Hospital Medicines List New Zealand December 2015 3 3 2015-12-01
Preferred Medicines List Alimentary Tract and Metabolism Antacids and Antiflatulents Antacids and Reflux Barrier Agents Aluminium hydroxide with magnesium hydroxide and simethicone Oral liq 200 mg with magnesium hydroxide 200 mg and simethicone 20 mg per 5 ml e.g. Mylanta 0 Tab 200 mg with magnesium hydroxide 200 mg and simethicone 20 mg e.g. Mylanta 0 Oral liq 400 mg with magnesium hydroxide 400 mg and simethicone 30 mg per 5 ml e.g. Mylanta Double Strength 0 Simethicone Oral drops 100 mg per ml Any 0 Sodium alginate with magnesium alginate Powder for oral soln 225 mg with magnesium alginate 87.5 mg, sachet e.g. Gaviscon Infant 0 Sodium citrate Oral liq 8.8% (300 mmol/l) Any 0 Sodium alginate with sodium bicarbonate and calcium carbonate Tab 500 mg with sodium bicarbonate 267 mg and calcium carbonate 160 mg e.g. Gaviscon Double Strength 0 Oral liq 500 mg with sodium bicarbonate 267 mg and calcium carbonate 160 mg per 10 ml Acidex 500 4.95 Phosphate Binding Agents Aluminium hydroxide Tab 600 mg Any 0 Calcium carbonate Oral liq 250 mg per ml (100 mg elemental per ml) Roxane 500 39.00

Only for use in children under 12 years of age for use as a phosphate binding agent

 Antidiarrhoeals and Intestinal Anti-Inflammatory Agents Antipropulsives Diphenoxylate hydrochloride with atropine sulphate Tab 2.5 mg with atropine sulphate 25 mcg Any 0 Loperamide hydrochloride Tab 2 mg Any 0 Cap 2 mg Diamide Relief 400 7.84 Rectal and Colonic Anti-Inflammatories Olsalazine Cap 250 mg Any 0 Tab 500 mg Any 0 Sodium cromoglycate Cap 100 mg Any 0 Budesonide Cap 3 mg Any 0

Crohn's disease

Both:

  1. Mild to moderate ileal, ileocaecal or proximal Crohn's disease; and

  2. Any of the following:

    1. Diabetes; or

    2. Cushingoid habitus; or

    3. Osteoporosis where there is significant risk of fracture; or

    4. Severe acne following treatment with conventional corticosteroid therapy; or

    5. History of severe psychiatric problems associated with corticosteroid treatment; or

    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

    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

 Mesalazine Enema 1 g per 100 ml Pentasa 7 41.30 Suppos 500 mg Asacol 20 22.80 Suppos 1 g Pentasa 30 54.60 Tab EC 400 mg Asacol 100 49.50 Tab long-acting 500 mg Pentasa 100 59.05 Tab EC 500 mg Asamax 100 49.50 Modified release granules 1 g Pentasa 120 141.72 Hydrocortisone acetate Rectal foam 10%, CFC free (14 applications) Colifoam 21.10 26.55 Sulphasalazine Tab 500 mg Salazopyrin 100 11.68 Tab EC 500 mg Salazopyrin EN 100 12.89 Local Preparations for Anal and Rectal Disorders Antihaemorrhoidal Preparations Fluocortolone caproate with fluocortolone pivalate and cinchocaine Oint 950 mcg with fluocortolone pivalate 920 mcg and cinchocaine hydrochloride 5 mg per g Ultraproct 30 6.35 Suppos 630 mcg with fluocortolone pivalate 610 mcg and cinchocaine hydrochloride 1 mg Ultraproct 12 2.66 Cinchocaine hydrochloride with hydrocortisone Oint 5 mg with hydrocortisone 5 mg per g Proctosedyl 30 15.00 Suppos 5 mg with hydrocortisone 5 mg per g Proctosedyl 12 9.90 Management of Anal Fissures Glyceryl trinitrate Oint 0.2% Rectogesic 30 22.00 Rectal Sclerosants Oily phenol [Phenol oily] Inj 5%, 5 ml vial Any 0 Antispasmodics and Other Agents Altering Gut Motility Antispasmodics and Other Agents Altering Gut Motility Hyoscine butylbromide Inj 20 mg, 1 ml ampoule Buscopan 5 9.57 Tab 10 mg Gastrosoothe 20 2.18 Glycopyrronium bromide Inj 200 mcg per ml, 1 ml ampoule Max Health 10 1 28.56 Mebeverine hydrochloride Tab 135 mg Colofac 90 18.00 Antiulcerants Antisecretory and Cytoprotective Misoprostol Tab 200 mcg Any 0 H2 Antagonists Cimetidine Tab 200 mg Any 0 Tab 400 mg Any 0 Ranitidine Inj 25 mg per ml, 2 ml ampoule Zantac 5 8.75 Tab 150 mg Ranitidine Relief 500 10.30 Tab 300 mg Ranitidine Relief 500 14.73 Oral liq 150 mg per 10 ml Peptisoothe 300 4.92 Proton Pump Inhibitors Omeprazole Cap 10 mg Omezol Relief 90 2.23 Cap 20 mg Omezol Relief 90 2.91 Cap 40 mg Omezol Relief 90 4.42 Inj 40 mg ampoule Dr Reddy's Omeprazole 5 19.00 Inj 40 mg ampoule with diluent Dr Reddy's Omeprazole 5 28.65 Tab dispersible 20 mg Any 0

Only for use in tube-fed patients

 Powder for oral liq Midwest 5 42.50 Lansoprazole Cap 30 mg Solox 28 2.32 Lanzol Relief 100 5.93 Cap 15 mg Solox 28 2.00 Lanzol Relief 100 5.08 Pantoprazole Tab EC 20 mg Pantoprazole Actavis 20 100 2.68 Tab EC 40 mg Pantoprazole Actavis 40 100 3.54 Inj 40 mg vial Any 0 Site Protective Agents Sucralfate Tab 1 g Any 0 Bismuth trioxide Tab 120 mg De-Nol 112 32.50 Bile and Liver Therapy Bile and Liver Therapy L-ornithine L-aspartate Grans for oral liquid 3 g Any 0

For patients with chronic hepatic encephalopathy who have not responded to treatment with, or are intolerant to lactulose, or where lactulose is contraindicated.

 Rifaximin Tab 550 mg Xifaxan 56 625.00

For patients with hepatic encephalopathy despite an adequate trial of maximum tolerated doses of lactulose.

 Diabetes Alpha Glucosidase Inhibitors Acarbose Tab 50 mg Glucobay 90 4.28 Tab 100 mg Glucobay 90 7.78 Hyperglycaemic Agents Glucose with sucrose and fructose Gel 19.7% with sucrose 35% and fructose 19.7%, 18 g sachet Any 0 Glucose [Dextrose] Gel 40% Any 0 Tab 1.5 g Any 0 Tab 3.1 g Any 0 Tab 4 g Any 0 Glucagon hydrochloride Inj 1 mg syringe kit Glucagen Hypokit 1 32.00 Diazoxide Cap 25 mg Proglicem 100 110.00 Cap 100 mg Proglicem 100 280.00 Oral liq 50 mg per ml Proglycem 30 620.00

For patients with confirmed hypoglycaemia caused by hyperinsulinism.

 Insulin - Intermediate-Acting Preparations Insulin isophane Inj insulin human 100 u per ml, 10 ml vial Any 0 Inj insulin human 100 u per ml, 3 ml cartridge Any 0 Insulin neutral with insulin isophane Inj insulin neutral 30% with insulin isophane 70%, 100 u per ml, 10 ml vial Any 0 Inj insulin neutral 30% with insulin isophane 70%, 100 u per ml, 3 ml cartridge Any 0 Inj insulin neutral 40% with insulin isophane 60%, 100 u per ml, 3 ml cartridge Any 0 Inj insulin neutral 50% with insulin isophane 50%, 100 u per ml, 3 ml cartridge Any 0 Insulin lispro with insulin lispro protamine Inj insulin lispro 50% with insulin lispro protamine 50%, 100 u per ml, 3 ml cartridge Humalog Mix 50 5 42.66 Inj insulin lispro 25% with insulin lispro protamine 75%, 100 u per ml, 3 ml cartridge Humalog Mix 25 5 42.66 Insulin aspart with insulin aspart protamine Inj insulin aspart 30% with insulin aspart protamine 70%, 100 u per ml, 3 ml prefilled pen NovoMix 30 FlexPen 5 52.15 Insulin - Long-Acting Preparations Insulin glargine Inj 100 u per ml, 3 ml disposable pen Lantus SoloStar 5 94.50 Inj 100 u per ml, 3 ml cartridge Lantus 5 94.50 Inj 100 u per ml, 10 ml vial Lantus 1 63.00 Insulin - Rapid-Acting Preparations Insulin aspart Inj 100 u per ml, 10 ml vial Any 0 Inj 100 u per ml, 3 ml cartridge Any 0 Inj 100 u per ml, 3 ml syringe NovoRapid FlexPen 5 51.19 Insulin lispro Inj 100 u per ml, 10 ml vial Any 0 Inj 100 u per ml, 3 ml cartridge Any 0 Insulin glulisine Inj 100 u per ml, 10 ml vial Apidra 1 27.03 Inj 100 u per ml, 3 ml cartridge Apidra 5 46.07 Inj 100 u per ml, 3 ml disposable pen Apidra Solostar 5 46.07 Insulin - Short-Acting Preparations Insulin neutral Inj human 100 u per ml, 10 ml vial Any 0 Inj human 100 u per ml, 3 ml cartridge Any 0 Oral Hypoglycaemic Agents Glibenclamide Tab 5 mg Any 0 Metformin hydrochloride Tab immediate-release 500 mg Metchek 1000 9.59 Tab immediate-release 850 mg Metformin Mylan 500 7.82 Pioglitazone Tab 15 mg Vexazone 90 3.47 Tab 30 mg Vexazone 90 5.06 Tab 45 mg Vexazone 90 7.10 Gliclazide Tab 80 mg Glizide 500 11.50 Glipizide Tab 5 mg Minidiab 100 2.85 Digestives Including Enzymes Digestives Including Enzymes Pancreatic enzyme Cap EC 10,000 BP u lipase, 9,000 BP u amylase and 210 BP u protease Creon 10000 100 34.93 Cap EC 25,000 BP u lipase, 18,000 BP u amylase and 1,000 BP u protease Creon 25000 100 94.38 Cap EC 25,000 BP u lipase, 22,500 BP u amylase and 1,250 BP u protease Any 0 Powder 25,000 u lipase with 30,000 u amylase and 1,400 u protease per g Any 0 Ursodeoxycholic acid Cap 250 mg Ursosan 100 53.40

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

Both:

  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:

  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 e.g. PicoPrep 0 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 e.g. Glycoprep-C 0 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. Glycoprep-C 0 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 Klean Prep 4 14.31 Bulk-Forming Agents Ispaghula (psyllium) husk Powder for oral soln Konsyl-D 500 5.51 Sterculia with frangula Powder for oral soln Any 0

For continuation only

 Faecal Softeners Docusate sodium with sennosides Tab 50 mg with sennosides 8 mg Laxsol 200 4.40 Poloxamer Oral drops 10% Coloxyl 30 3.78 Paraffin Enema 133 ml Any 0 Oral liquid 1 mg per ml Any 0 Docusate sodium Tab 50 mg Coloxyl 100 2.31 Tab 120 mg Coloxyl 100 3.13 Osmotic Laxatives Sodium phosphate with phosphoric acid Enema 10% with phosphoric acid 6.58% Fleet Phosphate Enema 1 2.50 Oral liq 16.4% with phosphoric acid 25.14% Any 0 Sodium citrate with sodium lauryl sulphoacetate Enema 90 mg with sodium lauryl sulphoacetate 9 mg per ml, 5 ml Micolette 50 19.95 Glycerol Suppos 1.27 g Any 0 Suppos 2.55 g Any 0 Suppos 3.6 g PSM 20 6.50 Macrogol 3350 with potassium chloride, sodium bicarbonate and sodium chloride Powder for oral soln 6.563 g with potassium chloride 23.3 mg, sodium bicarbonate 89.3 mg and sodium chloride 175.4 mg Any 0 Powder for oral soln 13.125 g with potassium chloride 46.6 mg, sodium bicarbonate 178.5 mg and sodium chloride 350.7 mg Lax-Sachets 30 7.65
Either:
  1. Both:

    1. The patient has problematic constipation despite an adequate trial of other oral pharmacotherapies including lactulose where lactulose is not contraindicated; and

    2. The patient would otherwise require a per rectal preparation; or

  2. For short-term use for faecal disimpaction.

 Lactulose Oral liq 10 g per 15 ml Laevolac 500 3.84 Stimulant Laxatives Sennosides Tab 7.5 mg Any 0 Bisacodyl Suppos 10 mg Dulcolax 6 3.00 Lax-Suppositories 10 3.78 Tab 5 mg Lax-Tabs 200 5.99 Metabolic Disorder Agents Metabolic Disorder Agents Arginine Inj 600 mg per ml, 25 ml vial Any 0 Powder Any 0 Betaine Powder Any 0

Metabolic disorders physician or metabolic disorders dietitian

 Haem arginate Inj 25 mg per ml, 10 ml ampoule Any 0 Imiglucerase Inj 40 iu per ml, 10 ml vial Any 0 Inj 40 iu per ml, 5 ml vial Any 0

Only for use in patients with approval by the Gaucher's Treatment Panel

 Levocarnitine Cap 500 mg Any 0 Inj 200 mg per ml, 5 ml vial Any 0 Oral soln 1,100 mg per 15 ml Any 0

Metabolic disorders physician, metabolic disorders dietitian or neurologist

 Sodium benzoate Cap 500 mg Any 0 Inj 20%, 10 ml ampoule Any 0 Powder Any 0 Soln 100 mg per ml Any 0 Sodium phenylbutyrate Inj 200 mg per ml, 10 ml ampoule Any 0 Oral liq 250 mg per ml Any 0 Tab 500 mg Any 0 Trientine dihydrochloride Cap 300 mg Any 0 Biotin Inj 10 mg per ml, 5 ml vial Any 0 Cap 50 mg Any 0 Cap 100 mg Any 0

Metabolic disorders physician or metabolic disorders dietitian.

 Pyridoxal-5-phosphate Tab 50 mg Any 0

Metabolic disorders physician, metabolic disorders dietitian or neurologist

 Minerals Calcium Calcium carbonate Tab eff 1.75 g (1 g elemental) Calsource 30 6.21 Tab 1.25 g (500 mg elemental) Arrow-Calcium 250 5.38 Fluoride Sodium fluoride Tab 1.1 mg (0.5 mg elemental) Any 0 Iodine Potassium iodate Tab 253 mcg (150 mcg elemental iodine) NeuroTabs 90 3.65 Potassium iodate with iodine Oral liq 10% with iodine 5% Any 0 Iron Ferrous gluconate with ascorbic acid Tab 170 mg (20 mg elemental) with ascorbic acid 40 mg Any 0 Ferrous sulphate with ascorbic acid Tab long-acting 325 mg (105 mg elemental) with ascorbic acid 500 mg Any 0 Ferrous sulphate with folic acid Tab long-acting 325 mg (105 mg elemental) with folic acid 350 mcg Any 0 Ferric carboxymaltose Inj 50 mg per ml, 10 ml vial Ferinject 1 150.00

Treatment with oral iron has proven ineffective or is clinically inappropriate.

 Iron polymaltose Inj 50 mg per ml, 2 ml ampoule Ferrum H 5 15.22 Ferrous sulphate Tab long-acting 325 mg (105 mg elemental) Ferrograd 30 2.06 Oral liq 30 mg (6 mg elemental) per ml Ferodan 500 10.28 Ferrous fumarate Tab 200 mg (65 mg elemental) Ferro-tab 100 2.89 Ferrous fumarate with folic acid Tab 310 mg (100 mg elemental) with folic acid 350 mcg Ferro-F-Tabs 60 4.75 Iron sucrose Inj 20 mg per ml, 5 ml ampoule Venofer 5 100.00 Magnesium Magnesium hydroxide Tab 311 mg (130 mg elemental) Any 0 Magnesium oxide Cap 663 mg (400 mg elemental) Any 0 Magnesium sulphate Inj 0.4 mmol per ml, 250 ml bag Any 0 Inj 2 mmol per ml, 5 ml ampoule DBL 10 12.65 Zinc Zinc Oral liq 5 mg per 5 drops Any 0 Zinc chloride Inj 5.3 mg per ml (5.1 mg per ml elemental), 2 ml ampoule Any 0 Zinc sulphate Cap 137.4 mg (50 mg elemental) Zincaps 100 11.00 Mouth and Throat Agents Used in Mouth Ulceration Benzydamine hydrochloride Soln 0.15% Any 0 Spray 0.15% Any 0 Spray 0.3% Any 0 Benzydamine hydrochloride with cetylpyridinium chloride Lozenge 3 mg with cetylpyridinium chloride Any 0 Carboxymethylcellulose Oral spray Any 0 Choline salicylate with cetalkonium chloride Adhesive gel 8.7% with cetalkonium chloride 0.01% Any 0 Dichlorobenzyl alcohol with amylmetacresol Lozenge 1.2 mg with amylmetacresol 0.6 mg Any 0 Sodium carboxymethylcellulose with pectin and gelatine Paste Any 0 Powder Any 0 Triamcinolone acetonide Paste 0.1% Kenalog in Orabase 5 5.33 Chlorhexidine gluconate Mouthwash 0.2% healthE 200 2.57 Oropharyngeal Anti-Infectives Amphotericin B Lozenge 10 mg Fungilin 20 5.86 Nystatin Oral liquid 100,000 u per ml Nilstat 24 3.35 m-Nystatin 24 2.55 Miconazole Oral gel 20 mg per g Decozol 40 4.79 Other Oral Agents Thymol glycerin Compound, BPC Any 0 Sodium hyaluronate [Hyaluronic acid] Inj 20 mg per ml, 1 ml syringe Any 0

Otolaryngologist

 Vitamins Multivitamin Preparations Multivitamins 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 e.g. Vitabdeck 0
Either:

  1. Patient has cystic fibrosis with pancreatic insufficiency; or

  2. Patient is an infant or child with liver disease or short gut syndrome.

 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) e.g. Pabrinex IV 0 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) e.g. Pabrinex IM 0 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) e.g. Pabrinex IV 0 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 e.g. Paediatric Seravit 0

Patient has inborn errors of metabolism.

 Tab (BPC cap strength) e.g. Mvite 0 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. Vitadol C 0 Multivitamin and mineral supplement Cap Clinicians Multivit & Mineral Boost 180 23.35

Limited to 3 months' treatment

Both:

  1. Patient was admitted to hospital with burns; and

  2. Any of the following:

    1. Burn size is greater than 15% of total body surface area (BSA) for all types of burns; or

    2. Burn size is greater than 10% of BSA for mid-dermal or deep dermal burns; or

    3. Nutritional status prior to admission or dietary intake is poor.

 Multivitamin renal Cap Clinicians Renal Vit 30 8.39
Either:

  1. The patient has chronic kidney disease and is receiving either peritoneal dialysis or haemodialysis; or

  2. The patient has chronic kidney disease grade 5, defined as patient with an estimated glomerular filtration rate of < 15 ml/min/1.73m² body surface area (BSA).

 Vitamin A Retinol Cap 25,000 iu Any 0 Oral liq 150,000 iu per ml Any 0 Tab 10,000 iu Any 0 Vitamin B Thiamine hydrochloride Inj 100 mg per ml, 2 ml vial Any 0 Tab 100 mg Any 0 Tab 50 mg Any 0 Inj 100 mg per ml, 1 ml vial e.g. Benerva 0 Vitamin B complex Tab strong, BPC Any 0 Hydroxocobalamin Inj 1 mg per ml, 1 ml ampoule Neo-B12 3 2.31 Pyridoxine hydrochloride Inj 100 mg per ml, 1 ml ampoule Any 0 Tab 25 mg Vitamin B6 25 90 2.15 Tab 50 mg Apo-Pyridoxine 500 11.55 Vitamin C Ascorbic acid Tab chewable 250 mg Any 0 Tab 100 mg Cvite 500 7.00 Vitamin D Alfacalcidol Oral drops 2 mcg per ml Any 0 Cap 0.25 mcg One-Alpha 100 26.32 Cap 1 mcg One-Alpha 100 87.98 Calcitriol Inj 1 mcg per ml, 1 ml ampoule Any 0 Oral liq 1 mcg per ml Any 0 Cap 0.25 mcg Calcitriol-AFT 100 10.10 Airflow 30 3.03 Cap 0.5 mcg Calcitriol-AFT 100 18.73 Airflow 30 5.62 Cholecalciferol Tab 1.25 mg (50,000 iu) Cal-d-Forte 12 7.76 Vitamin E Alpha tocopheryl acetate Cap 100 u Any 0 Cap 500 u Any 0 Oral liq 156 u per ml Any 0

Cystic fibrosis

Both:

  1. Cystic fibrosis patient; and

  2. Either:

    1. Patient has tried and failed the other available funded fat soluble vitamin A,D,E,K supplement (Vitabdeck); or

    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

All of the following:

  1. Infant or child with liver disease or short gut syndrome; and

  2. Requires vitamin supplementation; and

  3. Either:

    1. Patient has tried and failed the other available funded fat soluble vitamin A,D,E,K supplements (Vitabdeck); or

    2. The other available funded fat soluble vitamin A,D,E,K supplement (Vitabdeck) is contraindicated or clinically inappropriate for patient.

 Blood and Blood Forming Organs Antianaemics Hypoplastic and Haemolytic Epoetin alfa [Erythropoietin alfa] Inj 1,000 iu in 0.5 ml syringe Eprex 6 48.68 Inj 2,000 iu in 0.5 ml syringe Eprex 6 120.18 Inj 3,000 iu in 0.3 ml syringe Eprex 6 166.87 Inj 4,000 iu in 0.4 ml syringe Eprex 6 193.13 Inj 5,000 iu in 0.5 ml syringe Eprex 6 243.26 Inj 6,000 iu in 0.6 ml syringe Eprex 6 291.92 Inj 10,000 iu in 1 ml syringe Eprex 6 395.18 Inj 8,000 iu in 0.8 ml syringe Eprex 6 352.69 Inj 40,000 iu in 1 ml syringe Eprex 1 263.45

Initiation - chronic renal failure

All of the following:

  1. Patient in chronic renal failure; and

  2. Haemoglobin ≤ 100g/L; and

  3. Any of the following:
    1. Both:

      1. Patient does not have diabetes mellitus; and

      2. Glomerular filtration rate ≤ 30ml/min; or

    2. Both:

      1. Patient has diabetes mellitus; and

      2. Glomerular filtration rate ≤ 45ml/min; or

  4. Patient is on haemodialysis or peritoneal dialysis.

Initiation - myelodysplasia*

Re-assessment required after 2 months

All of the following:

  1. Patient has a confirmed diagnosis of myelodysplasia (MDS); and

  2. Has had symptomatic anaemia with haemoglobin < 100g/L and is red cell transfusion-dependent; and

  3. Patient has very low, low or intermediate risk MDS based on the WHO classification-based prognostic scoring system for myelodysplastic syndrome (WPSS); and

  4. Other causes of anaemia such as B12 and folate deficiency have been excluded; and

  5. Patient has a serum erythropoietin level of < 500 IU/L; and

  6. The minimum necessary dose of erythropoietin would be used and will not exceed 80,000 iu per week.

Continuation - myelodysplasia*

Re-assessment required after 12 months

All of the following:

  1. The patient's transfusion requirement continues to be reduced with erythropoietin treatment; and

  2. Transformation to acute myeloid leukaemia has not occurred; and

  3. The minimum necessary dose of erythropoietin would be used and will not exceed 80,000 iu per week.

Initiation - all other indications

Haematologist

For use in patients where blood transfusion is not a viable treatment alternative.

*Note: Indications marked with * are Unapproved Indications.

 Megaloblastic Folic acid Inj 5 mg per ml, 10 ml vial Any 0 Tab 0.8 mg Apo-Folic Acid 1000 20.60 Tab 5 mg Apo-Folic Acid 500 10.92 Oral liq 50 mcg per ml Biomed 25 24.00 Antifibrinolytics, Haemostatics and Local Sclerosants Antifibrinolytics, Haemostatics and Local Sclerosants Ferric subsulfate Gel 25.9% Any 0 Soln 500 ml Any 0 Polidocanol Inj 0.5%, 30 ml vial Any 0 Sodium tetradecyl sulphate Inj 3%, 2 ml ampoule Any 0 Thrombin Powder Any 0 Aprotinin Inj 10,000 kIU per ml (equivalent to 200 mg per ml), 50 ml vial Any 0

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 Tab 25 mg Revolade 28 1771.00 Tab 50 mg Revolade 28 3542.00

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:

    1. Patient has a platelet count of 20,000 to 30,000 platelets per microlitre and has evidence of significant mucocutaneous bleeding; or

    2. Patient has a platelet count of ≤ 20,000 platelets per microlitre and has evidence of active bleeding; or

    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.

 Aluminium chloride Topical soln 20% w/v e.g. Driclor 0

For use as a haemostatis agent.

 Tranexamic acid Tab 500 mg Cyklokapron 100 23.00 Inj 100 mg per ml, 5 ml ampoule Cyklokapron 10 55.00 Blood Factors Moroctocog alfa [Recombinant factor VIII] Inj 1,000 iu prefilled syringe Xyntha 1 840.00 Inj 2,000 iu prefilled syringe Xyntha 1 1680.00 Inj 250 iu prefilled syringe Xyntha 1 210.00 Inj 3,000 iu prefilled syringe Xyntha 1 2520.00 Inj 500 iu prefilled syringe Xyntha 1 420.00

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

 Octocog alfa [Recombinant factor VIII] Inj 1,000 iu vial Advate 1 1150.00 Kogenate FS 1 950.00 Inj 1,500 iu vial Advate 1 1725.00 Inj 2,000 iu vial Advate 1 2300.00 Kogenate FS 1 1900.00 Inj 250 iu vial Advate 1 287.50 Kogenate FS 1 237.50 Inj 3,000 iu vial Advate 1 3450.00 Kogenate FS 1 2850.00 Inj 500 iu vial Advate 1 575.00 Kogenate FS 1 475.00

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

 Nonacog alfa [Recombinant factor IX] Inj 250 iu vial BeneFIX 1 310.00 Inj 500 iu vial BeneFIX 1 620.00 Inj 1,000 iu vial BeneFIX 1 1240.00 Inj 2,000 iu vial BeneFIX 1 2480.00 Inj 3,000 iu vial BeneFIX 1 3720.00

When used in the treatment of haemophilia, access to funded treatment is managed by the Haemophilia Treaters Group in conjunction with the National Haemophilia Management Group.

 Factor eight inhibitor bypassing fraction Inj 500 U FEIBA NF 1 1450.00 Inj 1,000 U FEIBA NF 1 2900.00 Inj 2,500 U FEIBA NF 1 7250.00

When used in the treatment of haemophilia, access to funded treatment is managed by the Haemophilia Treaters Group in conjunction with the National Haemophilia Management Group.

