, can ..........53.00 Powder 2.2 g protein, 7.8 g carbohydrate and 3.4 g fat per 100 ml, can .........53.00 Powder 2.2 g protein, 7.8 g carbohydrate and 3.4 g fat per 100 ml, can .........53.00 Powder 6 g protein, 31.5 g carbohydrate and 5.88 g fat per sachet .................6.00 ¯ ¯ ¯ ¯ ¯ ¯ ¯ ¯ ¯

e.g. Neocate e.g. Neocate LCP Neocate Gold (Unflavoured)

400 g

e.g. Neocate Advance Neocate Advance (Vanilla) 400 g Elecare LCP (Unflavoured) 400 g Elecare (Unflavoured) Elecare (Vanilla) 48.5 g Vivonex Paediatric 400 g

¯Restricted Initiation Any of the following: 1 Extensively hydrolysed formula has been reasonably trialled and is inappropriate due to documented severe intolerance or allergy or malabsorption; or 2 History of anaphylaxis to cows’ milk protein formula or dairy products; or 3 Eosinophilic oesophagitis. Continuation Both: 1 An assessment as to whether the infant can be transitioned to a cows’ milk protein, soy, or extensively hydrolysed infant formula has been undertaken; and 2 The outcome of the assessment is that the infant continues to require an amino acid infant formula. EXTENSIVELY HYDROLYSED FORMULA – Restricted see terms below Powder 14 g protein, 53.4 g carbohydrate and 27.3 g fat per 100 g, 450 g can e.g. Gold Pepti Junior Karicare Aptamil

¯Restricted Initiation - new patients Any of the following: 1 Both: 1.1 Cows’ milk formula is inappropriate due to severe intolerance or allergy to its protein content; and 1.2 Either: 1.2.1 Soy milk formula has been trialled without resolution of symptoms; or 1.2.2 Soy milk formula is considered clinically inappropriate or contraindicated; or 2 Severe malabsorption; or 3 Short bowel syndrome; or 4 Intractable diarrhoea; or 5 Biliary atresia; or 6 Cholestatic liver diseases causing malsorption; or 7 Cystic fibrosis; or continued. . .

°

190

Item restricted (see ° above); Item restricted (see ¯ below) e.g. Brand indicates brand example only. It is not a contracted product.

¯


SPECIAL FOODS

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

continued. . . 8 Proven fat malabsorption; or 9 Severe intestinal motility disorders causing significant malabsorption; or 10 Intestinal failure. Initiation - step down from amino acid formula Both: 1 The infant is currently receiving funded amino acid formula; and 2 The infant is to be trialled on, or transitioned to, an extensively hydrolysed formula. Continuation Both: 1 An assessment as to whether the infant can be transitioned to a cows’ milk protein or soy infant formula has been undertaken; and 2 The outcome of the assessment is that the infant continues to require an extensively hydrolysed infant formula. FRUCTOSE-BASED FORMULA Powder 14.6 g protein, 49.7 g carbohydrate and 30.8 g fat per 100 g, 400 g can e.g. Galactomin 19 LACTOSE-FREE FORMULA Powder 1.3 g protein, 7.3 g carbohydrate and 3.5 g fat per 100 ml, 900 g can Powder 1.5 g protein, 7.2 g carbohydrate and 3.6 g fat per 100 ml, 900 g can LOW-CALCIUM FORMULA Powder 14.6 g protein, 53.7 g carbohydrate and 26.1 g fat per 100 g, 400 g can ¯ ¯¯ ¯ ¯

e.g. Karicare Aptamil Gold De-Lact e.g. S26 Lactose Free

e.g. Locasol

PAEDIATRIC ORAL FEED 1 KCAL/ML – Restricted see terms below Liquid 2.6 g protein, 10.3 g carbohydrate, 5.4 g fat and 0.6 g fibre per 100 ml, 100 ml bottle e.g. Infatrini ¯Restricted Both: 1 Either: 1.1 The patient is fluid restricted; or 1.2 The patient has increased nutritional requirements due to faltering growth;and 2 Patient is under 18 months old and weighs less than 8kg. PRETERM FORMULA – Restricted see terms below Powder 1.9 g protein, 7.5 g carbohydrate and 3.9 g fat per 14 g, can ............15.25 400 g S-26 Gold Premgro Liquid 2.2 g protein, 8.4 g carbohydrate and 4.4 g fat per 100 ml, bottle .........0.75 100 ml S26 LBW Gold RTF Liquid 2.3 g protein, 8.6 g carbohydrate and 4.2 g fat per 100 ml, 90 ml bottle e.g. Pre Nan Gold RTF Liquid 2.6 g protein, 8.4 g carbohydrate and 3.9 g fat per 100 ml, 70 ml bottle e.g. Karicare Aptamil Gold+Preterm ¯Restricted For infants born before 33 weeks’ gestation or weighing less than 1.5 kg at birth. THICKENED FORMULA Powder 1.8 g protein, 8.1 g carbohydrate and 3.3 g fat per 100 ml, 900 g can e.g. Karicare Aptamil Thickened AR

Products with Hospital Supply Status (HSS) are in bold Expiry date of HSS period is 30 June of the year indicated unless otherwise stated.

191


SPECIAL FOODS

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

Ketogenic Diet Products

HIGH FAT FORMULA – Restricted see terms below Powder 15.25 g protein, 3 g carbohydrate and 73 g fat per 100 g, can ..........35.50 Powder 15.3 g protein, 7.2 g carbohydrate and 67.7 g fat per 100 g, can ........................................................................................................... 35.50 ¯ ¯ ° ° °° ° ° ° ° ° ° 300 g Ketocal 4:1 (Unflavoured) Ketocal 4:1 (Vanilla) Ketocal 3:1 (Unflavoured)

300 g

¯Restricted For patients with intractable epilepsy, pyruvate dehydrogenase deficiency or glucose transported type-1 deficiency and other conditions requiring a ketogenic diet.

Paediatric Products

°Restricted Both: 1 Child is aged one to ten years; and 2 Any of the following: 2.1 The child is being fed via a tube or a tube is to be inserted for the purposes of feeding; or 2.2 Any condition causing malabsorption; or 2.3 Faltering growth in an infant/child; or 2.4 Increased nutritional requirements; or 2.5 The child is being transitioned from TPN or tube feeding to oral feeding. PAEDIATRIC ORAL FEED – Restricted see terms above Powder 14.9 g protein, 54.3 g carbohydrate and 24.7 g fat per 100 g, can ........................................................................................................... 20.00 900 g Pediasure (Vanilla) PAEDIATRIC ENTERAL FEED 0.76 KCAL/ML – Restricted see terms above Liquid 2.5 g protein, 12.5 g carbohydrate, 3.3 g fat and 0.7 g fibre per 100 ml, bag ................................................................................................ 4.00

500 ml

Nutrini Low Energy Multifibre RTH Pediasure RTH e.g. Nutrini RTH

PAEDIATRIC ENTERAL FEED 1 KCAL/ML – Restricted see terms above Liquid 2.8 g protein, 11.2 g carbohydrate and 5 g fat per 100 ml, bag .............2.68 Liquid 2.8 g protein, 12.3 g carbohydrate and 4.4 g fat per 100 ml, 500 ml bag PAEDIATRIC ENTERAL FEED 1.5 KCAL/ML – Restricted see terms above Liquid 4.1 g protein, 18.5 g carbohydrate, 6.7 g fat and 0.8 g fibre per 100 ml, bag ................................................................................................ 6.00 Liquid 4.1 g protein, 18.5 g carbohydrate and 6.7 g fat per 100 ml, 500 ml bag PAEDIATRIC ORAL FEED 1 KCAL/ML – Restricted see terms above Liquid 4.2 g protein, 16.7 g carbohydrate and 7.5 g fat per 100 ml, bottle .......................................................................................................... 1.07

500 ml

500 ml

Nutrini Energy Multi Fibre e.g. Nutrini Energy RTH

200 ml

Liquid 4.2 g protein, 16.7 g carbohydrate and 7.5 g fat per 100 ml, can ..........1.34

250 ml

Pediasure (Chocolate) Pediasure (Strawberry) Pediasure (Vanilla) Pediasure (Vanilla)

PAEDIATRIC ORAL FEED 1.5 KCAL/ML – Restricted see terms above Liquid 3.4 g protein, 18.8 g carbohydrate and 6.8 g fat per 100 ml, 200 ml bottle Liquid 4.0 g protein, 18.8 g carbohydrate, 6.8 g fat and 1.5 g fibre per 100 ml, 200 ml bottle

e.g. Fortini e.g. Fortini Multifibre

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192

Item restricted (see ° above); Item restricted (see ¯ below) e.g. Brand indicates brand example only. It is not a contracted product.

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SPECIAL FOODS

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

Renal Products

LOW ELECTROLYTE ENTERAL FEED 2 KCAL/ML – Restricted see terms below Liquid 7 g protein, 20.6 g carbohydrate, 9.6 g fat and 1.56 g fibre per 100 ml, bottle ............................................................................................. 6.08 ¯Restricted For patients with acute or chronic kidney disease LOW ELECTROLYTE ORAL FEED – Restricted see terms below Powder 7.5 g protein, 59 g carbohydrate and 26.3 g fat per 100 g, 400 g can ¯Restricted For children (up to 18 years) with acute or chronic kidney disease LOW ELECTROLYTE ORAL FEED 2 KCAL/ML – Restricted see terms below Liquid 7 g protein, 20.6 g carbohydrate, 9.6 g fat and 1.56 g fibre per 100 ml, carton ............................................................................................ 2.43 Liquid 9.1 g protein, 19 g carbohydrate and 10 g fat per 100 ml, carton ..........3.31 ¯ ¯ ¯ ¯

500 ml

Nepro RTH

e.g. Kindergen

200 ml 237 ml

Nepro (Strawberry) Nepro (Vanilla) Novasource Renal (Vanilla) e.g. Suplena e.g. Renilon 7.5

¯ ¯ ¯ ¯

Liquid 3 g protein, 25.5 g carbohydrate and 9.6 g fat per 100 ml, 237 ml bottle Liquid 7.5 g protein, 20 g carbohydrate and 10 g fat per 100 ml, 125 ml carton ¯Restricted For patients with acute or chronic kidney disease

Respiratory Products

LOW CARBOHYDRATE ORAL FEED 1.5 KCAL/ML – Restricted see terms below Liquid 6.2 g protein, 10.5 g carbohydrate and 9.32 g fat per 100 ml, bottle .......................................................................................................... 1.66 ¯Restricted For patients with CORD and hypercapnia, defined as a CO2 value exceeding 55 mmHg

237 ml

Pulmocare (Vanilla)

Surgical Products

HIGH ARGININE ORAL FEED 1.4 KCAL/ML – Restricted see terms below Liquid 7.6 g protein, 18.9 g carbohydrate, 3.9 g fat and 1.4 g fibre per 100 ml, carton ............................................................................................ 4.00

237 ml

Impact Advanced Recovery (Chocolate) Impact Advanced Recovery (Vanilla)

¯Restricted Three packs per day for 5 to 7 days prior to major gastrointestinal, head or neck surgery

Products with Hospital Supply Status (HSS) are in bold Expiry date of HSS period is 30 June of the year indicated unless otherwise stated.

193


SPECIAL FOODS

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

Standard Feeds

°Restricted Any of the following: 1 For patients with malnutrition, defined as any of the following: 1.1 BMI < 18.5; or 1.2 Greater than 10% weight loss in the last 3-6 months; or 1.3 BMI < 20 with greater than 5% weight loss in the last 3-6 months; or 2 For patients who have, or are expected to, eat little or nothing for 5 days; or 3 For patients who have a poor absorptive capacity and/or high nutrient losses and/or increased nutritional needs from causes such as catabolism; or 4 For use pre- and post-surgery; or 5 For patients being tube-fed; or 6 For tube-feeding as a transition from intravenous nutrition; or 7 For any other condition that meets the community Special Authority criteria. ENTERAL FEED 1.5 KCAL/ML – Restricted see terms above Liquid 5.4 g protien, 13.6 g carbohydrate and 3.3 g fat per 100 ml, 1,000 ml bottle e.g. Isosource Standard RTH Liquid 6 g protein, 18.3 g carbohydrate and 5.8 g fat per 100 ml, bag .............7.00 1,000 ml Nutrison Energy Liquid 6 g protein, 18.4 g carbohydrate, 5.8 g fat and 1.5 g fibre per 100 ml, 1,000 ml bag e.g. Nutrison Energy Multi Fibre Liquid 6.25 g protein, 20 g carbohydrate and 5 g fat per 100 ml, can ..............1.75 250 ml Ensure Plus HN Liquid 6.27 g protein, 20.4 g carbohydrate and 4.9 g fat per 100 ml, bag .........7.00 1,000 ml Ensure Plus HN RTH Liquid 6.38 g protein, 21.1 g carbohydrate, 4.9 g fat and 1.2 g fibre per 100 ml, bag ................................................................................................ 7.00 1,000 ml Jevity HiCal RTH ENTERAL FEED 1 KCAL/ML – Restricted see terms above Liquid 4 g protein, 13.6 g carbohydrate and 3.4 g fat per 100 ml, bottle ..........2.65 5.29 Liquid 4 g protein, 13.6 g carbohydrate and 3.4 g fat per 100 ml, can .............1.24 Liquid 4 g protein, 14.1 g carbohydrate, 3.47 g fat and 1.76 g fibre per 100 ml, bottle ............................................................................................. 2.65 5.29 Liquid 4 g protein, 14.1 g carbohydrate, 3.47 g fat and 1.76 g fibre per 100 ml, can ................................................................................................ 1.32 Liquid 4 g protein, 12.3 g carbohydrate and 3.9 g fat per 100 ml, 1,000 ml bag Liquid 4 g protein, 12.3 g carbohydrate, 3.9 g fat and 1.5 g fibre per 100 ml, 1000 ml bag 500 ml 1,000 ml 250 ml 500 ml 1,000 ml 237 ml Osmolite RTH Osmolite RTH Osmolite Jevity RTH Jevity RTH Jevity e.g. NutrisonStdRTH; NutrisonLowSodium e.g. Nutrison Multi Fibre

°

°

°

°

°°

°

° °°

°°

°

ENTERAL FEED 1.2 KCAL/ML – Restricted see terms above Liquid 5.55 g protein, 15.1 g carbohydrate, 3.93 g fat and 2 g fibre per 100 ml, 1,000 ml bag

e.g. Jevity Plus RTH

°

194

Item restricted (see ° above); Item restricted (see ¯ below) e.g. Brand indicates brand example only. It is not a contracted product.

