HML restriction checklists - December 2021


Use these checklists to determine if a patient meets the restrictions for funding in the hospital setting. The forms are a tool to support DHB hospital pharmacies to manage and document compliance with the restrictions in the HML as needed. DHB hospital pharmacies may choose to use some, all, or none of the forms in meeting obligations to act consistently with the HML.


Note: Forms should not be submitted to Pharmac or to Sector Services.


All forms

Download all restriction checklist forms.

Individual restriction checklist forms

(Sort by: Therapeutic Group / Chemical Name)
Alimentary Tract and Metabolism
RS1793 - Alglucosidase Alfa (1 page, 27 KB)
RS1632 - Alpha tocopheryl (1 page, 26 KB)
RS1176 - Alpha tocopheryl acetate (1 page, 26 KB)
RS1794 - Betaine (1 page, 26 KB)
RS1330 - Biotin (1 page, 24 KB)
RS1723 - Budesonide (2 pages, 32 KB)
RS1698 - Calcium carbonate (1 page, 24 KB)
RS1831 - Carglumic Acid (1 page, 24 KB)
RS1832 - Coenzyme Q10 (1 page, 26 KB)
RS1028 - Diazoxide (1 page, 24 KB)
RS1852 - Empagliflozin; Empagliflozin with metformin hydrochloride (1 page, 28 KB)
RS1417 - Ferric carboxymaltose (1 page, 24 KB)
RS1857 - GLP-1 Agonists (1 page, 27 KB)
RS1795 - Galsulfase (1 page, 26 KB)
RS1546 - Idursulfase (1 page, 26 KB)
RS1034 - Imiglucerase (1 page, 24 KB)
RS1261 - L-ornithine L-aspartate (1 page, 24 KB)
RS1607 - Laronidase (1 page, 26 KB)
RS1035 - Levocarnitine (1 page, 24 KB)
RS1601 - Methylnaltrexone bromide (1 page, 25 KB)
RS1498 - Multivitamin and mineral supplement (1 page, 25 KB)
RS1499 - Multivitamin renal (1 page, 25 KB)
RS1620 - Multivitamins - Cap (1 page, 24 KB)
RS1178 - Multivitamins - Powder (1 page, 24 KB)
RS1027 - Omeprazole - Tab dispersible 20 mg (1 page, 24 KB)
RS1331 - Pyridoxal-5-phosphate (1 page, 24 KB)
RS1703 - Ranitidine (1 page, 24 KB)
RS1833 - Riboflavin (1 page, 26 KB)
RS1416 - Rifaximin (1 page, 24 KB)
RS1796 - Sapropterin dihydrochloride (1 page, 27 KB)
RS1175 - Sodium hyaluronate (1 page, 24 KB)
RS1797 - Sodium phenylbutyrate (1 page, 25 KB)
RS1834 - Taurine (1 page, 25 KB)
RS1824 - Ursodeoxycholic acid (2 pages, 32 KB)
RS1843 - sodium picosulfate (1 page, 25 KB)
Blood and Blood Forming Organs
RS1500 - Aluminium chloride (1 page, 24 KB)
RS1332 - Aprotinin (1 page, 25 KB)
RS1181 - Bivalirudin (1 page, 24 KB)
RS1182 - Danaparoid (1 page, 24 KB)
RS1183 - Defibrotide (1 page, 25 KB)
RS1684 - Eftrenonacog alfa (1 page, 25 KB)
RS1648 - Eltrombopag (2 pages, 33 KB)
RS1780 - Emicizumab (1 page, 27 KB)
RS1660 - Epoetin alfa (1 page, 28 KB)
RS1661 - Epoetin beta (1 page, 28 KB)
RS1704 - Eptacog alfa (1 page, 25 KB)