 Eptacog alfa [Recombinant factor VIIa] Inj 1 mg syringe NovoSeven RT 1 1163.75 Inj 2 mg syringe NovoSeven RT 1 2327.50 Inj 5 mg syringe NovoSeven RT 1 5818.75 Inj 8 mg syringe NovoSeven RT 1 9310.00

When used in the treatment of haemophilia, access to funded 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 Konakion MM 5 8.00 Inj 10 mg per ml, 1 ml ampoule Konakion MM 5 9.21 Antithrombotics Anticoagulants Bivalirudin Inj 250 mg vial Any 0
Either:

  1. For use in heparin-induced thrombocytopaenia, heparin resistance or heparin intolerance; or

  2. For use in patients undergoing endovascular procedures.

 Danaparoid Inj 750 u in 0.6 ml ampoule Any 0

For use in heparin-induced thrombocytopaenia, heparin resistance or heparin intolerance

 Defibrotide Inj 80 mg per ml, 2.5 ml ampoule Any 0

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 Any 0 Fondaparinux sodium Inj 2.5 mg in 0.5 ml syringe Any 0 Inj 7.5 mg in 0.6 ml syringe Any 0

For use in heparin-induced thrombocytopaenia, heparin resistance or heparin intolerance

 Phenindione Tab 10 mg Any 0 Tab 25 mg Any 0 Tab 50 mg Any 0 Protamine sulphate Inj 10 mg per ml, 5 ml ampoule Any 0 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 Any 0 Trisodium citrate Inj 4%, 5 ml ampoule Any 0 Inj 46.7%, 5 ml ampoule Any 0 Inj 46.7%, 3 ml syringe Any 0 1 Warfarin sodium Tab 1 mg Marevan 100 6.86 Tab 2 mg Any 0 Tab 3 mg Marevan 100 9.70 Tab 5 mg Marevan 100 11.75 Heparinised saline Inj 100 iu per ml, 2 ml ampoule Any 0 Inj 100 iu per ml, 5 ml ampoule Any 0 Inj 10 iu per ml, 5 ml ampoule Pfizer 50 39.00 Heparin sodium Inj 1,000 iu per ml, 35 ml vial Any 0 Inj 100 iu per ml, 250 ml bag Any 0 Inj 5,000 iu in 0.2 ml ampoule Any 0 Inj 5,000 iu per ml, 1 ml ampoule Hospira 5 14.20 Inj 1,000 iu per ml, 1 ml ampoule Hospira 50 66.80 Inj 1,000 iu per ml, 5 ml ampoule Pfizer 50 61.04 Inj 5,000 iu per ml, 5 ml ampoule Pfizer 50 236.60 Dalteparin Inj 5,000 iu in 0.2 ml syringe Fragmin 10 39.94 Inj 2,500 iu in 0.2 ml syringe Fragmin 10 19.97 Inj 7,500 iu in 0.75 ml syringe Fragmin 10 60.03 Inj 10,000 iu in 1 ml syringe Fragmin 10 77.55 Inj 12,500 iu in 0.5 ml syringe Fragmin 10 99.96 Inj 15,000 iu in 0.6 ml syringe Fragmin 10 120.05 Inj 18,000 iu in 0.72 ml syringe Fragmin 10 158.47 Enoxaparin Inj 20 mg in 0.2 ml syringe Clexane 10 37.24 Inj 40 mg in 0.4 ml syringe Clexane 10 49.69 Inj 60 mg in 0.6 ml syringe Clexane 10 74.91 Inj 80 mg in 0.8 ml syringe Clexane 10 99.86 Inj 100 mg in 1 ml syringe Clexane 10 125.06 Inj 120 mg in 0.8 ml syringe Clexane 10 155.40 Inj 150 mg in 1 ml syringe Clexane 10 177.60 Inj 40 mg in 0.4 ml ampoule Any 0 Rivaroxaban Tab 10 mg Xarelto 15 153.00
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.

 Dabigatran Cap 75 mg Pradaxa 60 148.00 Cap 110 mg Pradaxa 60 148.00 Cap 150 mg Pradaxa 60 148.00 Antiplatelets Aspirin Suppos 300 mg Any 0 Tab 100 mg Ethics Aspirin EC 90 1.60 990 10.50 Ticlopidine Tab 250 mg Any 0 Dipyridamole Inj 5 mg per ml, 2 ml ampoule Any 0 Tab 25 mg Any 0 Tab long-acting 150 mg Pytazen SR 60 11.52 Clopidogrel Tab 75 mg Arrow - Clopid 84 5.48 Eptifibatide Inj 2 mg per ml, 10 ml vial Integrilin 1 111.00 Inj 750 mcg per ml, 100 ml vial Integrilin 1 324.00
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 Tab 5 mg Effient 28 108.00 Tab 10 mg Effient 28 120.00

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 Tab 90 mg Brilinta 56 90.00

Restricted to treatment of acute coronary syndromes specifically for patients who have recently (within the last 60 days) 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.

 Fibrinolytic Agents Alteplase Inj 10 mg vial Any 0 Inj 50 mg vial Any 0 Inj 2 mg vial Any 0 Tenecteplase Inj 50 mg vial Any 0 Urokinase Inj 10,000 iu vial Any 0 Inj 100,000 iu vial Any 0 Inj 50,000 iu vial Any 0 Inj 500,000 iu vial Any 0 Colony-Stimulating Factors Granulocyte Colony-Stimulating Factors Pegfilgrastim Inj 6 mg per 0.6 ml syringe Neulastim 1 1080.00

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.

 Filgrastim Inj 300 mcg in 0.5 ml syringe Zarzio 5 540.00 Inj 300 mcg in 1 ml vial Neupogen 5 650.00 Inj 480 mcg in 0.5 ml syringe Zarzio 5 864.00

Oncologist or haematologist

 Fluids and Electrolytes Intravenous Administration Calcium chloride Inj 100 mg per ml, 10 ml vial Any 0 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 Baxter 1000 3.10 500 5.00 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 Baxter 1000 1 7.00 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 Baxter 500 1.77 1000 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 Baxter 1000 5.38 Potassium dihydrogen phosphate Inj 1 mmol per ml, 10 ml ampoule Hospira 10 151.80 Ringer's solution Inj sodium 147 mmol/l with potassium 4 mmol/l, calcium 2.2 mmol/l, chloride 156 mmol/l, bag Baxter 1000 5.13 Sodium acetate Inj 4 mmol per ml, 20 ml ampoule Any 0 Potassium chloride Inj 225 mg (3 mmol) per ml, 20 ml ampoule Any 0 Inj 75 mg (1 mmol) per ml, 10 ml ampoule Any 0 Sodium chloride Inj 0.9%, 10 ml ampoule Pfizer 50 15.50 Multichem 50 11.50 Inj 0.9%, 5 ml ampoule Pfizer 50 15.50 Multichem 50 10.85 Inj 1.8%, 500 ml bottle Any 0 Inj 0.45%, bag Baxter 500 5.50 Inj 0.9%, bag Baxter 500 1.77 1000 1.80 50 3.01 100 2.28 250 3.60 Freeflex 500 1.70 1000 1.71 Inj 3%, bag Baxter 1000 5.69 Inj 23.4% (4 mmol/ml), 20 ml Biomed 5 31.25 Inj 0.9%, 20 ml ampoule Multichem 20 8.41 Inj 0.9%, 3 ml syringe, non-sterile pack BD PosiFlush 30 10.65

For use in flushing of in-situ vascular access devices only.

 Inj 0.9%, 5 ml syringe, non-sterile pack BD PosiFlush 30 10.80

For use in flushing of in-situ vascular access devices only.

 Inj 0.9%, 10 ml syringe, non-sterile pack BD PosiFlush 30 11.25

For use in flushing of in-situ vascular access devices only.

 Sodium bicarbonate Inj 8.4%, 10 ml vial Any 0 Inj 8.4%, 100 ml vial Biomed 1 20.50 Inj 8.4%, 50 ml vial Biomed 1 19.95 Calcium gluconate Inj 10%, 10 ml ampoule Hospira 10 34.24 Glucose [Dextrose] Inj 50%, 10 ml ampoule Biomed 5 27.50 Inj 50%, 90 ml bottle Biomed 1 14.50 Inj 70%, 1,000 ml bag Any 0 Inj 70%, 500 ml bag Any 0 Inj 5%, bag Baxter 1000 1.80 250 3.87 50 2.87 500 1.77 100 2.84 Inj 10%, bag Baxter 500 3.70 1000 5.29 Inj 50%, bag Baxter 500 6.84 Glucose with potassium chloride Inj 10% glucose with 10 mmol/l potassium chloride, 500 ml bag Any 0 Inj 5% glucose with 30 mmol/l potassium chloride, 1,000 ml bag Any 0 Inj 5% glucose with 20 mmol/l potassium chloride, bag Baxter 1000 7.36 Glucose with potassium chloride and sodium chloride Inj 10% glucose with potassium chloride 10 mmol/l and sodium chloride 15 mmol/l, 500 ml bag Any 0 Inj 2.5% glucose with potassium chloride 20 mmol/l and sodium chloride 0.45%, 3,000 ml bag Any 0 Inj 4% glucose with potassium chloride 20 mmol/l and sodium chloride 0.18%, bag Baxter 1000 4.30 500 3.45 Inj 4% glucose with potassium chloride 30 mmol/l and sodium chloride 0.18%, bag Baxter 1000 3.62 Potassium chloride with sodium chloride Inj 10 mmol potassium chloride with 0.29% sodium chloride, 100 ml bag Any 0 Inj 40 mmol potassium chloride with 0.9% sodium chloride, 100 ml bag Any 0 Inj 20 mmol/l potassium chloride with 0.9% sodium chloride, bag Baxter 1000 3.85 Inj 30 mmol/l potassium chloride with 0.9% sodium chloride, bag Baxter 1000 2.59 Inj 40 mmol/l potassium chloride with 0.9% sodium chloride, bag Baxter 1000 6.62 Glucose with sodium chloride Inj glucose 5% with sodium chloride 0.2%, 500 ml bag Any 0 Inj glucose 5% with sodium chloride 0.9%, bag Baxter 1000 4.54 Inj glucose 2.5% with sodium chloride 0.45%, bag Baxter 500 4.95 Inj glucose 5% with sodium chloride 0.45%, bag Baxter 1000 5.80 500 9.87 Water Inj 250 ml bag Any 0 Inj 500 ml bag Any 0 Inj, bag Baxter 1000 2.75 Inj 5 ml ampoule Multichem 50 10.25 Inj 10 ml ampoule Multichem 50 11.25 Inj 20 ml ampoule Multichem 20 6.50 Sodium dihydrogen phosphate [Sodium acid phosphate] Inj 1 mmol per ml, 20 ml ampoule Biomed 5 47.50 Oral Administration Compound electrolytes Powder for oral soln Any 0 Compound electrolytes with glucose Soln with electrolytes Any 0 Phosphorus Tab eff 500 mg (16 mmol) Any 0 Sodium polystyrene sulphonate Powder Resonium A 454 84.65 Potassium chloride Oral liq 2 mmol per ml Any 0 Tab eff 548 mg (14 mmol) with chloride 285 mg (8 mmol) Any 0 Tab long-acting 600 mg (8 mmol) Span-K 200 7.42 Sodium chloride Oral liq 2 mmol/ml Any 0 Tab 600 mg Any 0 Sodium bicarbonate Cap 840 mg Sodibic 100 8.52 Calcium polystyrene sulphonate Powder Calcium Resonium 300 169.85 Plasma Volume Expanders Gelatine, succinylated Inj 4%, 500 ml bag Gelofusine 10 108.00 Hydroxyethyl starch 130/0.4 with sodium chloride Inj 6% with sodium chloride 0.9%, 500 ml bag Voluven 20 198.00 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 Volulyte 6% 20 198.00 Cardiovascular System Agents Affecting the Renin-Angiotensin System ACE Inhibitors Trandolapril Cap 1 mg Any 0 Cap 2 mg Any 0

For continuation only

 Cilazapril Tab 0.5 mg Zapril 90 2.00 Tab 2.5 mg Zapril 90 4.31 Tab 5 mg Zapril 90 6.98 Quinapril Tab 5 mg Arrow-Quinapril 5 90 4.31 Tab 10 mg Arrow-Quinapril 10 90 3.15 Tab 20 mg Arrow-Quinapril 20 90 5.97 Captopril Oral liq 5 mg per ml Capoten 95 94.99
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.

 Lisinopril Tab 5 mg Arrow-Lisinopril 90 3.58 Ethics Lisinopril 90 1.80 Tab 10 mg Arrow-Lisinopril 90 4.08 Ethics Lisinopril 90 2.05 Tab 20 mg Arrow-Lisinopril 90 4.88 Ethics Lisinopril 90 2.76 Enalapril maleate Tab 5 mg Ethics Enalapril 100 0.96 Tab 10 mg Ethics Enalapril 100 1.24 Tab 20 mg Ethics Enalapril 100 1.78 Perindopril Tab 2 mg Apo-Perindopril 30 3.75 Tab 4 mg Apo-Perindopril 30 4.80 ACE Inhibitors with Diuretics Enalapril maleate with hydrochlorothiazide Tab 20 mg with hydrochlorothiazide 12.5 mg Any 0

For continuation only

 Cilazapril with hydrochlorothiazide Tab 5 mg with hydrochlorothiazide 12.5 mg Apo-Cilazapril/ Hydrochlorothiazide 100 10.72 Quinapril with hydrochlorothiazide Tab 10 mg with hydrochlorothiazide 12.5 mg Accuretic 10 30 3.65 Tab 20 mg with hydrochlorothiazide 12.5 mg Accuretic 20 30 4.78 Angiotensin II Antagonists Candesartan cilexetil Tab 4 mg Candestar 90 2.50 Tab 8 mg Candestar 90 3.68 Tab 16 mg Candestar 90 6.12 Tab 32 mg Candestar 90 10.66

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 Losartan Actavis 84 1.55 Tab 25 mg Losartan Actavis 84 1.90 Tab 50 mg Losartan Actavis 84 2.25 Tab 100 mg Losartan Actavis 84 2.60 Angiotensin II Antagonists with Diuretics Losartan potassium with hydrochlorothiazide Tab 50 mg with hydrochlorothiazide 12.5 mg Arrow-Losartan & Hydrochlorothiazide 30 2.18 Alpha-Adrenoceptor Blockers Alpha-Adrenoceptor Blockers Phenoxybenzamine hydrochloride Cap 10 mg Any 0 Inj 50 mg per ml, 2 ml ampoule Any 0 Terazosin Tab 1 mg Arrow 28 0.50 Tab 2 mg Arrow 28 0.45 Tab 5 mg Arrow 28 0.68 Phentolamine mesylate Inj 10 mg per ml, 1 ml ampoule Any 0 Doxazosin Tab 2 mg Apo-Doxazosin 500 6.75 Tab 4 mg Apo-Doxazosin 500 9.67 Prazosin Tab 1 mg Apo-Prazosin 100 5.53 Tab 2 mg Apo-Prazosin 100 7.00 Tab 5 mg Apo-Prazosin 100 11.70 Antiarrhythmics Antiarrhythmics Adenosine Inj 3 mg per ml, 10 ml vial Any 0

For use in cardiac catheterisation, electrophysiology and MRI.

 Inj 3 mg per ml, 2 ml vial Any 0 Ajmaline Inj 5 mg per ml, 10 ml ampoule Any 0

Cardiologist

 Amiodarone hydrochloride Inj 50 mg per ml, 3 ml ampoule Cordarone-X 6 22.80 Tab 100 mg Any 0 Tab 200 mg Any 0 Digoxin Inj 250 mcg per ml, 2 ml vial Any 0 Oral liq 50 mcg per ml Any 0 Tab 250 mcg Any 0 Tab 62.5 mcg Any 0 Disopyramide phosphate Cap 100 mg Any 0 Cap 150 mg Any 0 Propafenone hydrochloride Tab 150 mg Any 0 Atropine sulphate Inj 600 mcg per ml, 1 ml ampoule AstraZeneca 50 71.00 Flecainide acetate Tab 50 mg Tambocor 60 38.95 Cap long-acting 100 mg Tambocor CR 30 38.95 Cap long-acting 200 mg Tambocor CR 30 68.78 Inj 10 mg per ml, 15 ml ampoule Tambocor 5 52.45 Mexiletine hydrochloride Cap 150 mg Mexiletine Hydrochloride USP 100 162.00 Cap 250 mg Mexiletine Hydrochloride USP 100 202.00 Antihypotensives Antihypotensives Midodrine Tab 2.5 mg Any 0 Tab 5 mg Any 0

Patient has disabling orthostatic hypotension not due to drugs.

 Beta-Adrenoceptor Blockers Beta-Adrenoceptor Blockers Esmolol hydrochloride Inj 10 mg per ml, 10 ml vial Any 0 Atenolol Oral liq 5 mg per ml Atenolol-AFT 300 21.25 Tab 50 mg Mylan Atenolol 500 4.61 Tab 100 mg Mylan Atenolol 500 7.67 Sotalol Tab 80 mg Mylan 500 27.50 Tab 160 mg Mylan 100 10.50 Inj 10 mg per ml, 4 ml ampoule Sotacor 5 65.39 Labetalol Inj 5 mg per ml, 20 ml ampoule Any 0 Tab 50 mg Hybloc 100 8.23 Tab 100 mg Hybloc 100 10.06 Tab 200 mg Hybloc 100 17.55 Tab 400 mg Any 0 Carvedilol Tab 6.25 mg Dicarz 60 3.90 Tab 12.5 mg Dicarz 60 5.10 Tab 25 mg Dicarz 60 6.30 Metoprolol tartrate Tab long-acting 200 mg Slow-Lopresor 28 18.00 Inj 1 mg per ml, 5 ml vial Lopresor 5 24.00 Tab 50 mg Lopresor 100 16.00 Tab 100 mg Lopresor 60 21.00 Celiprolol Tab 200 mg Celol 180 21.40 Nadolol Tab 40 mg Apo-Nadolol 100 16.05 Tab 80 mg Apo-Nadolol 100 24.70 Propranolol Inj 1 mg per ml, 1 ml ampoule Any 0 Oral liq 4 mg per ml Any 0 Cap long-acting 160 mg Cardinol LA 100 18.17 Tab 10 mg Apo-Propranolol 100 3.65 Tab 40 mg Apo-Propranolol 100 4.65 Metoprolol succinate Tab long-acting 23.75 mg Metoprolol - AFT CR 30 0.96 Tab long-acting 47.5 mg Metoprolol - AFT CR 30 1.41 Tab long-acting 95 mg Metoprolol - AFT CR 30 2.42 Tab long-acting 190 mg Metoprolol - AFT CR 30 4.66 Timolol maleate Tab 10 mg Any 0 Pindolol Tab 5 mg Apo-Pindolol 100 9.72 Tab 10 mg Apo-Pindolol 100 15.62 Tab 15 mg Apo-Pindolol 100 23.46 Bisoprolol fumarate Tab 5 mg Bosvate 30 3.50 Tab 2.5 mg Bosvate 30 2.40 Tab 10 mg Bosvate 30 6.40 Calcium Channel Blockers Dihydropyridine Calcium Channel Blockers Isradipine Cap long-acting 2.5 mg Any 0 Cap long-acting 5 mg Any 0 Tab 2.5 mg Any 0 Cap 2.5 mg Any 0 Nimodipine Inj 200 mcg per ml, 50 ml vial Any 0 Tab 30 mg Any 0 Nicardipine hydrochloride Inj 2.5 mg per ml, 10 ml vial Any 0

Anaesthetist, intensivist or paediatric cardiologist

Both:

  1. Patient is a paediatric patient; and

  2. Any of the following:

    1. Patient has hypertension requiring urgent treatment with an intravenous agent; or

    2. Patient has excessive ventricular afterload; or

    3. Patient is awaiting or undergoing cardiac surgery using cardiopulmonary bypass.

 Nifedipine Cap 5 mg Any 0 Tab long-acting 10 mg Any 0 Tab long-acting 20 mg Nyefax Retard 100 9.59 Tab long-acting 30 mg Adefin XL 30 3.75 Tab long-acting 60 mg Adefin XL 30 5.75 30 5.75 Felodipine Tab long-acting 5 mg Plendil ER 30 1.55 Tab long-acting 10 mg Plendil ER 30 2.30 Tab long-acting 2.5 mg Plendil ER 30 1.45 Amlodipine Tab 5 mg Apo-Amlodipine 250 5.04 Tab 10 mg Apo-Amlodipine 250 7.21 Tab 2.5 mg Apo-Amlodipine 100 2.21 Other Calcium Channel Blockers Verapamil hydrochloride Tab 40 mg Isoptin 100 7.01 Tab 80 mg Isoptin 100 11.74 Tab long-acting 240 mg Verpamil SR 250 25.00 Inj 2.5 mg per ml, 2 ml ampoule Isoptin 5 7.54 Tab long-acting 120 mg Verpamil SR 250 15.20 Perhexiline maleate Tab 100 mg Pexsig 100 62.90 Diltiazem hydrochloride Inj 5 mg per ml, 5 ml vial Any 0 Tab 30 mg Dilzem 100 4.60 Cap long-acting 120 mg Cardizem CD 30 1.91 Apo-Diltiazem CD 500 31.83 Cap long-acting 180 mg Cardizem CD 30 7.56 Apo-Diltiazem CD 500 47.67 Cap long-acting 240 mg Cardizem CD 30 10.22 Apo-Diltiazem CD 500 63.58 Tab 60 mg Dilzem 100 8.50 Centrally-Acting Agents Centrally-Acting Agents Clonidine hydrochloride Inj 150 mcg per ml, 1 ml ampoule Catapres 5 16.07 Tab 150 mcg Catapres 100 34.32 Tab 25 mcg Clonidine BNM 112 10.53 Methyldopa Tab 125 mg Prodopa 100 14.25 Tab 250 mg Prodopa 100 15.10 Tab 500 mg Prodopa 100 23.15 Clonidine Patch 2.5 mg, 100 mcg per day Catapres-TTS-1 4 12.80 Patch 5 mg, 200 mcg per day Catapres-TTS-2 4 18.04 Patch 7.5 mg, 300 mcg per day Catapres-TTS-3 4 22.68 Diuretics Loop Diuretics Furosemide (frusemide) Inj 10 mg per ml, 25 ml ampoule Any 0 Oral liq 10 mg per ml Any 0 Inj 10 mg per ml, 2 ml ampoule Frusemide-Claris 5 1.30 Tab 40 mg Diurin 40 1000 8.00 Tab 500 mg Urex Forte 50 25.00 Bumetanide Inj 500 mcg per ml, 4 ml vial Any 0 Tab 1 mg Burinex 100 16.36 Osmotic Diuretics Mannitol Inj 10%, 1,000 ml bag Baxter 1000 14.21 Inj 15%, 500 ml bag Baxter 500 9.84 Inj 20%, 500 ml bag Baxter 500 10.80 Potassium Sparing Combination Diuretics Amiloride hydrochloride with furosemide Tab 5 mg with furosemide 40 mg Any 0 Amiloride hydrochloride with hydrochlorothiazide Tab 5 mg with hydrochlorothiazide 50 mg Any 0 Potassium Sparing Diuretics Spironolactone Tab 25 mg Spiractin 100 3.65 Tab 100 mg Spiractin 100 11.80 Oral liq 5 mg per ml Biomed 25 30.00 Amiloride hydrochloride Tab 5 mg Apo-Amiloride 100 17.50 Oral liq 1 mg per ml Biomed 25 30.00 Thiazide and Related Diuretics Metolazone Tab 5 mg Any 0
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

 Indapamide Tab 2.5 mg Dapa-Tabs 90 2.25 Chlorothiazide Oral liq 50 mg per ml Biomed 25 26.00 Chlortalidone [Chlorthalidone] Tab 25 mg Hygroton 50 8.00 Bendroflumethiazide [Bendrofluazide] Tab 2.5 mg Arrow-Bendrofluazide 500 5.48 Tab 5 mg Arrow-Bendrofluazide 500 8.95 Lipid-Modifying Agents Fibrates Bezafibrate Tab 200 mg Bezalip 90 9.05 Tab long-acting 400 mg Bezalip Retard 30 6.78 Gemfibrozil Tab 600 mg Lipazil 60 17.60 HMG CoA Reductase Inhibitors (Statins) Simvastatin Tab 10 mg Arrow-Simva 90 0.95 Tab 20 mg Arrow-Simva 90 1.61 Tab 40 mg Arrow-Simva 90 2.83 Tab 80 mg Arrow-Simva 90 7.91 Atorvastatin Tab 10 mg Zarator 90 2.52 Tab 20 mg Lipitor 30 26.70 Zarator 90 4.17 Tab 40 mg Lipitor 30 37.02 Zarator 90 7.32 Tab 80 mg Lipitor 30 110.50 Zarator 90 16.23 Pravastatin Tab 10 mg Any 0 Tab 20 mg Cholvastin 30 3.45 Tab 40 mg Cholvastin 30 6.36 Resins Cholestyramine Powder for oral liq 4 g Any 0 Colestipol hydrochloride Grans for oral liq 5 g Any 0 Selective Cholesterol Absorption Inhibitors Ezetimibe Tab 10 mg Ezemibe 30 3.35
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:

    1. The patient has rhabdomyolysis (defined as muscle aches and creatine kinase more than 10 × normal) when treated with one statin; or

    2. The patient is intolerant to both simvastatin and atorvastatin; or

    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 Tab 10 mg with simvastatin 10 mg Zimybe 30 5.15 Tab 10 mg with simvastatin 20 mg Zimybe 30 6.15 Tab 10 mg with simvastatin 40 mg Zimybe 30 7.15 Tab 10 mg with simvastatin 80 mg Zimybe 30 8.15
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.