¯


SPECIAL FOODS

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

ORAL FEED – Restricted see terms on the preceding page Powder 16 g protein, 59.8 g carbohydrate and 14 g fat per 100 g, can ..........13.00 Powder 18.7 g protein, 54.5 g carbohydrate and 18.9 g fat per 100 g, can ............................................................................................................. 9.50 Powder 23 g protein, 65 g carbohydrate and 2.5 g fat per 100 g, can ............10.22

°

850 g 900 g 900 g 900 g

Ensure (Vanilla) Ensure (Chocolate) Fortisip (Vanilla) Sustagen Hospital Formula (Chocolate) Sustagen Hospital Formula (Vanilla)

°

°

°

ORAL FEED 1 KCAL/ML – Restricted see terms on the preceding page Liquid 3.8 g protein, 23 g carbohydrate and 12.7 g fibre per 100 ml, 237 ml carton ORAL FEED 1.5 KCAL/ML – Restricted see terms on the preceding page Liquid 5.5 g protein, 21.1 g carbohydrate and 4.81 g fat per 100 ml, can .........1.33

e.g. Resource Fruit Beverage 237 ml Ensure Plus (Chocolate) Ensure Plus (Strawberry) Ensure Plus (Vanilla) Ensure Plus (Banana) Ensure Plus (Chocolate) Ensure Plus (Fruit of the Forest) Ensure Plus (Vanilla) e.g. Fortijuice e.g. Fortisip e.g. Fortisip Multi Fibre

°

°

Liquid 6.25 g protein, 20.2 g carbohydrate and 4.92 g fat per 100 ml, carton ........................................................................................................ 1.26

200 ml

°° °

Liquid 4 g protein and 33.5 g carbohydrate per 100 ml, 200 ml bottle Liquid 6 g protein, 18.4 g carbohydrate and 5.8 g fat per 100 ml, 200 ml bottle Liquid 6 g protein, 18.4 g carbohydrate, 5.8 g fat and 2.3 g fibre per 100 ml, 200 ml bottle

Products with Hospital Supply Status (HSS) are in bold Expiry date of HSS period is 30 June of the year indicated unless otherwise stated.

195


VACCINES

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

Bacterial and Viral Vaccines

DIPHTHERIA, TETANUS, PERTUSSIS AND POLIO VACCINE – Restricted see terms below Inj 30 IU diphtheria toxoid with 30 IU tetanus toxoid, 25 mcg pertussis toxoid, 25 mcg pertussis filamentous haemagluttinin, 8 mcg pertactin and 80 D-antigen units poliomyelitis virus in 0.5 ml syring ¯Restricted For primary vaccination in children DIPHTHERIA, TETANUS, PERTUSSIS, POLIO, HEPATITIS B AND HAEMOPHILUS INFLUENZAE TYPE B VACCINE – Restricted see terms below Inj 30 IU diphtheria toxoid with 40 IU tetanus toxoid, 25 mcg pertussis toxoid, 25 mcg pertussis filamentous haemagluttinin, 8 mcg pertactin, 80 D-antigen units poliomyelitis virus, 10 mcg hepatitis B surface antigen in 0.5 ml syringe (1) and inj 10 mcg haemophilus influenzae type B vaccine vial ¯Restricted Either: 1 For primary vaccination in children; or 2 For revaccination of children following immunosuppression. ¯ ¯ ¯ ¯ ¯

Bacterial Vaccines

BACILLUS CALMETTE-GUERIN VACCINE – Restricted see terms below Inj 1.5 mg vial with diluent ¯Restricted For infants at increased risk of tuberculosis Note: increased risk is defined as: 1 Living in a house or family with a person with current or past history of TB; or 2 Having one or more household members or carers who within the last 5 years lived in a country with a rate of TB > or equal to 40 per 100,000 for 6 months or longer; or 3 During their first 5 years will be living 3 months or longer in a country with a rate of TB > or equal to 40 per 100,000. A list of countries with high rates of TB are available at www.moh.govt.nz/immunisation or www.bcgatlas.org/index.php. DIPHTHERIA AND TETANUS VACCINE – Restricted see terms below Inj 2 IU diphtheria toxoid with 20 IU tetanus toxoid in 0.5 ml syringe ¯Restricted Any of the following: 1 For vaccination of patients aged between 45 and 65 years old; or 2 For vaccination of previously unimmunised patients; or 3 For revaccination of children following immunosuppression; or 4 For revaccination for patients with tetanus-prone wounds; or 5 For use in testing for primary immunodeficiency diseases, on the recommendation of an internal medicine physician or paediatrician. DIPHTHERIA, TETANUS AND PERTUSSIS VACCINE – Restricted see terms below Inj 2 IU diphtheria toxoid with 20 IU tetanus toxoid, 8 mcg pertussis toxoid, 8 mcg pertussis filamentous haemagluttinin and 2.5 mcg pertactin in 0.5 ml syringe ¯Restricted Either: 1 For primary vaccination in children aged 7-18 years; or 2 For pregnant women between gestational weeks 28 and 38 during epidemics.

°

196

Item restricted (see ° above); Item restricted (see ¯ below) e.g. Brand indicates brand example only. It is not a contracted product.

¯


VACCINES

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

HAEMOPHILUS INFLUENZAE TYPE B VACCINE – Restricted see terms below Inj 10 mcg vial with diluent syringe ¯Restricted Any of the following: 1 For primary vaccination in children; or 2 For revaccination of children following immunosuppression; or 3 For children aged 0-18 years with functional asplenia; or 4 For patients pre- and post-splenectomy; or 5 For use in testing for primary immunodeficiency diseases, on the recommendation of an internal medicine physician or paediatrician. MENINGOCOCCAL (A, C, Y AND W-135) CONJUGATE VACCINE – Restricted see terms below Inj 48 mcg in 0.5 ml vial ¯Restricted Any of the following: 1 For patients pre- and post-splenectomy; or 2 For children aged 0-18 years with functional asplenia; or 3 For organisation and community based outbreaks; or 4 For use in transplant patients; or 5 For use following immunosuppression. MENINGOCOCCAL (A, C, Y AND W-135) POLYSACCHARIDE VACCINE – Restricted see terms below Inj 200 mcg vial with diluent ¯Restricted Any of the following: 1 For patients pre- and post-splenectomy; or 2 For children aged 2-18 years with functional asplenia; or 3 For organisation and community based outbreaks. MENINGOCOCCAL C CONJUGATE VACCINE – Restricted see terms below Inj 10 mcg in 0.5 ml syringe ¯Restricted Any of the following: 1 For patients pre- and post-splenectomy; or 2 For children aged 0-18 years with functional asplenia; or 3 For organisation and community based outbreaks; or 4 For use in transplant patients aged under 2 years; or 5 For use following immunosuppression in patients aged under 2 years. PNEUMOCOCCAL (PCV10) CONJUGATE VACCINE – Restricted see terms below Inj 16 mcg in 0.5 ml syringe ¯Restricted For primary vaccination in children PNEUMOCOCCAL (PCV13) CONJUGATE VACCINE – Restricted see terms below Inj 30.8 mcg in 0.5 ml syringe ¯Restricted Any of the following: 1 For high risk children under the age of 5; or 2 For patients aged less than 18 years pre- or post-splenectomy or with functional asplenia; or 3 For revaccination of children following immunosuppression; or 4 For use in testing for primary immunodeficiency diseases, on the recommendation of an internal medicine physician or paediatrician.

¯ ¯ ¯ ¯ ¯ ¯

Products with Hospital Supply Status (HSS) are in bold Expiry date of HSS period is 30 June of the year indicated unless otherwise stated.

197


VACCINES

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

PNEUMOCOCCAL (PPV23) POLYSACCHARIDE VACCINE – Restricted see terms below Inj 575 mcg in 0.5 ml vial ¯Restricted Any of the following: 1 For patients pre- and post-splenectomy; or 2 For children aged 2-18 years with functional asplenia; or 3 For revaccination of children following immunosuppression; or 4 For use in testing for primary immunodeficiency diseases, on the recommendation of an internal medicine physician or paediatrician. SALMONELLA TYPHI VACCINE – Restricted see terms below Inj 25 mcg in 0.5 ml syringe ¯Restricted For use during typhoid fever outbreaks

°

¯ ¯ ¯¯ ¯¯ ¯

Viral Vaccines

HEPATITIS A VACCINE – Restricted see terms below Inj 720 ELISA units in 0.5 ml syringe Inj 1440 ELISA units in 1 ml syringe ¯Restricted Any of the following: 1 For use in transplant patients; or 2 For use in children with chronic liver disease; or 3 For close contacts of known hepatitis A carriers. HEPATITIS B VACCINE – Restricted see terms below Inj 5 mcg in 0.5 ml vial Inj 10 mcg in 1 ml vial ¯Restricted Any of the following: 1 Household or sexual contacts of known hepatitis B carriers; or 2 Children born to mothers who are hepatitis B surface antigen (HBsAg) positive; or 3 Dialysis patients; or 4 HIV-positive patients; or 5 Hepatitis C positive patients; or 6 For use in transplant patients; or 7 For use following immunosuppression; or 8 For use in testing for primary immunodeficiency diseases, on the recommendation of an internal medicine physician or paediatrician. HUMAN PAPILLOMAVIRUS (6, 11, 16 AND 18) VACCINE [HPV] – Restricted see terms below Inj 120 mcg in 0.5 ml syringe ¯Restricted Any of the following: 1 Women aged between 9 and 19 years old; or 2 Male patients aged between 9 and 25 years old with confirmed HIV infection; or 3 For use in transplant patients. INFLUENZA VACCINE – Restricted see terms on the next page Inj 45 mcg in 0.5 ml syringe ............................................................................90.00 10 Fluarix Influvac

¯

198

Item restricted (see ° above); Item restricted (see ¯ below) e.g. Brand indicates brand example only. It is not a contracted product.

¯


VACCINES

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

¯Restricted Any of the following: 1 All people 65 years of age and over; or 2 People under 65 years of age who: 2.1 Have any of the following cardiovascular diseases: 2.1.1 Ischaemic heart disease; or 2.1.2 Congestive heart disease; or 2.1.3 Rheumatic heart disease; or 2.1.4 Congenital heart disease; or 2.1.5 Cerebro-vascular disease; or 2.2 Have any of the following chronic respiratory diseases: 2.2.1 Asthma, if on a regular preventative therapy; or 2.2.2 Other chronic respiratory disease with impaired lung function; or 2.3 Have diabetes; 2.4 Have chronic renal disease; 2.5 Have any cancer, excluding basal and squamous skin cancers if not invasive; 2.6 Have any of the following other conditions: 2.6.1 Autoimmune disease; 2.6.2 Immune suppression; 2.6.3 HIV; 2.6.4 Transplant recipients; 2.6.5 Neuromuscular and CNS diseases; 2.6.6 Haemoglobinopathies; 2.6.7 Are children on long term aspirin; or 2.7 Are pregnant, or 2.8 Are children aged four and under who have been hospitalised for respiratory illness or have a history of significant respiratory illness; or 3 People under 18 years of age living within the boundaries of the Canterbury District Health Board. Note: The following conditions are excluded from funding: G asthma not requiring regular preventative therapy; and G hypertension and/or dyslipidaemia without evidence of end-organ disease. MEASLES, MUMPS AND RUBELLA VACCINE – Restricted see terms below Inj 1000 TCID50 measles, 12500 TCID50 mumps and 1000 TCID50 rubella vial with diluent ¯Restricted Any of the following: 1 For primary vaccination in children; or 2 For revaccination following immunosuppression; or 3 For any individual susceptible to measles, mumps or rubella. POLIOMYELITIS VACCINE – Restricted see terms below Inj 80 D-antigen units in 0.5 ml syringe ¯Restricted Either: 1 For previously unvaccinated individuals; or 2 For revaccination following immunosuppression. RABIES VACCINE Inj 2.5 IU vial with diluent VARICELLA ZOSTER VACCINE [CHICKEN POX VACCINE] – Restricted see terms on the next page Inj 1350 PFU vial with diluent Inj 2000 PFU vial with diluent

¯ ¯ ¯¯

Products with Hospital Supply Status (HSS) are in bold Expiry date of HSS period is 30 June of the year indicated unless otherwise stated.

199


VACCINES

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

¯Restricted Any of the following: 1 For non-immune patients: 1.1 with chronic liver disease who may in future be candidates for transplantation; or 1.2 with deteriorating renal function before transplantation; or 1.3 prior to solid organ transplant; or 1.4 prior to any elective immunosuppression; or 1.5 for post exposure prophylaxis who are immune competent inpatients. 2 For patients at least 2 years after bone marrow transplantation, on advice of their specialist; or 3 For patients at least 6 months after completion of chemotherapy, on advice of their specialist; or 4 For HIV positive non-immune to varicella with mild or moderate immunosuppression on advice of HIV specialist; or 5 For household contacts of paediatric patients who are immunocompromised, or undergoing a procedure leading to immune compromise where the household contact has: 5.1 adult household contact - a negative serology result for varicella; or 5.2 child household contact - no clinical history of varicella or negative varicella serology.