RS1759 - Eptifibatide (1 page, 24 KB)
RS1705 - Factor eight inhibitor bypassing fraction (1 page, 25 KB)
RS1188 - Filgrastim (1 page, 24 KB)
RS1184 - Fondaparinux sodium (1 page, 24 KB)
RS1535 - Idarucizumab (1 page, 24 KB)
RS1689 - Lysine acetylsalicylate (1 page, 25 KB)
RS1706 - Moroctocog alfa [Recombinant factor VIII] (1 page, 25 KB)
RS1679 - Nonacog gamma (1 page, 24 KB)
RS1707 - Octocog alfa [Recombinant factor VIII] (Advate) (1 page, 25 KB)
RS1708 - Octocog alfa [Recombinant factor VIII] (Kogenate FS) (1 page, 25 KB)
RS1743 - Pegfilgrastim (1 page, 25 KB)
RS1536 - Plerixafor (1 page, 27 KB)
RS1682 - Rurioctocog alfa pegol [Recombinant factor VIII] (1 page, 25 KB)
RS1297 - Sodium chloride - Inj (1 page, 24 KB)
RS1774 - Ticagrelor (2 pages, 31 KB)
Cardiovascular System
RS1266 - Adenosine - Inj 3 mg per ml, 10 ml vial (1 page, 25 KB)
RS1001 - Ajmaline (1 page, 24 KB)
RS1621 - Ambrisentan (1 page, 24 KB)
RS1622 - Bosentan (2 pages, 32 KB)
RS1263 - Captopril - Oral liq 5 mg per ml (1 page, 24 KB)
RS1640 - Eplerenone (1 page, 25 KB)
RS1624 - Epoprostenol (1 page, 24 KB)
RS1005 - Ezetimibe (1 page, 25 KB)
RS1006 - Ezetimibe with simvastatin (1 page, 25 KB)
RS1008 - Hydralazine hydrochloride - Tab 25 mg (1 page, 25 KB)
RS1625 - Iloprost - Nebuliser soln 10 mcg per ml, 2 ml (1 page, 25 KB)
RS1566 - Ivabradine (1 page, 25 KB)
RS1007 - Levosimendan (1 page, 25 KB)
RS1427 - Midodrine (1 page, 24 KB)
RS1699 - Nicardipine hydrochloride (1 page, 25 KB)
RS1868 - Rosuvastatin (1 page, 27 KB)
RS1738 - Sacubitril with valsartan (1 page, 26 KB)
RS1798 - Sildenafil (2 pages, 33 KB)
Dermatologicals
RS1125 - Betamethasone valerate with clioquinol (1 page, 24 KB)
RS1299 - Mafenide acetate (1 page, 24 KB)
RS1127 - Methyl aminolevulinate hydrochloride (1 page, 24 KB)
RS1781 - Pimecrolimus (1 page, 25 KB)
RS1859 - Tacrolimus Ointment (1 page, 25 KB)
Genito-Urinary System
RS1131 - Finasteride (1 page, 24 KB)
RS1133 - Potassium citrate (1 page, 24 KB)
RS1533 - Progesterone (1 page, 26 KB)
RS1132 - Tamsulosin (1 page, 24 KB)
RS1130 - Terbutaline (1 page, 24 KB)
Hormone Preparations
RS1855 - Cabergoline (1 page, 24 KB)
RS1540 - Cinacalcet (1 page, 26 KB)
RS1301 - Liothyronine sodium - Tab 20 mcg (1 page, 24 KB)
RS1302 - Oxandroline - Tab 2.5 mg (1 page, 24 KB)
RS1276 - Propylthiouracil (1 page, 25 KB)
RS1826 - Somatropin (7 pages, 55 KB)
RS1825 - Zoledronic acid Inj 4 mg per 5 ml, vial (1 page, 26 KB)
Infections
RS1088 - Albendazole (1 page, 24 KB)
RS1041 - Amikacin (1 page, 24 KB)
RS1071 - Amphotericin B - Inj (liposomal) 50 mg vial (1 page, 25 KB)
RS1316 - Amphotericin B - Inj 50 mg vial (1 page, 25 KB)
RS1090 - Artemether with lumefantrine (1 page, 24 KB)