 Other Lipid-Modifying Agents Acipimox Cap 250 mg Any 0 Nicotinic acid Tab 50 mg Apo-Nicotinic Acid 100 3.96 Tab 500 mg Apo-Nicotinic Acid 100 17.37 Nitrates Nitrates Glyceryl trinitrate Oral spray, 400 mcg per dose Glytrin 250 4.45 Patch 50 mg, 10 mg per day Nitroderm TTS 10 30 30 18.62 Patch 25 mg, 5 mg per day Nitroderm TTS 5 30 30 15.73 Inj 5 mg per ml, 10 ml ampoule Hospira 5 5 100.00 Inj 1 mg per ml, 5 ml ampoule Nitronal 10 22.70 Inj 1 mg per ml, 50 ml vial Nitronal 10 86.60 Tab 600 mcg Lycinate 100 8.00 Oral pump spray, 400 mcg per dose Nitrolingual Pump Spray 250 4.45 Isosorbide mononitrate Tab 20 mg Ismo-20 100 17.10 Tab long-acting 60 mg Duride 90 3.94 Tab long-acting 40 mg Ismo 40 Retard 30 7.50 Other Cardiac Agents Other Cardiac Agents Levosimendan Inj 2.5 mg per ml, 10 ml vial Any 0 Inj 2.5 mg per ml, 5 ml vial Any 0

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 Sympathomimetics Dobutamine hydrochloride Inj 12.5 mg per ml, 20 ml ampoule Dobutamine-Claris 5 24.45 Isoprenaline Inj 200 mcg per ml, 1 ml ampoule Any 0 Inj 200 mcg per ml, 5 ml ampoule Any 0 Metaraminol Inj 0.5 mg per ml, 20 ml syringe Any 0 Inj 1 mg per ml, 1 ml ampoule Any 0 Inj 1 mg per ml, 10 ml syringe Any 0 Inj 10 mg per ml, 1 ml ampoule Any 0 Noradrenaline Inj 0.06 mg per ml, 100 ml bag Any 0 Inj 0.06 mg per ml, 50 ml syringe Any 0 Inj 0.1 mg per ml, 100 ml bag Any 0 Inj 0.12 mg per ml, 100 ml bag Any 0 Inj 0.12 mg per ml, 50 ml syringe Any 0 Inj 0.16 mg per ml, 50 ml syringe Any 0 Inj 1 mg per ml, 100 ml bag Any 0 Inj 1 mg per ml, 4 ml ampoule Any 0 Phenylephrine hydrochloride Inj 10 mg per ml, 1 ml vial Neosynephrine HCL 25 115.50 Adrenaline Inj 1 in 1,000, 30 ml vial Any 0 Inj 1 in 10,000, 10 ml syringe Any 0 Inj 1 in 1,000, 1 ml ampoule Hospira 50 100.00 5 5.25 Aspen Adrenaline 5 4.98 Inj 1 in 10,000, 10 ml ampoule Hospira 5 27.00 Aspen Adrenaline 10 49.00 Dopamine hydrochloride Inj 40 mg per ml, 5 ml ampoule DBL Sterile Dopamine Concentrate 5 16.89 Ephedrine Inj 3 mg per ml, 10 ml syringe Any 0 Inj 30 mg per ml, 1 ml ampoule Max Health 10 51.48 Vasodilators Vasodilators Amyl nitrite Liq 98% in 3 ml capsule Any 0 Milrinone Inj 1 mg per ml, 10 ml ampoule Any 0 Pentoxifylline [Oxpentifylline] Tab 400 mg Any 0 Papaverine hydrochloride Inj 30 mg per ml, 1 ml vial Any 0 Inj 12 mg per ml, 10 ml ampoule Hospira 5 217.90 Hydralazine hydrochloride Tab 25 mg Any 0
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 Apresoline 5 1 25.90 5 25.90 Alprostadil hydrochloride Inj 500 mcg per ml, 1 ml ampoule Prostin VR 5 1650.00 Sodium nitroprusside Inj 50 mg vial Any 0 Nicorandil Tab 10 mg Ikorel 60 27.95 Tab 20 mg Ikorel 60 33.28 Minoxidil Tab 10 mg Loniten 100 70.00

For patients with severe refractory hypertension who have failed to respond to extensive multiple therapies.

 Diazoxide Inj 15 mg per ml, 20 ml ampoule Any 0 Endothelin Receptor Antagonists Bosentan Tab 62.5 mg Tracleer 60 4585.00 pms-Bosentan 60 1500.00 Mylan-Bosentan 56 375.00 Tab 125 mg Tracleer 60 4585.00 pms-Bosentan 60 1500.00 Mylan-Bosentan 56 375.00

  1. For use in patients with approval by the Pulmonary Arterial Hypertension Panel; or

  2. In hospital stabilisation in emergency situations.

 Ambrisentan Tab 5 mg Volibris 30 4585.00 Tab 10 mg Volibris 30 4585.00

  1. For use in patients with approval by the Pulmonary Arterial Hypertension Panel; or

  2. In hospital stabilisations in emergency situations.

 Phosphodiesterase Type 5 Inhibitors Sildenafil Tab 100 mg Vedafil 4 2.75 Tab 25 mg Vedafil 4 0.75 Tab 50 mg Vedafil 4 0.75
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:

    1. Patient has Raynaud's phenomenon; and

    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

    3. Patient is following lifestyle management (proper body insulation, avoidance of cold exposure, smoking cessation support, avoidance of sympathomimetic drugs); and

    4. Patient has persisting severe symptoms despite treatment with calcium channel blockers and nitrates (unless contraindicated or not tolerated).

 Prostacyclin Analogues Epoprostenol Inj 0.5 mg vial Veletri 1 36.61 Inj 1.5 mg vial Veletri 1 73.21

For use as a bridge to transplant for patients with Pulmonary Arterial Hypertension who are on the active waiting list for lung transplantation.

 Iloprost Inj 50 mcg in 0.5 ml ampoule Arrow-Iloprost 1 89.50 Nebuliser soln 10 mcg per ml, 2 ml Ventavis 30 1185.00
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 hospital stabilisation in emergency situations.

 Dermatologicals Anti-Infective Preparations Antibacterials Mupirocin Oint 2% Any 0 Mafenide acetate Powder 50 g sachet Any 0

For the treatment of burns patients.

 Fusidic acid Crm 2% DP Fusidic Acid Cream 15 2.52 Oint 2% Foban 15 3.45 Hydrogen peroxide Soln 3% (10 vol) Pharmacy Health 100 1.40 Crm 1% Crystaderm 15 8.56 Sulphadiazine silver Crm 1% Flamazine 50 12.30 Antifungals Amorolfine Nail soln 5% MycoNail 5 19.95 Ciclopirox olamine Nail soln 8% Apo-Ciclopirox 7 6.50 Soln 1% Any 0

For continuation only

 Econazole nitrate Crm 1% Any 0

For continuation only

 Foaming soln 1% Any 0 Miconazole nitrate Lotn 2% Any 0

For continuation only

 Tinc 2% Any 0 Crm 2% Multichem 15 0.55 Nystatin Crm 100,000 u per g Any 0 Metronidazole Gel 0.75% Any 0 Clotrimazole Soln 1% Any 0

For continuation only

 Crm 1% Clomazol 20 0.52 Ketoconazole Shampoo 2% Sebizole 100 2.99 Antiparasitics Lindane [Gamma benzene hexachloride] Crm 1% Any 0 Malathion [Maldison] Lotn 0.5% Any 0 Shampoo 1% Any 0 Malathion with permethrin and piperonyl butoxide Spray 0.25% with permethrin 0.5% and piperonyl butoxide 2% Any 0

Note: Temporary listing to cover out-of-stock.

 Permethrin Crm 5% Lyderm 30 4.20 Lotn 5% A-Scabies 30 3.19 Antiacne Preparations Antiacne Preparations Adapalene Crm 0.1% Any 0 Gel 0.1% Any 0 Benzoyl peroxide Soln 5% Any 0 Isotretinoin Cap 10 mg Isotane 10 100 12.47 Cap 20 mg Isotane 20 100 19.27 Tretinoin Crm 0.05% Any 0 Antipruritic Preparations Antipruritic Preparations Crotamiton Crm 10% Itch-Soothe 20 3.37 Calamine Crm, aqueous, BP Pharmacy Health 100 1.49 Lotn, BP PSM 2000 12.94 Barrier Creams and Emollients Barrier Creams Dimethicone Crm 5% tube healthE Dimethicone 5% 100 1.65 Crm 5% pump bottle healthE Dimethicone 5% 500 4.73 Crm 10% pump bottle healthE Dimethicone 10% 500 4.90 Zinc Crm e.g. Zinc Cream (Orion);Zinc Cream (PSM) 0 Oint e.g. Zinc oxide (PSM) 0 Paste Any 0 Zinc with wool fat Crm zinc 15.25% with wool fat 4% e.g. Sudocrem 0 Zinc and castor oil Oint, BP healthE 20 1.39 Crm Orion 20 1.63 Emollients Cetomacrogol with glycerol Crm 90% with glycerol 10%, Pharmacy Health 100 2.10 100 2.00 healthE 100 3.20 Crm 90% with glycerol 10% Pharmacy Health Sorbolene with Glycerin 1000 6.50 500 4.50 Crm 90% with glycerol 10%, 500 ml, 1 bottle healthE 1 5.46 Glycerol with paraffin Crm glycerol 10% with white soft paraffin 5% and liquid paraffin 10% e.g. QV cream 0 Paraffin with wool fat Lotn liquid paraffin 15.9% with wool fat 0.6% e.g. AlphaKeri;BK ;DP; Hydroderm Lotn 0 Lotn liquid paraffin 91.7% with wool fat 3% e.g. Alpha Keri Bath Oil 0 Urea Crm 10% Any 0 Wool fat Crm Any 0 Aqueous cream Crm 500 g AFT 500 1.96 Crm 100 g AFT 100 1.23 Pharmacy Health SLS-free 100 1.00

Note: DV limit applies to the pack sizes of 100 g or less.

 Emulsifying ointment Oint BP Jaychem 100 1.84

Note: DV limit applies to pack sizes of less than 200 g.

 Oint BP, 500 g AFT 500 2.73

Note: DV limit applies to pack sizes of greater than 200 g.

 Oil in water emulsion Crm healthE Fatty Cream 500 2.63 Crm, 100 g healthE Fatty Cream 1 1 1.60 Paraffin Oint liquid paraffin 50% with white soft paraffin 50% healthE 100 3.10 Yellow soft Any 0 White soft healthE 10 0.85

Note: DV limit applies to pack sizes of 30 g or less, and to both white soft paraffin and yellow soft paraffin.

 Cetomacrogol Crm BP, 100 g healthE 1 1.47 Crm BP, 500 g healthE 500 2.74 Corticosteroids Corticosteroids Betamethasone dipropionate Crm 0.05% Any 0 Oint 0.05% Any 0 Clobetasone butyrate Crm 0.05% Any 0 Diflucortolone valerate Crm 0.1% Any 0 Fatty oint 0.1% Any 0

For continuation only

 Hydrocortisone with paraffin and wool fat Lotn 1% with paraffin liquid 15.9% and wool fat 0.6% Any 0 Hydrocortisone and paraffin liquid and lanolin Lotn 1% with paraffin liquid 15.9% and lanolin 0.6% DP Lotn HC 250 10.57 Hydrocortisone Crm 1%, 500 g Pharmacy Health 500 14.00 Crm 1%, 100 g Pharmacy Health 100 3.75 Triamcinolone acetonide Crm 0.02% Aristocort 100 6.30 Oint 0.02% Aristocort 100 6.35 Clobetasol propionate Crm 0.05% Clobetasol BNM 30 3.20 Oint 0.05% Clobetasol BNM 30 3.20 Hydrocortisone butyrate Crm 0.1% Locoid Lipocream 30 2.30 100 6.85 Oint 0.1% Locoid 100 6.85 Milky emul 0.1% Locoid Crelo 100 6.85 Methylprednisolone aceponate Crm 0.1% Advantan 15 4.95 Oint 0.1% Advantan 15 4.95 Hydrocortisone acetate Crm 1% AFT 14.20 2.48 Betamethasone valerate Crm 0.1% Beta Cream 50 3.15 Lotn 0.1% Any 0 Oint 0.1% Beta Ointment 50 3.15 Mometasone furoate Crm 0.1% Elocon Alcohol Free 15 1.51 50 2.90 Oint 0.1% Elocon 15 1.51 50 2.90 Lotn 0.1% Any 0 Elocon 30 7.35 Corticosteroids with Anti-Infective Agents Betamethasone valerate with clioquinol Crm 0.1% with clioquiniol 3% Any 0
Either:

  1. For the treatment of intertrigo; or

  2. For continuation use

 Betamethasone valerate with fusidic acid Crm 0.1% with fusidic acid 2% Any 0 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 Any 0 Hydrocortisone with natamycin and neomycin Crm 1% with natamycin 1% and neomycin sulphate 0.5% Pimafucort 15 2.79 Oint 1% with natamycin 1% and neomycin sulphate 0.5% Pimafucort 15 2.79 Hydrocortisone with miconazole Crm 1% with miconazole nitrate 2% Micreme H 15 2.00 Psoriasis and Eczema Preparations Psoriasis and Eczema Preparations Coal tar with salicylic acid and sulphur Oint 12% with salicylic acid 2% and sulphur 4% Any 0 Methoxsalen [8-methoxypsoralen] Lotn 1.2% Any 0 Tab 10 mg Any 0 Potassium permanganate Tab 400 mg Any 0 Crystals Any 0 Calcipotriol Crm 50 mcg per g Daivonex 30 16.00 100 45.00 Oint 50 mcg per g Daivonex 100 45.00 Soln 50 mcg per ml Daivonex 30 16.00 Coal tar with triethanolamine lauryl sulphate and fluorescein Soln 2.3% with triethanolamine lauryl sulphate and fluorescein sodium Pinetarsol 500 3.36 1000 5.82 Acitretin Cap 10 mg Novatretin 60 17.86 Cap 25 mg Novatretin 60 41.36 Betamethasone dipropionate with calcipotriol Oint 500 mcg with calcipotriol 50 mcg per g Daivobet 30 26.12 Gel 500 mcg with calcipotriol 50 mcg per g Daivobet 30 26.12 Scalp Preparations Scalp Preparations Clobetasol propionate Scalp app 0.05% Dermol 30 6.96 Hydrocortisone butyrate Scalp lotn 0.1% Locoid 100 3.65 Betamethasone valerate Scalp app 0.1% Beta Scalp 100 7.75 Wart Preparations Wart Preparations Silver nitrate Sticks with applicator Any 0 Podophyllotoxin Soln 0.5% Condyline 3.50 33.60 Imiquimod Crm 5%, 250 mg sachet Apo-Imiquimod Cream 5% 12 17.98 Other Skin Preparations Other Skin Preparations Diphemanil metilsulfate Powder 2% Any 0 Sunscreen, proprietary Crm Any 0 Lotn Marine Blue Lotion SPF 50+ 100 3.30 200 5.10 Antineoplastics Methyl aminolevulinate hydrochloride Crm 16% Any 0

Dermatologist or plastic surgeon

 Fluorouracil sodium Crm 5% Efudix 20 8.95 Wound Management Products Calcium gluconate Gel 2.5% healthE 1 21.00 Genito-Urinary System Anti-Infective Agents Anti-Infective Agents Acetic acid Soln 3% Any 0 Soln 5% Any 0 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 Any 0 Miconazole nitrate Vaginal crm 2% with applicator Micreme 40 3.95 Nystatin Vaginal crm 100,000 u per 5 g with applicator(s) Any 0 Clotrimazole Vaginal crm 1% with applicator Clomazol 35 1.45 Vaginal crm 2% with applicator Clomazol 20 2.20 Chlorhexidine gluconate Lotn 1%, 200 ml healthE 1 2.98 Crm 1% healthE 50 1.21 Contraceptives Antiandrogen Oral Contraceptives Cyproterone acetate with ethinyloestradiol Tab 2 mg with ethinyloestradiol 35 mcg and 7 inert tablets Ginet 168 5.36 Combined Oral Contraceptives Ethinyloestradiol with desogestrel Tab 20 mcg with desogestrel 150 mcg Any 0 Tab 30 mcg with desogestrel 150 mcg Any 0 Ethinyloestradiol with norethisterone Tab 35 mcg with norethisterone 1 mg Any 0 Tab 35 mcg with norethisterone 500 mcg Any 0 Norethisterone with mestranol Tab 1 mg with mestranol 50 mcg Any 0 Ethinyloestradiol with levonorgestrel Tab 20 mcg with levonorgestrel 100 mcg Any 0 Tab 30 mcg with levonorgestrel 150 mcg Any 0 Tab 50 mcg with levonorgestrel 125 mcg Microgynon 50 ED 84 9.45 Tab 20 mcg with levonorgestrel 100 mcg and 7 inert tablets Ava 20 ED 84 2.65 Tab 30 mcg with levonorgestrel 150 mcg and 7 inert tablets Ava 30 ED 84 2.30 Contraceptive Devices Intra-uterine device IUD 29.1 mm length x 23.2 mm width Choice TT380 Short 1 31.60 IUD 33.6 mm length x 29.9 mm width Choice TT380 Standard 1 31.60 Emergency Contraception Levonorgestrel Tab 1.5 mg Postinor-1 1 3.50 Progestogen-Only Contraceptives Medroxyprogesterone acetate Inj 150 mg per ml, 1 ml syringe Depo-Provera 1 7.00 Norethisterone Tab 350 mcg Noriday 28 84 6.25 Levonorgestrel Intra-uterine system, 20 mcg per day e.g. Mirena 0

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:

    1. Serum ferritin level < 16 mcg/l (within the last 12 months); or

    2. Haemoglobin level < 120 g/l; or

    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.

 Tab 30 mcg Any 0 Subdermal implant (2 x 75 mg rods) Jadelle 1 133.65 Obstetric Preparations Antiprogestogens Mifepristone Tab 200 mg Any 0 Oxytocics Carboprost trometamol Inj 250 mcg per ml, 1 ml ampoule Any 0 Oxytocin with ergometrine maleate Inj 5 iu with ergometrine maleate 500 mcg per ml, 1 ml ampoule Syntometrine 5 11.13 Oxytocin Inj 10 iu per ml, 1 ml ampoule Oxytocin BNM 5 5.03 Inj 5 iu per ml, 1 ml ampoule Oxytocin BNM 5 4.03 Dinoprostone Pessaries 10 mg Any 0 Gel 1 mg in 2.5 ml Prostin E2 1 52.65 Gel 2 mg in 2.5 ml Prostin E2 1 64.60 Ergometrine maleate Inj 500 mcg per ml, 1 ml ampoule DBL Ergometrine 5 94.70 Tocolytics Progesterone Cap 100 mg Utrogestan 30 16.50

Obstetrician or gynaecologist

Both:

  1. For the prevention of pre-term labour*; and

  2. Either:

    1. The patient has a short cervix on ultrasound (defined as < 25mm at 16 to 28 weeks) or

    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 Inj 500 mcg ampoule Any 0

Obstetrician

 Oestrogens Oestrogens Oestriol Crm 1 mg per g with applicator Any 0 Pessaries 500 mcg Any 0 Urologicals 5-Alpha Reductase Inhibitors Finasteride Tab 5 mg Finpro 30 2.08
Both:

  1. Patient has symptomatic benign prostatic hyperplasia; and

  2. Either:

    1. The patient is intolerant of non-selective alpha blockers or these are contraindicated; or

    2. Symptoms are not adequately controlled with non-selective alpha blockers.

 Alpha-1A Adrenoceptor Blockers Tamsulosin Cap 400 mcg Tamsulosin-Rex 100 13.51
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 Sodium citro-tartrate Grans eff 4 g sachets Ural 28 2.93 Potassium citrate Oral liq 3 mmol per ml Biomed 200 30.00
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.

 Urinary Antispasmodics Oxybutynin Oral liq 5 mg per 5 ml Apo-Oxybutynin 473 56.45 Tab 5 mg Apo-Oxybutynin 500 11.20 Solifenacin succinate Tab 5 mg Vesicare 30 37.50 Tab 10 mg Vesicare 30 37.50

Patient has overactive bladder and a documented intolerance of, or is non-responsive to, oxybutynin.

Tolterodine tartrate Tab 1 mg Arrow-Tolterodine 56 14.56 Tab 2 mg Arrow-Tolterodine 56 14.56

Patient has overactive bladder and a documented intolerance of, or is non-responsive to, oxybutynin.

Hormone Preparations Anabolic Agents Anabolic Agents Oxandrolone Tab 2.5 mg Any 0

For the treatment of burns patients.

 Androgen Agonists and Antagonists Androgen Agonists and Antagonists 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 Any 0 Cyproterone acetate Tab 50 mg Procur 50 15.87 Tab 100 mg Procur 50 30.40 Testosterone Patch 2.5 mg per day Androderm 60 80.00 Testosterone cypionate Inj 100 mg per ml, 10 ml vial Depo-Testosterone 1 76.50 Testosterone undecanoate Cap 40 mg Andriol Testocaps 60 16.80 Inj 250 mg per ml, 4 ml vial Reandron 1000 1 86.00 Calcium Homeostasis Calcium Homeostasis Zoledronic acid Inj 4 mg per 5 ml, vial Zometa 1 550.00

Oncologist, haematologist or palliative care specialist

Any of the following:

  1. Patient has hypercalcaemia of malignancy; or

  2. Both:

    1. Patient has bone metastases or involvement; and

    2. Patient has severe bone pain resistant to standard first-line treatments; or

  3. Both:

    1. Patient has bone metastases or involvement; and

    2. Patient is at risk of skeletal-related events (pathological fracture, spinal cord compression, radiation to bone or surgery to bone).

 Calcitonin Inj 100 iu per ml, 1 ml ampoule Miacalcic 5 121.00 Corticosteroids Corticosteroids Betamethasone Inj 4 mg per ml, 1 ml ampoule Any 0 Tab 500 mcg Any 0 Betamethasone sodium phosphate with betamethasone acetate Inj 3.9 mg with betamethasone acetate 3 mg per ml, 1 ml ampoule Any 0 Methylprednisolone (as sodium succinate) Inj 1 g vial Solu-Medrol 1 16.00 Inj 125 mg vial Solu-Medrol 1 22.25 Inj 40 mg vial Solu-Medrol 1 10.50 Inj 500 mg vial Solu-Medrol 1 9.00 Tab 100 mg Medrol 20 180.00 Tab 4 mg Medrol 100 80.00 Prednisolone Enema 200 mcg per ml, 100 ml Any 0 Oral liq 5 mg per ml Redipred 30 7.50 Triamcinolone hexacetonide Inj 20 mg per ml, 1 ml vial Any 0 Hydrocortisone Tab 5 mg Douglas 100 100 8.10 Tab 20 mg Douglas 100 100 20.32 Inj 100 mg vial Solu-Cortef 1 4.99 Triamcinolone acetonide Inj 10 mg per ml, 1 ml ampoule Kenacort-A 10 5 20.80 Inj 40 mg per ml, 1 ml ampoule Kenacort-A 40 5 51.70 Fludrocortisone acetate Tab 100 mcg Florinef 100 14.32 Dexamethasone Oral liq 1 mg per ml Biomed 25 45.00 Tab 1 mg Douglas 100 5.87 Tab 4 mg Douglas 100 8.16 Dexmethsone 30 1.84 Tab 0.5 mg Dexmethsone 30 0.88 Methylprednisolone acetate Inj 40 mg per ml, 1 ml vial Depo-Medrol 5 40.00 Methylprednisolone acetate with lidocaine [lignocaine] Inj 40 mg with lidocaine [lignocaine], 1 ml vial Depo-Medrol with Lidocaine 1 9.25 Dexamethasone phosphate Inj 4 mg per ml, 1 ml ampoule Dexamethasone-hameln 10 25.80 Inj 4 mg per ml, 2 ml ampoule Dexamethasone-hameln 5 17.98 Prednisone Tab 1 mg Apo-Prednisone 500 10.68 Apo-Prednisone S29 100 2.13 Tab 2.5 mg Apo-Prednisone 500 12.09 Tab 5 mg Apo-Prednisone 500 11.09 Tab 20 mg Apo-Prednisone 500 29.03 Hormone Replacement Therapy Oestrogens Oestradiol Patch 100 mcg per day Any 0 Patch 25 mcg per day Any 0 Patch 50 mcg per day Any 0 Tab 1 mg Any 0 Tab 2 mg Any 0 Oestradiol valerate Tab 1 mg Progynova 84 12.36 Tab 2 mg Progynova 84 12.36 Oestrogens (conjugated equine) Tab 300 mcg Any 0 Tab 625 mcg Any 0 Progestogen and Oestrogen Combined Preparations Oestradiol with norethisterone acetate Tab 1 mg with 0.5 mg norethisterone acetate Any 0 Tab 2 mg with 1 mg norethisterone acetate Any 0 Tab 2 mg with 1 mg norethisterone acetate (10), and tab 2 mg oestradiol (12) and tab 1 mg oestradiol (6) Any 0 Oestrogens with medroxyprogesterone acetate Tab 625 mcg conjugated equine with 2.5 mg medroxyprogesterone acetate Any 0 Tab 625 mcg conjugated equine with 5 mg medroxyprogesterone acetate Any 0 Progestogens Medroxyprogesterone acetate Tab 2.5 mg Provera 30 30 3.09 Tab 5 mg Provera 100 100 13.06 Tab 10 mg Provera 30 30 6.85 Other Endocrine Agents Other Endocrine Agents Gestrinone Cap 2.5 mg Any 0 Metyrapone Cap 250 mg Any 0 Pentagastrin Inj 250 mcg per ml, 2 ml ampoule Any 0 Clomiphene citrate Tab 50 mg Serophene 10 29.84 Danazol Cap 100 mg Azol 100 68.33 Cap 200 mg Azol 100 97.83 Cabergoline Tab 0.5 mg Dostinex 2 4.75 8 19.00
Any of the following:

  1. Inhibition of lactation; or

  2. Patient has pathological hyperprolactinemia; or

  3. Patient has acromegaly.

 Other Oestrogen Preparations Other Oestrogen Preparations Ethinyloestradiol Tab 10 mcg NZ Medical & Scientific 100 17.60 Oestradiol Implant 50 mg Any 0 Oestriol Tab 2 mg Any 0 Other Progestogen Preparations Other Progestogen Preparations Medroxyprogesterone Tab 100 mg Provera 100 96.50 Norethisterone Tab 5 mg Primolut N 100 18.29 Pituitary and Hypothalamic Hormones and Analogues Pituitary and Hypothalamic Hormones and Analogues Corticotrorelin (ovine) Inj 100 mcg vial Any 0 Thyrotropin alfa Inj 900 mcg vial Any 0 Adrenocorticotropic Hormones Tetracosactide [Tetracosactrin] Inj 250 mcg per ml, 1 ml ampoule Synacthen 10 177.18 Inj 1 mg per ml, 1 ml ampoule Synacthen Depot 1 29.56 GnRH Agonists and Antagonists Buserelin Inj 1 mg per ml, 5.5 ml vial Any 0 Gonadorelin Inj 100 mcg vial Any 0 Goserelin Implant 10.8 mg Zoladex 1 443.76 Implant 3.6 mg Zoladex 1 166.20 Leuprorelin acetate Inj 45 mg syringe Eligard 1 832.05 Inj 7.5 mg syringe Eligard 1 166.20 Inj 22.5 mg syringe Eligard 1 443.76 Inj 30 mg vial Eligard 1 591.68 Inj 3.75 mg syringe Lucrin Depot PDS 1 221.60 Inj 11.25 mg syringe Lucrin Depot PDS 1 591.68 Inj 30 mg syringe Lucrin Depot PDS 1 1109.40 Gonadotrophins Choriogonadotropin alfa Inj 250 mcg in 0.5 ml syringe Any 0 Growth Hormone Somatropin Inj 5 mg cartridge Omnitrope 1 109.50 Inj 10 mg cartridge Omnitrope 1 219.00 Inj 15 mg cartridge Omnitrope 1 328.50

Initiation - growth hormone deficiency in children

Endocrinologist

Paediatric Endocrinologist

Either:

  1. Growth hormone deficiency causing symptomatic hypoglycaemia, or with other significant growth hormone deficient sequelae (e.g. cardiomyopathy, hepatic dysfunction) and diagnosed with GH < 5 mcg/l on at least two random blood samples in the first 2 weeks of life, or from samples during established hypoglycaemia (whole blood glucose < 2 mmol/l using a laboratory device); or

  2. All of the following:

    1. Height velocity < 25th percentile for age; and adjusted for bone age/pubertal status if appropriate over 6 or 12 months using the standards of Tanner and Davies (1985); and

    2. A current bone age is < 14 years (female patients) or < 16 years (male patients); and

    3. Peak growth hormone value of < 5.0 mcg per litre in response to two different growth hormone stimulation tests. In children who are 5 years or older, GH testing with sex steroid priming is required; and

    4. If the patient has been treated for a malignancy, they should be disease free for at least one year based upon follow-up laboratory and radiological imaging appropriate for the malignancy, unless there are strong medical reasons why this is either not necessary or appropriate; and

    5. Appropriate imaging of the pituitary gland has been obtained.

Continuation - growth hormone deficiency in children

Endocrinologist

Paediatric Endocrinologist

Re-assessment required after 12 months

All of the following:

  1. A current bone age is ≤ 14 years (female patients) or ≤ 16 years (male patients); and

  2. Height velocity is ≥ 25th percentile for age (adjusted for bone age/pubertal status if appropriate) while on growth hormone treatment, as calculated over six months using the standards of Tanner and Davis (1985); and

  3. Height velocity is ≥ 2.0 cm per year, as calculated over 6 months; and

  4. No serious adverse effect that the patients specialist considers is likely to be attributable to growth hormone treatment has occurred; and

  5. No malignancy has developed since starting growth hormone.

Initiation - Turner syndrome

Endocrinologist

Paediatric Endocrinologist

All of the following:

  1. The patient has a post-natal genotype confirming Turner Syndrome; and

  2. Height velocity is < 25th percentile over 6-12 months using the standards of Tanner and Davies (1985); and

  3. A current bone age is < 14 years.

Continuation - Turner syndrome

Endocrinologist

Paediatric Endocrinologist

Re-assessment required after 12 months

All of the following:

  1. Height velocity ≥ 50th percentile for age (while on growth hormone calculated over 6 to 12 months using the Ranke’s Turner Syndrome growth velocity charts); and

  2. Height velocity is ≥ 2 cm per year, calculated over six months; and

  3. A current bone age is ≤ 14 years; and

  4. No serious adverse effect that the specialist considers is likely to be attributable to growth hormone treatment has occurred; and

  5. No malignancy has developed since starting growth hormone.

Initiation - short stature without growth hormone deficiency

Endocrinologist

Paediatric Endocrinologist

All of the following:

  1. The patient’s height is more than 3 standard deviations below the mean for age or for bone age if there is marked growth acceleration or delay; and

  2. Height velocity is < 25th percentile for age (adjusted for bone age/pubertal status if appropriate), as calculated over 6 to 12 months using the standards of Tanner and Davies(1985); and

  3. A current bone age is < 14 years (female patients) or < 16 years (male patients); and

  4. The patient does not have severe chronic disease (including malignancy or recognized severe skeletal dysplasia) and is not receiving medications known to impair height velocity.