°

200

Item restricted (see ° above); Item restricted (see ¯ below) e.g. Brand indicates brand example only. It is not a contracted product.

¯


PART III - OPTIONAL PHARMACEUTICALS

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

Optional Pharmaceuticals

NOTE: In addition to the products expressly listed here in Part III: Optional Pharmaceuticals, a number of additional Optional Pharmaceuticals, including some wound care products and disposable laparoscopic equipment, are listed in an addendum to Part III which is available at www.pharmac.govt.nz. The Optional Pharmaceuticals listed in the addendum are deemed to be listed in Part III, and the Rules of the Pharmaceutical Schedule applying to products listed in Part III apply to them. BLOOD GLUCOSE DIAGNOSTIC TEST METER 1 meter with 50 lancets, a lancing device, and 10 diagnostic test strips .........20.00 1 Caresens II Caresens N Caresens N POP Meter ................................................................................................................9.00 1 FreeStyle Lite On Call Advanced 19.00 Accu-Chek Performa BLOOD GLUCOSE DIAGNOSTIC TEST STRIP Blood glucose test strips ................................................................................10.56 21.65 28.75 Blood glucose test strips × 50 and lancets × 5 .............................................19.10 BLOOD KETONE DIAGNOSTIC TEST METER Meter ..............................................................................................................40.00 INSULIN PEN NEEDLES 29 g × 12.7 mm ..............................................................................................10.50 31 g × 5 mm ...................................................................................................11.75 31 g × 6 mm ...................................................................................................10.50 31 g × 8 mm ...................................................................................................10.50 32 g × 4 mm ...................................................................................................10.50 INSULIN SYRINGES, DISPOSABLE WITH ATTACHED NEEDLE Syringe 0.3 ml with 29 g × 12.7 mm needle ..................................................13.00 Syringe 0.3 ml with 31 g × 8 mm needle .......................................................13.00 Syringe 0.5 ml with 29 g × 12.7 mm needle ..................................................13.00 Syringe 0.5 ml with 31 g × 8 mm needle .......................................................13.00 Syringe 1 ml with 29 g × 12.7 mm needle .....................................................13.00 Syringe 1 ml with 31 g × 8 mm needle ..........................................................13.00 KETONE BLOOD BETA-KETONE ELECTRODES Test strips .......................................................................................................15.50 MASK FOR SPACER DEVICE Size 2 ................................................................................................................2.99 PEAK FLOW METER Low Range .....................................................................................................11.44 Normal Range ................................................................................................11.44 50 test 1 100 100 100 100 100 100 100 100 100 100 100 50 test CareSens CareSens N FreeStyle Lite Accu-Chek Performa Freestyle Optium On Call Advanced Freestyle Optium B-D Micro-Fine B-D Micro-Fine ABM ABM B-D Micro-Fine B-D Micro-Fine B-D Ultra Fine B-D Ultra Fine II B-D Ultra Fine B-D Ultra Fine II ABM B-D Ultra Fine ABM B-D Ultra Fine II Freestyle Optium Ketone EZ-fit Paediatric Mask Breath-Alert Breath-Alert

10 strip 1 1 1

Products with Hospital Supply Status (HSS) are in bold Expiry date of HSS period is 30 June of the year indicated unless otherwise stated.

201


PART III - OPTIONAL PHARMACEUTICALS

Price (ex man. excl. GST) $ Brand or Generic Manufacturer

Per

PREGNANCY TEST - HCG URINE Cassette .........................................................................................................22.80

40 test

Innovacon hCG One Step Pregnancy Test Accu-Chek Ketur-Test Space Chamber Plus Volumatic

SODIUM NITROPRUSSIDE Test strip ...........................................................................................................6.00 SPACER DEVICE 230 ml (single patient) ......................................................................................4.72 800 ml ...............................................................................................................8.50

50 strip 1 1

°

202

Item restricted (see ° above); Item restricted (see ¯ below) e.g. Brand indicates brand example only. It is not a contracted product.

¯


INDEX Generic Chemicals and Brands

- Symbols 8-methoxypsoralen .........................52 -AA-Scabies .......................................49 Abacavir sulphate ...........................78 Abacavir sulphate with lamivudine ................................. 78 Abciximab .....................................138 Abilify ............................................113 ABM Hydroxocobalamin .................23 Acarbose ........................................15 Accarb ............................................15 Accu-Chek Ketur-Test ...................202 Accu-Chek Performa ....................201 Accuretic 10 ....................................36 Accuretic 20 ....................................36 Acetadote .....................................171 Acetazolamide ..............................168 Acetic acid Extemporaneous ......................179 Genito-Urinary ............................55 Acetic acid with hydroxyquinoline, glycerol and ricinoleic acid .........55 Acetic acid with propylene glycol ....................................... 170 Acetylcholine chloride ...................168 Acetylcysteine ...............................171 Aciclovir Infection ......................................84 Sensory ....................................165 Acid Citrate Dextrose A ..................29 Acidex .............................................12 Acipimox .........................................44 Acitretin ...........................................52 Aclasta ............................................90 Actemra ........................................156 Actinomycin D ...............................123 Adalimumab ..................................138 Adapalene ......................................49 Adefin XL ........................................40 Adefovir dipivoxil .............................80 Adenosine .......................................38 Adrenaline ......................................44 Advantan ........................................51 Advate ............................................28 Aerrane ...........................................98 Agents Affecting the Renin-Angiotensin System .........36 Agents for Parkinsonism and Related Disorders ...................... 97 Agents Used in the Treatment of Poisonings ............................... 171 Ajmaline ..........................................38 Alanase .........................................159 Albendazole ....................................74 Aldara .............................................53 Alendronate sodium ..................88–89 Alendronate sodium with cholecalciferol ............................ 89 Alfacalcidol .....................................24 Alfentanil hydrochloride ................102 Alinia ...............................................75 Alitraq ...........................................188 Allersoothe ....................................160 Allopurinol .......................................93 Alpha tocopheryl acetate ................24 Alpha-Adrenoceptor Blockers .........37 Alphamox ........................................67 Alprazolam ....................................117 Alprostadil hydrochloride ................45 Alteplase .........................................32 Alum .............................................179 Aluminium hydroxide ......................12 Aluminium hydroxide with magnesium hydroxide and simethicone ............................... 12 Amantadine hydrochloride ..............97 AmBisome ......................................71 Ambrisentan ...................................46 Amethocaine .........................101, 167 Nervous ....................................101 Sensory ....................................167 Amikacin .........................................65 Amiloride hydrochloride ..................42 Amiloride hydrochloride with furosemide ................................. 42 Amiloride hydrochloride with hydrochlorothiazide ................... 42 Aminophylline ...............................163 Amiodarone hydrochloride ..............38 Amisulpride ...................................113 Amitrip ..........................................105 Amitriptyline ..................................105 Amlodipine ......................................40 Amorolfine ......................................48 Amoxycillin ......................................67 Amoxycillin with clavulanic acid ............................................ 67 Amphotericin B Alimentary ..................................22 Infection ......................................71 Amsacrine ....................................125 Amyl nitrite ......................................45 Anabolic Agents ..............................59 Anaesthetics ...................................98 Anagrelide hydrochloride ..............125 Analgesics ....................................102 Anastrozole ...................................133 Andriol Testocaps ...........................59 Androderm ......................................59 Androgen Agonists and Antagonists ................................ 59 Anexate ........................................171 Antabuse ......................................121 Antacids and Antiflatulents .............12 Anti-Infective Agents .......................55 Anti-Infective Preparations Dermatological ...........................48 Sensory ....................................165 Anti-Inflammatory Preparations ............................ 166 Antiacne Preparations ....................49 Antiallergy Preparations ...............159 Antianaemics ..................................26 Antiarrhythmics ...............................38 Antibacterials ..................................65 Anticholinergic Agents ..................160 Anticholinesterases ........................88 Antidepressants ............................105 Antidiarrhoeals and Intestinal Anti-Inflammatory Agents .......... 12 Antiepilepsy Drugs .......................107 Antifibrinolytics, Haemostatics and Local Sclerosants ............... 27 Antifungals ......................................71 Antihypotensives .............................38 Antimigraine Preparations ............111 Antimycobacterials .........................73 Antinaus ........................................112 Antinausea and Vertigo Agents ..................................... 111 Antiparasitics ..................................74 Antipruritic Preparations .................49 Antipsychotic Agents ....................113 Antiretrovirals ..................................76 Antirheumatoid Agents ...................88 Antiseptics and Disinfectants ............................ 172 Antispasmodics and Other Agents Altering Gut Motility ....................................... 14 Antithrombotics ...............................29 Antithymocyte globulin (equine) ................................... 157 Antithymocyte globulin

203


INDEX Generic Chemicals and Brands

(rabbit) ..................................... 157 Antiulcerants ...................................14 Antivirals .........................................80 Anxiolytics .....................................117 Anzatax .........................................131 Apidra .............................................16 Apidra Solostar ...............................16 Apo-Allopurinol ...............................93 Apo-Amiloride .................................42 Apo-Amlodipine ..............................40 Apo-Amoxi ......................................67 Apo-Azithromycin ...........................66 Apo-Cilazapril/ Hydrochlorothiazide ................... 36 Apo-Clarithromycin .........................67 Apo-Clomipramine ........................105 Apo-Diclo ........................................95 Apo-Diltiazem CD ...........................40 Apo-Doxazosin ...............................37 Apo-Gliclazide ................................17 Apo-Megestrol ..............................132 Apo-Moclobemide .........................106 Apo-Nadolol ....................................39 Apo-Oxybutynin ..............................58 Apo-Perindopril ...............................36 Apo-Pindolol ...................................39 Apo-Prazo .......................................37 Apo-Prazosin ..................................37 Apo-Prednisone ..............................60 Apo-Prednisone S29 ......................60 Apo-Propranolol ..............................40 Apo-Pyridoxine ...............................24 Apo-Risperidone ...........................115 Apo-Ropinirole ................................98 Apo-Zopiclone ..............................118 Apomine .........................................97 Apomorphine hydrochloride ...........97 Apraclonidine ................................169 Aprepitant .....................................111 Apresoline .......................................45 Aprotinin .........................................27 Aqueous cream ..............................50 Arachis oil [Peanut oil] ..................179 Arava ..............................................88 Aremed .........................................133 Arginine Alimentary ..................................19 Various .....................................176 Argipressin [Vasopressin] ...............64 Aripiprazole ...................................113 Aristocort ........................................51 Aromasin ......................................133 Arrow - Clopid .................................31 Arrow-Amitriptyline .......................105 Arrow-Bendrofluazide .....................42 Arrow-Brimonidine ........................169 Arrow-Calcium ................................20 Arrow-Citalopram ..........................107 Arrow-Diazepam ...........................117 Arrow-Doxorubicin ........................123 Arrow-Etidronate .............................90 Arrow-Fluoxetine ...........................107 Arrow-Gabapentin ........................108 Arrow-Lamotrigine ........................109 Arrow-Lisinopril ...............................36 Arrow-Losartan & Hydrochlorothiazide ................... 37 Arrow-Morphine LA ......................104 Arrow-Nifedipine XR .......................40 Arrow-Norfloxacin ...........................69 Arrow-Ornidazole ............................75 Arrow-Quinapril 10 ..........................36 Arrow-Quinapril 20 ..........................36 Arrow-Quinapril 5 ............................36 Arrow-Ranitidine .............................14 Arrow-Roxithromycin ......................67 Arrow-Sertraline ...........................107 Arrow-Simva ...................................43 Arrow-Sumatriptan ........................111 Arrow-Tolterodine ...........................58 Arrow-Topiramate .........................110 Arrow-Tramadol ............................105 Arrow-Venlafaxine XR ...................106 Arsenic trioxide .............................125 Artemether with lumefantrine .........75 Artesunate ......................................75 Articaine hydrochloride with adrenaline .................................. 99 Asacol .............................................13 Asamax ...........................................13 Ascorbic acid Alimentary ..................................24 Extemporaneous ......................179 Aspen Adrenaline ...........................44 Aspen Ciprofloxacin ........................68 Aspirin Blood ..........................................31 Nervous ....................................102 Asthalin .........................................161 Atazanavir sulphate ........................79 Atenolol ...........................................39 Atenolol-AFT ...................................39 ATGAM .........................................157 Ativan ............................................117 Atomoxetine ..................................119 Atorvastatin ....................................43 Atovaquone with proguanil hydrochloride ............................. 75 Atracurium besylate ........................94 Atripla .............................................78 Atropine sulphate Cardiovascular ...........................38 Sensory ....................................169 Atropt ............................................169 Augmentin ......................................67 Auranofin ........................................88 Ava 20 ED .......................................55 Ava 30 ED .......................................55 Avanza ..........................................106 Avelox .............................................68 Avelox IV 400 ..................................68 Azactam ..........................................69 Azathioprine .................................157 Azithromycin ...................................66 Azol .................................................62 AZT .................................................79 Aztreonam ......................................69 -BB-D Micro-Fine .............................201 B-D Ultra Fine ...............................201 B-D Ultra Fine II ............................201 Bacillus calmette-guerin (BCG) ...................................... 157 Bacillus calmette-guerin vaccine .................................... 196 Baclofen ..........................................94 Bacterial and Viral Vaccines .........196 Bacterial Vaccines ........................196 Baraclude .......................................81 Barium sulphate ...........................175 Barrier Creams and Emollients .................................. 49 Basiliximab ...................................144 Beclazone 100 ..............................161 Beclazone 250 ..............................161 Beclazone 50 ................................161 Beclomethasone dipropionate ..................... 159, 161 Bee venom ...................................159 Bendrofluazide ................................42 Bendroflumethazide [Bendrofluazide] ......................... 42 BeneFIX ..........................................28 Benzathine benzylpenicillin ............68 Benzbromaron AL 100 ....................93 Benzbromarone ..............................93 Benzocaine .....................................99 Benzoin .........................................179 Benzoyl peroxide ............................49

