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