Continuation - short stature without growth hormone deficiency

Endocrinologist

Paediatric Endocrinologist

Re-assessment required after 12 months

All of the following:

  1. Height velocity is ≥ 50th percentile (adjusted for bone age/pubertal status if appropriate) as calculated over 6 to 12 months using the standards of Tanner and Davies (1985); and

  2. Height velocity is ≥ 2 cm per year as calculated over six months; and

  3. Current bone age is ≤ 14 years (female patients) or ≤ 16 years (male patients); and

  4. No serious adverse effect that the patient’s specialist considers is likely to be attributable to growth hormone treatment has occurred.

Initiation - short stature due to chronic renal insufficiency

Endocrinologist

Paediatric Endocrinologist

Renal Physician on the recommendation of a Paediatric Endocrinologist or Endocrinologist

All of the following:

  1. The patient’s height is more than 2 standard deviations below the mean; and

  2. Height velocity is < 25th percentile (adjusted for bone age/pubertal status if appropriate) as calculated over 6 to 12 months using the standards of Tanner and Davies (1985); and

  3. A current bone age is ≤ to 14 years (female patients) or ≤ to 16 years (male patients); and

  4. The patient is metabolically stable, has no evidence of metabolic bone disease and absence of any other severe chronic disease; and

  5. The patient is under the supervision of a specialist with expertise in renal medicine; and

  6. Either:

    1. The patient has a GFR ≤ 30 ml/min/1.73 m2 as measured by the Schwartz method (Height(cm)/plasma creatinine (umol/l x 40 = corrected GFR (ml/min/1.73 m2 ) in a child who may or may not be receiving dialysis; or

    2. The patient has received a renal transplant and has received < 5mg/ m2 /day of prednisone or equivalent for at least 6 months.

Continuation - short stature due to chronic renal insufficiency

Endocrinologist

Paediatric Endocrinologist

Renal Physician on the recommendation of a Paediatric Endocrinologist or Endocrinologist

Re-assessment required after 12 months

All of the following:

  1. Height velocity is ≥ 50th percentile (adjusted for bone age/pubertal status if appropriate) as calculated over 6 to 12 months using the standards of Tanner and Davies (1985); and

  2. Height velocity is ≥ 2 cm per year as calculated over six months; and

  3. A current bone age is ≤ 14 years (female patients) or ≤ 16 years (male patients); and

  4. No serious adverse effect that the patients specialist considers is likely to be attributable to growth hormone has occurred; and

  5. No malignancy has developed after growth hormone therapy was commenced; and

  6. The patient has not experienced significant biochemical or metabolic deterioration confirmed by diagnostic results; and

  7. The patient has not received renal transplantation since starting growth hormone treatment; and

  8. If the patient requires transplantation, growth hormone prescription should cease before transplantation and a new application should be made after transplantation based on the above criteria.

Initiation - Prader-Willi syndrome

Endocrinologist

Paediatric Endocrinologist

All of the following:

  1. The patient has a diagnosis of Prader-Willi syndrome that has been confirmed by genetic testing or clinical scoring criteria; and

  2. The patient’s height velocity is < 25th percentile for bone age adjusted for bone age/pubertal status if appropriate as calculated over 6 to 12 months using the standards of Tanner and Davies (1985) or pubertal status over 6 to 12 months; and

  3. Either:

    1. The patient is under two years of age and height velocity has been assessed over a minimum six month period from the age of 12 months, with at least three supine length measurements over this period demonstrating clear and consistent evidence of linear growth failure (with height velocity < 25th percentile); or

    2. The patient is aged two years or older; and

  4. A current bone age is < 14 years (female patients) or < 16 years (male patients); and

  5. Sleep studies or overnight oximetry have been performed and there is no obstructive sleep disorder requiring treatment, or if an obstructive sleep disorder is found, it has been adequately treated under the care of a paediatric respiratory physician and/or ENT surgeon; and

  6. There is no evidence of type II diabetes or uncontrolled obesity defined by BMI that has increased by ≥ 0.5 standard deviations in the preceding 12 months.

Continuation - Prader-Willi syndrome

Endocrinologist

Paediatric Endocrinologist

Re-assessment required after 12 months

All of the following:

  1. Height velocity is ≥ 50th percentile (adjusted for bone age/pubertal status if appropriate) as calculated over 6 to 12 months using the standards of Tanner and Davies (1985); and

  2. Height velocity is ≥ 2 cm per year as calculated over six months; and

  3. A current bone age is ≤ 14 years (female patients) or ≤ 16 years (male patients); and

  4. No serious adverse effect that the patient’s specialist con siders is likely to be attributable to growth hormone treatment has occurred; and

  5. No malignancy has developed after growth hormone therapy was commenced; and

  6. The patient has not developed type II diabetes or uncontrolled obesity as defined by BMI that has increased by ≥ 0.5 standard deviations in the preceding 12 months.

Initiation - adults and adolescents

Endocrinologist

Paediatric Endocrinologist

All of the following:

  1. The patient has a medical condition that is known to cause growth hormone deficiency (e.g. surgical removal of the pituitary for treatment of a pituitary tumour); and

  2. The patient has undergone appropriate treatment of other hormonal deficiencies and psychological illnesses; and

  3. The patient has severe growth hormone deficiency (see notes); and

  4. The patient’s serum IGF-I is more than 1 standard deviation below the mean for age and sex; and

  5. The patient has poor quality of life, as defined by a score of 16 or more using the disease-specific quality of life questionnaire for adult growth hormone deficiency (QoL-AGHDA®).

Notes:

For the purposes of adults and adolescents, severe growth hormone deficiency is defined as a peak serum growth hormone level of ≤ 3 mcg per litre during an adequately performed insulin tolerance test (ITT) or glucagon stimulation test.

Patients with one or more additional anterior pituitary hormone deficiencies and a known structural pituitary lesion only require one test. Patients with isolated growth hormone deficiency require two growth hormone stimulation tests, of which, one should be ITT unless otherwise contraindicated. Where an additional test is required, an arginine provocation test can be used with a peak serum growth hormone level of ≤ 0.4 mcg per litre.

The dose of somatropin should be started at 0.2 mg daily and be titrated by 0.1 mg monthly until it is within 1 standard deviation of the mean normal value for age and sex; and

The dose of somatropin not to exceed 0.7 mg per day for male patients, or 1 mg per day for female patients.

At the commencement of treatment for hypopituitarism, patients must be monitored for any required adjustment in replacement doses of corticosteroid and levothyroxine.

Continuation - adults and adolescents

Endocrinologist

Paediatric Endocrinologist

Re-assessment required after 12 months

Either:
  1. All of the following:

    1. The patient has been treated with somatropin for < 12 months; and

    2. There has been an improvement in the Quality of Life Assessment defined as a reduction of at least 8 points on the Quality of Life Assessment of Growth Hormone Deficiency in Adults (QoL-AGHDA®) score from baseline; and

    3. Serum IGF-I levels have increased to within ±1SD of the mean of the normal range for age and sex; and

    4. The dose of somatropin does not exceed 0.7 mg per day for male patients, or 1 mg per day for female patients; or

  2. All of the following:

    1. The patient has been treated with somatropin for more than 12 months; and

    2. The patient has not had a deterioration in Quality of Life defined as a 6 point or greater increase from their lowest QoL-AGHDA® score on treatment (other than due to obvious external factors such as external stressors); and

    3. Serum IGF-I levels have continued to be maintained within ±1SD of the mean of the normal range for age and sex (other than for obvious external factors); and

    4. The dose of somatropin has not exceeded 0.7 mg per day for male patients or 1 mg per day for female patients.

 Thyroid and Antithyroid Preparations Thyroid and Antithyroid Preparations Carbimazole Tab 5 mg Any 0 Iodine Soln BP 50 mg per ml Any 0 Levothyroxine Tab 100 mcg Any 0 Tab 25 mcg Any 0 Tab 50 mcg Any 0 Liothyronine sodium Inj 20 mcg vial Any 0 Tab 20 mcg Any 0

For a maximum of 14 days' treatment in patients with thyroid cancer who are due to receive radioiodine therapy

 Potassium iodate Tab 170 mg Any 0 Potassium perchlorate Cap 200 mg Any 0 Protirelin Inj 100 mcg per ml, 2 ml ampoule Any 0 Propylthiouracil Tab 50 mg PTU 100 35.00
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.

 Vasopressin Agents Vasopressin Agents Argipressin [Vasopressin] Inj 20 u per ml, 1 ml ampoule Any 0 Desmopressin acetate Inj 15 mcg per ml, 1 ml ampoule Any 0 Inj 4 mcg per ml, 1 ml ampoule Any 0 Nasal drops 100 mcg per ml Any 0 Tab 100 mcg Minirin 30 36.40
Nasal spray 10 mcg per dose Desmopressin-PH&T 6 22.95 Tab 200 mcg Minirin 30 93.60

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 0.1 mg per ml, 8.5 ml ampoule Glypressin 5 450.00 Inj 1 mg per 8.5 ml ampoule Glypressin 5 215.00 Infections Antibacterials Aminoglycosides Streptomycin sulphate Inj 400 mg per ml, 2.5 ml ampoule Any 0

Infectious disease physician, clinical microbiologist or respiratory physician

 Gentamicin sulphate Inj 40 mg per ml, 2 ml ampoule Pfizer 10 10 6.00 Inj 10 mg per ml, 1 ml ampoule Hospira 5 8.56 Inj 10 mg per ml, 2 ml ampoule APP Pharmaceuticals 25 175.10 Amikacin Inj 15 mg per ml, 5 ml syringe Any 0 Inj 250 mg per ml, 2 ml vial DBL Amikacin 5 431.20 Inj 5 mg per ml, 10 ml syringe Any 0 Inj 5 mg per ml, 5 ml syringe Biomed 10 176.00

Infectious disease physician, clinical microbiologist or respiratory physician

 Tobramycin Inj 100 mg per ml, 5 ml vial Any 0

Infectious disease physician, clinical microbiologist or respiratory physician

 Inj 40 mg per ml, 2 ml vial DBL Tobramycin 5 38.00

Infectious disease physician, clinical microbiologist or respiratory physician

 Solution for inhalation 60 mg per ml, 5 ml TOBI 56 2200.00

Patient has cystic fibrosis

 Powder Any 0

For addition to orthopaedic bone cement.

 Paromomycin Cap 250 mg Humatin 16 126.00

Infectious disease physician or clinical microbiologist

Carbapenems Imipenem with cilastatin Inj 500 mg with 500 mg cilastatin vial Imipenem+Cilastatin RBX 1 13.79

Infectious disease physician or clinical microbiologist

 Ertapenem Inj 1 g vial Invanz 1 73.50

Infectious disease physician or clinical microbiologist

 Meropenem Inj 500 mg vial DBL Meropenem 10 35.22 Inj 1 g vial DBL Meropenem 10 65.21

Infectious disease physician or clinical microbiologist

 Cephalosporins and Cephamycins - 1st Generation Cefazolin Inj 500 mg vial AFT 5 3.99 Inj 1 g vial AFT 5 3.38 Cefalexin Grans for oral liq 25 mg per ml Cefalexin Sandoz 100 8.00 Grans for oral liq 50 mg per ml Cefalexin Sandoz 100 11.00 Cap 500 mg Cephalexin ABM 20 5.70 Cephalosporins and Cephamycins - 2nd Generation Cefuroxime Inj 1.5 g vial Zinacef 1 1.30 Inj 750 mg vial Zinacef 5 3.70 Tab 250 mg Zinnat 50 29.40 Cefaclor Cap 250 mg Ranbaxy-Cefaclor 100 26.00 Grans for oral liq 25 mg per ml Ranbaxy-Cefaclor 100 3.53 Cefoxitin Inj 1 g vial Hospira 5 74.25 Cefoxitin Actavis 10 58.00 Cephalosporins and Cephamycins - 3rd Generation Cefotaxime Inj 1 g vial DBL Cefotaxime 10 17.10 Inj 500 mg vial Cefotaxime Sandoz 1 1.90 Ceftazidime Inj 1 g vial Fortum 1 1.55 Inj 2 g vial Fortum 1 3.34 Inj 500 mg vial Fortum 1 5.30

Infectious disease physician, clinical microbiologist or respiratory physician

 Ceftriaxone Inj 2 g vial Ceftriaxone-AFT 1 2.75 Inj 1 g vial Ceftriaxone-AFT 5 5.22 Inj 500 mg vial Ceftriaxone-AFT 1 1.50 Cephalosporins and Cephamycins - 4th Generation Cefepime Inj 1 g vial Cefepime-AFT 1 3.95 Inj 2 g vial Cefepime-AFT 1 6.92

Infectious disease physician or clinical microbiologist

 Cephalosporins and Cephamycins - 5th Generation Ceftaroline fosamil Inj 600 mg vial Zinforo 10 1450.00

Infectious disease physician or clinical microbiologist

Multi-resistant organism salvage therapy

Either:

  1. for patients where alternative therapies have failed; or

  2. for patients who have a contraindication or hypersensitivity to standard current therapies.

 Macrolides Erythromycin (as stearate) Tab 250 mg Any 0 Tab 500 mg Any 0

For continuation only

 Roxithromycin Tab 150 mg Arrow-Roxithromycin 50 7.48 Tab 300 mg Arrow-Roxithromycin 50 14.40 Erythromycin (as lactobionate) Inj 1 g vial Erythrocin IV 1 16.00 Clarithromycin Tab 250 mg Apo-Clarithromycin 14 3.98 Grans for oral liq 25 mg per ml Klacid 70 23.12 Inj 500 mg vial Martindale 1 20.40 Tab 500 mg Apo-Clarithromycin 14 10.40

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.

 Erythromycin (as ethylsuccinate) Tab 400 mg E-Mycin 100 16.95 Grans for oral liq 200 mg per 5 ml E-Mycin 100 5.00 Grans for oral liq 400 mg per 5 ml E-Mycin 100 6.77 Azithromycin Tab 500 mg Apo-Azithromycin 2 1.05 Grans for oral liq 200 mg per 5 ml (40 mg per ml) Zithromax 15 12.50 Tab 250 mg Apo-Azithromycin 30 9.00
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.

 Penicillins Ticarcillin with clavulanic acid Inj 3 g with clavulanic acid 0.1 mg vial Any 0

Infectious disease physician, clinical microbiologist or respiratory physician

 Amoxicillin with clavulanic acid Tab 500 mg with clavulanic acid 125 mg Augmentin 20 1.95 Curam Duo 100 9.75 Grans for oral liq 25 mg with clavulanic acid 6.25 mg per ml Augmentin 100 1.61 Grans for oral liq 50 mg with clavulanic acid 12.5 mg per ml Augmentin 100 2.19 Inj 1,000 mg with clavulanic acid 200 mg vial m-Amoxiclav 10 12.80 Inj 500 mg with clavulanic acid 100 mg vial m-Amoxiclav 10 10.14 Amoxicillin Inj 250 mg vial Ibiamox 5 6.32 10 10.67 Inj 500 mg vial Ibiamox 5 1 7.23 10 12.41 Inj 1 g vial Ibiamox 5 11.00 10 17.29 Cap 250 mg Apo-Amoxi 500 16.18 Cap 500 mg Apo-Amoxi 500 20.94 Grans for oral liq 250 mg per 5 ml Amoxicillin Actavis 100 0.97 Grans for oral liq 125 mg per 5 ml Amoxicillin Actavis 100 0.88 Benzylpenicillin sodium [Penicillin G] Inj 600 mg (1 million units) vial Sandoz 10 10.35 Flucloxacillin Cap 250 mg Staphlex 250 18.70 Cap 500 mg Staphlex 500 62.90 Inj 250 mg vial Flucloxin 10 8.80 Inj 500 mg vial Flucloxin 10 9.20 Inj 1 g vial Flucloxin 10 11.60 DBL Flucloxacillin 5 5.80 Grans for oral liq 25 mg per ml AFT 100 2.49 100 2.29 Grans for oral liq 50 mg per ml AFT 100 3.25 100 3.08 Procaine penicillin Inj 1.5 g in 3.4 ml syringe Cilicaine 5 123.50 Benzathine benzylpenicillin Inj 900 mg (1.2 million units) in 2.3 ml syringe Bicillin LA 10 315.00 Phenoxymethylpenicillin [Penicillin V] Cap 250 mg Cilicaine VK 50 2.88 Cap 500 mg Cilicaine VK 50 4.73 Grans for oral liq 125 mg per 5 ml AFT 100 1.64 Grans for oral liq 250 mg per 5 ml AFT 100 1.74 Piperacillin with tazobactam Inj 4 g with tazobactam 0.5 g vial Hospira 1 5.84

Infectious disease physician, clinical microbiologist or respiratory physician

 Quinolones Ciprofloxacin Inj 2 mg per ml, 100 ml bag Aspen Ciprofloxacin 10 41.00 Oral liq 100 mg per ml Any 0 Oral liq 50 mg per ml Any 0 Tab 250 mg Cipflox 28 1.75 Tab 500 mg Cipflox 28 2.00 Tab 750 mg Cipflox 28 3.75

Infectious disease physician or clinical microbiologist

 Norfloxacin Tab 400 mg Arrow-Norfloxacin 100 13.50 Moxifloxacin Tab 400 mg Avelox 5 52.00 Inj 1.6 mg per ml, 250 ml bag Avelox IV 400 1 70.00

Mycobacterium infection

Infectious disease physician, clinical microbiologist or respiratory physician

Either:
  1. Active tuberculosis, with any of the following:

    1. Documented resistance to one or more first-line medications; or

    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

    3. Impaired visual acuity (considered to preclude ethambutol use); or

    4. Significant pre-existing liver disease or hepatotoxicity from tuberculosis medications; or

    5. Significant documented intolerance and/or side effects following a reasonable trial of first-line medications; or

  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.

 Tetracyclines Demeclocycline hydrochloride Cap 150 mg Any 0 Cap 300 mg Any 0 Tab 150 mg Any 0 Minocycline Cap 100 mg Any 0

For continuation only

 Tab 50 mg Any 0 Tigecycline Inj 50 mg vial Any 0

Infectious disease physician or clinical microbiologist

 Doxycycline Inj 5 mg per ml, 20 ml vial Any 0 Tab 50 mg Any 0

For continuation only

 Tab 100 mg Doxine 250 6.75 Tetracycline Tab 250 mg Any 0 Cap 500 mg Tetracyclin Wolff 30 46.00 Other Antibacterials Daptomycin Inj 350 mg vial Cubicin 1 175.16 Inj 500 mg vial Cubicin 1 243.52

Infectious disease physician or clinical microbiologist

 Hexamine hippurate Tab 1 g Any 0 Lincomycin Inj 300 mg per ml, 2 ml vial Any 0

Infectious disease physician or clinical microbiologist

 Linezolid Inj 2 mg per ml, 300 ml bag Zyvox 10 1650.00 Oral liq 20 mg per ml Zyvox 150 775.00 Tab 600 mg Zyvox 10 800.00

Infectious disease physician or clinical microbiologist

 Nitrofurantoin Tab 100 mg Any 0 Tab 50 mg Any 0 Sulphadiazine Tab 500 mg Any 0

Infectious disease physician, clinical microbiologist or maternal-foetal medicine specialist

 Teicoplanin Inj 400 mg vial Any 0

Infectious disease physician or clinical microbiologist

 Fosfomycin Powder for oral solution, 3 g sachet Any 0

Infectious disease physician or clinical microbiologist

 Pivmecillinam Tab 200 mg Any 0

Infectious disease physician or clinical microbiologist

 Vancomycin Inj 500 mg vial Mylan 1 2.64

Infectious disease physician or clinical microbiologist

 Chloramphenicol Inj 1 g vial Any 0

Infectious disease physician or clinical microbiologist

Clindamycin Oral liq 15 mg per ml Any 0 Cap 150 mg Clindamycin ABM 16 5.80 Inj 150 mg per ml, 4 ml ampoule Dalacin C 10 100.00

Infectious disease physician or clinical microbiologist

 Fusidic acid Tab 250 mg Fucidin 12 34.50

Infectious disease physician or clinical microbiologist

 Colistin sulphomethate [Colestimethate] Inj 150 mg per ml, 1 ml vial Colistin-Link 1 65.00

Infectious disease physician, clinical microbiologist or respiratory physician

 Trimethoprim Tab 100 mg Any 0 Tab 300 mg TMP 50 15.00 Trimethoprim with sulphamethoxazole [Co-trimoxazole] Inj 16 mg with sulphamethoxazole 80 mg per ml, 5 ml ampoule Any 0 Tab 80 mg with sulphamethoxazole 400 mg Any 0 Oral liq 8 mg with sulphamethoxazole 40 mg per ml Deprim 100 2.15 Aztreonam Inj 1 g vial Azactam 5 131.00

Infectious disease physician or clinical microbiologist

Antifungals Imidazoles Ketoconazole Tab 200 mg Any 0

Oncologist

 Polyene Antimycotics Amphotericin B Inj (liposomal) 50 mg vial AmBisome 1 345.00 10 3450.00

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:

    1. Possible invasive fungal infection; and

    2. A multidisciplinary team (including an infectious disease physician or a clinical microbiologist) considers the treatment to be appropriate.

 Inj 50 mg vial Any 0

Infectious disease physician, clinical microbiologist, haematologist, oncologist, transplant specialist or respiratory physician

 Nystatin Tab 500,000 u Nilstat 50 17.09 Cap 500,000 u Nilstat 50 15.47 Triazoles Fluconazole Oral liquid 50 mg per 5 ml Diflucan 35 98.50 35 0.00 Inj 2 mg per ml, 50 ml vial Fluconazole-Claris 1 4.95 Cap 50 mg Ozole 28 3.49 Cap 150 mg Ozole 1 0.71 Cap 200 mg Ozole 28 9.69 Inj 2 mg per ml, 100 ml vial Fluconazole-Claris 1 6.47

Consultant

 Itraconazole Oral liquid 10 mg per ml Any 0 Cap 100 mg Itrazole 15 2.99

Infectious disease physician, clinical microbiologist, clinical immunologist or dermatologist

 Voriconazole Inj 200 mg vial Vfend 1 185.00 Oral liq 40 mg per ml Vfend 70 730.00 Tab 50 mg Vfend 56 730.00 Vttack 56 130.00 Tab 200 mg Vfend 56 2930.00 Vttack 56 500.00

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:

  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:

    1. Patient has fluconazole resistant candidiasis; or

    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.

 Posaconazole Oral liq 40 mg per ml Noxafil 105 761.13

Infectious disease physician or haematologist

Initiation

Re-assessment required after 6 weeks

Both:
  1. Either:

    1. Patient has acute myeloid leukaemia; or

    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:

    1. Patient is to be treated with high dose remission re-induction therapy; or

    2. Patient is to be treated with high dose consolidation therapy; or

    3. Patient is receiving a high risk stem cell transplant.

 Other Antifungals Flucytosine Cap 500 mg Any 0

Infectious disease physician or clinical microbiologist.

Terbinafine Tab 250 mg Dr Reddy's Terbinafine 14 1.50 Caspofungin Inj 50 mg vial Cancidas 1 667.50 Inj 70 mg vial Cancidas 1 862.50

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:

    1. Possible invasive fungal infection; and

    2. A multidisciplinary team (including an infectious disease physician or a clinical microbiologist) considers the treatment to be appropriate.

 Antimycobacterials Antileprotics Clofazimine Cap 50 mg Any 0

Infectious disease physician, clinical microbiologist or dermatologist

 Dapsone Tab 100 mg Dapsone 100 110.00 Tab 25 mg Dapsone 100 95.00

Infectious disease physician, clinical microbiologist or dermatologist

 Antituberculotics Cycloserine Cap 250 mg Any 0

Infectious disease physician, clinical microbiologist or respiratory physician

 Isoniazid with rifampicin Tab 100 mg with rifampicin 150 mg Rifinah 100 85.54 Tab 150 mg with rifampicin 300 mg Rifinah 100 170.60

Internal medicine physician, paediatrician, clinical microbiologist, dermatologist or public health physician

Pyrazinamide Tab 500 mg Any 0

Infectious disease physician, clinical microbiologist or respiratory physician

 Rifampicin Cap 150 mg Rifadin 100 55.75 Cap 300 mg Rifadin 100 116.25 Inj 600 mg vial Rifadin 1 128.85 Oral liq 100 mg per 5 ml Rifadin 60 12.00 Tab 600 mg Rifadin 30 108.70

Internal medicine physician, clinical microbiologist, dermatologist, paediatrician or public health physician

 Isoniazid Tab 100 mg PSM 100 20.00

Internal medicine physician, paediatrician, clinical microbiologist, dermatologist or public health physician

Rifabutin Cap 150 mg Mycobutin 30 213.19

Infectious disease physician, clinical microbiologist, respiratory physician or gastroenterologist

 Ethambutol hydrochloride Tab 100 mg Myambutol 56 48.01 Tab 400 mg Myambutol 56 49.34

Infectious disease physician, clinical microbiologist or respiratory physician

 Para-aminosalicylic Acid Grans for oral liq 4 g Paser 30 280.00

Infectious disease physician, clinical microbiologist or respiratory physician

 Protionamide Tab 250 mg Peteha 100 305.00

Infectious disease physician, clinical microbiologist or respiratory physician

 Antiparasitics Anthelmintics Albendazole Tab 200 mg Any 0 Tab 400 mg Any 0

Infectious disease physician or clinical microbiologist

 Praziquantel Tab 600 mg Any 0 Ivermectin Tab 3 mg Stromectol 4 17.20

Infectious disease physician, clinical microbiologist or dermatologist.