204


INDEX Generic Chemicals and Brands

Benztrop .........................................97 Benztropine mesylate .....................97 Benzydamine hydrochloride ...........22 Benzydamine hydrochloride with cetylpyridinium chloride ............. 22 Benzylpenicillin sodium [Penicillin G] ............................................... 68 Beractant ......................................164 Beta Scalp ......................................52 Beta-Adrenoceptor Agonists .........161 Beta-Adrenoceptor Blockers ...........39 Betadine .......................................173 Betadine Skin Prep .......................173 Betagan ........................................168 Betahistine dihydrochloride ..........111 Betaine ...........................................19 Betamethasone ..............................59 Betamethasone dipropionate ..........51 Betamethasone dipropionate with calcipotriol .......................... 52 Betamethasone sodium phosphate with betamethasone acetate ............. 59 Betamethasone valerate ................................ 51–52 Betamethasone valerate with clioquinol .................................... 51 Betamethasone valerate with fusidic acid ................................. 52 Betaxolol .......................................168 Bevacizumab ................................144 Bezafibrate .....................................42 Bezalip ............................................42 Bezalip Retard ................................42 Bicalaccord ...................................132 Bicalutamide .................................132 Bicillin LA ........................................68 Bile and Liver Therapy ....................15 Bimatoprost ..................................169 Biodone ........................................103 Biodone Extra Forte ......................103 Biodone Forte ...............................103 Biotin ...............................................20 Bisacodyl ........................................19 Bismuth subgallate .......................179 Bismuth subnitrate and iodoform paraffin ..................................... 177 Bismuth trioxide ..............................15 Bisoprolol ........................................39 Bivalirudin .......................................29 Bleomycin sulphate ......................123 Blood glucose diagnostic test meter ....................................... 201 Blood glucose diagnostic test strip .......................................... 201 Blood ketone diagnostic test meter ....................................... 201 Boceprevir ......................................83 Bonney’s blue dye ........................176 Boric acid ......................................179 Bortezomib ...................................125 Bosentan ........................................46 Bosvate ...........................................39 Botox ..............................................94 Botulism antitoxin .........................171 Breath-Alert ..................................201 Bridion ............................................95 Brilinta ............................................31 Brimonidine tartrate ......................169 Brimonidine tartrate with timolol ...................................... 169 Brinzolamide .................................168 Bromocriptine .................................97 Brufen SR .......................................95 Budesonide Alimentary ..................................12 Respiratory .......................159, 161 Budesonide with eformoterol .............................. 162 Bumetanide ....................................41 Bupafen ........................................100 Bupivacaine hydrochloride .............99 Bupivacaine hydrochloride with adrenaline ................................ 100 Bupivacaine hydrochloride with fentanyl .................................... 100 Bupivacaine hydrochloride with glucose .................................... 100 Buprenorphine with naloxone .................................. 121 Bupropion hydrochloride ...............121 Burinex ...........................................41 Buscopan ........................................14 Buserelin .........................................62 Buspirone hydrochloride ...............117 Busulfan ........................................123 Butacort Aqueous .........................159 -CCabergoline ....................................61 Caffeine ........................................119 Caffeine citrate .............................163 Cal-d-Forte .....................................24 Calamine ........................................49 Calcipotriol ......................................52 Calcitonin ........................................59 Calcitriol ..........................................24 Calcitriol-AFT ..................................24 Calcium carbonate ....................12, 20 Calcium Channel Blockers .............40 Calcium chloride .............................32 Calcium chloride with magnesium chloride, potassium chloride, sodium acetate, sodium chloride and sodium citrate .......................... 167 Calcium folinate ............................131 Calcium Folinate Ebewe ...............131 Calcium gluconate Blood ..........................................32 Dermatological ...........................54 Calcium Homeostasis .....................59 Calcium polystyrene sulphonate ................................. 35 Calcium Resonium .........................35 Calsource .......................................20 Cancidas .........................................73 Candesartan cilexetil ......................37 Candestar .......................................37 Capecitabine .................................124 Capoten ..........................................36 Capsaicin Musculoskeletal System .............96 Nervous ....................................102 Captopril .........................................36 Carbaccord ...................................127 Carbamazepine ............................108 Carbasorb-X .................................172 Carbimazole ...................................63 Carbomer ......................................169 Carboplatin ...................................127 Carboplatin Ebewe .......................127 Carboprost trometamol ...................56 Carboxymethylcellulose Alimentary ..................................22 Extemporaneous ......................179 Cardinol LA .....................................40 Cardizem CD ..................................40 CareSens ......................................201 Caresens II ...................................201 CareSens N ..................................201 Caresens N ...................................201 Caresens N POP ..........................201 Carmellose sodium .......................170 Carmustine ...................................123 Carvedilol .......................................39 Caspofungin ...................................73 Catapres .........................................41 Catapres-TTS-1 ..............................41 Catapres-TTS-2 ..............................41

205


INDEX Generic Chemicals and Brands

Catapres-TTS-3 ..............................41 Ceenu ...........................................123 Cefaclor ..........................................66 Cefalexin .........................................65 Cefalexin Sandoz ............................65 Cefazolin .........................................66 Cefepime ........................................66 Cefotaxime .....................................66 Cefotaxime Sandoz ........................66 Cefoxitin ..........................................66 Ceftazadime ...................................66 Ceftriaxone .....................................66 Ceftriaxone-AFT .............................66 Cefuroxime .....................................66 Celecoxib ........................................95 Celiprolol .........................................39 CellCept ........................................158 Celol ...............................................39 Centrally-Acting Agents ..................41 Cephalexin ABM .............................65 Cetirizine - AFT ............................159 Cetirizine hydrochloride ................159 Cetomacrogol .................................50 Cetomacrogol with glycerol ............50 Cetrimide ......................................179 Champix .......................................122 Charcoal .......................................172 Chemotherapeutic Agents ............123 Chicken pox vaccine .....................199 Chlorafast .....................................165 Chloral hydrate .............................118 Chlorambucil .................................123 Chloramphenicol Infection ......................................70 Sensory ....................................165 Chlorhexidine Genito-Urinary ............................55 Various .............................172, 177 Chlorhexidine gluconate Alimentary ..................................22 Extemporaneous ......................179 Genito-Urinary ............................55 Chlorhexidine with cetrimide .......................... 172, 177 Chlorhexidine with ethanol ...........172 Chloroform ....................................179 Chloroquine phosphate ..................75 Chlorothiazide .................................42 Chlorpheniramine maleate ...........159 Chlorpromazine hydrochloride ........................... 113 Chlorsig ........................................165 Chlortalidone [Chlorthalidone] ......................... 42 Chlorthalidone ................................42 Cholecalciferol ................................24 Cholestyramine ...............................43 Choline salicylate with cetalkonium chloride .................. 22 Cholvastin .......................................43 Choriogonadotropin alfa .................63 Ciclopirox olamine ..........................48 Ciclosporin ....................................133 Cidofovir .........................................84 Cilazapril .........................................36 Cilazapril with hydrochlorothiazide ................... 36 Cilicaine ..........................................68 Cilicaine VK ....................................68 Cimetidine .......................................14 Cinchocaine hydrochloride with hydrocortisone ........................... 13 Cipflox .............................................68 Ciprofloxacin Infection ......................................68 Sensory ....................................165 Cisplatin ........................................127 Cisplatin Ebewe ............................127 Citalopram hydrobromide .............107 Citanest ........................................101 Citric acid ......................................179 Citric acid with magnesium oxide and sodium picosulfate .............. 18 Citric acid with sodium bicarbonate .............................. 175 Cladribine .....................................124 Clarithromycin .................................67 Clexane ..........................................30 Clindamycin ....................................70 Clindamycin ABM ...........................70 Clobazam .....................................108 Clobetasol propionate ...............51–52 Clobetasone butyrate .....................51 Clofazimine .....................................73 Clomazol ...................................48, 55 Clomiphene citrate ..........................61 Clomipramine hydrochloride .........105 Clonazepam .................107–108, 117 Clonidine .........................................41 Clonidine BNM ................................41 Clonidine hydrochloride ..................41 Clopidogrel .....................................31 Clopine .........................................113 Clopixol .................................116, 117 Clostridium botulinum type A toxin ........................................... 94 Clotrimazole Dermatological ...........................48 Genito-Urinary ............................55 Clove oil ........................................179 Clozapine ......................................113 Clozaril .........................................113 Co-trimoxazole ...............................71 Coal tar .........................................179 Coal tar with salicylic acid and sulphur ....................................... 52 Coal tar with triethanolamine laryl sulphate and fluorescein ............ 52 Cocaine hydrochloride ..................100 Cocaine hydrochloride with adrenaline ................................ 100 Codeine phosphate Extemporaneous ......................179 Nervous ....................................102 Cogentin .........................................97 Colaspase [L-asparaginase] .........126 Colchicine .......................................94 Colestimethate ................................70 Colestipol hydrochloride .................43 Colgout ...........................................94 Colifoam .........................................13 Colistin sulphomethate [Colestimethate] ......................... 70 Colistin-Link ....................................70 Collodion flexible ..........................179 Colofac ...........................................14 Colony-Stimulating Factors .............32 Coloxyl ............................................18 Compound electrolytes .............32, 35 Compound electrolytes with glucose ................................ 32, 35 Compound hydroxybenzoate ..................... 179 Compound sodium lactate [Hartmann’s solution] ................. 33 Compound sodium lactate with glucose ...................................... 33 Concerta .......................................120 Condyline ........................................53 Contraceptives ................................55 Contrast Media .............................173 Corangin .........................................44 Cordarone-X ...................................38 Corticosteroids Dermatological ...........................51 Hormone ....................................59 Corticotrorelin (ovine) .....................62 Cosopt ..........................................168 Cough Suppressants ....................161

206


INDEX Generic Chemicals and Brands

Crotamiton ......................................49 Crystaderm .....................................48 CT Plus+ .......................................175 Curam Duo .....................................67 Curosurf ........................................164 Cvite ...............................................24 Cyclizine hydrochloride .................111 Cyclizine lactate ............................112 Cyclopentolate hydrochloride ........................... 169 Cyclophosphamide .......................123 Cycloserine .....................................73 Cyklokapron ....................................28 Cymevene .......................................84 Cyproheptadine hydrochloride ........................... 159 Cyproterone acetate .......................59 Cyproterone acetate with ethinyloestradiol ......................... 55 Cysteamine hydrochloride ............179 Cytarabine ....................................124 -DD-Penamine ....................................88 Dabigatran ......................................29 Dacarbazine .................................126 Dactinomycin [Actinomycin D] ............................................. 123 Daivobet .........................................52 Daivonex .........................................52 Dalacin C ........................................70 Dalteparin .......................................29 Danaparoid .....................................29 Danazol ..........................................62 Danthron with poloxamer ................19 Dantrium .........................................94 Dantrolene ......................................94 Dapa-Tabs ......................................42 Dapsone .........................................73 Daptomycin .....................................70 Darunavir ........................................79 Dasatinib .......................................127 Daunorubicin ................................123 DBL Aminophylline .......................163 DBL Cefepime ................................66 DBL Cefotaxime .............................66 DBL Ceftazidime .............................66 DBL Epirubicin Hydrochloride .......................... 124 DBL Ergometrine ............................57 DBL Gemcitabine .........................124 DBL Leucovorin Calcium ..............131 DBL Morphine Sulphate ...............104 DBL Pethidine Hydrochloride .......................... 105 DBL Rocuronium Bromide ..............94 DBL Tobramycin .............................65 DDI .................................................78 De-Nol ............................................15 De-Worm ........................................75 Decongestants ..............................161 Decongestants and Antiallergics ............................. 166 Decozol ...........................................22 Deferiprone ...................................172 Defibrotide ......................................29 Demeclocycline hydrochloride ............................. 69 Deoxycoformycin ..........................126 Depo-Medrol ...................................60 Depo-Medrol with Lidocaine ...........60 Depo-Provera .................................56 Depo-Testosterone .........................59 Deprim ............................................71 Dermol ......................................51, 52 Desferrioxamine mesilate .............172 Desflurane ......................................98 Desmopressin acetate ....................64 Desmopressin-PH&T ......................64 Dexamethasone Hormone ....................................59 Sensory ....................................166 Dexamethasone phosphate ............60 Dexamethasone with framycetin and gramicidin ......................... 165 Dexamethasone with neomycin sulphate and polymyxin B sulphate ................................... 165 Dexamethasone with tobramycin ............................... 165 Dexamethasone-hameln ................60 Dexamphetamine sulphate ...........119 Dexmedetomidine hydrochloride ............................. 98 Dextrose with sodium citrate and citric acid [Acid Citrate Dextrose A] ................................ 29 DHC Continus ...............................102 Diabetes .........................................15 Diacomit ........................................110 Diagnostic Agents .........................176 Diagnostic and Surgical Preparations ............................ 167 Diamide Relief ................................12 Diamox .........................................168 Diatrizoate meglumine with diatrizoate sodium ................... 173 Diatrizoate sodium ........................173 Diazepam .............................107, 117 Diazoxide Alimentary ..................................15 Cardiovascular ...........................45 Dichlorobenzyl alcohol with amylmetacresol ......................... 22 Diclax SR ........................................95 Diclofenac sodium Musculoskeletal System .............95 Sensory ....................................166 Dicobalt edetate ............................172 Didanosine [DDI] ............................78 Diflucan ...........................................72 Diflucortolone valerate ....................51 Digestives Including Enzymes .................................... 17 Digoxin ............................................38 Digoxin immune Fab .....................171 Dihydrocodeine tartrate ................102 Dihydroergotamine mesylate .................................. 111 Dilatrend .........................................39 Diltiazem hydrochloride ..................40 Dilzem .............................................40 Dimercaprol ..................................172 Dimercaptosuccinic acid ...............172 Dimethicone ....................................49 Dimethyl sulfoxide .........................177 Dinoprostone ..................................57 Diphemanil metilsulfate ..................53 Diphenoxylate hydrochloride with atropine sulphate ....................... 12 Diphtheria and tetanus vaccine .................................... 196 Diphtheria antitoxin .......................171 Diphtheria, tetanus and pertussis vaccine .................................... 196 Diphtheria, tetanus, pertussis and polio vaccine ..................... 196 Diphtheria, tetanus, pertussis, polio, hepatitis B and haemophilus influenzae type B vaccine .................................... 196 Diprivan ..........................................99 Dipyridamole ...................................31 Disodium edetate ..........................172 Disodium hydrogen phosphate with sodium dihydrogen phosphate ................................ 179 Disopyramide phosphate ................38 Disulfiram ......................................121 Dithranol .......................................179