RS1091 - Artesunate (1 page, 24 KB)
RS1092 - Atovaquone with proguanil hydrochloride (1 page, 25 KB)
RS1598 - Azithromycin (2 pages, 32 KB)
RS1277 - Aztreonam, Chloramphenicol (1 page, 24 KB)
RS1076 - Caspofungin (1 page, 25 KB)
RS1049 - Cefepime (1 page, 24 KB)
RS1446 - Ceftaroline (1 page, 25 KB)
RS1048 - Ceftazadime (1 page, 24 KB)
RS1093 - Chloroquine phosphate (1 page, 24 KB)
RS1108 - Cidofovir (1 page, 24 KB)
RS1055 - Ciprofloxacin (1 page, 24 KB)
RS1709 - Clarithromycin (1 page, 26 KB)
RS1061 - Clindamycin (1 page, 24 KB)
RS1077 - Clofazimine (1 page, 24 KB)
RS1062 - Colistin sulphomethate [Colestimethate] (1 page, 24 KB)
RS1079 - Cycloserine (1 page, 24 KB)
RS1078 - Dapsone (1 page, 24 KB)
RS1063 - Daptomycin (1 page, 24 KB)
RS1800 - Emtricitabine with tenofovir disoproxil (3 pages, 36 KB)
RS1045 - Ertapenem (1 page, 24 KB)
RS1080 - Ethambutol hydrochloride (1 page, 24 KB)
RS1072 - Fluconazole (1 page, 24 KB)
RS1279 - Flucytosine (1 page, 24 KB)
RS1109 - Foscarnet sodium (1 page, 24 KB)
RS1315 - Fosfomycin (1 page, 24 KB)
RS1064 - Fusidic acid (1 page, 24 KB)
RS1110 - Ganciclovir (1 page, 24 KB)
RS1046 - Imipenem with cilastatin (1 page, 24 KB)
RS1113 - Interferon gamma (1 page, 24 KB)
RS1281 - Isoniazid (1 page, 24 KB)
RS1282 - Isoniazid with rifampicin (1 page, 25 KB)
RS1073 - Itraconazole (1 page, 24 KB)
RS1283 - Ivermectin (1 page, 24 KB)
RS1410 - Ketoconazole - Tab 200 mg (1 page, 24 KB)
RS1528 - Ledipasvir with sofosbuvir (1 page, 13 KB)
RS1065 - Lincomycin (1 page, 24 KB)
RS1066 - Linezolid (1 page, 24 KB)
RS1094 - Mefloquine hydrochloride (1 page, 24 KB)
RS1047 - Meropenem (1 page, 24 KB)
RS1644 - Moxifloxacin (1 page, 28 KB)
RS1095 - Nitazoxanide (1 page, 24 KB)
RS1571 - Non-Nucleoside Reverse Transcriptase Inhibitors (1 page, 26 KB)
RS1572 - Nucleoside Reverse Transcriptase Inhibitors (1 page, 26 KB)
RS1307 - Oseltamivir (1 page, 24 KB)
RS1083 - Para-aminosalicylic Acid (1 page, 25 KB)
RS1603 - Paromomycin (1 page, 24 KB)
RS1827 - Pegylated interferon alfa-2a (5 pages, 43 KB)
RS1096 - Pentamidine isethionate (1 page, 24 KB)
RS1053 - Piperacillin with tazobactam (1 page, 24 KB)
RS1322 - Pivmecillinam (1 page, 24 KB)
RS1074 - Posaconazole (1 page, 26 KB)
RS1097 - Primaquine phosphate (1 page, 24 KB)
RS1573 - Protease Inhibitors (1 page, 26 KB)
RS1084 - Protionamide (1 page, 24 KB)
RS1085 - Pyrazinamide (1 page, 24 KB)
RS1098 - Pyrimethamine (1 page, 24 KB)
RS1099 - Quinine dihydrochloride (1 page, 24 KB)
RS1086 - Rifabutin (1 page, 24 KB)
RS1087 - Rifampicin (1 page, 24 KB)
RS1569 - Roxithromycin tab dispersible 50 mg (1 page, 24 KB)
RS1100 - Sodium stibogluconate (1 page, 24 KB)