Mebendazole Oral liq 100 mg per 5 ml Any 0 Tab 100 mg De-Worm 24 24.19 Antiprotozoals Artemether with lumefantrine Tab 20 mg with lumefantrine 120 mg Any 0

Infectious disease physician or clinical microbiologist

 Artesunate Inj 60 mg vial Any 0

Infectious disease physician or clinical microbiologist

 Atovaquone with proguanil hydrochloride Tab 250 mg with proguanil hydrochloride 100 mg Malarone 12 64.00 Tab 62.5 mg with proguanil hydrochloride 25 mg Malarone Junior 12 25.00

Infectious disease physician or clinical microbiologist

 Chloroquine phosphate Tab 250 mg Any 0

Infectious disease physician, clinical microbiologist, dermatologist or rheumatologist

 Mefloquine Tab 250 mg Lariam 8 33.48

Infectious disease physician, clinical microbiologist, dermatologist or rheumatologist

 Pentamidine isethionate Inj 300 mg vial Pentacarinat 5 180.00

Infectious disease physician or clinical microbiologist

 Primaquine phosphate Tab 7.5 mg Any 0

Infectious disease physician or clinical microbiologist

 Pyrimethamine Tab 25 mg Any 0

Infectious disease physician, clinical microbiologist or maternal-foetal medicine specialist

 Quinine dihydrochloride Inj 300 mg per ml, 2 ml vial Any 0 Inj 60 mg per ml, 10 ml ampoule Any 0

Infectious disease physician or clinical microbiologist

 Sodium stibogluconate Inj 100 mg per ml, 1 ml vial Any 0

Infectious disease physician or clinical microbiologist

 Spiramycin Tab 500 mg Any 0

Maternal-foetal medicine specialist

 Quinine sulphate Tab 300 mg Q 300 100 6.66 500 54.06 Metronidazole Inj 5 mg per ml, 100 ml bag AFT 5 6.94 Tab 200 mg Trichozole 100 10.45 Tab 400 mg Trichozole 100 18.15 Oral liq benzoate 200 mg per 5 ml Flagyl-S 100 25.00 Suppos 500 mg Flagyl 10 24.48 Ornidazole Tab 500 mg Arrow-Ornidazole 10 16.50 Nitazoxanide Oral liq 100 mg per 5 ml Any 0 Tab 500 mg Alinia 30 1680.00

Infectious disease physician or clinical microbiologist

 Antiretrovirals HIV Fusion Inhibitors Enfuvirtide Inj 108 mg vial x 60 Fuzeon 1 2380.00

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:

    1. Patient has evidence of HIV replication, despite ongoing therapy; or

    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:

    1. Previous treatment with a non-nucleoside reverse transcriptase inhibitor has failed; and

    2. Previous treatment with a nucleoside reverse transcriptase inhibitor has failed; and

    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

 Non-Nucleoside Reverse Transcriptase Inhibitors Nevirapine Oral suspension 10 mg per ml Viramune Suspension 240 134.55 Tab 200 mg Nevirapine Alphapharm 60 65.00 Etravirine Tab 200 mg Intelence 60 770.00 Efavirenz Oral liq 30 mg per ml Any 0 Tab 50 mg Stocrin 30 63.38 Tab 200 mg Stocrin 90 190.15 Tab 600 mg Stocrin 30 63.38

Confirmed HIV

Both:

  1. Confirmed HIV infection; and

  2. Any of the following:

    1. Symptomatic patient; or

    2. Patient aged 12 months and under; or

    3. Both:

      1. Patient aged 1 to 5 years; and

      2. Any of the following:

        1. CD4 counts < 1000 cells/mm3; or

        2. CD4 counts < 0.25 × total lymphocyte count; or

        3. Viral load counts > 100000 copies per ml; or

    4. Both:

      1. Patient aged 6 years and over; and

      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:

    1. Patient has had unprotected receptive anal intercourse with a known HIV positive person; or

    2. Patient has shared intravenous injecting equipment with a known HIV positive person; or

    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.

 Nucleoside Reverse Transcriptase Inhibitors Didanosine [DDI] Cap 125 mg Any 0 Cap 200 mg Any 0 Cap 250 mg Any 0 Cap 400 mg Any 0 Stavudine Cap 30 mg Any 0 Cap 40 mg Any 0 Powder for oral soln 1 mg per ml Any 0 Abacavir sulphate with lamivudine Tab 600 mg with lamivudine 300 mg Kivexa 30 630.00 Emtricitabine Cap 200 mg Emtriva 30 307.20 Zidovudine [AZT] Inj 10 mg per ml, 20 ml vial Retrovir IV 5 750.00 Cap 100 mg Retrovir 100 152.25 Oral liq 10 mg per ml Retrovir 200 30.45 Abacavir sulphate Tab 300 mg Ziagen 60 229.00 Oral liq 20 mg per ml Ziagen 240 256.31 Lamivudine Oral liq 10 mg per ml Any 0 Zidovudine [AZT] with lamivudine Tab 300 mg with lamivudine 150 mg Alphapharm 60 44.00 Efavirenz with emtricitabine and tenofovir disoproxil fumarate Tab 600 mg with emtricitabine 200 mg and tenofovir disoproxil fumarate 300 mg Atripla 30 1313.19 Emtricitabine with tenofovir disoproxil fumarate Tab 200 mg with tenofovir disoproxil fumarate 300 mg Truvada 30 838.20

Confirmed HIV

Both:

  1. Confirmed HIV infection; and

  2. Any of the following:

    1. Symptomatic patient; or

    2. Patient aged 12 months and under; or

    3. Both:

      1. Patient aged 1 to 5 years; and

      2. Any of the following:

        1. CD4 counts < 1000 cells/mm3; or

        2. CD4 counts < 0.25 × total lymphocyte count; or

        3. Viral load counts > 100000 copies per ml; or

    4. Both:

      1. Patient aged 6 years and over; and

      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:

    1. Patient has had unprotected receptive anal intercourse with a known HIV positive person; or

    2. Patient has shared intravenous injecting equipment with a known HIV positive person; or

    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.

 Protease Inhibitors Indinavir Cap 200 mg Any 0 Cap 400 mg Any 0 Ritonavir Oral liq 80 mg per ml Any 0 Tab 100 mg Norvir 30 43.31 Atazanavir sulphate Cap 150 mg Reyataz 60 568.34 Cap 200 mg Reyataz 60 757.79 Lopinavir with ritonavir Tab 200 mg with ritonavir 50 mg Kaletra 120 735.00 Oral liq 80 mg with ritonavir 20 mg per ml Kaletra 300 735.00 Tab 100 mg with ritonavir 25 mg Kaletra 60 183.75 Darunavir Tab 400 mg Prezista 60 837.50 Tab 600 mg Prezista 60 1190.00

Confirmed HIV

Both:

  1. Confirmed HIV infection; and

  2. Any of the following:

    1. Symptomatic patient; or

    2. Patient aged 12 months and under; or

    3. Both:

      1. Patient aged 1 to 5 years; and

      2. Any of the following:

        1. CD4 counts < 1000 cells/mm3; or

        2. CD4 counts < 0.25 × total lymphocyte count; or

        3. Viral load counts > 100000 copies per ml; or

    4. Both:

      1. Patient aged 6 years and over; and

      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:

    1. Patient has had unprotected receptive anal intercourse with a known HIV positive person; or

    2. Patient has shared intravenous injecting equipment with a known HIV positive person; or

    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.

 Strand Transfer Inhibitors Raltegravir potassium Tab 400 mg Isentress 60 1090.00

Confirmed HIV

Both:

  1. Confirmed HIV infection; and

  2. Any of the following:

    1. Symptomatic patient; or

    2. Patient aged 12 months and under; or

    3. Both:

      1. Patient aged 1 to 5 years; and

      2. Any of the following:

        1. CD4 counts < 1000 cells/mm3; or

        2. CD4 counts < 0.25 × total lymphocyte count; or

        3. Viral load counts > 100000 copies per ml; or

    4. Both:

      1. Patient aged 6 years and over; and

      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:

    1. Patient has had unprotected receptive anal intercourse with a known HIV positive person; or

    2. Patient has shared intravenous injecting equipment with a known HIV positive person; or

    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.

 Antivirals Hepatitis B Adefovir dipivoxil Tab 10 mg Hepsera 30 670.00

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:
    1. Both:

      1. Patient is cirrhotic; and

      2. Adefovir dipivoxil to be used in combination with lamivudine; or

    2. Both:

      1. Patient is not cirrhotic; and

      2. Adefovir dipivoxil to be used as monotherapy.

 Tenofovir disoproxil fumarate Tab 300 mg Viread 30 531.00

Confirmed hepatitis B

Any of the following:
  1. All of the following:

    1. Patient has confirmed Hepatitis B infection (HBsAg positive for more than 6 months); and

    2. Patient has had previous lamivudine, adefovir or entecavir therapy; and

    3. HBV DNA greater than 20,000 IU/mL or increased ≤ 10-fold over nadir; and

    4. Any of the following:

      1. Lamivudine resistance - detection of M204I/V mutation; or

      2. Adefovir resistance - detection of A181T/V or N236T mutation; or

      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:

  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:

    1. Symptomatic patient; or

    2. Patient aged 12 months and under; or

    3. Both:

      1. Patient aged 1 to 5 years; and

      2. Any of the following:

        1. CD4 counts < 1000 cells/mm3; or

        2. CD4 counts < 0.25 × total lymphocyte count; or

        3. Viral load counts > 100000 copies per ml; or

    4. Both:

      1. Patient aged 6 years and over; and

      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:

    1. Patient has had unprotected receptive anal intercourse with a known HIV positive person; or

    2. Patient has shared intravenous injecting equipment with a known HIV positive person; or

    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.

 Entecavir Tab 0.5 mg Baraclude 30 400.00

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:

    1. ALT greater than upper limit of normal; or

    2. Bridging fibrosis or cirrhosis (Metavir stage 3 or greater or moderate fibrosis) on liver histology; and

  5. Either:

    1. HBeAg positive; or

    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 Oral liq 5 mg per ml Zeffix 240 270.00 Tab 100 mg Zeffix 28 6.00

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

  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 <100,000 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

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.

 Hepatitis C Boceprevir Cap 200 mg Victrelis 336 5015.00

Chronic hepatitis C - genotype 1, first-line

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

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

  3. Any one of:

    1. Patient was a responder relapser; or

    2. Patient was a partial responder; or

    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 Cidofovir Inj 75 mg per ml, 5 ml vial Any 0

Infectious disease physician, clinical microbiologist, otolaryngologist or oral surgeon

 Foscarnet sodium Inj 24 mg per ml, 250 ml bottle Any 0

Infectious disease physician or clinical microbiologist

 Ganciclovir Inj 500 mg vial Cymevene 5 380.00

Infectious disease physician or clinical microbiologist

 Aciclovir Inj 250 mg vial Zovirax IV 5 14.09 Aciclovir-Claris 5 10.10 Tab dispersible 200 mg Lovir 25 1.78 Tab dispersible 400 mg Lovir 56 5.98 Tab dispersible 800 mg Lovir 35 6.64 Valaciclovir Tab 500 mg Valtrex 30 102.72
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 Tab 450 mg Valcyte 60 1050.00

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:

    1. The donor was cytomegalovirus positive and the patient is cytomegalovirus negative; or

    2. The recipient is cytomegalovirus positive.

Cytomegalovirus in immunocompromised patients

Both:

  1. Patient is immunocompromised; and

  2. Any of the following:

    1. Patient has cytomegalovirus syndrome or tissue invasive disease; or

    2. Patient has rapidly rising plasma CMV DNA in absence of disease; or

    3. Patient has cytomegalovirus retinitis.

 Influenza Oseltamivir Tab 75 mg Any 0 Powder for oral suspension 6 mg per ml Any 0
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 Relenza Rotadisk 20 37.38
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.

 Immune Modulators Immune Modulators Interferon alfa-2a Inj 3 m iu prefilled syringe Any 0 Inj 6 m iu prefilled syringe Any 0 Inj 9 m iu prefilled syringe Any 0 Interferon alfa-2b Inj 18 m iu, 1.2 ml multidose pen Any 0 Inj 30 m iu, 1.2 ml multidose pen Any 0 Inj 60 m iu, 1.2 ml multidose pen Any 0 Interferon gamma Inj 100 mcg in 0.5 ml vial Any 0

Patient has chronic granulomatous disease and requires interferon gamma.

 Pegylated interferon alfa-2a Inj 135 mcg prefilled syringe Any 0 Inj 135 mcg prefilled syringe (4) with ribavirin tab 200 mg (112) Any 0 Inj 135 mcg prefilled syringe (4) with ribavirin tab 200 mg (168) Any 0 Inj 180 mcg prefilled syringe Pegasys 4 900.00 Inj 180 mcg prefilled syringe (4) with ribavirin tab 200 mg (112) Pegasys RBV Combination Pack 1 1159.84 Inj 180 mcg prefilled syringe (4) with ribavirin tab 200 mg (168) Pegasys RBV Combination Pack 1 1290.00

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. Patient has chronic hepatitis C, genotype 1, 4, 5 or 6 infection; or

    2. Patient has chronic hepatitis C and is co-infected with HIV; or

    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:

    1. Patient has responder relapsed; or

    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:

    1. Patient has responder relapsed; or

    2. Patient was a partial responder; or

    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

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:

    1. HBeAg positive; or

    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.

 Musculoskeletal System Anticholinesterases Anticholinesterases Edrophonium chloride Inj 10 mg per ml, 1 ml ampoule Any 0 Inj 10 mg per ml, 15 ml vial Any 0

For the diagnosis of myasthenia gravis

 Neostigmine metilsulfate with glycopyrronium bromide Inj 2.5 mg with glycopyrronium bromide 0.5 mg per ml, 1 ml ampoule Max Health 10 27.86 Neostigmine metilsulfate Inj 2.5 mg per ml, 1 ml ampoule AstraZeneca 50 98.00 Pyridostigmine bromide Tab 60 mg Mestinon 100 38.90 Antirheumatoid Agents Antirheumatoid Agents Auranofin Tab 3 mg Any 0 Sodium aurothiomalate Inj 10 mg in 0.5 ml ampoule Any 0 Inj 20 mg in 0.5 ml ampoule Any 0 Inj 50 mg in 0.5 ml ampoule Any 0 Penicillamine Tab 250 mg D-Penamine 100 98.98 Tab 125 mg D-Penamine 100 61.93 Leflunomide Tab 10 mg Arava 30 55.00 Tab 20 mg Arava 30 76.00 Tab 100 mg Arava 3 54.44 Hydroxychloroquine Tab 200 mg Plaquenil 100 10.50 Drugs Affecting Bone Metabolism Bisphosphonates Risedronate sodium Tab 35 mg Risedronate Sandoz 4 4.00 Pamidronate disodium Inj 3 mg per ml, 10 ml vial Pamisol 1 6.80 Inj 6 mg per ml, 10 ml vial Pamisol 1 13.20 Inj 9 mg per ml, 10 ml vial Pamisol 1 19.20 Zoledronic acid Inj 5 mg per 100 ml, vial Aclasta 100 600.00

Inherited bone fragility disorders

Patient has been diagnosed with an inherited bone fragility disorder (e.g. osteogenesis imperfecta).

Osteoporosis

Both:
  1. 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 alendronate (Underlying cause - Osteoporosis) or raloxifene; and

  2. The patient will not be prescribed more than 5 mg of zoledronic acid 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:

    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. The patient has a history of one significant osteoporotic fracture demonstrated radiologically; or

    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 5 mg of zoledronic acid 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 5 mg of zoledronic acid 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:

    1. Bone or articular pain; or

    2. Bone deformity; or

    3. Bone, articular or neurological complications; or

    4. Asymptomatic disease, but risk of complications; or

    5. Preparation for orthopaedic surgery; and

  3. The patient will not be prescribed more than 5 mg of zoledronic acid in the 12-month approval period.

Continuation - Paget's disease

Re-assessment required after 12 months

Both:
  1. Any of the following:

    1. The patient has relapsed (based on increases in serum alkaline phosphatase); or

    2. The patient's serum alkaline phosphatase has not normalised following previous treatment with zoledronic acid; or

    3. Symptomatic disease (prescriber determined); and

  2. The patient will not be prescribed more than 5 mg of zoledronic acid 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.

 Etidronate disodium Tab 200 mg Arrow-Etidronate 100 13.50 Alendronate sodium Tab 70 mg Fosamax 4 12.90

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:

    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. The patient has a history of one significant osteoporotic fracture demonstrated radiologically; or

    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.

 Tab 40 mg Fosamax 30 133.00
Both:

  1. Paget's disease; and

  2. Any of the following:

    1. Bone or articular pain; or

    2. Bone deformity; or

    3. Bone, articular or neurological complications; or

    4. Asymptomatic disease, but risk of complications due to site (base of skull, spine, long bones of lower limbs); or

    5. Preparation for orthopaedic surgery.

 Alendronate sodium with cholecalciferol Tab 70 mg with cholecalciferol 5,600 iu Fosamax Plus 4 12.90

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:

    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. The patient has a history of one significant osteoporotic fracture demonstrated radiologically; or

    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.

 Other Drugs Affecting Bone Metabolism Raloxifene Tab 60 mg Evista 28 53.76
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.

 Teriparatide Inj 250 mcg per ml, 2.4 ml cartridge Forteo 1 490.00

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 Enzymes Hyaluronidase Inj 1,500 iu ampoule Any 0 Hyperuricaemia and Antigout Hyperuricaemia and Antigout Probenecid Tab 500 mg Any 0 Rasburicase Inj 1.5 mg vial Any 0

Haematologist

 Benzbromarone Tab 100 mg Benzbromaron AL 100 100 45.00
All of the following:

  1. Patient has been diagnosed with gout; and

  2. Any of the following:

    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 addition of probenecid at doses of up to 2 g per day or maximum tolerated dose; or

    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 use of probenecid at doses of up to 2 g per day or maximum tolerated dose; or

    3. Both:

      1. The patient has renal impairment such that probenecid is contraindicated or likely to be ineffective and serum urate remains greater than 0.36 mmol/l despite optimal treatment with allopurinol (see Note); and

      2. The patient has a rate of creatinine clearance greater than or equal to 20 ml/min; or

    4. All of the following:

      1. The patient is taking azathioprine and requires urate-lowering therapy; and

      2. Allopurinol is contraindicated; and

      3. Appropriate doses of probenecid are ineffective or probenecid cannot be used due to reduced renal function; and

  3. The patient is receiving monthly liver function tests.

Notes: Benzbromarone has been associated with potentially fatal hepatotoxicity. In chronic renal insufficiency, particularly when the glomerular filtration rate is 30 ml/minute or less, probenecid may not be effective. 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 www.rheumatology.org.nz/downloads/Benzbromarone-prescriber-information-NZRA-V2.pdf

 Febuxostat Tab 80 mg Adenuric 28 39.50 Tab 120 mg Adenuric 28 39.50
Both:

  1. Patient has been diagnosed with gout; and

  2. Any of the following:

    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 addition of probenecid at doses of up to 2 g per day or maximum tolerated dose; or

    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 use of probenecid at doses of up to 2 g per day or maximum tolerated dose; or

    3. The patient has renal impairment such that probenecid is contraindicated or likely to be ineffective and serum urate remains greater than 0.36 mmol/l despite optimal treatment with allopurinol (see Note)

Note: In chronic renal insufficiency, particularly when the glomerular filtration rate is 30 ml/minute or less, probenecid may not be effective. The efficacy and safety of febuxostat have not been fully evaluated in patients with severe renal impairment (creatinine clearance less than 30 ml/minute). No dosage adjustment of febuxostat is necessary in patients with mild or moderate renal impairment. 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.

 Allopurinol Tab 100 mg Apo-Allopurinol 1000 15.11 Tab 300 mg Apo-Allopurinol 500 15.91 Colchicine Tab 500 mcg Colgout 100 10.08 Muscle Relaxants and Related Agents Muscle Relaxants and Related Agents Dantrolene Cap 25 mg Dantrium 100 65.00 Cap 50 mg Dantrium 100 77.00 Inj 20 mg vial Dantrium IV 6 800.00 Orphenadrine citrate Tab 100 mg Any 0 Vecuronium bromide Inj 10 mg vial Any 0 Inj 4 mg ampoule Any 0 Atracurium besylate Inj 10 mg per ml, 2.5 ml ampoule Tracrium 5 10.00 Inj 10 mg per ml, 5 ml ampoule Tracrium 5 12.50 Mivacurium chloride Inj 2 mg per ml, 5 ml ampoule Mivacron 5 33.92 Inj 2 mg per ml, 10 ml ampoule Mivacron 5 67.17 Pancuronium bromide Inj 2 mg per ml, 2 ml ampoule AstraZeneca 50 260.00 Suxamethonium chloride Inj 50 mg per ml, 2 ml ampoule AstraZeneca 50 78.00 Baclofen Inj 0.05 mg per ml, 1 ml ampoule Lioresal Intrathecal 1 11.55 Oral liq 1 mg per ml Any 0 Tab 10 mg Pacifen 100 3.85 Inj 2 mg per ml, 5 ml ampoule Lioresal Intrathecal 1 209.29 Clostridium botulinum type A toxin Inj 100 u vial Botox 1 467.50 Inj 500 u vial Dysport 2 1295.00 Rocuronium bromide Inj 10 mg per ml, 5 ml vial DBL Rocuronium Bromide 10 38.25 Reversers of Neuromuscular Blockade Sugammadex Inj 100 mg per ml, 2 ml vial Bridion 10 1200.00 Inj 100 mg per ml, 5 ml vial Bridion 10 3000.00
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 Non-Steroidal Anti-Inflammatory Drugs Indomethacin Cap 25 mg Any 0 Cap 50 mg Any 0 Cap long-acting 75 mg Any 0 Inj 1 mg vial Any 0 Suppos 100 mg Any 0 Mefenamic acid Cap 250 mg Any 0

For continuation only

 Meloxicam Tab 7.5 mg Any 0
Either:
  1. Haemophilic arthropathy, with both of the following:

    1. The patient has moderate to severe haemophilia with less than or equal to 5% of normal circulating functional clotting factor; and

    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.

 Sulindac Tab 100 mg Any 0 Tab 200 mg Any 0 Celecoxib Cap 100 mg Any 0 Cap 200 mg Any 0 Cap 400 mg Any 0

For preoperative and/or postoperative use for a total of up to 8 days' use.

 Etoricoxib Tab 30 mg Any 0 Tab 60 mg Any 0 Tab 90 mg Any 0 Tab 120 mg Any 0

For preoperative and/or postoperative use for a total of up to 8 days' use.

 Diclofenac sodium Tab 50 mg dispersible Voltaren D 20 1.50 Suppos 12.5 mg Voltaren 10 2.04 Suppos 25 mg Voltaren 10 2.44 Suppos 50 mg Voltaren 10 4.22 Suppos 100 mg Voltaren 10 7.00 Tab long-acting 75 mg Apo-Diclo SR 500 15.20 Tab long-acting 100 mg Apo-Diclo SR 500 26.20 Inj 25 mg per ml, 3 ml ampoule Voltaren 5 13.20 Tab EC 25 mg Diclofenac Sandoz 50 1.30 Tab EC 50 mg Diclofenac Sandoz 50 1.00 Ibuprofen Inj 5 mg per ml, 2 ml ampoule Any 0 Tab 200 mg Any 0 Tab 400 mg Any 0

For continuation only

 Tab 600 mg Any 0

For continuation only

 Oral liq 20 mg per ml Fenpaed 200 1.89 Tab long-acting 800 mg Brufen SR 30 7.99 Inj 10 mg per ml, 2 ml vial Any 0 Naproxen Tab long-acting 1 g Naprosyn SR 1000 90 21.00 Tab long-acting 750 mg Naprosyn SR 750 90 18.00 Tab 250 mg Noflam 250 500 18.06 Tab 500 mg Noflam 500 250 18.91 Tenoxicam Tab 20 mg Reutenox 20 3.05 Inj 20 mg vial AFT 1 9.95 Ketoprofen Cap long-acting 200 mg Oruvail SR 28 12.07 Parecoxib Inj 40 mg vial Dynastat 10 100.00 Topical Products for Joint and Muscular Pain Topical Products for Joint and Muscular Pain Capsaicin Crm 0.025% Zostrix 45 9.95

Patient has osteoarthritis that is not responsive to paracetamol and oral non-steroidal anti-inflammatories are contraindicated.