207


INDEX Generic Chemicals and Brands

Diuretics ..........................................41 Diurin 40 .........................................41 Dobutamine hydrochloride ..............44 Docetaxel ......................................131 Docetaxel Sandoz ........................131 Docusate sodium Alimentary ..................................18 Sensory ....................................170 Docusate sodium with sennosides ................................ 18 Domperidone ................................112 Donepezil hydrochloride ...............121 Donepezil-Rex ..............................121 Dopamine hydrochloride .................44 Dopergin .........................................98 Dopress ........................................105 Dornase alfa .................................163 Dorzolamide .................................168 Dorzolamide with timolol ...............168 Dostinex ..........................................61 Dothiepin hydrochloride ................105 Doxapram .....................................164 Doxazosin .......................................37 Doxepin hydrochloride ..................105 Doxine ............................................69 Doxorubicin hydrochloride ............123 Doxycycline ....................................69 DP-Anastrozole ............................133 Dr Reddy’s Omeprazole .................14 Dr Reddy’s Ondansetron ..............112 Dr Reddy’s Pantoprazole ................15 Dr Reddy’s Pramipexole .................98 Dr Reddy’s Quetiapine .................114 Dr Reddy’s Risperidone ................115 Dr Reddy’s Terbinafine ...................73 Droperidol .....................................112 Drugs Affecting Bone Metabolism ................................ 88 Dulcolax ..........................................19 Duolin ...........................................160 Duovisc .........................................168 Duride .............................................44 Dynastat .........................................96 Dysport ...........................................94 -EE-Mycin ...........................................67 Econazole nitrate ............................48 Edrophonium chloride ....................88 Efavirenz .........................................77 Efavirenz with emtricitabine and tenofovir disoproxil fumarate .................................... 78 Efexor XR .....................................106 Effient .............................................31 Eformoterol fumarate ....................162 Efudix ..............................................53 Elecare (Unflavoured) ...................190 Elecare (Vanilla) ...........................190 Elecare LCP (Unflavoured) ...........190 Electrolytes ...................................178 Eligard ............................................63 Eltrombopag ...................................27 Emend Tri-Pack ............................111 EMLA ............................................101 Emtricitabine ...................................78 Emtricitabine with tenofovir disoproxil fumarate .................... 78 Emtriva ...........................................78 Emulsifying ointment ......................50 Enalapril maleate ............................36 Enalapril maleate with hydrochlorothiazide ................... 36 Enbrel ...........................................134 Endocrine Therapy .......................132 Endoxan .......................................123 Enfuvirtide ......................................76 Enoxaparin .....................................30 Ensure (Chocolate) .......................195 Ensure (Vanilla) ............................195 Ensure Plus (Banana) ..................195 Ensure Plus (Chocolate) ...............195 Ensure Plus (Fruit of the Forest) ..................................... 195 Ensure Plus (Strawberry) .............195 Ensure Plus (Vanilla) ....................195 Ensure Plus HN ............................194 Ensure Plus HN RTH ....................194 Entacapone ....................................98 Entapone ........................................98 Entecavir .........................................81 Enzymes .........................................93 Ephedrine .......................................45 Epirubicin Ebewe ..........................124 Epirubicin hydrochloride ...............124 Eprex ..............................................26 Eptacog alfa [Recombinant factor VIIa] ........................................... 28 Eptifibatide ......................................31 Ergometrine maleate ......................57 Ergotamine tartrate with caffeine .................................... 111 Erlotinib ........................................128 Ertapenem ......................................65 Erythrocin IV ...................................67 Erythromycin (as ethylsuccinate) ........................... 67 Erythromycin (as lactobionate) .............................. 67 Erythromycin (as stearate) .............67 Erythropoietin alpha .......................26 Erythropoietin beta .........................26 Escitalopram .................................107 Esmolol hydrochloride ....................39 Etanercept ....................................134 Ethambutol hydrochloride ...............74 Ethanol .........................................171 Ethanol with glucose .....................171 Ethanol, dehydrated .....................171 Ethics Aspirin EC ............................31 Ethics Enalapril ...............................36 Ethics Paracetamol .......................102 Ethinyloestradiol .............................62 Ethinyloestradiol with desogestrel ................................ 55 Ethinyloestradiol with levonorgestrel ............................ 55 Ethinyloestradiol with norethisterone ............................ 55 Ethosuximide ................................108 Ethyl chloride ................................100 Etidronate disodium ........................90 Etomidate .......................................98 Etopophos ....................................126 Etoposide ......................................126 Etoposide (as phosphate) .............126 Etoricoxib ........................................95 Etravirine ........................................77 Evista ..............................................92 Exemestane ..................................133 Extemporaneously Compounded Preparations ............................ 179 EZ-fit Paediatric Mask ..................201 Ezetimibe ........................................43 Ezetimibe with simvastatin .............43 -FFactor eight inhibitors bypassing agent ......................................... 28 FEIBA .............................................28 Felodipine .......................................40 Fenpaed .........................................95 Fentanyl ........................................103 Ferodan ..........................................21 Ferric subsulfate .............................27 Ferriprox .......................................172 Ferro-F-Tabs ...................................21 Ferro-tab .........................................21 Ferrograd ........................................21 Ferrous fumarate ............................21 Ferrous fumarate with folic

208


INDEX Generic Chemicals and Brands

acid ............................................ 21 Ferrous gluconate with ascorbic acid ............................................ 21 Ferrous sulphate .............................21 Ferrous sulphate with ascorbic acid ............................................ 21 Ferrous sulphate with folic acid ............................................ 21 Ferrum H ........................................21 Fexofenadine hydrochloride .........160 Filgrastim ........................................32 Finasteride ......................................57 Flagyl ..............................................75 Flagyl-S ..........................................75 Flamazine .......................................48 Flecainide acetate ..........................38 Fleet Phosphate Enema .................19 Flixonase Hayfever & Allergy ...................................... 159 Flixotide ........................................162 Flixotide Accuhaler .......................162 Florinef ...........................................60 Fluanxol ........................................116 Fluarix ...........................................198 Flucloxacillin ...................................68 Flucloxin .........................................68 Flucon ...........................................166 Fluconazole ....................................72 Fluconazole-Claris ..........................72 Flucytosine .....................................73 Fludara Oral ..................................124 Fludarabine Ebewe .......................124 Fludarabine phosphate .................124 Fludrocortisone acetate ..................60 Fluids and Electrolytes ...................32 Flumazenil ....................................171 Flumetasone pivalate with clioquinol .................................. 165 Fluocortolone caproate with fluocortolone pivalate and cinchocaine ................................ 13 Fluorescein sodium ......................167 Fluorescein sodium with lignocaine hydrochloride .......... 167 Fluorescite ....................................167 Fluorometholone ...........................166 Fluorouracil ...................................124 Fluorouracil Ebewe .......................124 Fluorouracil sodium ........................53 Fluox .............................................107 Fluoxetine hydrochloride ...............107 Flupenthixol decanoate ................116 Fluphenazine decanoate ..............116 Flutamide ......................................132 Flutamin ........................................132 Fluticasone ...................................162 Fluticasone propionate .................159 Fluticasone with salmeterol ..........163 Foban .............................................48 Folic acid ........................................27 Fondaparinux sodium .....................30 Food Modules ...............................182 Food/Fluid Thickeners ..................183 Forteo .............................................93 Fortisip (Vanilla) ............................195 Fortum ............................................66 Fosamax .........................................88 Fosamax Plus .................................89 Foscarnet sodium ...........................84 Fosfomycin .....................................70 Fragmin ..........................................29 Framycetin sulphate .....................165 Freeflex ...........................................34 FreeStyle Lite ...............................201 Freestyle Optium ..........................201 Freestyle Optium Ketone ..............201 Fresofol 1% .....................................99 Frusemide-Claris ............................41 Fucidin ............................................70 Fucithalmic ...................................165 Fungilin ...........................................22 Furosemide (frusemide) .................41 Fusidate sodium [Fusidic acid] ........................................... 48 Fusidic acid .....................................48 Dermatological ...........................48 Infection ......................................70 Sensory ....................................165 Fuzeon ............................................76 -GGabapentin ...................................108 Gadobenic acid .............................175 Gadobutrol ....................................175 Gadodiamide ................................175 Gadoteric acid ..............................175 Gadovist .......................................175 Gadoxetate disodium ....................176 Gamma benzene hexachloride .............................. 48 Ganciclovir ......................................84 Gastrografin ..................................173 Gastrosoothe ..................................14 Gefitinib ........................................128 Gelafusal ........................................35 Gelatine, succinylated ....................35 Gelofusine ......................................35 Gemcitabine .................................124 Gemcitabine Actavis 1000 ............124 Gemcitabine Actavis 200 ..............124 Gemcitabine Ebewe .....................124 Gemfibrozil .....................................42 Genoptic .......................................165 Genox ...........................................133 Gentamicin sulphate Infection ......................................65 Sensory ....................................165 Gestrinone ......................................62 Glatiramer acetate ........................117 Glaucoma Preparations ................168 Glibenclamide .................................17 Gliclazide ........................................17 Glipizide ..........................................17 Glivec ............................................128 Glucagen Hypokit ...........................15 Glucagon hydrochloride ..................15 Glucerna Select (Vanilla) ..............187 Glucerna Select RTH (Vanilla) .................................... 187 Glucose Alimentary ..................................15 Blood ..........................................33 Extemporaneous ......................180 Glucose with potassium chloride ...................................... 33 Glucose with potassium chloride and sodium chloride .................. 33 Glucose with sodium chloride .........33 Glucose with sucrose and fructose ...................................... 15 Glycerin with sodium saccharin ................................. 180 Glycerin with sucrose ...................180 Glycerol Alimentary ..................................19 Extemporaneous ......................180 Glycerol with paraffin ......................50 Glyceryl trinitrate Alimentary ..................................14 Cardiovascular ...........................44 Glycine ..........................................177 Glycopyrronium bromide ................14 Glypressin .......................................64 Glytrin .............................................44 Gonadorelin ....................................62 Goserelin ........................................62 -HHabitrol .........................................121 Habitrol (Classic) ..........................121 Habitrol (Fruit) ...............................121

209


INDEX Generic Chemicals and Brands

Habitrol (Mint) ...............................121 Haem arginate ................................20 Haemophilus influenzae type B vaccine .................................... 197 Haldol ...........................................116 Haldol Concentrate .......................116 Haloperidol ...................................113 Haloperidol decanoate .................116 Hartmann’s solution ........................32 Healon GV ....................................168 healthE Dimethicone 5% ................49 healthE Fatty Cream .......................50 Heparin sodium ..............................30 Heparinised saline ..........................30 Heparon Junior .............................188 Hepatitis A vaccine .......................198 Hepatitis B vaccine .......................198 Hepsera ..........................................80 Herceptin ......................................156 Hexamine hippurate .......................70 Histamine acid phosphate ............176 Holoxan ........................................123 Hormone Replacement Therapy ..................................... 61 HPV ..............................................198 Humalog Mix 25 ..............................16 Humalog Mix 50 ..............................16 Human papillomavirus (6, 11, 16 and 18) vaccine [HPV] ............. 198 Humatin ..........................................65 Humira ..........................................138 HumiraPen ....................................138 Hyaluronidase .................................93 Hybloc .............................................39 Hydralazine hydrochloride ..............45 Hydrea ..........................................126 Hydrocortisone Dermatological ...........................51 Extemporaneous ......................180 Hormone ....................................60 Hydrocortisone acetate Alimentary ..................................13 Dermatological ...........................51 Hydrocortisone butyrate ...........51, 53 Hydrocortisone with ciprofloxacin ............................. 166 Hydrocortisone with miconazole ................................ 52 Hydrocortisone with natamycin and neomycin ............................ 52 Hydrocortisone with paraffin and wool fat ...................................... 51 Hydrogen peroxide .........................48 Hydroxocobalamin ........................171 Hydroxocobalamin acetate .............23 Hydroxychloroquine ........................88 Hydroxyethyl starch 130/0.4 with magnesium chloride, potassium chloride, sodium acetate and sodium chloride ...................................... 35 Hydroxyethyl starch 130/0.4 with sodium chloride ......................... 35 Hydroxyurea .................................126 Hygroton .........................................42 Hylo-Fresh ....................................170 Hyoscine butylbromide ...................14 Hyoscine hydrobromide ................112 Hyperuricaemia and Antigout .........93 Hypnovel .......................................118 Hypromellose ........................167, 170 Hypromellose with dextran ...........170 Hysite ............................................169 -IIbiamox ...........................................67 Ibuprofen ........................................95 Idarubicin hydrochloride ...............124 Ifosfamide .....................................123 Ikorel ...............................................45 Ilomedin ..........................................47 Iloprost ............................................47 Imatinib mesilate ...........................128 Imiglucerase ...................................20 Imipenem with cilastatin .................65 Imipramine hydrochloride .............105 Imiquimod .......................................53 Immune Modulators ........................85 Immunosuppressants ...................133 Impact Advanced Recovery (Chocolate) .............................. 193 Impact Advanced Recovery (Vanilla) .................................... 193 Imuprine .......................................157 Imuran ..........................................157 Indapamide .....................................42 Indigo carmine ..............................176 Indinavir ..........................................80 Indocyanine green ........................176 Indomethacin ..................................96 Infliximab ......................................144 Influenza vaccine ..........................198 Influvac .........................................198 Inhaled Corticosteroids .................161 Innovacon hCG One Step Pregnancy Test ........................ 202 Insulin aspart ..................................16 Insulin aspart with insulin aspart protamine ................................... 16 Insulin glargine ...............................16 Insulin glulisine ...............................16 Insulin isophane ..............................16 Insulin lispro ....................................16 Insulin lispro with insulin lispro protamine ................................... 16 Insulin neutral .................................16 Insulin neutral with insulin isophane .................................... 16 Insulin pen needles .......................201 Insulin syringes, disposable with attached needle ....................... 201 Integrilin ..........................................31 Intelence .........................................77 Interferon alfa-2a ............................85 Interferon alfa-2b ............................85 Interferon beta-1-alpha .................118 Interferon beta-1-beta ...................118 Interferon gamma ...........................85 Intra-uterine device .........................55 Invanz .............................................65 Iodine ..............................................63 Iodine with ethanol ........................172 Iodised oil .....................................173 Iodixanol .......................................173 Iohexol ..........................................174 Iomeprol ........................................174 Iopromide ......................................174 Ioscan ...........................................173 Iotrolan ..........................................174 Ipratropium bromide .............159–160 Iressa ............................................128 Irinotecan Actavis 100 ..................126 Irinotecan Actavis 40 ....................126 Irinotecan hydrochloride ...............126 Iron polymaltose .............................21 Iron sucrose ....................................21 Irrigation Solutions ........................177 Isentress .........................................80 Ismo 40 Retard ...............................44 Ismo-20 ...........................................44 Isoflurane ........................................98 Isoniazid .........................................74 Isoniazid with rifampicin ..................74 Isoprenaline ....................................45 Isopropyl alcohol ...........................172 Isoptin .............................................41 Isosorbide mononitrate ...................44 Isotretinoin ......................................49 Ispaghula (psyllium) husk ...............18