RS1101 - Spiramycin (1 page, 24 KB)
RS1574 - Strand Transfer Inhibitors (1 page, 26 KB)
RS1043 - Streptomycin sulphate (1 page, 24 KB)
RS1067 - Sulphadiazine (1 page, 24 KB)
RS1068 - Teicoplanin (1 page, 24 KB)
RS1054 - Ticarcillin with clavulanic acid (1 page, 24 KB)
RS1059 - Tigecycline (1 page, 24 KB)
RS1475 - Tobramcyin (1 page, 24 KB)
RS1044 - Tobramycin (1 page, 24 KB)
RS1435 - Tobramycin Solution for inhalation 60 mg per ml, 5 ml (1 page, 24 KB)
RS1799 - Valganciclovir (1 page, 27 KB)
RS1069 - Vancomycin (1 page, 24 KB)
RS1075 - Voriconazole (1 page, 26 KB)
RS1369 - Zanamivir - Powder for inhalation 5 mg (1 page, 25 KB)
Musculoskeletal System
RS1309 - Capsaicin (1 page, 24 KB)
RS1665 - Densosumab (1 page, 30 KB)
RS1015 - Edrophonium chloride (1 page, 24 KB)
RS1592 - Etoricoxib (1 page, 24 KB)
RS1844 - Febuxostat (1 page, 28 KB)
RS1776 - Hydroxychloroquine (1 page, 25 KB)
RS1666 - Raloxifene (1 page, 28 KB)
RS1016 - Rasburicase (1 page, 24 KB)
RS1370 - Sugammadex (1 page, 25 KB)
RS1143 - Teriparatide (1 page, 27 KB)
RS1663 - Zoledronic acid Inj 5 mg per 100 ml, vial (3 pages, 38 KB)
Nervous System
RS1154 - Aprepitant (1 page, 24 KB)
RS1172 - Buprenorphine with naloxone (1 page, 25 KB)
RS1145 - Capsaicin (1 page, 24 KB)
RS1169 - Dexamphetamine sulphate (1 page, 26 KB)
RS1155 - Hyoscine hydrobromide - Patch 1.5 mg (1 page, 25 KB)
RS1151 - Lacosamide (1 page, 26 KB)
RS1576 - Melatonin (1 page, 27 KB)
RS1292 - Methoxyflurane (1 page, 24 KB)
RS1294 - Methylphenidate hydrochloride (1 page, 27 KB)
RS1803 - Modafinil (1 page, 26 KB)
RS1842 - Multiple Sclerosis (2 pages, 32 KB)
RS1173 - Naltrexone hydrochloride (1 page, 25 KB)
RS1310 - Nicotine (1 page, 24 KB)
RS1379 - Olanzapine (1 page, 26 KB)
RS1381 - Paliperidone (1 page, 25 KB)
RS1146 - Paracetamol (1 page, 24 KB)
RS1351 - Riluzole (1 page, 26 KB)
RS1380 - Risperidone (1 page, 26 KB)
RS1436 - Rivastigmine (1 page, 25 KB)
RS1152 - Stiripentol (1 page, 25 KB)
RS1763 - Sucrose (1 page, 24 KB)
RS1702 - Varenicline (1 page, 26 KB)
RS1865 - Vigabatrin (1 page, 27 KB)
Oncology Agents and Immunosuppressants
RS1202 - Abciximab (1 page, 24 KB)
RS1807 - Abiraterone acetate (1 page, 26 KB)
RS1838 - Adalimumab (15 pages, 92 KB)
RS1659 - Aflibercept (2 pages, 33 KB)
RS1712 - Alectinib (1 page, 25 KB)
RS1565 - Aminolevulinic acid hydrochloride (1 page, 25 KB)
RS1418 - Azacitidine (1 page, 27 KB)
RS1206 - Bacillus calmette-guerin (BCG) (1 page, 24 KB)
RS1203 - Basiliximab (1 page, 24 KB)
RS1835 - Bendamustine hydrochloride (2 pages, 33 KB)
RS1691 - Bevacizumab (1 page, 26 KB)
RS1725 - Bortezomib (1 page, 24 KB)
RS1613 - Cetuximab (1 page, 25 KB)