Nervous System Agents for Parkinsonism and Related Disorders Agents for Essential Tremor, Chorea and Related Disorders Riluzole Tab 50 mg Rilutek 56 400.00

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:

    1. The patient is ambulatory; or

    2. The patient is able to use upper limbs; or

    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:

    1. The patient is ambulatory; or

    2. The patient is able to use upper limb; or

    3. The patient is able to swallow.

 Tetrabenazine Tab 25 mg Motetis 112 118.00 Anticholinergics Orphenadrine hydrochloride Tab 50 mg Any 0 Procyclidine hydrochloride Tab 5 mg Any 0 Benztropine mesylate Tab 2 mg Benztrop 60 7.99 Inj 1 mg per ml, 2 ml ampoule Cogentin 5 95.00 Dopamine Agonists and Related Agents Bromocriptine Cap 5 mg Any 0 Tab 2.5 mg Any 0 Selegiline hydrochloride Tab 5 mg Any 0 Amantadine hydrochloride Cap 100 mg Symmetrel 60 38.24 Entacapone Tab 200 mg Entapone 100 28.00 Ropinirole hydrochloride Tab 1 mg Apo-Ropinirole 100 5.32 Tab 2 mg Apo-Ropinirole 100 7.72 Tab 5 mg Apo-Ropinirole 100 14.48 Tab 0.25 mg Apo-Ropinirole 100 2.36 Apomorphine hydrochloride Inj 10 mg per ml, 1 ml ampoule Any 0 Inj 10 mg per ml, 2 ml ampoule Apomine 5 119.00 Levodopa with benserazide Cap 50 mg with benserazide 12.5 mg Madopar 62.5 100 8.00 Tab dispersible 50 mg with benserazide 12.5 mg Madopar Rapid 100 10.00 Cap 100 mg with benserazide 25 mg Madopar 125 100 12.50 Cap long-acting 100 mg with benserazide 25 mg Madopar HBS 100 17.00 Cap 200 mg with benserazide 50 mg Madopar 250 100 25.00 Levodopa with carbidopa Tab 100 mg with carbidopa 25 mg e.g. Kinson 0 Sinemet 100 20.00 Tab 250 mg with carbidopa 25 mg e.g. Sindopa 0 Sinemet 100 40.00 Tab long-acting 200 mg with carbidopa 50 mg Sinemet CR 100 47.50 Tolcapone Tab 100 mg Tasmar 100 126.20 Pramipexole hydrochloride Tab 0.25 mg Ramipex 100 7.20 Tab 1 mg Ramipex 100 24.39 Lisuride hydrogen maleate Tab 200 mcg Dopergin 30 25.00 Anaesthetics General Anaesthetics Dexmedetomidine Inj 100 mcg per ml, 2 ml vial Precedex 5 479.85 Etomidate Inj 2 mg per ml, 10 ml ampoule Any 0 Ketamine Inj 1 mg per ml, 100 ml bag Biomed 1 27.00 Inj 10 mg per ml, 10 ml syringe Biomed 1 14.00 Inj 100 mg per ml, 2 ml vial Any 0 Inj 4 mg per ml, 50 ml syringe Biomed 1 25.00 Methohexital sodium Inj 10 mg per ml, 50 ml vial Any 0 Thiopental [Thiopentone] sodium Inj 500 mg ampoule Any 0 Isoflurane Soln for inhalation 100%, 250 ml bottle Aerrane 6 1020.00 Propofol Inj 10 mg per ml, 100 ml vial Provive MCT-LCT 1% 1 7.60 Fresofol 1% 1 7.60 Inj 10 mg per ml, 20 ml vial Diprivan 5 42.00 Provive MCT-LCT 1% 5 7.60 Inj 10 mg per ml, 50 ml syringe Diprivan 1 47.00 Inj 10 mg per ml, 50 ml vial Diprivan 1 25.00 Provive MCT-LCT 1% 1 4.00 Fresofol 1% 1 4.00 Inj 10 mg per ml, 20 ml ampoule Fresofol 1% 5 7.60 Sevoflurane Soln for inhalation 100%, 250 ml bottle Baxter 6 1230.00 Desflurane Soln for inhalation 100%, 240 ml bottle Suprane 6 1230.00 6 1230.00 Local Anaesthetics Articaine hydrochloride with adrenaline Inj 4% with adrenaline 1:100,000, 2.2 ml dental cartridge Any 0 Inj 4% with adrenaline 1:100,000, 1.7 ml dental cartridge Any 0 Inj 4% with adrenaline 1:200,000, 1.7 ml dental cartridge Any 0 Inj 4% with adrenaline 1:200,000, 2.2 ml dental cartridge Any 0 Bupivacaine hydrochloride with glucose Inj 0.5% with glucose 8%, 4 ml ampoule Marcain Heavy 5 38.00 Cocaine hydrochloride with adrenaline Paste 15% with adrenaline 0.06% Any 0 Paste 25% with adrenaline 0.06% Any 0 Ethyl chloride Spray 100% Any 0 Lidocaine [Lignocaine] hydrochloride with adrenaline and tetracaine hydrochloride Soln 4% with adrenaline 0.1% and tetracaine hydrochloride 0.5%, 5 ml syringe Topicaine 1 17.50 Lidocaine [Lignocaine] hydrochloride with phenylephrine hydrochloride Nasal spray 5% with phenylephrine hydrochloride 0.5% Any 0 Mepivacaine hydrochloride Inj 3%, 1.8 ml dental cartridge Scandonest 3% 50 43.60 Inj 3%, 2.2 ml dental cartridge Scandonest 3% 50 43.60 Prilocaine hydrochloride with felypressin Inj 3% with felypressin 0.03 iu per ml, 1.8 ml dental cartridge Any 0 Inj 3% with felypressin 0.03 iu per ml, 2.2 ml dental cartridge Any 0 Tetracaine [Amethocaine] hydrochloride Gel 4% Any 0 Benzocaine Gel 20% Any 0 Articaine hydrochloride Inj 1% Any 0 1 Lidocaine [lignocaine] Crm 4% LMX4 30 27.00 Crm 4% (5 g tubes) LMX4 5 27.00 Bupivacaine hydrochloride Inj 2.5 mg per ml, 20 ml ampoule sterile pack Marcain 5 29.20 Inj 5 mg per ml, 10 ml ampoule sterile pack Marcain 5 20.25 Inj 5 mg per ml, 4 ml ampoule Marcain Isobaric 5 50.00 Inj 1.25 mg per ml, 100 ml bag Any 0 Inj 1.25 mg per ml, 200 ml bag Any 0 Inj 2.5 mg per ml, 100 ml bag Marcain 5 150.00 Inj 2.5 mg per ml, 200 ml bag Any 0 Inj 5 mg per ml, 20 ml ampoule sterile pack Marcain 5 20.70 Inj 2.5 mg per ml, 20 ml ampoule Any 0 Inj 5 mg per ml, 20 ml ampoule Any 0 Inj 1.25 mg per ml, 500 ml bag Any 0 Bupivacaine hydrochloride with adrenaline Inj 5 mg per ml with adrenaline 1:200,000, 20 ml vial Marcain with Adrenaline 5 115.00 Inj 2.5 mg per ml with adrenaline 1:400,000, 20 ml vial Marcain with Adrenaline 5 135.00 Bupivacaine hydrochloride with fentanyl Inj 1.25 mg with fentanyl 2 mcg per ml, 100 ml bag Bupafen 10 210.00 Inj 1.25 mg with fentanyl 2 mcg per ml, 200 ml bag Bupafen 10 210.00 Inj 1.25 mg with fentanyl 2 mcg per ml, 15 ml syringe Biomed 10 72.00 Inj 1.25 mg with fentanyl 2 mcg per ml, 20 ml syringe Biomed 10 92.00 Inj 0.625 mg with fentanyl 2 mcg per ml, 100 ml bag Any 0 Inj 1.25 mg with fentanyl 2 mcg per ml, 100 ml syringe Any 0 Inj 1.25 mg with fentanyl 2 mcg per ml, 50 ml syringe Any 0 Lidocaine [Lignocaine] with prilocaine Crm 2.5% with prilocaine 2.5%, 5 g EMLA 5 45.00 Patch 25 mcg with prilocaine 25 mcg EMLA 20 115.00 Crm 2.5% with prilocaine 2.5% EMLA 30 45.00 Lidocaine [Lignocaine] hydrochloride Inj 1%, 20 ml ampoule Lidocaine-Claris 1 2.40 Inj 1%, 5 ml ampoule Lidocaine-Claris 25 8.75 Inj 2%, 20 ml ampoule Lidocaine-Claris 1 2.40 Inj 2%, 5 ml ampoule Lidocaine-Claris 25 6.90 Spray 10% Xylocaine 50 75.00 Gel 2% Orion 20 3.40 Gel 2%, 10 ml urethral syringe Pfizer 10 43.26 Soln 4% Any 0 Oral (viscous) soln 2% Xylocaine Viscous 200 55.00 Inj 1%, 20 ml ampoule, sterile pack Any 0 Inj 2%, 20 ml ampoule, sterile pack Any 0 Lidocaine [Lignocaine] hydrochloride with adrenaline Inj 1% with adrenaline 1:100,000, 5 ml ampoule Xylocaine 10 27.00 Inj 1% with adrenaline 1:200,000, 20 ml vial Xylocaine 5 50.00 Inj 2% with adrenaline 1:200,000, 20 ml vial Xylocaine 5 60.00 Inj 2% with adrenaline 1:80,000, 1.7 ml dental cartridge Any 0 Inj 2% with adrenaline 1:80,000, 1.8 ml dental cartridge Any 0 Inj 2% with adrenaline 1:80,000, 2.2 ml dental cartridge Any 0 Prilocaine hydrochloride Inj 0.5%, 50 ml vial Citanest 5 100.00 Inj 2%, 5 ml ampoule Citanest 10 55.00 Ropivacaine hydrochloride with fentanyl Inj 2 mg with fentanyl 2 mcg per ml, 100 ml bag Naropin 5 198.50 Inj 2 mg with fentanyl 2 mcg per ml, 200 ml bag Naropin 5 270.00 Ropivacaine hydrochloride Inj 10 mg per ml, 10 ml ampoule Ropivacaine Kabi 5 10.90 Inj 2 mg per ml, 100 ml bag Naropin 5 60.00 Inj 2 mg per ml, 20 ml ampoule Ropivacaine Kabi 5 9.50 Inj 2 mg per ml, 200 ml bag Naropin 5 79.50 Inj 7.5 mg per ml, 10 ml ampoule Ropivacaine Kabi 5 10.20 Inj 7.5 mg per ml, 20 ml ampoule Ropivacaine Kabi 5 12.50 Inj 10 mg per ml, 20 ml ampoule Ropivacaine Kabi 5 16.30 Inj 2 mg per ml, 10 ml ampoule Ropivacaine Kabi 5 9.05 Cocaine hydrochloride Paste 5% Any 0 Soln 15%, 2 ml syringe Any 0 Soln 4%, 2 ml syringe Biomed 1 25.46 Lidocaine [Lignocaine] hydrochloride with chlorhexidine Gel 2% with chlorhexidine 0.05%, 10 ml urethral syringe Pfizer 10 43.26 Analgesics Non-Opioid Analgesics Aspirin Tab dispersible 300 mg Any 0 Tab EC 300 mg Any 0 Nefopam hydrochloride Tab 30 mg Any 0 Sucrose Oral liq 25% Any 0 Methoxyflurane Soln for inhalation 99.9%, 3 ml bottle Any 0
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.

 Paracetamol Inj 10 mg per ml, 50 ml vial Perfalgan 12 1 12.90
Tab 500 mg Any 0 Tab soluble 500 mg Paragesic Soluble 20 1.60 Oral liq 120 mg per 5 ml Paracare 1000 4.15 Oral liq 250 mg per 5 ml Paracare Double Strength 1000 4.35 Suppos 125 mg Gacet 10 3.69 Suppos 250 mg Gacet 10 3.79 Suppos 25 mg Biomed 20 56.35 Suppos 50 mg Biomed 20 56.35 Suppos 500 mg Paracare 50 12.60 Inj 10 mg per ml, 100 ml vial Perfalgan 12 1 12.90

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.

Capsaicin Crm 0.075% Zostrix HP 45 12.50

For post-herpetic neuralgia or diabetic peripheral neuropathy

 Opioid Analgesics Alfentanil Inj 0.5 mg per ml, 2 ml ampoule Hameln 10 39.07 Morphine sulphate Inj 1 mg per ml, 10 ml syringe Biomed 10 45.00 Inj 1 mg per ml, 50 ml syringe Biomed 10 87.50 Inj 2 mg per ml, 30 ml syringe Biomed 10 135.00 Inj 1 mg per ml, 2 ml syringe Any 0 Inj 10 mg per ml, 100 mg cassette Any 0 Inj 10 mg per ml, 100 ml bag Any 0 Inj 200 mcg in 0.4 ml syringe Any 0 Inj 300 mcg in 0.3 ml syringe Any 0 Cap long-acting 10 mg m-Eslon 10 1.70 Cap long-acting 30 mg m-Eslon 10 2.50 Cap long-acting 60 mg m-Eslon 10 5.40 Cap long-acting 100 mg m-Eslon 10 6.38 Tab immediate-release 10 mg Sevredol 10 2.80 Tab immediate-release 20 mg Sevredol 10 5.52 Inj 10 mg per ml, 1 ml ampoule DBL Morphine Sulphate 5 9.09 Inj 30 mg per ml, 1 ml ampoule DBL Morphine Sulphate 5 12.43 Inj 5 mg per ml, 1 ml ampoule DBL Morphine Sulphate 5 12.48 Inj 15 mg per ml, 1 ml ampoule DBL Morphine Sulphate 5 9.77 Tab long-acting 10 mg Arrow-Morphine LA 10 1.95 Tab long-acting 30 mg Arrow-Morphine LA 10 2.98 Tab long-acting 60 mg Arrow-Morphine LA 10 5.75 Tab long-acting 100 mg Arrow-Morphine LA 10 6.45 Inj 1 mg per ml, 100 ml bag Biomed 10 185.00 Remifentanil hydrochloride Inj 1 mg vial Ultiva 5 10.00 Inj 2 mg vial Ultiva 5 18.00 Tramadol hydrochloride Inj 10 mg per ml, 100 ml bag Any 0 Oral drops 100 mg per ml Any 0 Cap 50 mg Arrow-Tramadol 100 2.50 Tab sustained-release 100 mg Tramal SR 100 20 2.00 Tab sustained-release 150 mg Tramal SR 150 20 3.00 Tab sustained-release 200 mg Tramal SR 200 20 4.00 Inj 50 mg per ml, 1 ml ampoule Tramal 50 5 4.50 Inj 50 mg per ml, 2 ml ampoule Tramal 100 5 4.50 Codeine phosphate Tab 15 mg PSM 100 4.75 Tab 30 mg PSM 100 5.80 Tab 60 mg PSM 100 12.50 Methadone hydrochloride Inj 10 mg per ml, 1 ml vial AFT 10 61.00 Oral liq 2 mg per ml Biodone 200 5.55 Oral liq 5 mg per ml Biodone Forte 200 5.00 Oral liq 10 mg per ml Biodone Extra Forte 200 6.55 Tab 5 mg Methatabs 10 1.85 Morphine tartrate Inj 80 mg per ml, 1.5 ml ampoule Hospira 5 35.60 Inj 80 mg per ml, 5 ml ampoule Hospira 5 107.67 Oxycodone hydrochloride Inj 1 mg per ml, 100 ml bag Any 0 Cap immediate-release 5 mg OxyNorm 20 1.98 Cap immediate-release 10 mg OxyNorm 20 3.91 Cap immediate-release 20 mg OxyNorm 20 6.84 Tab controlled-release 10 mg Oxycodone ControlledRelease Tablets(BNM) 20 6.75 Tab controlled-release 20 mg Oxycodone ControlledRelease Tablets(BNM) 20 11.50 Tab controlled-release 40 mg Oxycodone ControlledRelease Tablets(BNM) 20 18.50 Tab controlled-release 80 mg Oxycodone ControlledRelease Tablets(BNM) 20 34.00 Tab controlled-release 5 mg OxyContin 20 7.51 Oral liq 5 mg per 5 ml OxyNorm 250 11.20 Inj 10 mg per ml, 1 ml ampoule OxyNorm 5 8.57 Oxycodone Orion 5 10.08 Inj 10 mg per ml, 2 ml ampoule OxyNorm 5 16.89 Oxycodone Orion 5 19.87 Inj 50 mg per ml, 1 ml ampoule OxyNorm 5 51.00 Pethidine hydrochloride Inj 10 mg per ml, 100 ml bag Any 0 Inj 10 mg per ml, 50 ml syringe Any 0 Inj 5 mg per ml, 10 ml syringe Any 0 Inj 5 mg per ml, 100 ml bag Any 0 Inj 50 mg per ml, 1 ml ampoule DBL Pethidine Hydrochloride 5 5.51 Inj 50 mg per ml, 2 ml ampoule DBL Pethidine Hydrochloride 5 5.83 Tab 100 mg PSM 10 6.25 Tab 50 mg PSM 10 4.46 Morphine hydrochloride Oral liq 1 mg per ml RA-Morph 200 8.84 Oral liq 2 mg per ml RA-Morph 200 14.00 Oral liq 5 mg per ml RA-Morph 200 18.00 Oral liq 10 mg per ml RA-Morph 200 26.00 Dihydrocodeine tartrate Tab long-acting 60 mg DHC Continus 60 13.64 Fentanyl Inj 10 mcg per ml, 10 ml syringe Any 0 Inj 10 mcg per ml, 100 ml bag Biomed 10 210.00 Inj 10 mcg per ml, 50 ml bag Biomed 10 210.00 Inj 10 mcg per ml, 50 ml syringe Biomed 10 165.00 Inj 20 mcg per ml, 100 ml bag Any 0 Inj 20 mcg per ml, 50 ml syringe Biomed 10 185.00 Inj 50 mcg per ml, 10 ml ampoule Boucher and Muir 10 10.45 Inj 50 mcg per ml, 2 ml ampoule Boucher and Muir 10 3.95 Patch 75 mcg per hour Fentanyl Sandoz 5 9.18 Patch 12.5 mcg per hour Fentanyl Sandoz 5 2.92 Patch 25 mcg per hour Fentanyl Sandoz 5 3.66 Patch 50 mcg per hour Fentanyl Sandoz 5 6.64 Patch 100 mcg per hour Fentanyl Sandoz 5 11.29 Paracetamol with codeine Tab paracetamol 500 mg with codeine phosphate 8 mg Paracetamol + Codeine (Relieve) 100 2.11 Antidepressants Cyclic and Related Agents Doxepin hydrochloride Cap 10 mg Any 0 Cap 25 mg Any 0 Cap 50 mg Any 0 Maprotiline hydrochloride Tab 25 mg Any 0 Tab 75 mg Any 0 Mianserin hydrochloride Tab 30 mg Any 0

For continuation only

 Clomipramine hydrochloride Tab 25 mg Apo-Clomipramine 100 8.68 Tab 10 mg Apo-Clomipramine 100 12.60 Amitriptyline Tab 10 mg Arrow-Amitriptyline 100 1.68 Tab 25 mg Arrow-Amitriptyline 100 1.68 Tab 50 mg Arrow-Amitriptyline 100 2.82 Imipramine hydrochloride Tab 10 mg Tofranil 50 5.48 60 6.58 Tab 25 mg Tofranil 50 8.80 Dothiepin hydrochloride Cap 25 mg Dopress 100 6.17 Tab 75 mg Dopress 100 10.50 Nortriptyline hydrochloride Tab 10 mg Norpress 100 4.00 Tab 25 mg Norpress 180 9.00 Monoamine-Oxidase Inhibitors - Non-Selective Phenelzine sulphate Tab 15 mg Any 0 Tranylcypromine sulphate Tab 10 mg Any 0 Monoamine-Oxidase Type A Inhibitors Moclobemide Tab 150 mg Apo-Moclobemide 500 85.10 Tab 300 mg Apo-Moclobemide 100 30.70 Other Antidepressants Venlafaxine Cap modified release 75 mg Efexor XR 28 11.40
Cap modified release 150 mg Efexor XR 28 13.98
Cap modified release 37.5 mg Efexor XR 28 5.69
Tab modified release 75 mg Arrow-Venlafaxine XR 28 6.44 Tab modified release 150 mg Arrow-Venlafaxine XR 28 8.86 Tab modified release 37.5 mg Arrow-Venlafaxine XR 28 5.06 Tab modified release 225 mg Arrow-Venlafaxine XR 28 14.34

Initiation

Re-assessment required after two years

Both:

  1. The patient has 'treatment-resistant' depression; and

  2. Either:

    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. Both:

      1. The patient is currently a hospital in-patient as a result of an acute depressive episode; and.

      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

Re-assessment required after two years

The patient has a high risk of relapse (prescriber determined)

Mirtazapine Tab 30 mg Apo-Mirtazapine 30 2.55 Tab 45 mg Apo-Mirtazapine 30 3.25 Selective Serotonin Reuptake Inhibitors Citalopram hydrobromide Tab 20 mg Arrow-Citalopram 84 2.34 PSM Citalopram 84 1.79 Fluoxetine hydrochloride Cap 20 mg Arrow-Fluoxetine 90 1.74 Tab dispersible 20 mg, scored Arrow-Fluoxetine 30 2.50 Paroxetine hydrochloride Tab 20 mg Loxamine 90 4.32 Escitalopram Tab 10 mg Air Flow Products 28 1.40 Tab 20 mg Air Flow Products 28 2.40 Sertraline Tab 50 mg Arrow-Sertraline 90 3.64 Tab 100 mg Arrow-Sertraline 90 6.28 Antiepilepsy Drugs Agents for the Control of Status Epilepticus Paraldehyde Inj 5 ml ampoule Any 0 Phenytoin sodium Inj 50 mg per ml, 2 ml ampoule Hospira 5 88.63 Inj 50 mg per ml, 5 ml ampoule Hospira 5 133.92 Clonazepam Inj 1 mg per ml, 1 ml ampoule Rivotril 5 19.00 Diazepam Rectal tubes 5 mg Stesolid 5 25.05 Rectal tubes 10 mg Stesolid 5 30.50 Inj 5 mg per ml, 2 ml ampoule Hospira 5 11.83 Lorazepam Inj 2 mg vial Any 0 Inj 4 mg per ml, 1 ml vial Any 0 Control of Epilepsy Carbamazepine Oral liq 20 mg per ml Tegretol 250 26.37 Tab 200 mg Tegretol 100 14.53 Tab 400 mg Tegretol 100 34.58 Tab long-acting 200 mg Tegretol CR 100 16.98 Tab long-acting 400 mg Tegretol CR 100 39.17 Clobazam Tab 10 mg Any 0 Ethosuximide Cap 250 mg Any 0 Oral liq 50 mg per ml Any 0 Phenytoin Tab 50 mg Any 0 Phenytoin sodium Cap 100 mg Any 0 Cap 30 mg Any 0 Oral liq 6 mg per ml Any 0 Primidone Tab 250 mg Any 0 Sodium valproate Inj 100 mg per ml, 4 ml vial Epilim IV 1 16.60 Oral liq 40 mg per ml Any 0 Tab 100 mg Any 0 Tab EC 200 mg Any 0 Tab EC 500 mg Any 0 Vigabatrin Tab 500 mg Any 0
Both:
  1. Either:

    1. Patient has infantile spasms; or

    2. Both:

      1. Patient has epilepsy; and

      2. 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; and

  2. Either:

    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. 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.

 Clonazepam Oral drops 2.5 mg per ml Any 0 Gabapentin Cap 100 mg Neurontin 100 7.16 Nupentin 100 7.16 Arrow-Gabapentin 100 7.16 Cap 300 mg Neurontin 100 11.00 Nupentin 100 11.50 100 11.00 Arrow-Gabapentin 100 11.00 Cap 400 mg Neurontin 100 13.75 Nupentin 100 13.75 Arrow-Gabapentin 100 13.75

  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 or Chronic Kidney Disease-associated pruritus

Re-assessment required after 3 months

Either:

  1. The patient has been diagnosed with neuropathic pain; or

  2. Both:

    1. The patient has Chronic Kidney Disease Stage 5-associated pruritus* where no other cause for pruritus can be identified (e.g. scabies, allergy); and

    2. The patient has persistent pruritus not relieved with a trial of emollient/moisturising creams alone.

Continuation - Neuropathic pain or Chronic Kidney Disease-associated pruritus

Either:

  1. The patient has demonstrated a marked improvement in their control of pain or itch (prescriber determined); or

  2. The patient has previously demonstrated clinical responsiveness to gabapentin and has now developed neuropathic pain in a new site.

Notes: Indications marked with * are Unapproved Indications. Dosage adjustment of gabapentin is recommended for patients with renal impairment.

 Lamotrigine Tab dispersible 5 mg Arrow-Lamotrigine 56 15.00 Lamictal 30 9.64 Tab dispersible 25 mg Arrow-Lamotrigine 56 20.40 Lamictal 56 29.09 Logem 56 19.38 Tab dispersible 50 mg Arrow-Lamotrigine 56 34.70 Lamictal 56 47.89 Logem 56 32.97 Tab dispersible 100 mg Arrow-Lamotrigine 56 59.90 Lamictal 56 79.16 Logem 56 56.91 Tab dispersible 2 mg Lamictal 30 6.74 Topiramate Tab 25 mg Topamax 60 26.04 Arrow-Topiramate 60 11.07 Topiramate Actavis 60 11.07 Tab 50 mg Topamax 60 44.26 Arrow-Topiramate 60 18.81 Topiramate Actavis 60 18.81 Tab 100 mg Topamax 60 75.25 Arrow-Topiramate 60 31.99 Topiramate Actavis 60 31.99 Tab 200 mg Topamax 60 129.85 Arrow-Topiramate 60 55.19 Topiramate Actavis 60 55.19 Cap sprinkle 15 mg Topamax 60 20.84 Cap sprinkle 25 mg Topamax 60 26.04 Phenobarbitone Tab 15 mg PSM 500 30.00 Tab 30 mg PSM 500 31.00 Levetiracetam Inj 100 mg per ml, 5 ml vial Any 0 Tab 250 mg Levetiracetam-Rex 60 24.03 Tab 500 mg Levetiracetam-Rex 60 28.71 Tab 750 mg Levetiracetam-Rex 60 45.23 Lacosamide Inj 10 mg per ml, 20 ml vial Any 0 Tab 50 mg Vimpat 14 25.04 Tab 100 mg Vimpat 14 50.06 56 200.24 Tab 150 mg Vimpat 14 75.10 56 300.40 Tab 200 mg Vimpat 56 400.55

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.

 Stiripentol Cap 250 mg Diacomit 60 509.29 Powder for oral liq 250 mg sachet Diacomit 60 509.29

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.

 Antimigraine Preparations Acute Migraine Treatment Dihydroergotamine mesylate Inj 1 mg per ml, 1 ml ampoule Any 0 Ergotamine tartrate with caffeine Tab 1 mg with caffeine 100 mg Any 0 Metoclopramide hydrochloride with paracetamol Tab 5 mg with paracetamol 500 mg Any 0 Sumatriptan Tab 50 mg Arrow-Sumatriptan 100 29.80 Tab 100 mg Arrow-Sumatriptan 100 54.80 Inj 12 mg per ml, 0.5 ml cartridge Arrow-Sumatriptan 2 13.80 Rizatriptan Tab orodispersible 10 mg Rizamelt 30 8.10 Prophylaxis of Migraine Pizotifen Tab 500 mcg Sandomigran 100 23.21 100 23.21 Antinausea and Vertigo Agents Antinausea and Vertigo Agents Droperidol Inj 2.5 mg per ml, 1 ml ampoule Any 0 Promethazine theoclate Tab 25 mg Any 0

For continuation only

 Granisetron Tab 1 mg Granirex 50 5.98 Metoclopramide hydrochloride Inj 5 mg per ml, 2 ml ampoule Pfizer 10 4.50 Oral liq 5 mg per 5 ml Any 0 Tab 10 mg Metamide 100 1.82 Ondansetron Inj 2 mg per ml, 2 ml ampoule Ondanaccord 5 1.82 Inj 2 mg per ml, 4 ml ampoule Ondanaccord 5 2.18 Tab 4 mg Onrex 50 5.51 Tab 8 mg Onrex 50 6.19 Tab dispersible 4 mg Dr Reddy's Ondansetron 10 1.00 Tab dispersible 8 mg Ondansetron ODT-DRLA 10 1.50 Tropisetron Inj 1 mg per ml, 2 ml ampoule Tropisetron-AFT 1 8.95 Inj 1 mg per ml, 5 ml ampoule Tropisetron-AFT 1 13.95 Betahistine dihydrochloride Tab 16 mg Vergo 16 84 4.95 Cyclizine lactate Inj 50 mg per ml, 1 ml ampoule Nausicalm 5 14.95 Hyoscine hydrobromide Patch 1.5 mg Any 0 Scopoderm TTS 2 11.95
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.

 Inj 400 mcg per ml, 1 ml ampoule Hospira 5 46.50 Cyclizine hydrochloride Tab 50 mg Nausicalm 10 0.59 Nauzene 20 0.59 Prochlorperazine Inj 12.5 mg per ml, 1 ml ampoule Any 0 Suppos 25 mg Any 0 Tab buccal 3 mg Any 0 Tab 5 mg Antinaus 500 9.75 Aprepitant Cap 2 x 80 mg and 1 x 125 mg Emend Tri-Pack 3 100.00

Patient is undergoing highly emetogenic chemotherapy and/or anthracycline-based chemotherapy for the treatment of malignancy.