210


INDEX Generic Chemicals and Brands

Isradipine ........................................40 Itch-Soothe .....................................49 Itraconazole ....................................72 Itrazole ............................................72 Ivermectin .......................................75 -JJadelle ............................................56 Jevity ............................................194 Jevity HiCal RTH ..........................194 Jevity RTH ....................................194 -KKaletra ............................................80 Kenacomb ....................................166 Kenacort-A ......................................60 Kenacort-A40 ..................................60 Ketamine hydrochloride ..................99 Ketocal 3:1 (Unflavoured) .............192 Ketocal 4:1 (Unflavoured) .............192 Ketocal 4:1 (Vanilla) ......................192 Ketoconazole Dermatological ...........................48 Infection ......................................71 Ketone blood beta-ketone electrodes ................................ 201 Ketoprofen ......................................96 Ketorolac trometamol ...................166 Kivexa .............................................78 Klacid ..............................................67 Klean Prep ......................................18 Kogenate FS ...................................28 Konakion MM ..................................29 Konsyl-D .........................................18 -LL-asparaginase .............................126 L-ornithine L-aspartate ...................15 Labetalol .........................................39 Lacosamide ..................................109 Lactose .........................................180 Lactulose ........................................19 Laevolac .........................................19 Lamictal ........................................109 Lamivudine ...............................78, 81 Lamotrigine ...................................109 Lansoprazole ..................................14 Lantus .............................................16 Lantus SoloStar ..............................16 Lapatinib .......................................128 Latanoprost ...................................169 Lax-Sachets ....................................19 Lax-Tabs .........................................19 Laxatives ........................................18 Laxofast 120 ...................................18 Laxofast 50 .....................................18 Laxsol .............................................18 Leflunomide ....................................88 Letraccord .....................................133 Letrozole .......................................133 Leukotriene Receptor Antagonists .............................. 162 Leunase ........................................126 Leuprorelin acetate .........................63 Leustatin .......................................124 Levetiracetam ...............................109 Levetiracetam-Rex ........................109 Levobunolol hydrochloride ............168 Levocabastine ..............................166 Levocarnitine ..................................20 Levodopa with benserazide ............98 Levodopa with carbidopa ................98 Levomepromazine ........................114 Levonorgestrel ................................56 Levophed ........................................45 Levosimendan ................................44 Levothyroxine ..................................63 Lidocaine [Lignocaine] hydrochloride ........................... 100 Lidocaine [Lignocaine] hydrochloride with adrenaline ................................ 101 Lidocaine [Lignocaine] hydrochloride with adrenaline and tetracaine hydrochloride ........................... 101 Lidocaine [Lignocaine] hydrochloride with chlorhexidine ........................... 101 Lidocaine [Lignocaine] hydrochloride with phenylephrine hydrochloride ........................... 101 Lidocaine [Lignocaine] with prilocaine ................................. 101 Lidocaine-Claris ............................100 Lignocaine ............................100, 101 Lincomycin ......................................70 Lindane [Gamma benzene hexachloride] ............................. 48 Linezolid .........................................70 Lioresal Intrathecal .........................94 Liothyronine sodium .......................63 Lipazil .............................................42 Lipid-Modifying Agents ...................42 Liquifilm Forte ...............................170 Liquifilm Tears ...............................170 Lisinopril .........................................36 Lissamine green ...........................167 Lisuride hydrogen maleate .............98 Lithicarb FC ..................................114 Lithium carbonate .........................114 Local Preparations for Anal and Rectal Disorders ........................ 13 Locoid .......................................51, 53 Locoid Crelo ...................................51 Locoid Lipocream ...........................51 Lodoxamide ..................................166 Logem ...........................................109 Lomustine .....................................123 Long-Acting Beta-Adrenoceptor Agonists ................................... 162 Loniten ............................................45 Loperamide hydrochloride ..............12 Lopinavir with ritonavir ....................80 Lopresor .........................................39 Lorafix ...........................................160 Lorapaed ......................................160 Loratadine .....................................160 Lorazepam ............................107, 117 Lormetazepam .............................118 Losartan potassium ........................37 Losartan potassium with hydrochlorothiazide ................... 37 Lostaar ............................................37 Lovir ................................................84 Loxalate ........................................107 Loxamine ......................................107 Lucrin Depot PDS ...........................63 Lycinate ..........................................44 Lyderm ............................................49 -Mm-Amoxiclav ...................................67 m-Cefuroxime .................................66 m-Eslon ........................................104 m-Mometasone ...............................51 Mabthera ......................................149 Macrogol 3350 with ascorbic acid, potassium chloride and sodium chloride ......................... 18 Macrogol 3350 with potassium chloride, sodium bicarbonate and sodium chloride .................. 19 Macrogol 3350 with potassium chloride, sodium bicarbonate, sodium chloride and sodium sulphate ..................................... 18 Macrogol 400 and propylene glycol ....................................... 170 Madopar 125 ..................................98

211


INDEX Generic Chemicals and Brands

Madopar 250 ..................................98 Madopar 62.5 .................................98 Madopar HBS .................................98 Madopar Rapid ...............................98 Mafenide acetate ............................48 Magnesium hydroxide Alimentary ..................................21 Extemporaneous ......................180 Magnesium oxide ...........................21 Magnesium sulphate ......................21 Magnevist .....................................176 Malathion [Maldison] .......................49 Malathion with permethrin and piperonyl butoxide ...................... 49 Maldison .........................................48 Mannitol ..........................................41 Maprotiline hydrochloride .............105 Marcain ...........................................99 Marcain Heavy ..............................100 Marcain Isobaric .............................99 Marcain with Adrenaline ...............100 Marevan ..........................................31 Marine Blue Lotion SPF 30+ ..........53 Marine Blue Lotion SPF 50+ ..........53 Martindale Acetylcysteine .............171 Mask for spacer device .................201 Mast Cell Stabilisers .....................163 Maxidex ........................................166 Measles, mumps and rubella vaccine .................................... 199 Mebendazole ..................................75 Mebeverine hydrochloride ..............14 Medrol .............................................60 Medroxyprogesterone .....................62 Medroxyprogesterone acetate Genito-Urinary ............................56 Hormone ....................................61 Mefenamic acid ..............................96 Mefloquine hydrochloride ...............75 Megestrol acetate .........................132 Meglumine gadopentetate ............176 Melatonin ......................................118 Meloxicam ......................................96 Melphalan .....................................123 Meningococcal (A, C, Y and W-135) conjugate vaccine .................................... 197 Meningococcal (A, C, Y and W-135) polysaccharide vaccine .................................... 197 Meningococcal C conjugate vaccine .................................... 197 Menthol .........................................180 Mepivacaine hydrochloride ...........101 Mercaptopurine ............................125 Meropenem ....................................65 Mesalazine .....................................13 Mesna ...........................................131 Mestinon .........................................88 Metabolic Disorder Agents .............19 Metabolic Products .......................184 Metamide ......................................112 Metaraminol ....................................45 Metformin ........................................17 Methacholine chloride ..................176 Methadone hydrochloride Extemporaneous ......................180 Nervous ....................................103 Methatabs .....................................103 Methoblastin .................................125 Methohexital sodium .......................99 Methopt .........................................170 Methotrexate .................................125 Methotrexate Ebewe .....................125 Methotrexate Sandoz ...................125 Methoxsalen [8-methoxypsoralen] .................. 52 Methoxyflurane .............................102 Methyl aminolevulinate hydrochloride ............................. 53 Methyl hydroxybenzoate ...............180 Methylcellulose .............................180 Methylcellulose with glycerin and sodium saccharin .................... 180 Methylcellulose with glycerin and sucrose .................................... 180 Methyldopa .....................................41 Methylene blue .............................176 Methylphenidate hydrochloride ........................... 120 Methylprednisolone (as sodium succinate) .................................. 60 Methylprednisolone aceponate .................................. 51 Methylprednisolone acetate ............60 Methylprednisolone acetate with lignocaine .................................. 60 Methylthioninium chloride [Methylene blue] ...................... 176 Methylxanthines ............................163 Metoclopramide hydrochloride ........................... 112 Metoclopramide hydrochloride with paracetamol ..................... 111 Metolazone .....................................42 Metoprolol - AFT CR .......................39 Metoprolol succinate .......................39 Metoprolol tartrate ..........................39 Metronidazole Dermatological ...........................48 Infection ......................................75 Metyrapone .....................................62 Mexiletine hydrochloride .................38 Mexiletine Hydrochloride USP ........................................... 38 Miacalcic .........................................59 Mianserin hydrochloride ...............106 Micolette .........................................19 Miconazole .....................................22 Miconazole nitrate Dermatological ...........................48 Genito-Urinary ............................55 Micreme H ......................................52 Microgynon 50 ED ..........................55 Midazolam ....................................118 Midodrine ........................................38 Mifepristone ....................................56 Milrinone .........................................45 Minerals ..........................................20 Minidiab ..........................................17 Minirin .............................................64 Minocycline .....................................69 Minoxidil ..........................................45 Mirtazapine ...................................106 Misoprostol .....................................14 Mitomycin C ..................................124 Mitozantrone .................................124 Mitozantrone Ebewe .....................124 Mivacron .........................................94 Mivacurium chloride ........................94 Moclobemide ................................106 Modafinil .......................................120 Modecate ......................................116 Mogine ..........................................109 Mometasone furoate .......................51 Monosodium glutamate with sodium aspartate ..................... 178 Monosodium l-aspartate ...............178 Montelukast ..................................162 Moroctocog alfa [Recombinant factor VIII] .................................. 28 Morphine hydrochloride ................103 Morphine sulphate ........................104 Morphine tartrate ..........................104 Motetis ............................................97 Mouth and Throat ...........................22 Moxifloxacin ....................................68 Mucolytics and Expectorants ............................ 163