RS1685 - Dasatinib (1 page, 27 KB)
RS1695 - Dexrazoxane (1 page, 26 KB)
RS1804 - Erlotinib (1 page, 26 KB)
RS1837 - Etanercept (11 pages, 73 KB)
RS1811 - Everolimus (1 page, 26 KB)
RS1732 - Fulvestrant (1 page, 26 KB)
RS1805 - Gefitinib (1 page, 26 KB)
RS1402 - Imatinib mesilate - Tab 100 mg (1 page, 26 KB)
RS1862 - Infliximab (13 pages, 80 KB)
RS1828 - Lapatinib (1 page, 25 KB)
RS1836 - Lenalidomide (2 pages, 32 KB)
RS1733 - Mepolizumab (1 page, 28 KB)
RS1635 - Mercaptopurine (1 page, 25 KB)
RS1437 - Nilotinib (1 page, 26 KB)
RS1809 - Nivolumab (2 pages, 36 KB)
RS1550 - Obinutuzumab (1 page, 27 KB)
RS1856 - Octreotide (2 pages, 33 KB)
RS1722 - Olaparib (1 page, 27 KB)
RS1652 - Omalizumab (2 pages, 34 KB)
RS1731 - Palbociclib (Ibrance) (1 page, 27 KB)
RS1198 - Pazopanib (1 page, 27 KB)
RS1788 - Pegaspargase (1 page, 25 KB)
RS1810 - Pembrolizumab (2 pages, 36 KB)
RS1596 - Pemetrexed (1 page, 27 KB)
RS1551 - Pertuzumab (1 page, 26 KB)
RS1637 - Ranibizumab (1 page, 27 KB)
RS1785 - Rituximab (Mabthera) (3 pages, 37 KB)
RS1864 - Rituximab (Riximyo) (16 pages, 96 KB)
RS1726 - Ruxolitinib (1 page, 26 KB)
RS1863 - Secukinumab (4 pages, 42 KB)
RS1525 - Siltuximab (1 page, 26 KB)
RS1812 - Sirolimus (3 pages, 39 KB)
RS1806 - Sunitinib (2 pages, 34 KB)
RS1651 - Tacrolimus (1 page, 25 KB)
RS1645 - Temozolomide (2 pages, 32 KB)
RS1192 - Thalidomide (1 page, 25 KB)
RS1860 - Tocilizumab (7 pages, 54 KB)
RS1554 - Trastuzumab (2 pages, 33 KB)
RS1715 - Trastuzumab emtansine (1 page, 26 KB)
RS1861 - Upadacitinib (1 page, 28 KB)
RS1713 - Venetoclax (1 page, 28 KB)
Respiratory System and Allergies
RS1117 - Bee venom (1 page, 24 KB)
RS1787 - Dornase alfa (1 page, 27 KB)
RS1501 - Icatibant (1 page, 25 KB)
RS1818 - Ivacaftor (1 page, 27 KB)
RS1518 - Long-acting muscarinic antagonists with long-acting beta-adrenoceptor agonists (1 page, 25 KB)
RS1813 - Nintedanib (1 page, 27 KB)
RS1118 - Paper wasp venom (1 page, 24 KB)
RS1814 - Pirfenidone (1 page, 27 KB)
RS1119 - Yellow jacket wasp venom (1 page, 24 KB)
Sensory Organs
RS1606 - Dexamethasone (2 pages, 32 KB)
Various
RS1683 - Chlorhexidine with cetrimide (1 page, 26 KB)
RS1444 - Deferasirox (1 page, 27 KB)
RS1445 - Deferiprone (1 page, 24 KB)
RS1354 - Povidone-iodine - Vaginal tab 200 mg (1 page, 24 KB)
Special Foods
RS1867 - Amino acid formula (1 page, 27 KB)
RS1467 - Carbohydrate (1 page, 26 KB)
RS1212 - Carbohydrate and fat supplement (1 page, 25 KB)
RS1215 - Diabetic Products (1 page, 25 KB)
RS1216 - Elemental and Semi-Elemental Products (1 page, 25 KB)
RS1775 - Enteral liquid peptide formula (1 page, 26 KB)
RS1502 - Extensively hydrolysed formula (1 page, 26 KB)
RS1468 - Fat (1 page, 26 KB)