 Domperidone Tab 10 mg Prokinex 100 3.20 Antipsychotic Agents General Chlorpromazine hydrochloride Inj 25 mg per ml, 2 ml ampoule Any 0 Oral liq 10 mg per ml Any 0 Tab 10 mg Any 0 Tab 100 mg Any 0 Tab 25 mg Any 0 Levomepromazine Inj 25 mg per ml, 1 ml ampoule Any 0 Tab 100 mg Any 0 Tab 25 mg Any 0 Pericyazine Tab 10 mg Any 0 Tab 2.5 mg Any 0 Trifluoperazine hydrochloride Tab 1 mg Any 0 Tab 2 mg Any 0 Tab 5 mg Any 0 Zuclopenthixol acetate Inj 50 mg per ml, 1 ml ampoule Any 0 Inj 50 mg per ml, 2 ml ampoule Any 0 Clozapine Tab 100 mg Clozaril 50 14.73 100 29.45 Clopine 100 34.65 50 17.33 Tab 25 mg Clozaril 50 5.69 100 11.36 Clopine 100 13.37 50 6.69 Tab 50 mg Clopine 100 17.33 50 8.67 Tab 200 mg Clopine 100 69.30 50 34.65 Oral liq 50 mg per ml Clopine 100 17.33 Quetiapine Tab 100 mg Quetapel 90 4.20 Tab 200 mg Quetapel 90 7.20 Tab 25 mg Quetapel 90 2.10 90 2.10 Tab 300 mg Quetapel 90 12.00 90 12.00 Haloperidol Tab 500 mcg Serenace 100 6.23 Tab 1.5 mg Serenace 100 9.43 Tab 5 mg Serenace 100 29.72 Oral liq 2 mg per ml Serenace 100 23.84 Inj 5 mg per ml, 1ml ampoule Serenace 10 21.55 Olanzapine Inj 10 mg vial Any 0 Tab 2.5 mg Zypine 28 0.75 Tab 5 mg Zypine 28 1.65 Tab 10 mg Zypine 28 2.55 Tab orodispersible 10 mg Zypine ODT 28 3.05 Tab orodispersible 5 mg Zypine ODT 28 1.75 Risperidone Tab orodispersible 0.5 mg Risperdal Quicklet 28 21.42
Tab orodispersible 1 mg Risperdal Quicklet 28 42.84
Tab orodispersible 2 mg Risperdal Quicklet 28 85.71
Oral liq 1 mg per ml Risperon 30 9.75 Tab 0.5 mg Actavis 60 1.90 Tab 1 mg Actavis 60 2.10 Tab 2 mg Actavis 60 2.34 Tab 3 mg Actavis 60 2.55 Tab 4 mg Actavis 60 3.50

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.

Ziprasidone Inj 100 mg Any 0 Inj 20 mg Any 0 Cap 20 mg Zeldox 60 87.88 Zusdone 60 14.56
Cap 40 mg Zeldox 60 164.78 Zusdone 60 24.75
Cap 60 mg Zeldox 60 247.17 Zusdone 60 33.87
Cap 80 mg Zeldox 60 329.56 Zusdone 60 39.74

  1. Patient is suffering from schizophrenia or related psychoses; and

  2. Either:

    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. 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.

Aripiprazole Tab 10 mg Abilify 30 123.54 Tab 30 mg Abilify 30 260.07 Tab 15 mg Abilify 30 175.28 Tab 20 mg Abilify 30 213.42 Tab 5 mg Abilify 30 123.54

Initiation - schizophrenia or related psychoses

Both:

  1. Patient is suffering from schizophrenia or related psychoses; and

  2. Either:

    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. 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.

Initiation - Autism spectrum disorder*

Psychiatrist or paediatrician

All of the following:

  1. The patient has been diagnosed with an autism spectrum disorder* and has symptoms of severe irritability; and

  2. An effective dose of risperidone has been trialled and has been discontinued because of unacceptable side effects or inadequate response; and

  3. The patient is aged less than 18 years.

Note: Indications marked with * are Unapproved Indications

 Amisulpride Tab 100 mg Solian 30 6.22 Tab 200 mg Solian 60 21.92 Oral liq 100 mg per ml Solian 60 52.50 Tab 400 mg Solian 60 44.52 Zuclopenthixol hydrochloride Tab 10 mg Clopixol 100 31.45 Lithium carbonate Tab long-acting 400 mg Any 0 Cap 250 mg Douglas 100 9.42 Tab 250 mg Lithicarb FC 500 34.30 Tab 400 mg Lithicarb FC 100 12.83 Depot Injections Pipothiazine palmitate Inj 50 mg per ml, 1 ml ampoule Any 0 Inj 50 mg per ml, 2 ml ampoule Any 0

For continuation only

 Paliperidone Inj 25 mg syringe Invega Sustenna 1 194.25 Inj 50 mg syringe Invega Sustenna 1 271.95 Inj 75 mg syringe Invega Sustenna 1 357.42 Inj 100 mg syringe Invega Sustenna 1 435.12 Inj 150 mg syringe Invega Sustenna 1 435.12

Initiation

Re-assessment required after 12 months

Either:

  1. The patient has had an initial Special Authority approval for risperidone depot injection or olanzapine depot injection; or

  2. 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

The initiation of paliperidone 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 an atypical antipsychotic depot injection.

 Zuclopenthixol decanoate Inj 200 mg per ml, 1 ml ampoule Clopixol 5 19.80 Inj 500 mg per ml, 1 ml ampoule e.g. Clopixol Conc 0 Flupenthixol decanoate Inj 20 mg per ml, 2 ml ampoule Fluanxol 5 20.90 Inj 20 mg per ml, 1 ml ampoule Fluanxol 5 13.14 Inj 100 mg per ml, 1 ml ampoule Fluanxol 5 40.87 Olanzapine Inj 210 mg vial Zyprexa Relprevv 1 280.00 Inj 300 mg vial Zyprexa Relprevv 1 460.00 Inj 405 mg vial Zyprexa Relprevv 1 560.00

Initiation

Re-assessment required after 12 months

Either:

  1. The patient has had an initial Special Authority approval for risperidone depot injection or paliperidone depot injection; or

  2. 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

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 an atypical antipsychotic depot injection.

 Fluphenazine decanoate Inj 12.5 mg per 0.5 ml ampoule Modecate 5 17.60 Inj 25 mg per ml, 1 ml ampoule Modecate 5 27.90 Inj 100 mg per ml, 1 ml ampoule Modecate 5 154.50 Haloperidol decanoate Inj 100 mg per ml, 1 ml ampoule Haldol Concentrate 5 55.90 Inj 50 mg per ml, 1 ml ampoule Haldol 5 28.39 Risperidone Inj 25 mg vial Risperdal Consta 1 135.98 Inj 37.5 mg vial Risperdal Consta 1 178.71 Inj 50 mg vial Risperdal Consta 1 217.56

Initiation

Re-assessment required after 12 months

Either:

  1. The patient has had an initial Special Authority approval for paliperidone depot injection or olanzapine depot injection; or

  2. 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

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 an atypical antipsychotic depot injection.

 Anxiolytics Anxiolytics Alprazolam Tab 1 mg Any 0 Tab 250 mcg Any 0 Tab 500 mcg Any 0 Oxazepam Tab 10 mg Ox-Pam 100 6.17 Tab 15 mg Ox-Pam 100 8.53 Clonazepam Tab 500 mcg Paxam 100 7.53 Tab 2 mg Paxam 100 14.37 Diazepam Tab 2 mg Arrow-Diazepam 500 11.44 Tab 5 mg Arrow-Diazepam 500 13.71 Lorazepam Tab 1 mg Ativan 250 10.79 Tab 2.5 mg Ativan 100 13.88 Buspirone hydrochloride Tab 5 mg Pacific Buspirone 100 28.00 Tab 10 mg Pacific Buspirone 100 17.00 Multiple Sclerosis Treatments Multiple Sclerosis Treatments Fingolimod Cap 0.5 mg Gilenya 28 2650.00

Only for use in patients with approval by the Multiple Sclerosis Treatment Assessment Committee (MSTAC). Applications will be considered by MSTAC at its regular meetings and approved subject to eligibility according to the Entry and Stopping criteria (set out in Section B of the Pharmaceutical Schedule).

 Natalizumab Inj 20 mg per ml, 15 ml vial Tysabri 1 1750.00

Only for use in patients with approval by the Multiple Sclerosis Treatment Assessment Committee (MSTAC). Applications will be considered by MSTAC at its regular meetings and approved subject to eligibility according to the Entry and Stopping criteria (set out in Section B of the Pharmaceutical Schedule).

Natalizumab can only be dispensed from a pharmacy registered in the Tysabri Australasian Prescribing Programme operated by the supplier.

 Other Multiple Sclerosis Treatments Glatiramer acetate Inj 20 mg per ml, 1 ml syringe Any 0 Interferon beta-1-alpha Inj 6 million iu in 0.5 ml pen injector Avonex Pen 4 1170.00 Inj 6 million iu in 0.5 ml syringe Avonex 4 1170.00 Inj 6 million iu vial Avonex 4 1170.00 Interferon beta-1-beta Inj 8 million iu per ml, 1 ml vial Any 0

Only for use in patients with approval by the Multiple Sclerosis Treatment Assessment Committee (MSTAC). Applications will be considered by MSTAC at its regular meetings and approved subject to eligibility according to the Entry and Stopping criteria (set out in Section B of the Pharmaceutical Schedule).

 Sedatives and Hypnotics Sedatives and Hypnotics Chloral hydrate Oral liq 100 mg per ml Any 0 Oral liq 200 mg per ml Any 0 Lormetazepam Tab 1 mg Any 0

For continuation only

 Nitrazepam Tab 5 mg Nitrados 100 5.22 Triazolam Tab 125 mcg Any 0 Tab 250 mcg Any 0

For continuation only

 Melatonin Cap 2 mg Any 0 Cap 3 mg Any 0 Tab 1 mg Any 0 Tab 2 mg Any 0 Tab 3 mg Any 0 Tab modified-release 2 mg e.g. Circadin 0

For in hospital use only. For the treatment of insomnia where benzodiazepines and zopiclone are contraindicated.

Midazolam Inj 1 mg per ml, 5 ml ampoule Hypnovel 10 10.75 Pfizer 10 10.00 Inj 5 mg per ml, 3 ml ampoule Hypnovel 5 11.90 Pfizer 5 11.90 Oral liq 2 mg per ml Any 0 Tab 7.5 mg Hypnovel 100 40.00 Temazepam Tab 10 mg Normison 25 1.27 Zopiclone Tab 7.5 mg Zopiclone Actavis 30 0.98 500 8.99 Phenobarbitone Inj 200 mg per ml, 1 ml ampoule Any 0 Stimulants / ADHD Treatments Stimulants / ADHD Treatments Caffeine Tab 100 mg Any 0 Modafinil Tab 100 mg Any 0

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:

    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. The patient has at least one of: cataplexy, sleep paralysis or hypnagogic hallucinations; and

  3. Either:

    1. An effective dose of a listed formulation of methylphenidate or dexamphetamine has been trialled and discontinued because of intolerable side effects; or

    2. Methylphenidate and dexamphetamine are contraindicated.

 Methylphenidate hydrochloride Cap modified-release 10 mg Ritalin LA 30 15.60 Cap modified-release 20 mg Ritalin LA 30 20.40 Cap modified-release 30 mg Ritalin LA 30 25.52 Cap modified-release 40 mg Ritalin LA 30 30.60 Tab extended-release 18 mg Concerta 30 58.96 Tab extended-release 27 mg Concerta 30 65.44 Tab extended-release 36 mg Concerta 30 71.93 Tab extended-release 54 mg Concerta 30 86.24 Tab immediate-release 5 mg Rubifen 30 3.20 Tab immediate-release 20 mg Rubifen 30 7.85 Tab sustained-release 20 mg Ritalin SR 100 50.00 Rubifen SR 30 10.95 Tab immediate-release 10 mg Ritalin 30 3.00 Rubifen 30 3.00

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:

    1. Patient is taking a currently listed formulation of methylphenidate hydrochloride (immediate-release or sustained-release) which has not been effective due to significant administration and/or compliance difficulties; or

    2. There is significant concern regarding the risk of diversion or abuse of immediate-release methylphenidate hydrochloride.

 Dexamfetamine sulfate Tab 5 mg PSM 100 17.00

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

 Atomoxetine Cap 10 mg Strattera 28 107.03 Cap 18 mg Strattera 28 107.03 Cap 25 mg Strattera 28 107.03 Cap 40 mg Strattera 28 107.03 Cap 60 mg Strattera 28 107.03 Cap 80 mg Strattera 28 139.11 Cap 100 mg Strattera 28 139.11
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:

    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

    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. An effective dose of a subsidised formulation of a stimulant has been trialled and has been discontinued because of inadequate clinical response; or

    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 (immediate-release, sustained-release and extended-release) or dexamphetamine sulphate tablets.

 Treatments for Dementia Treatments for Dementia Rivastigmine Patch 4.6 mg per 24 hour Exelon 30 90.00 Patch 9.5 mg per 24 hour Exelon 30 90.00

Initiation

Re-assessment required after 6 months

Both:

  1. The patient has been diagnosed with dementia; and

  2. The patient has experienced intolerable nausea and/or vomiting from donepezil tablets.

Continuation

Re-assessment required after 12 months

Both:

  1. The treatment remains appropriate; and

  2. The patient has demonstrated a significant and sustained benefit from treatment.

 Donepezil hydrochloride Tab 5 mg Donepezil-Rex 90 5.48 Tab 10 mg Donepezil-Rex 90 10.51 Treatments for Substance Dependence Treatments for Substance Dependence Disulfiram Tab 200 mg Antabuse 100 24.30 Naltrexone hydrochloride Tab 50 mg Naltraccord 30 76.00

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 Gum 2 mg Habitrol (Classic) 384 22.26 Habitrol (Fruit) 384 22.26 Habitrol (Mint) 384 22.26 Gum 4 mg Habitrol (Classic) 384 25.67 Habitrol (Fruit) 384 25.67 Habitrol (Mint) 384 25.67 Patch 7 mg per 24 hours Habitrol 28 10.57 Patch 14 mg per 24 hours Habitrol 28 11.31 Patch 21 mg per 24 hours Habitrol 28 11.95 Lozenge 2 mg Habitrol 216 14.14 Lozenge 1 mg Habitrol 216 12.91 Soln for inhalation 15 mg cartridge e.g. Nicorette Inhalator 0
Oral spray 1 mg per dose e.g. Nicorette QuickMist Mouth Spray 0
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.

Bupropion hydrochloride Tab modified-release 150 mg Zyban 30 4.97 Varenicline Tab 0.5 mg x 11 and 1 mg x 14 Champix 25 60.48 Tab 1 mg Champix 56 135.48 28 67.74
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:

    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

    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.

 Buprenorphine with naloxone Tab 2 mg with naloxone 0.5 mg Suboxone 28 57.40 Tab 8 mg with naloxone 2 mg Suboxone 28 166.00

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.

 Oncology Agents and Immunosuppressants Chemotherapeutic Agents Alkylating Agents Carmustine Inj 100 mg vial BiCNU 1 532.00 Chlorambucil Tab 2 mg Any 0 Melphalan Inj 50 mg vial Any 0 Tab 2 mg Any 0 Thiotepa Inj 15 mg vial Any 0 Inj 100 mg vial Any 0 Cyclophosphamide Tab 50 mg Procytox 100 158.00 Endoxan 50 79.00 Inj 1 g vial Endoxan 1 35.03 Inj 2 g vial Endoxan 1 70.06 Ifosfamide Inj 1 g vial Holoxan 1 96.00 Inj 2 g vial Holoxan 1 180.00 Busulfan Inj 6 mg per ml, 10 ml ampoule Any 0 Tab 2 mg Myleran 100 89.25 Lomustine Cap 10 mg Ceenu 20 132.59 Cap 40 mg Ceenu 20 399.15 Anthracyclines and Other Cytotoxic Antibiotics Dactinomycin [Actinomycin D] Inj 0.5 mg vial Cosmegen 1 145.00 Bleomycin sulphate Inj 15,000 iu (10 mg) vial DBL Bleomycin Sulfate 1 150.48 Daunorubicin Inj 2 mg per ml, 10 ml vial Pfizer 1 118.72 Doxorubicin hydrochloride Inj 2 mg per ml, 25 ml vial Doxorubicin Ebewe 1 11.50 Arrow-Doxorubicin 1 17.00 Inj 2 mg per ml, 5 ml vial Any 0 Inj 2 mg per ml, 50 ml vial Doxorubicin Ebewe 1 23.00 Inj 2 mg per ml, 100 ml vial Doxorubicin Ebewe 1 46.00 Arrow-Doxorubicin 1 65.00 Inj 50 mg vial Any 0 Epirubicin hydrochloride Inj 2 mg per ml, 5 ml vial Epirubicin Ebewe 1 25.00 Inj 2 mg per ml, 25 ml vial Epirubicin Ebewe 1 30.00 Inj 2 mg per ml, 50 ml vial Epirubicin Ebewe 1 32.50 Inj 2 mg per ml, 100 ml vial Epirubicin Ebewe 1 65.00 Idarubicin hydrochloride Inj 5 mg vial Zavedos 1 125.00 Inj 10 mg vial Zavedos 1 250.00 Mitozantrone Inj 2 mg per ml, 10 ml vial Mitozantrone Ebewe 1 97.50 Mitomycin C Inj 5 mg vial Arrow 1 79.75 Antimetabolites Fluorouracil Inj 50 mg per ml, 100 ml vial Fluorouracil Ebewe 1 30.00 Inj 50 mg per ml, 20 ml vial Fluorouracil Ebewe 1 10.00 Inj 50 mg per ml, 50 ml vial Fluorouracil Ebewe 1 17.00 Thioguanine Tab 40 mg Any 0 Azacitidine Inj 100 mg vial Vidaza 1 605.00

Initiation

Haematologist

Re-assessment required after 12 months

All of the following:
  1. Any of the following:

    1. The patient has International Prognostic Scoring System (IPSS) intermediate-2 or high risk myelodysplastic syndrome; or

    2. The patient has chronic myelomonocytic leukaemia (10%-29% marrow blasts without myeloproliferative disorder); or

    3. The patient has acute myeloid leukaemia with 20-30% blasts and multi-lineage dysplasia, according to World Health Organisation Classification (WHO); and

  2. The patient has performance status (WHO/ECOG) grade 0-2; and

  3. The patient does not have secondary myelodysplastic syndrome resulting from chemical injury or prior treatment with chemotherapy and/or radiation for other diseases; and

  4. The patient has an estimated life expectancy of at least 3 months.

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.

Continuation

Haematologist

Re-assessment required after 12 months

Both:

  1. No evidence of disease progression, and

  2. The treatment remains appropriate and patient is benefitting from treatment.

 Capecitabine Tab 150 mg Capecitabine Winthrop 60 30.00 Tab 500 mg Capecitabine Winthrop 120 120.00 Cladribine Inj 1 mg per ml, 10 ml vial Leustatin 7 5249.72 Inj 2 mg per ml, 5 ml vial Any 0 Cytarabine Inj 100 mg per ml, 10 ml vial Pfizer 1 8.83 Inj 100 mg per ml, 20 ml vial Pfizer 1 17.65 Inj 20 mg per ml, 25 ml vial Pfizer 1 18.15 Inj 20 mg per ml, 5 ml vial Pfizer 5 55.00 Fludarabine phosphate Tab 10 mg Fludara Oral 20 412.00 Inj 50 mg vial Fludarabine Ebewe 5 525.00 Gemcitabine Inj 10 mg per ml, 100 ml vial Gemcitabine Ebewe 1 15.89 Inj 10 mg per ml, 20 ml vial Gemcitabine Ebewe 1 8.36 Methotrexate Tab 2.5 mg Trexate 30 3.18 Tab 10 mg Trexate 50 21.00 Inj 100 mg per ml, 10 ml vial Methotrexate Ebewe 1 25.00 Inj 100 mg per ml, 50 ml vial Methotrexate Ebewe 1 99.99 Inj 2.5 mg per ml, 2 ml vial Any 0 Inj 25 mg per ml, 2 ml vial Hospira 5 20.20 Inj 25 mg per ml, 20 ml vial Hospira 1 27.78 Inj 7.5 mg prefilled syringe Methotrexate Sandoz 1 17.19 Inj 10 mg prefilled syringe Methotrexate Sandoz 1 17.25 Inj 15 mg prefilled syringe Methotrexate Sandoz 1 17.38 Inj 20 mg prefilled syringe Methotrexate Sandoz 1 17.50 Inj 25 mg prefilled syringe Methotrexate Sandoz 1 17.63 Inj 30 mg prefilled syringe Methotrexate Sandoz 1 17.75 Mercaptopurine Tab 50 mg Puri-nethol 25 49.41 Other Cytotoxic Agents Amsacrine Inj 50 mg per ml, 1.5 ml ampoule Any 0 Inj 75 mg Any 0 Anagrelide hydrochloride Cap 0.5 mg Any 0 Pentostatin [Deoxycoformycin] Inj 10 mg vial Any 0 Lenalidomide Cap 10 mg Revlimid 21 6207.00 Cap 25 mg Revlimid 21 7627.00

Initiation

Haematologist

Re-assessment required after 6 months

All of the following:

  1. Patient has relapsed or refractory multiple myeloma with progressive disease; and

  2. Either:

    1. Lenalidomide to be used as third line* treatment for multiple myeloma; or

    2. Both:

      1. Lenalidomide to be used as second line treatment for multiple myeloma; and

      2. The patient has experienced severe (grade ≥ 3), dose limiting, peripheral neuropathy with either bortezomib or thalidomide that precludes further treatment with either of these treatments; and

  3. Lenalidomide to be administered at a maximum dose of 25 mg/day in combination with dexamethasone.

Continuation

Haematologist

Re-assessment required after 6 months

Both:

  1. No evidence of disease progression; and

  2. The treatment remains appropriate and patient is benefitting from treatment.

Notes: Indication marked with * is an Unapproved Indication (refer to Interpretations and Definitions). A line of treatment is considered to comprise either: a) a known therapeutic chemotherapy regimen and supportive treatments or b) a transplant induction chemotherapy regimen, stem cell transplantation and supportive treatments. Prescriptions must be written by a registered prescriber in the lenalidomide risk management programme operated by the supplier.

 Colaspase [L-asparaginase] Inj 10,000 iu vial Leunase 1 102.32 Dacarbazine Inj 200 mg vial Hospira 1 51.84 Etoposide Cap 50 mg Vepesid 20 340.73 Cap 100 mg Vepesid 10 340.73 Inj 20 mg per ml, 5 ml vial Hospira 1 25.00 Irinotecan hydrochloride Inj 20 mg per ml, 2 ml vial Irinotecan Actavis 40 1 11.50 Inj 20 mg per ml, 5 ml vial Irinotecan Actavis 100 1 17.80 Procarbazine hydrochloride Cap 50 mg Natulan 50 498.00 Hydroxyurea Cap 500 mg Hydrea 100 31.76 Tretinoin Cap 10 mg Vesanoid 100 479.50 Temozolomide Cap 5 mg Temaccord 5 8.00 Cap 20 mg Temaccord 5 36.00 Cap 100 mg Temaccord 5 175.00 Cap 250 mg Temaccord 5 410.00
All of the following:
  1. Either:

    1. Patient has newly diagnosed glioblastoma multiforme; or

    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.

 Arsenic trioxide Inj 1 mg per ml, 10 ml vial AFT 10 4817.00 Thalidomide Cap 50 mg Thalomid 28 378.00 Cap 100 mg Thalomid 28 756.00

Initiation

Any of the following:

  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

 Bortezomib Inj 3.5 mg vial Velcade 1 1892.50 Inj 1 mg vial Velcade 1 540.70

Initiation - treatment naive multiple myeloma/amyloidosis

Both:
  1. Either:

    1. The patient has treatment-naive symptomatic multiple myeloma; or

    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. The patient has relapsed or refractory multiple myeloma; or

    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:

  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.

 Etoposide (as phosphate) Inj 100 mg vial Etopophos 1 40.00 Pegaspargase Inj 750 iu per ml, 5 ml vial Oncaspar 1 3005.00

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.

 Platinum Compounds Carboplatin Inj 10 mg per ml, 5 ml vial DBL Carboplatin 1 15.07 Inj 10 mg per ml, 15 ml vial DBL Carboplatin 1 14.05 Inj 10 mg per ml, 45 ml vial DBL Carboplatin 1 32.59 Cisplatin Inj 1 mg per ml, 50 ml vial DBL Cisplatin 1 12.29 Inj 1 mg per ml, 100 ml vial DBL Cisplatin 1 22.46 Oxaliplatin Inj 50 mg vial Oxaliplatin Actavis 50 1 15.32 Inj 100 mg vial Oxaliplatin Actavis 100 1 25.01 Protein-Tyrosine Kinase Inhibitors Nilotinib Cap 150 mg Tasigna 120 4680.00 Cap 200 mg Tasigna 120 6532.00

Initiation

Haematologist

Re-assessment required after 6 months

All of the following:

  1. Patient has a diagnosis of chronic myeloid leukaemia (CML) in blast crisis, accelerated phase, or in chronic phase; and

  2. Either:

    1. Patient has documented CML treatment failure* with imatinib; or

    2. Patient has experienced treatment limiting toxicity with imatinib precluding further treatment with imatinib; and

  3. Maximum nilotinib dose of 800 mg/day; and

  4. Subsidised for use as monotherapy only.

Note: *treatment failure as defined by Leukaemia Net Guidelines.

Continuation

Haematologist

Re-assessment required after 6 months

All of the following:

  1. Lack of treatment failure while on nilotinib as defined by Leukaemia Net Guidelines; and

  2. Nilotinib treatment remains appropriate and the patient is benefiting from treatment; and

  3. Maximum nilotinib dose of 800 mg/day; and

  4. Subsidised for use as monotherapy only.

 Imatinib mesilate Tab 100 mg Glivec 60 2400.00

Initiation

Re-assessment required after 12 months

Both:

  1. Patient has diagnosis (confirmed by an oncologist) of unresectable and/or metastatic malignant gastrointestinal stromal tumour (GIST); and

  2. Maximum dose of 400 mg/day.

Continuation

Re-assessment required after 12 months

Adequate clinical response to treatment with imatinib (prescriber determined).

 Cap 100 mg Imatinib-AFT 60 298.90 Cap 400 mg Imatinib-AFT 30 597.80

Note: Imatinib-AFT is not a registered for the treatment of Gastro Intestinal Stromal Tumours (GIST). The Glivec brand of imatinib mesilate (supplied by Novartis) remains fully subsidised under Special Authority for patients with unresectable and/or metastatic malignant GIST, see SA1460 in Section B of the Pharmaceutical Schedule.

 Dasatinib Tab 20 mg Sprycel 60 3774.06 Tab 50 mg Sprycel 60 6214.20 Tab 70 mg Sprycel 60 7692.58 Tab 100 mg Sprycel 30 6214.20

For use in patients with approval from the CML/GIST Co-ordinator

 Erlotinib Tab 100 mg Tarceva 30 1000.00 Tab 150 mg Tarceva 30 1500.00

Initiation

Re-assessment required after 3 months

Either:
  1. All of the following:

    1. Patient has locally advanced or metastatic, unresectable, non-squamous Non Small Cell Lung Cancer (NSCLC); and

    2. There is documentation confirming that the disease expresses activating mutations of EGFR tyrosine kinase; and

    3. Any of the following:

      1. Patient is treatment naive; or

      2. Both:

        1. Patient has documented disease progression following treatment with first line platinum based chemotherapy; and

        2. Patient has not received prior treatment with gefitinib; or

      3. Both:

        1. The patient has discontinued getitinib within 6 weeks of starting treatment due to intolerance; and

        2. The cancer did not progress while on gefitinib; and

    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.