212


INDEX Generic Chemicals and Brands

Multihance ....................................175 Multiple Sclerosis Treatments ............................... 117 Multivitamins ...................................23 Mupirocin ........................................48 Muscle Relaxants and Related Agents ....................................... 94 Myambutol ......................................74 Mycobutin .......................................74 Mycophenolate mofetil ..................158 Mydriacyl ......................................169 Mydriatics and Cycloplegics .........169 Mylan Atenolol ................................39 Mylan Fentanyl Patch ...................103 Myleran .........................................123 -NNadolol ...........................................39 Naloxone hydrochloride ................171 Naltraccord ...................................121 Naltrexone hydrochloride ..............121 Naphazoline hydrochloride ...........166 Naphcon Forte ..............................166 Naproxen ........................................96 Naropin .........................................101 Natamycin .....................................165 Natulan .........................................126 Nausicalm .............................111, 112 Navelbine ......................................132 Navoban .......................................112 Nedocromil ...................................163 Nefopam hydrochloride ................102 Neocate Advance (Vanilla) ...........190 Neocate Gold (Unflavoured) .........190 Neoral ...........................................133 NeoRecormon ................................26 Neostigmine metilsulfate ................88 Neostigmine metilsulfate with glycopyrronium bromide ............ 88 Neosynephrine HCL .......................45 Neotigason .....................................52 Nepro (Strawberry) .......................193 Nepro (Vanilla) ..............................193 Nepro RTH ...................................193 Neulastim ........................................32 Neupogen .......................................32 Nevirapine ......................................77 Nevirapine Alphapharm ..................77 Nicorandil ........................................45 Nicotine .........................................121 Nicotinic acid ..................................44 Nifedipine ........................................40 Nilstat ........................................22, 71 Nimodipine ......................................40 Nitazoxanide ...................................75 Nitrates ...........................................44 Nitrazepam ...................................118 Nitroderm TTS 10 ...........................44 Nitroderm TTS 5 .............................44 Nitrofurantoin ..................................70 Nitronal ...........................................44 Noflam 250 .....................................96 Noflam 500 .....................................96 Non-Steroidal Anti-Inflammatory Drugs ......................................... 95 Nonacog alfa [Recombinant factor IX] .................................... 28 Noradrenaline .................................45 Norethisterone Genito-Urinary ............................56 Hormone ....................................62 Norethisterone with mestranol ................................... 55 Norfloxacin ......................................69 Normison ......................................118 Norpress .......................................106 Nortriptyline hydrochloride ............106 Norvir ..............................................80 Novasource Renal (Vanilla) ..........193 Novatretin .......................................52 NovoMix 30 FlexPen .......................16 NovoSeven RT ................................28 Noxafil .............................................72 Nupentin .......................................108 Nutrini Energy Multi Fibre .............192 Nutrini Low Energy Multifibre RTH ......................................... 192 Nutrison Concentrated .................188 Nutrison Energy ............................194 Nyefax Retard .................................40 Nystatin Alimentary ..................................22 Dermatological ...........................48 Genito-Urinary ............................55 Infection ......................................71 -OObstetric Preparations ....................56 Octocog alfa [Recombinant factor VIII] ............................................ 28 Octreotide .....................................132 Octreotide MaxRx .........................132 Ocular Lubricants .........................169 Oestradiol .................................61–62 Oestradiol valerate .........................61 Oestradiol with norethisterone acetate ....................................... 61 Oestriol Genito-Urinary ............................57 Hormone ....................................62 Oestrogens .....................................57 Oestrogens (conjugated equine) ....................................... 61 Oestrogens with medroxyprogesterone acetate ....................................... 61 Oil in water emulsion ......................50 Oily phenol [Phenol oily] .................14 Olanzapine ...........................114, 116 Olanzine .......................................114 Olanzine-D ....................................114 Olive oil .........................................180 Olopatadine ..................................166 Olsalazine .......................................13 Omeprazole ....................................14 Omezol Relief .................................14 Omnipaque ...................................174 Omniscan .....................................175 On Call Advanced .........................201 Oncaspar ......................................126 OncoTICE .....................................157 Ondanaccord ................................112 Ondansetron .................................112 One-Alpha ......................................24 Onkotrone .....................................124 Onrex ............................................112 Optional Pharmaceuticals ............201 Ora-Blend .....................................180 Ora-Blend SF ................................180 Ora-Plus .......................................180 Ora-Sweet ....................................180 Ora-Sweet SF ...............................180 Oracort ...........................................22 Oratane ...........................................49 Ornidazole ......................................75 Orphenadrine citrate .......................94 Orphenadrine hydrochloride ...........97 Oruvail SR ......................................96 Oseltamivir ......................................85 Osmolite .......................................194 Osmolite RTH ...............................194 Ospamox ........................................67 Other Cardiac Agents .....................44 Other Endocrine Agents .................61 Other Oestrogen Preparations .............................. 62 Other Otological Preparations ............................ 170 Other Progestogen Preparations .............................. 62

213


INDEX Generic Chemicals and Brands

Other Skin Preparations .................53 Oxaliplatin .....................................127 Oxaliplatin Actavis 100 .................127 Oxaliplatin Actavis 50 ...................127 Oxandroline ....................................59 Oxazepam ....................................117 Oxpentifylline ..................................46 Oxybuprocaine hydrochloride ........................... 167 Oxybutynin ......................................58 Oxycodone hydrochloride .............104 Oxycodone Orion .........................104 OxyContin .....................................104 Oxydone BNM ..............................104 Oxymetazoline hydrochloride ........................... 161 OxyNorm ......................................104 Oxytocin ..........................................57 Oxytocin BNM .................................57 Oxytocin with ergometrine maleate ...................................... 57 Ozole ..............................................72 -PPacifen ............................................94 Pacific Buspirone ..........................117 Paclitaxel ......................................131 Paclitaxel Actavis ..........................131 Paclitaxel Ebewe ..........................131 Pamidronate BNM ..........................90 Pamidronate disodium ....................90 Pamisol ...........................................90 Panadol ........................................102 Pancreatic enzyme .........................17 Pancuronium bromide ....................94 Pantoprazole ...................................15 Pantoprazole Actavis 20 .................15 Pantoprazole Actavis 40 .................15 Papaverine hydrochloride ...............46 Paper wasp venom .......................159 Para-aminosalicylic Acid .................74 Paracare .......................................102 Paracare Double Strength ............102 Paracetamol .................................102 Paracetamol + Codeine (Relieve) .................................. 104 Paracetamol with codeine ............104 Paracetamol-AFT .........................102 Paraffin Alimentary ..................................18 Dermatological ...........................50 Extemporaneous ......................180 Paraffin liquid with soft white paraffin ..................................... 170 Paraffin liquid with wool fat ...........170 Paraffin with wool fat .......................50 Paraldehyde ..................................107 Parecoxib ........................................96 Paromomycin ..................................65 Paroxetine hydrochloride ..............107 Paser ..............................................74 Patent blue V ................................176 Paxam ..........................................117 Pazopanib .....................................129 Peak flow meter ............................201 Peanut oil ......................................179 Pediasure (Chocolate) ..................192 Pediasure (Strawberry) .................192 Pediasure (Vanilla) ........................192 Pediasure RTH .............................192 Pegaspargase ..............................126 Pegasus RBV Combination Pack ........................................... 86 Pegasys ..........................................86 Pegfilgrastim ...................................32 Pegylated interferon alfa-2a ............86 Penembact .....................................65 Penicillamine ..................................88 Penicillin G ......................................68 Penicillin V ......................................68 Pentagastrin ...................................62 Pentamidine isethionate .................75 Pentasa ..........................................13 Pentostatin [Deoxycoformycin] ................... 126 Pentoxifylline [Oxpentifylline] ..........46 Peptamen OS 1.0 (Vanilla) ...........188 Peptisoothe .....................................14 Pergolide ........................................98 Perhexiline maleate ........................41 Pericyazine ...................................114 Perindopril ......................................36 Permax ...........................................98 Permethrin ......................................49 Peteha ............................................74 Pethidine hydrochloride ................105 Pexsig .............................................41 Phenelzine sulphate .....................106 Phenindione ....................................30 Phenobarbitone ....................110, 118 Phenobarbitone sodium ................180 Phenol Extemporaneous ......................180 Various .....................................177 Phenol oily ......................................14 Phenol with ioxaglic acid ..............177 Phenoxybenzamine hydrochloride ............................. 37 Phenoxymethylpenicillin [Penicillin V] ............................... 68 Phentolamine mesylate ..................37 Phenylephrine hydrochloride Cardiovascular ...........................45 Sensory ....................................169 Phenytoin ......................................110 Phenytoin sodium .................108, 110 Pholcodine ....................................161 Phosphorus ....................................35 Phytomenadione .............................29 Picibanil ........................................158 Pilocarpine hydrochloride .............169 Pilocarpine nitrate .........................180 Pimafucort ......................................52 Pindolol ...........................................39 Pinetarsol ........................................52 Pinorax ...........................................19 Pinorax Forte ..................................19 Pioglitazone ....................................17 Piperacillin with tazobactam ...........68 Pipothiazine palmitate ..................116 Pituitary and Hypothalamic Hormones and Analogues ......... 62 Pivmecillinam ..................................70 Pizaccord ........................................17 Pizotifen ........................................111 PKU Anamix Junior LQ (Berry) ..................................... 185 PKU Anamix Junior LQ (Orange) .................................. 185 PKU Anamix Junior LQ (Unflavoured) ........................... 185 Plaquenil .........................................88 Plendil ER .......................................40 Plerfutren ......................................176 pms-Bosentan ................................46 Pneumococcal (PCV10) conjugate vaccine .................... 197 Pneumococcal (PCV13) conjugate vaccine .................... 197 Pneumococcal (PPV23) polysaccharide vaccine ........... 198 Podophyllotoxin ..............................53 Polidocanol .....................................27 Poliomyelitis vaccine .....................199 Poloxamer .......................................18 Poly Gel ........................................169 Poly-Tears .....................................170 Polyhexamethylene biguanide ................................. 180 Polyvinyl alcohol ...........................170

214


INDEX Generic Chemicals and Brands

Polyvinyl alcohol with povidone .................................. 170 Poractant alfa ................................164 Posaconazole .................................72 Postinor-1 .......................................56 Potassium chloride ...................33, 35 Potassium chloride with sodium chloride ...................................... 34 Potassium citrate ............................58 Potassium dihydrogen phosphate .................................. 34 Potassium iodate Alimentary ..................................21 Hormone ....................................63 Potassium iodate with iodine ..........21 Potassium perchlorate ....................63 Potassium permanganate ...............52 Povidone K30 ...............................180 Povidone-iodine ............................173 Povidone-iodine with ethanol ..................................... 173 Pradaxa ..........................................29 Pralidoxime iodide ........................171 Pramipexole hydrochloride .............98 Prasugrel ........................................31 Pravastatin ......................................43 Praziquantel ....................................75 Prazosin ..........................................37 Prednisolone ...................................60 Prednisolone acetate ....................166 Prednisolone sodium phosphate ................................ 166 Prednisone .....................................60 Pregnancy test - hCG urine ..........202 Prezista ...........................................79 Prilocaine hydrochloride ...............101 Prilocaine hydrochloride with felypressin ............................... 101 Primaquine phosphate ...................76 Primaxin .........................................65 Primidone .....................................110 Primolut N .......................................62 Probenecid .....................................94 Procaine penicillin ...........................68 Procarbazine hydrochloride ..........126 Prochlorperazine ..........................112 Proctosedyl .....................................13 Procyclidine hydrochloride ..............97 Procytox ........................................123 Prodopa ..........................................41 Progesterone ..................................57 Proglicem ........................................15 Prograf ..........................................133 Prokinex ........................................112 Promethazine hydrochloride .........160 Promethazine theoclate ................112 Propafenone hydrochloride ............38 Propamidine isethionate ...............165 Propofol ..........................................99 Propranolol .....................................40 Propylene glycol ...........................180 Propylthiouracil ...............................63 Prostin E2 .......................................57 Prostin VR ......................................45 Protamine sulphate .........................30 Protionamide ..................................74 Protirelin .........................................63 Provera .....................................61, 62 Provisc ..........................................168 Provive MCT-LCT 1% .....................99 Proxymetacaine hydrochloride ........................... 167 Pseudoephedrine hydrochloride ........................... 161 Psoriasis and Eczema Preparations .............................. 52 PTU ................................................63 Pulmocare (Vanilla) ......................193 Pulmonary Surfactants .................164 Pulmozyme ...................................163 Puri-nethol ....................................125 Pyrazinamide ..................................74 Pyridostigmine bromide ..................88 PyridoxADE ....................................24 Pyridoxal-5-phosphate ....................20 Pyridoxine hydrochloride ................24 Pyrimethamine ...............................76 Pytazen SR .....................................31 -QQ 300 ..............................................76 Quetapel .......................................114 Quetiapine ....................................114 Quinapril .........................................36 Quinapril with hydrochlorothiazide ................... 36 Quinine dihydrochloride ..................76 Quinine sulphate .............................76 -RRA-Morph .....................................103 Rabies vaccine .............................199 Raloxifene .......................................92 Raltegravir potassium .....................80 Ramipex .........................................98 Ranbaxy-Cefaclor ...........................66 Ranibizumab .................................149 Ranitidine ........................................14 Rapamune ....................................158 Rasburicase ....................................94 Reandron 1000 ...............................59 Recombinant factor IX ....................28 Recombinant factor VIIa .................28 Recombinant factor VIII ..................28 Rectogesic ......................................14 Red back spider antivenom ..........171 Redipred .........................................60 Relenza Rotadisk ...........................85 Remicade .....................................144 Remifentanil hydrochloride ...........105 Remifentanil-AFT ..........................105 ReoPro .........................................138 Resource Beneprotein ..................183 Resource Diabetic (Vanilla) ..........187 Respiratory Stimulants .................164 Retinol ............................................23 Retinol Palmitate ..........................170 Retrovir ...........................................79 Revolade ........................................27 Reyataz ..........................................79 Riboflavin 5-phosphate .................168 Ridal .............................................115 Rifabutin .........................................74 Rifampicin .......................................74 Rilutek .............................................97 Riluzole ...........................................97 Ringer’s solution .............................34 Riodine .........................................173 Risedronate Sandoz .......................92 Risedronate sodium ........................92 Risperdal ......................................115 Risperdal Consta ..........................117 Risperdal Quicklet ........................115 Risperidone ..........................115, 117 Risperon .......................................115 Ritalin ............................................120 Ritalin LA ......................................120 Ritalin SR ......................................120 Ritonavir .........................................80 Rituximab ......................................149 Rivaroxaban ....................................30 Rivotril ...........................................107 Rizamelt ........................................111 Rizatriptan benzoate .....................111 Rocuronium bromide ......................94 Ropinirole hydrochloride .................98 Ropivacaine hydrochloride ...........101 Ropivacaine hydrochloride with fentanyl .................................... 101 Rose bengal sodium .....................167