RS1470 - Fat-modified feed (1 page, 25 KB)
RS1217 - Hepatic Products (1 page, 24 KB)
RS1317 - High Calorie Products (1 page, 25 KB)
RS1231 - High arginine oral feed 1.4 kcal/ml (1 page, 24 KB)
RS1225 - High fat formula (1 page, 24 KB)
RS1327 - High protein enteral feed (1 page, 25 KB)
RS1229 - Low electrolyte enteral feed 1.8 kcal/ml (1 page, 24 KB)
RS1227 - Low electrolyte oral feed (1 page, 24 KB)
RS1228 - Low electrolyte oral feed (1 page, 24 KB)
RS1232 - Metabolic Products (1 page, 25 KB)
RS1473 - Paediatric Products (1 page, 25 KB)
RS1614 - Paediatric oral/enteral feed 1 kcal/ml (1 page, 26 KB)
RS1415 - Preoperative carbohydrate feed 0.5 kcal/ml (1 page, 25 KB)
RS1224 - Preterm formula (1 page, 24 KB)
RS1469 - Protein (1 page, 25 KB)
RS1214 - Standard Feeds (1 page, 26 KB)
Vaccines
RS1233 - Bacillus calmette-guerin vaccine (1 page, 26 KB)
RS1790 - Diphtheria, tetanus and pertussis vaccine (1 page, 26 KB)
RS1387 - Diphtheria, tetanus, pertussis and polio vaccine (1 page, 25 KB)
RS1478 - Diphtheria, tetanus, pertussis, polio, hepatitis B and haemophilus influenzae type B vaccine (1 page, 26 KB)
RS1520 - Haemophilus influenzae type B vaccine (1 page, 25 KB)
RS1638 - Hepatitis A vaccine (1 page, 24 KB)
RS1588 - Hepatitis B recombinant vaccine (1 page, 25 KB)
RS1671 - Hepatitis B recombinant vaccine (1 page, 26 KB)
RS1693 - Human papillomavirus (6, 11, 16, 18, 31, 33, 45, 52 and 58) vaccine [HPV] (1 page, 27 KB)
RS1819 - Influenza vaccine Inj 60 mcg in 0.5 ml syringe (adjuvanted quadrivalent vaccine) (1 page, 25 KB)
RS1675 - Influenza vaccine Inj 60 mcg in 0.5 ml syringe (paediatric quadrivalent vaccine) (2 pages, 31 KB)
RS1829 - Influenza vaccine Inj 60 mcg in 0.5 ml syringe (paediatric quadrivalent vaccine) (2 pages, 32 KB)
RS1830 - Influenza vaccine Inj 60 mcg in 0.5 ml syringe (quadrivalent vaccine) (2 pages, 32 KB)
RS1487 - Measles, mumps and rubella vaccine (1 page, 26 KB)
RS1848 - Meningococcal (A, C, Y and W-135) conjugate vaccine (1 page, 27 KB)
RS1851 - Meningococcal B multicomponent vaccine (1 page, 26 KB)
RS1849 - Meningococcal C conjugate vaccine (1 page, 26 KB)
RS1768 - Pneumococcal (PCV10) conjugate vaccine (1 page, 25 KB)
RS1769 - Pneumococcal (PCV13) conjugate vaccine (2 pages, 32 KB)
RS1587 - Pneumococcal (PPV23) polysaccharide vaccine (1 page, 28 KB)
RS1398 - Poliomyelitis vaccine (1 page, 25 KB)
RS1590 - Rotavirus oral vaccine (1 page, 25 KB)
RS1243 - Salmonella typhi vaccine (1 page, 24 KB)
RS1591 - Varicella vaccine [Chickenpox vaccine] (1 page, 27 KB)
RS1777 - Varicella vaccine [Chickenpox vaccine] (1 page, 27 KB)
RS1779 - Varicella zoster vaccine [shingles vaccine] (1 page, 26 KB)