215


INDEX Generic Chemicals and Brands

Roxane ...........................................12 Roxithromycin .................................67 Rubifen .........................................120 Rubifen SR ...................................120 -SS-26 Gold Premgro .......................191 S26 LBW Gold RTF ......................191 Salamol .........................................161 Salazopyrin .....................................13 Salazopyrin EN ...............................13 Salbutamol ....................................161 Salbutamol with ipratropium bromide .................................... 160 Salicylic acid .................................181 Salmeterol ....................................162 Salmonella typhi vaccine ..............198 Sandimmun ..................................133 Sandomigran ................................111 Sandostatin LAR ...........................132 Scalp Preparations .........................52 Sclerosing Agents .........................164 Scopoderm TTS ...........................112 Sebizole ..........................................48 Secretin pentahydrochloride .........176 Sedatives and Hypnotics ..............118 Selegiline hydrochloride .................98 Sennosides .....................................19 Serenace ......................................113 Seretide ........................................163 Seretide Accuhaler .......................163 Serevent .......................................162 Serevent Accuhaler ......................162 Serophene ......................................61 Seroquel .......................................114 Sertraline ......................................107 Sevoflurane .....................................99 Sevredol .......................................104 Silagra ............................................46 Sildenafil .........................................46 Silver nitrate Dermatological ...........................53 Extemporaneous ......................181 Simethicone ....................................12 Simulect ........................................144 Simvastatin .....................................43 Sincalide .......................................176 Sinemet ..........................................98 Sinemet CR ....................................98 Singulair ........................................162 Sirolimus .......................................158 Siterone ..........................................59 Slow-Lopresor ................................39 Snake antivenom ..........................172 Sodibic ............................................35 Sodium acetate ...............................34 Sodium acid phosphate ..................34 Sodium alginate with magnesium alginate ...................................... 12 Sodium alginate with sodium bicarbonate and calcium carbonate ................................... 12 Sodium aurothiomalate ...................88 Sodium benzoate ............................20 Sodium bicarbonate Blood ....................................34–35 Extemporaneous ......................181 Sodium calcium edetate ...............172 Sodium carboxymethylcellulose with pectin and gelatine ............. 22 Sodium chloride Blood ....................................34–35 Respiratory .......................161, 164 Various .....................................177 Sodium chloride with sodium bicarbonate .............................. 161 Sodium citrate Alimentary ..................................12 Extemporaneous ......................181 Sodium citrate with sodium chloride and potassium chloride ...................................... 30 Sodium citrate with sodium lauryl sulphoacetate ............................ 19 Sodium citro-tartrate .......................58 Sodium cromoglycate Alimentary ..................................13 Respiratory .......................159, 163 Sensory ....................................166 Sodium dihydrogen phosphate [Sodium acid phosphate] ........... 34 Sodium fluoride ..............................20 Sodium hyaluronate Alimentary ..................................22 Sensory ............................168, 170 Sodium hyaluronate with chondroitin sulphate ................ 168 Sodium hypochlorite .....................173 Sodium metabisulfite ....................181 Sodium nitrite ...............................171 Sodium nitroprusside Cardiovascular ...........................46 Part III - OPTIONAL PHARMACEUTICALS .........202 Sodium phenylbutyrate ...................20 Sodium phosphate with phosphoric acid ......................... 19 Sodium polystyrene sulphonate ................................. 35 Sodium stibogluconate ...................76 Sodium tetradecyl sulphate ............27 Sodium thiosulfate ........................171 Sodium valproate ..........................110 Sodium with potassium .................178 Solian ............................................113 Solifenacin succinate ......................58 Solox ...............................................14 Solu-Cortef .....................................60 Solu-Medrol ....................................60 Somatropin .....................................63 Sotacor ...........................................40 Sotalol .............................................40 Soya oil .........................................171 Space Chamber Plus ....................202 Spacer device ...............................202 Span-K ............................................35 Specialised Formulas ...................186 Spiractin ..........................................42 Spiramycin ......................................76 Spiriva ...........................................160 Spironolactone ................................42 Spirotone ........................................42 Sprycel .........................................127 Standard Feeds ............................194 Staphlex ..........................................68 Starch ...........................................181 Stavudine ........................................79 Sterculia with frangula ....................18 Stesolid .........................................107 Stimulants / ADHD Treatments ............................... 119 Stiripentol .....................................110 Stocrin ............................................77 Strattera ........................................119 Streptomycin sulphate ....................65 Stromectol ......................................75 Suboxone .....................................121 Sucralfate .......................................15 Sucrose ........................................102 Sugammadex .................................95 Sulindac ..........................................96 Sulphacetamide sodium ...............165 Sulphadiazine .................................70 Sulphadiazine silver ........................48 Sulphasalazine ...............................13 Sulphur .........................................181 Sumatriptan ..................................111 Sunitinib ........................................130 Sunscreen, proprietary ...................53 Suprane ..........................................98

216


INDEX Generic Chemicals and Brands

Surgam ...........................................96 Surgical Preparations ...................177 Survanta .......................................164 Sustagen Diabetic (Vanilla) ..........187 Sustagen Hospital Formula (Chocolate) .............................. 195 Sustagen Hospital Formula (Vanilla) .................................... 195 Sutent ...........................................130 Suxamethonium chloride ................94 Symmetrel ......................................97 Sympathomimetics .........................44 Synacthen .......................................62 Synacthen Depot ............................62 Syntometrine ..................................57 Syrup ............................................181 Systane Unit Dose ........................170 -TTacrolimus ....................................133 Talc ...............................................164 Tambocor ........................................38 Tambocor CR ..................................38 Tamoxifen citrate ...........................133 Tamsulosin ......................................58 Tamsulosin-Rex ..............................58 Tarceva .........................................128 Tasmar ............................................98 Tazocin EF ......................................68 Teicoplanin ......................................71 Temaccord ....................................126 Temazepam ..................................118 Temozolomide ..............................126 Tenecteplase ..................................32 Tenofovir disoproxil fumarate ..........82 Tenoxicam ......................................96 Terazosin ........................................37 Terbinafine ......................................73 Terbutaline ......................................57 Terbutaline sulphate .....................161 Teriparatide .....................................93 Terlipressin .....................................64 Testosterone ...................................59 Testosterone cypionate ...................59 Testosterone esters ........................59 Testosterone undecanoate .............59 Tetrabenazine .................................97 Tetracaine [Amethocaine] hydrochloride Nervous ....................................101 Sensory ....................................167 Tetracosactide [Tetracosactrin] .......................... 62 Tetracosactrin .................................62 Tetracyclin Wolff .............................69 Tetracycline .....................................69 Thalidomide ..................................127 Thalomid .......................................127 Theophylline .................................163 Thiamine hydrochloride ..................24 Thioguanine ..................................125 Thiopental [Thiopentone] sodium ....................................... 99 Thiopentone ....................................99 Thiotepa ........................................123 Thrombin ........................................27 Thymol glycerin ..............................22 Thyroid and Antithyroid Preparations .............................. 63 Thyrotropin alfa ...............................62 Tiaprofenic acid ..............................96 Ticagrelor ........................................31 Ticarcillin with clavulanic acid .........68 Ticlopidine ......................................31 Tigecycline ......................................69 Timolol ..........................................168 Timolol maleate ..............................40 Timoptol XE ..................................168 Tiotropium bromide .......................160 TMP ................................................71 Tobramycin Infection ......................................65 Sensory ....................................165 Tobrex ...........................................165 Tocilizumab ...................................156 Tofranil ..........................................105 Tolcapone .......................................98 Tolterodine tartrate .........................58 Topamax .......................................110 Topical Products for Joint and Muscular Pain ............................ 96 Topiramate ....................................110 Tracleer ...........................................46 Tracrium ..........................................94 Tramadol hydrochloride ................105 Tramal 100 ....................................105 Tramal 50 ......................................105 Tramal SR 100 ..............................105 Tramal SR 150 ..............................105 Tramal SR 200 ..............................105 Trandolapril .....................................36 Tranexamic acid ..............................28 Tranylcypromine sulphate .............106 Trastuzumab .................................156 Travoprost .....................................169 Treatments for Dementia ..............121 Treatments for Substance Dependence ............................ 121 Tretinoin Dermatological ...........................49 Oncology ..................................127 Tri-sodium citrate ..........................181 Triamcinolone acetonide Alimentary ..................................22 Dermatological ...........................51 Hormone ....................................60 Triamcinolone acetonide with gramicidin, neomycin and nystatin .................................... 166 Triamcinolone acetonide with neomycin sulphate, gramicidin and nystatin ............................... 52 Triamcinolone hexacetonide ...........60 Triazolam ......................................118 Trichloracetic acid .........................181 Trichozole .......................................75 Trientine dihydrochloride .................20 Trifluoperazine hydrochloride ........................... 115 Trimeprazine tartrate ....................160 Trimethoprim ...................................71 Trimethoprim with sulphamethoxazole [Co-trimoxazole] ........................ 71 Trisodium citrate .............................30 Trometamol ...................................177 Tropicamide ..................................169 Tropisetron ....................................112 Tropisetron-AFT ............................112 Truvada ...........................................78 Tuberculin, purified protein derivative ................................. 176 Two Cal HN ...................................188 TwoCal HN RTH (Vanilla) .............188 Tykerb ...........................................128 -UUltraproct ........................................13 Univent .........................................160 Ural .................................................58 Urea Dermatological ...........................50 Extemporaneous ......................181 Urex Forte .......................................41 Urokinase .......................................32 Urologicals ......................................57 Uromitexan ...................................131 Ursodeoxycholic acid ......................17 Ursosan ..........................................17 Utrogestan ......................................57

217


INDEX Generic Chemicals and Brands

-VValaciclovir ......................................84 Valcyte ............................................84 Valganciclovir ..................................84 Valtrex .............................................84 Vancomycin ....................................71 Varenicline ....................................122 Varicella zoster vaccine [Chicken pox vaccine] ............................. 199 Vasodilators ....................................45 Vasopressin ....................................64 Vasopressin Agents ........................64 Vecuronium bromide .......................94 Velcade .........................................125 Venlafaxine ...................................106 Venofer ...........................................21 Ventavis ..........................................47 Ventolin .........................................161 Vepesid .........................................126 Verapamil hydrochloride .................41 Vergo 16 .......................................111 Verpamil SR ...................................41 Vesanoid .......................................127 Vesicare ..........................................58 Vfend ..............................................72 Victrelis ...........................................83 Vigabatrin .....................................110 Vimpat ..........................................109 Vinblastine sulphate .....................131 Vincristine sulphate ......................132 Vinorelbine ....................................132 Viral Vaccines ...............................198 Viramune Suspension ....................77 Viread .............................................82 Visipaque ......................................173 Vistil ..............................................170 Vistil Forte ....................................170 VitA-POS ......................................170 Vital HN ........................................188 Vitamin A with vitamins D and C ................................................ 23 Vitamin B complex ..........................24 Vitamins ..........................................23 Vivonex Paediatric ........................190 Vivonex TEN .................................187 Volibris ............................................46 Voltaren ..........................................95 Voltaren Ophtha ............................166 Volulyte 6% .....................................35 Volumatic ......................................202 Voluven ...........................................35 Voriconazole ...................................72 Votrient .........................................129 -WWarfarin sodium ..............................31 Wart Preparations ...........................53 Water Blood ..........................................35 Various .....................................177 Wool fat Dermatological ...........................50 Extemporaneous ......................181 -XXanthan ........................................181 Xarelto ............................................30 Xeloda ..........................................124 Xylocaine ..............................100, 101 Xylocaine Viscous ........................100 Xylometazoline hydrochloride ........................... 161 Xyntha ............................................28 -YYellow jacket wasp venom ............159 -ZZanamivir ........................................85 Zantac .............................................14 Zapril ..............................................36 Zarator ............................................43 Zarzio ..............................................32 Zavedos ........................................124 Zeldox ...........................................115 Zetlam .............................................81 Zetop ............................................159 Ziagen .............................................78 Zidovudine [AZT] ............................79 Zidovudine [AZT] with lamivudine ................................. 79 Zinc Alimentary ..................................21 Dermatological ...........................49 Zinc and castor oil ..........................49 Zinc chloride ...................................21 Zinc oxide .....................................181 Zinc sulphate ..................................21 Zinc with wool fat ............................50 Zincaps ...........................................21 Zinnat ..............................................66 Ziprasidone ...................................115 Zithromax ........................................66 Zofran Zydis ..................................112 Zoladex ...........................................62 Zoledronic acid Hormone ....................................59 Musculoskeletal System .............90 Zometa ...........................................59 Zopiclone ......................................118 Zostrix .............................................96 Zostrix HP .....................................102 Zovirax IV .......................................84 Zuclopenthixol acetate ..................116 Zuclopenthixol decanoate .............117 Zuclopenthixol hydrochloride ........................... 116 Zyban ............................................121 Zypine ...........................................114 Zypine ODT ..................................114 Zyprexa Relprevv ..........................116

218


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Hospital Medicines List queries: Freephone Information line 0800 66 00 50 Fax: 64 4 974 7819 Email: HML@pharmac.govt.nz

Pharmaceutical Management Agency Level 9, 40 Mercer Street, PO Box 10-254, Wellington 6143, New Zealand Phone: 64 4 460 4990 - Fax: 64 4 460 4995 - www.pharmac.govt.nz Freephone Information line (9am-5pm weekdays) 0800 66 00 50

ISSN 1172-3694 (Print) - ISSN 1179-3708 (Online) While care has been taken in compiling this Update, Pharmaceutical Management Agency takes no responsibility for any errors or omissions and shall not be liable to any person for any damages or loss arising out of reliance by that person for any purpose on any of the contents of this Update. Errors and omissions brought to the attention of Pharmaceutical Management Agency will be corrected if necessary by an erratum or otherwise in the next edition of the Update.

If Undelivered, Return To: PO Box 10-254, Wellington 6143, New Zealand

Metadata

Title

Hospital Medicines List - effective 1 March 2014

Abstract

Section H for Hospital Pharmaceuticals Effective 1 March 2014 New Zealand Pharmaceutical Schedule Including the Hospital Medicines List (HML) Introducing PHARMAC 2 4 March 2014 Volume 2 Number 0 Editors: Kaye Wilson, Donna Jennings & Sarah Le Leu email: schedule@pharmac.govt.nz…

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