 Sunitinib Cap 12.5 mg Sutent 28 2315.38 Cap 25 mg Sutent 28 4630.77 Cap 50 mg Sutent 28 9261.54

Re-assessment required after 3 months

Initiation - RCC

  1. The patient has metastatic renal cell carcinoma; and

  2. Any of the following:

    1. The patient is treatment naive; or

    2. The patient has only received prior cytokine treatment; or

    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

    4. Both:

      1. The patient has discontinued pazopanib within 3 months of starting treatment due to intolerance; and

      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:

    1. Lactate dehydrogenase level > 1.5 times upper limit of normal; or

    2. Haemoglobin level < lower limit of normal; or

    3. Corrected serum calcium level > 10 mg/dL (2.5 mmol/L); or

    4. Interval of < 1 year from original diagnosis to the start of systemic therapy; or

    5. Karnofsky performance score of ≤ 70; or

    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:

    1. The patient's disease has progressed following treatment with imatinib; or

    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. The patient has had a complete response (disappearance of all lesions and no new lesions); or

    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

    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

  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.

 Lapatinib Tab 250 mg Tykerb 70 1899.00

Initiation

Re-assessment required after 12 months

Either:
  1. 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 has not previously received trastuzumab treatment for HER 2 positive metastatic breast cancer; and

    3. Lapatinib not to be given in combination with trastuzumab; and

    4. Lapatinib to be discontinued at disease progression; or

  2. 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 started trastuzumab for metastatic breast cancer but discontinued trastuzumab within 3 months of starting treatment due to intolerance; and

    3. The cancer did not progress whilst on trastuzumab; and

    4. Lapatinib not to be given in combination with trastuzumab; and

    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 Tab 200 mg Votrient 30 1334.70 Tab 400 mg Votrient 30 2669.40

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:

    1. The patient is treatment naive; or

    2. The patient has only received prior cytokine treatment; or

    3. Both:

      1. The patient has discontinued sunitinib within 3 months of starting treatment due to intolerance; and

      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:

    1. Lactate dehydrogenase level > 1.5 times upper limit of normal; or

    2. Haemoglobin level < lower limit of normal; or

    3. Corrected serum calcium level > 10 mg/dL (2.5 mmol/L); or

    4. Interval of < 1 year from original diagnosis to the start of systemic therapy; or

    5. Karnofsky performance score of ≤ 70; or

    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.

 Gefitinib Tab 250 mg Iressa 30 1700.00

Initiation

Re-assessment required after 3 months

All of the following:

  1. Patient has locally advanced, or metastatic, unresectable, non-squamous Non Small Cell Lung Cancer (NSCLC); and

  2. Either:

    1. Patient is treatment naive; or

    2. Both:

      1. The patient has discontinued erlotinib within 6 weeks of starting treatment due to intolerance; and

      2. The cancer did not progress whilst on erlotinib; and

  3. 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.

 Taxanes Docetaxel Inj 10 mg per ml, 2 ml vial DBL Docetaxel 1 13.70 Inj 10 mg per ml, 8 ml vial DBL Docetaxel 1 29.99 Paclitaxel Inj 6 mg per ml, 5 ml vial Paclitaxel Ebewe 5 45.00 Inj 6 mg per ml, 16.7 ml vial Paclitaxel Ebewe 1 19.02 Inj 6 mg per ml, 100 ml vial Paclitaxel Ebewe 1 73.06 Inj 6 mg per ml, 25 ml vial Paclitaxel Ebewe 1 26.69 Inj 6 mg per ml, 50 ml vial Paclitaxel Ebewe 1 36.53 Treatment of Cytotoxic-Induced Side Effects Mesna Tab 400 mg Uromitexan 50 227.50 Tab 600 mg Uromitexan 50 339.50 Inj 100 mg per ml, 4 ml ampoule Uromitexan 15 148.05 Inj 100 mg per ml, 10 ml ampoule Uromitexan 15 339.90 Calcium folinate Inj 3 mg per ml, 1 ml ampoule Any 0 Inj 10 mg per ml, 30 ml vial Calcium Folinate Ebewe 1 22.51 Tab 15 mg DBL Leucovorin Calcium 10 104.26 Inj 10 mg per ml, 5 ml ampoule Calcium Folinate Ebewe 5 18.25 Inj 10 mg per ml, 10 ml vial Calcium Folinate Ebewe 1 7.33 Inj 10 mg per ml, 100 ml vial Calcium Folinate Ebewe 1 67.51 Vinca Alkaloids Vinblastine sulphate Inj 1 mg per ml, 10 ml vial Hospira 5 186.46 Vincristine sulphate Inj 1 mg per ml, 1 ml vial Hospira 5 64.80 Inj 1 mg per ml, 2 ml vial Hospira 5 69.60 Vinorelbine Inj 10 mg per ml, 1 ml vial Navelbine 1 8.00 Inj 10 mg per ml, 5 ml vial Navelbine 1 40.00 Endocrine Therapy Endocrine Therapy Abiraterone acetate Tab 250 mg Zytiga 120 4276.19

Initiation

Medical oncologist, radiation oncologist or urologist

Re-assessment required after 5 months

All of the following:

  1. Patient has prostate cancer; and

  2. Patient has metastases; and

  3. Patient's disease is castration resistant; and

  4. Either:
    1. All of the following:

      1. Patient is symptomatic; and

      2. Patient has disease progression (rising serum PSA) after second line anti-androgen therapy; and

      3. Patient has ECOG performance score of 0-1; and

      4. Patient has not had prior treatment with taxane chemotherapy; or

    2. All of the following:

      1. Patient.s disease has progressed following prior chemotherapy containing a taxane; and

      2. Patient has ECOG performance score of 0-2; and

      3. Patient has not had prior treatment with abiraterone.

Continuation

Medical oncologist, radiation oncologist or urologist

Re-assessment required after 5 months

All of the following:

  1. Significant decrease in serum PSA from baseline; and

  2. No evidence of clinical disease progression; and

  3. No initiation of taxane chemotherapy with abiraterone; and

  4. The treatment remains appropriate and the patient is benefiting from treatment.

 Octreotide Inj 100 mcg per ml, 1 ml ampoule DBL 5 22.40 Inj 50 mcg per ml, 1 ml ampoule DBL 5 13.50 Inj 500 mcg per ml, 1 ml ampoule DBL 5 89.40 Inj 10 mg vial Sandostatin LAR 1 1772.50
Inj 20 mg vial Sandostatin LAR 1 2358.75
Inj 30 mg vial Sandostatin LAR 1 2951.25

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:

    1. Treatment with surgery, radiotherapy and a dopamine agonist has failed; or

    2. Treatment with octreotide is for an interim period while awaiting the effects of radiotherapy and a dopamine agonist has failed; or

    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 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:

    1. Gastrinoma; and

    2. Either:

      1. Patient has failed surgery; or

      2. Patient in metastatic disease after H2 antagonists (or proton pump inhibitors) have failed; or

  3. Both:

    1. Insulinomas; and

    2. Surgery is contraindicated or has failed; or

  4. For pre-operative control of hypoglycaemia and for maintenance therapy; or

  5. Both:

    1. Carcinoid syndrome (diagnosed by tissue pathology and/or urinary 5HIAA analysis); and

    2. Disabling symptoms not controlled by maximal medical therapy.

Flutamide Tab 250 mg Flutamin 100 100 55.00 Tamoxifen citrate Tab 10 mg Genox 100 17.50 Tab 20 mg Genox 100 8.75 30 2.63 Megestrol acetate Tab 160 mg Apo-Megestrol 30 54.30 Bicalutamide Tab 50 mg Bicalaccord 28 4.90 Aromatase Inhibitors Letrozole Tab 2.5 mg Letraccord 30 4.85 Letrole 30 2.95 Exemestane Tab 25 mg Aromasin 30 14.50 Anastrozole Tab 1 mg DP-Anastrozole 30 26.55 Aremed 30 26.55 Immunosuppressants Calcineurin Inhibitors Ciclosporin Cap 100 mg Neoral 50 177.81 Cap 25 mg Neoral 50 44.63 Cap 50 mg Neoral 50 88.91 Oral liq 100 mg per ml Neoral 50 198.13 Inj 50 mg per ml, 5 ml ampoule Sandimmun 10 276.30 Tacrolimus Inj 5 mg per ml, 1 ml ampoule Any 0 Cap 0.5 mg Tacrolimus Sandoz 100 85.60 Cap 1 mg Tacrolimus Sandoz 100 171.20 Cap 5 mg Tacrolimus Sandoz 50 428.00

Initiation - organ transplant recipients

For use in organ transplant recipients

Steroid-resistant nephrotic syndrome*

Either:

  1. The patient is a child with steroid-resistant nephrotic syndrome* (SRNS) where ciclosporin has been trialled in combination with prednisone and discontinued because of unacceptable side effects or inadequate clinical response; or

  2. All of the following:

    1. The patient is an adult with SRNS; and

    2. Ciclosporin has been trialled in combination with prednisone and discontinued because of unacceptable side effects or inadequate clinical response; and

    3. Cyclophosphamide or mycophenolate have been trialled and discontinued because of unacceptable side effects or inadequate clinical response, or these treatments are contraindicated.

Note: Indications marked with * are Unapproved Indications

 Fusion Proteins Etanercept Inj 25 mg vial Enbrel 4 799.96 Inj 50 mg autoinjector Enbrel 4 1599.96 Inj 50 mg syringe Enbrel 4 1599.96

Initiation - juvenile idiopathic arthritis

Rheumatologist or named specialist

Re-assessment required after 4 months

Either:
  1. Both:

    1. The patient has had an initial Special Authority approval for adalimumab for juvenile idiopathic arthritis (JIA); and

    2. Either:

      1. The patient has experienced intolerable side effects from adalimumab; or

      2. The patient has received insufficient benefit from adalimumab to meet the renewal criteria for adalimumab for JIA; or

  2. All of the following:

    1. Patient diagnosed with Juvenile Idiopathic Arthritis (JIA); and

    2. To be used as an adjunct to methotrexate therapy or monotherapy where use of methotrexate is limited by toxicity or intolerance; and

    3. Patient has had severe active polyarticular course JIA for 6 months duration or longer; and

    4. Patient has tried and not responded to at least three months of oral or parenteral methotrexate (at a dose of 10-20 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

    5. Both:
      1. Either:

        1. Patient has persistent symptoms of poorly-controlled and active disease in at least 20 swollen, tender joints; or

        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. Physician's global assessment indicating severe disease.

Continuation - juvenile idiopathic arthritis

Rheumatologist or named specialist

Re-assessment required after 6 months

Both:

  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:

    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. 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:

    1. The patient has had an initial Special Authority approval for adalimumab for rheumatoid arthritis; and

    2. Either:

      1. The patient has experienced intolerable side effects from adalimumab; or

      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:

    1. Patient has had severe and active erosive rheumatoid arthritis for six months duration or longer; and

    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

    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

    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:

      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 ciclosporin; or

      2. Patient has tried and not responded to at least three months of oral or parenteral methotrexate in combination with intramuscular gold; or

      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:

      1. Patient has persistent symptoms of poorly controlled and active disease in at least 20 swollen, tender joints; or

      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:

      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. 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:

    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. 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. The patient has had an initial Special Authority approval for adalimumab for ankylosing spondylitis; and

    2. Either:

      1. The patient has experienced intolerable side effects from adalimumab; or

      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:

    1. Patient has a confirmed diagnosis of ankylosing spondylitis present for more than six months; and

    2. Patient has low back pain and stiffness that is relieved by exercise but not by rest; and

    3. Patient has bilateral sacroiliitis demonstrated by plain radiographs, CT or MRI scan; and

    4. Patient's ankylosing spondylitis has not responded adequately to treatment with two or more non-steroidal anti-inflammatory 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

    5. Either:

      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. 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

    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. The patient has had an initial Special Authority approval for adalimumab for psoriatic arthritis; and

    2. Either:

      1. The patient has experienced intolerable side effects from adalimumab; or

      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:

    1. Patient has had severe active psoriatic arthritis for six months duration or longer; and

    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

    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

    4. Either:

      1. Patient has persistent symptoms of poorly controlled and active disease in at least 15 swollen, tender joints; or

      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

    5. Any of the following:

      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. Patient has an elevated erythrocyte sedimentation rate (ESR) greater than 25 mm per hour; or

      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:
  1. Either:

    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. 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. The patient has experienced intolerable side effects from adalimumab; or

    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. 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

    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, ciclosporin, 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. Both:

      1. Patient had "whole body" severe chronic plaque psoriasis at the start of treatment; and

      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

    2. Both:

      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

      2. Either:

        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

        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.

Indication - pyoderma gangrenosum

Dermatologist

All of the following:

  1. Patient has pyoderma gangrenosum*; and

  2. Patient has received three months of conventional therapy including a minimum of three pharmaceuticals (e.g. prednisone, ciclosporin, azathioprine, or methotrexate) and not received an adequate response; and

  3. A maximum of 4 doses.

Note: Indications marked with * are Unapproved Indications (refer to Section A: General Rules, Part I (Interpretations and Definitions) and Part V (Miscellaneous Provisions) rule 5.5).

Renewal - pyoderma gangrenosum

Dermatologist

All of the following:

  1. Patient has shown clinical improvement; and

  2. Patient continues to require treatment; and

  3. A maximum of 4 doses

Initiation - adult-onset Still’s disease

Rheumatologist

Re-assessment required after 6 months

Either:
  1. Both:
    1. Either:

      1. The patient has had an initial Special Authority approval for etanercept for adult-onset Still’s disease (AOSD); or

      2. The patient has been started on tocilizumab for AOSD in a DHB hospital in accordance with the HML rules; and

    2. Either:

      1. The patient has experienced intolerable side effects from etanercept and/or tocilizumab; or

      2. The patient has received insufficient benefit from at least a three-month trial of adalimumab and/or tocilizumab such that they do not meet the renewal criteria for AOSD; or

  2. All of the following:

    1. Patient diagnosed with AOSD according to the Yamaguchi criteria (J Rheumatol 1992;19:424-430); and

    2. Patient has tried and not responded to at least 6 months of glucocorticosteroids, non-steroidal antiinflammatory drugs (NSAIDs) and methotrexate; and

    3. Patient has persistent symptoms of disabling poorly controlled and active disease.

Continuation - adult-onset Still’s disease

Paediatric rheumatologist

Re-assessment required after 6 months

The patient has a sustained improvement in inflammatory markers and functional status.

 Monoclonal Antibodies Bevacizumab Inj 25 mg per ml, 16 ml vial Any 0 Inj 25 mg per ml, 4 ml vial Any 0
Either:

  1. Ocular neovascularisation; or

  2. Exudative ocular angiopathy.

 Ranibizumab Inj 10 mg per ml, 0.23 ml vial Any 0 Inj 10 mg per ml, 0.3 ml vial Any 0

Initiation

Re-assessment required after 3 doses

Both:
  1. Either

    1. Age-related macular degeneration; or

    2. Chorodial neovascular membrane; and

  2. Any of the following:

    1. The patient has had a severe ophthalmic inflammatory response following bevacizumab; or

    2. The patient has had a myocardial infarction or stroke within the last three months; or

    3. The patient has failed to respond to bevacizumab following three intraocular injections; or

    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.

 Infliximab Inj 100 mg Remicade 1 806.00

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:

    1. The patient has experienced intolerable side effects from a reasonable trial of adalimumab and/or etanercept; or

    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:

    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. 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

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:

    1. The patient has experienced intolerable side effects from a reasonable trial of adalimumab and/or etanercept; or

    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:

    1. The patient has experienced intolerable side effects from a reasonable trial of adalimumab and/or etanercept; or

    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. 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. 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:

    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. 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

Both:

  1. Patient had a good clinical response to initial treatment; and

  2. Either:

    1. A withdrawal of infliximab has been trialled and patient has relapsed after trial withdrawal; or

    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:

    1. Patient has a Crohn's Disease Activity Index (CDAI) score of greater than or equal to 300; or

    2. Patient has extensive small intestine disease affecting more than 50 cm of the small intestine; or

    3. Patient has evidence of short gut syndrome or would be at risk of short gut syndrome with further bowel resection; or

    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. CDAI score has reduced by 100 points from the CDAI score when the patient was initiated on infliximab; or

    2. CDAI score is 150 or less; or

    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:

    1. Patient has a Paediatric Crohn's Disease Activity Index (PCDAI) score of greater than or equal to 30; or

    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)

Gastroenterologist

Re-assessment required after 6 months

All of the following:
  1. One of the following:

    1. PCDAI score has reduced by 10 points from the PCDAI score when the patient was initiated on infliximab; or

    2. PCDAI score is 15 or less; or

    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:

    1. Patient has one or more complex externally draining enterocutaneous fistula(e); or

    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. 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 (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

All of the following:

  1. Patient has histologically confirmed ulcerative colitis; and

  2. Either:

    1. Patient is 18 years or older and the Simple Clinical Colitis Activity Index (SCCAI) is ≥ 4; or

    2. Patient is under 18 years and the Paediatric Ulcerative Colitis Activity Index (PUCAI) score is ≥ 65; 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 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. Either:

    1. Patient is 18 years or older and the SCCAI score has reduced by ≥ 2 points from the SCCAI score when the patient was initiated on infliximab; or

    2. Patient is under 18 years and the PUCAI score has reduced by ≥ 30 points from the PUCAI 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:

    1. The patient has experienced intolerable side effects from adalimumab or etanercept; or

    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. 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

    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, ciclosporin, 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 3 doses

Both:
  1. Either:
    1. Both:

      1. Patient had "whole body" severe chronic plaque psoriasis at the start of treatment; and

      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

    2. Both:

      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

      2. Either:

        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

        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.

 Tocilizumab Inj 20 mg per ml, 10 ml vial Actemra 1 550.00 Inj 20 mg per ml, 20 ml vial Actemra 1 1100.00 Inj 20 mg per ml, 4 ml vial Actemra 1 220.00

Initiation -Rheumatoid Arthritis

Rheumatologist

Re-assessment required after 6 months

Either:
  1. 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:

      1. The patient has experienced intolerable side effects from adalimumab and/or etanercept; or

      2. The patient has received insufficient benefit from at least a three-month trial of adalimumab and/or etanercept such that they do not meet the renewal criteria for rheumatoid arthritis; and

    3. The patient has been started on rituximab for rheumatoid arthritis in a DHB hospital in accordance with the HML rules; and

    4. Either:

      1. The patient has experienced intolerable side effects from rituximab; or

      2. At four months following the initial course of rituximab the patient has received insufficient benefit such that they do not meet the renewal criteria for rheumatoid arthritis; or

  2. All of the following:

    1. Patient has had severe and active erosive rheumatoid arthritis for six months duration or longer; and

    2. Tocilizumab is to be used as monotherapy; and

    3. Either:

      1. Treatment with methotrexate is contraindicated; or

      2. Patient has tried and did not tolerate oral and/or parenteral methotrexate; and

    4. Either:

      1. Patient has tried and not responded to at least three months therapy at the maximum tolerated dose of ciclosporin alone or in combination with another agent; or

      2. Patient has tried and not responded to at least three months therapy at the maximum tolerated dose of leflunomide alone or in combination with another agent; and

    5. Either:

      1. Patient has persistent symptoms of poorly controlled and active disease in at least 20 active, swollen, tender joints; or

      2. Patient has persistent symptoms of poorly controlled and active disease in at least four active joints from the following: wrist, elbow, knee, ankle, and either shoulder or hip; and

    6. Either:

      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. 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

Either:

  1. Following 6 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. 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.

Initiation - systemic juvenile idiopathic arthritis

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

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.

Initiation - adult-onset Still's disease

Rheumatologist

Re-assessment required after 6 months

Either:
  1. Both:

    1. The patient has had an initial Special Authority approval for adalimumab or etanercept for adult-onset Still's disease (AOSD); and

    2. Either:

      1. The patient has experienced intolerable side effects from adalimumab and/or etanercept; or

      2. The patient has received insufficient benefit from at least a three-month trial of adalimumab and/or etanercept such that they do not meet the renewal criteria for AOSD; or

  2. All of the following:

    1. Patient diagnosed with AOSD according to the Yamaguchi criteria (J Rheumatol 1992;19:424-430); and

    2. Patient has tried and not responded to at least 6 months of glucocorticosteroids, non-steroidal antiinflammatory drugs (NSAIDs) and methotrexate; and

    3. Patient has persistent symptoms of disabling poorly controlled and active disease.

Continuation - adult-onset Still's disease

Rheumatologist

Re-assessment required after 6 months

The patient has a sustained improvement in inflammatory markers and functional status.

 Omalizumab Inj 150 mg vial Xolair 1 500.00

Initiation

Respiratory physician

Re-assessment required after 6 months

All of the following:

  1. Patient is over the age of 6; and

  2. Patient has a diagnosis of severe, life threatening asthma; and

  3. Past or current evidence of atopy, documented by skin prick testing or RAST; and

  4. Total serum human immunoglobulin E (IgE) between 76 IU/mL and 1300 IU/ml at baseline; and

  5. Proven compliance with optimal inhaled therapy including high dose inhaled corticosteroid (budesonide 1600 micrograms per day or fluticasone propionate 1000 micrograms per day or equivalent), plus long-acting beta-2 agonist therapy (at least salmeterol 50 micrograms bd or eformoterol 12 micrograms bd) for at least 12 months, unless contraindicated or not tolerated; and

  6. Patient has received courses of systemic corticosteroids equivalent to at least 28 days treatment in the past 12 months, unless contraindicated or not tolerated; and

  7. At least four admissions to hospital for a severe asthma exacerbation over the previous 24 months with at least one of those being in the previous 12 months; and

  8. An Asthma Control Questionnaire (ACQ-5) score of at least 3.0 as assessed in the previous month.

Continuation

Respiratory physician

Re-assessment required after 6 months

All of the following:

  1. Hospital admissions have been reduced as a result of treatment; and

  2. A reduction in the Asthma Control Questionnaire (ACQ-5) score of at least 1.0 from baseline; and

  3. A reduction in the maintenance oral corticosteroid dose of at least 50% from baseline.

 Basiliximab Inj 20 mg vial Simulect 1 3200.00

For use in solid organ transplants

 Rituximab Inj 10 mg per ml, 10 ml vial Mabthera 2 1075.50 Inj 10 mg per ml, 50 ml vial Mabthera 1 2688.30

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.

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. The patient has indolent low grade NHL with relapsed disease following prior chemotherapy; and

    2. To be used for a maximum of 6 treatment cycles; or

  2. Both:

    1. The patient has indolent, low grade lymphoma requiring first-line systemic chemotherapy; and

    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. The patient has treatment naive aggressive CD20 positive NHL; and

    2. To be used with a multi-agent chemotherapy regimen given with curative intent; and

    3. To be used for a maximum of 8 treatment cycles; or

  2. Both:

    1. The patient has aggressive CD20 positive NHL with relapsed disease following prior chemotherapy; and

    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

  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:

    1. The patient is chemotherapy treatment naive; or

    2. Both:

      1. The patient's disease has relapsed following no more than three prior lines of chemotherapy treatment; and

      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. The patient has had an initial community Special Authority approval for at least one of etanercept and/or adalimumab for rheumatoid arthritis; and

    2. Either:

      1. The patient has experienced intolerable side effects from a reasonable trial of adalimumab and/or etanercept; or

      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:

    1. Rituximab to be used as an adjunct to methotrexate or leflunomide therapy; or

    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

  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:

    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 ciclosporin; or

    2. Patient has tried and not responded to at least three months of oral or parenteral methotrexate in combination with intramuscular gold; or

    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:

    1. Patient has persistent symptoms of poorly controlled and active disease in at least 20 swollen, tender joints; or

    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:

    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. 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:

    1. Rituximab to be used as an adjunct to methotrexate or leflunomide therapy; or

    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. 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

    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

    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:

    1. Rituximab to be used as an adjunct to methotrexate or leflunomide therapy; or

    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. 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

    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:

    1. Rituximab to be used as an adjunct to methotrexate or leflunomide therapy; or

    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:

    1. Patient was previously treated with rituximab for severe cold haemagglutinin disease*; 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 – 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:

    1. Patient was previously treated with rituximab for warm autoimmune haemolytic anaemia*; 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 – immune thrombocytopenic purpura (ITP)

Haematologist

Limited to 4 weeks' treatment

Both:
  1. Either:

    1. Patient has immune thrombocytopenic purpura* with a platelet count of ≤ 20,000 platelets per microlitre; or

    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:

    1. Treatment with steroids and splenectomy have been ineffective; or

    2. Treatment with steroids has been ineffective and splenectomy is an absolute contraindication; or

    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:

    1. Patient was previously treated with rituximab for immune 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 – 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

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

Limited to 4 weeks' treatment

All of the following:

  1. Patient has been diagnosed with ANCA associated vasculitis*; and

  2. Either:

    1. Patient does not have MPO-ANCA positive vasculitis*; or

    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:

    1. Induction therapy with daily oral or pulse intravenous cyclophosphamide has failed to achieve complete absence of disease after at least 3 months; or

    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

    3. Cyclophosphamide and methotrexate are contraindicated; or

    4. Patient is a female of child-bearing potential; or

    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

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

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.

 Trastuzumab Inj 150 mg vial Herceptin 1 1350.00 Inj 440 mg vial Herceptin 1 3875.00

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:

    1. 9 weeks' concurrent treatment with adjuvant chemotherapy is planned; or

    2. 12 months' concurrent treatment with adjuvant chemotherapy is planned; or

    3. 12 months' sequential treatment following adjuvant chemotherapy is planned; or

    4. 12 months' treatment with neoadjuvant and adjuvant chemotherapy is planned, or

    5. 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. The patient has metastatic breast cancer expressing HER-2 IHC 3+ or ISH+ (including FISH or other current technology); and

    2. The patient has not previously received lapatinib treatment for HER 2 positive metastatic breast cancer; and

    3. Trastuzumab not to be given in combination with lapatinib; and

    4. Trastuzumab to be discontinued at disease progression; or

  2. 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 started lapatinib treatment for metastatic breast cancer but discontinued lapatinib within 3 months of starting treatment due to intolerance; and

    3. The cancer did not progress whilst on lapatinib; and

    4. Trastuzumab not to be given in combination with lapatinib; and

    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:
    1. All of the following:

      1. The patient has not previously received lapatinib treatment for metastatic breast cancer; and

      2. Trastuzumab not to be given in combination with lapatinib; and

      3. Trastuzumab to be discontinued at disease progression; or

    2. All of the following:

      1. The patient started lapatinib treatment for metastatic breast cancer but discontinued lapatinib within 3 months of starting treatment due to intolerance; and

      2. The cancer did not progress whilst on lapatinib; and

      3. Trastuzumab not to be given in combination with lapatinib; and

      4. Trastuzumab to be discontinued at disease progression; or

    3. All of the following:

      1. The cancer has not progressed at any time point during the previous 12 months whilst on trastuzumab; and

      2. Trastuzumab not to be given in combination with lapatinib; and

      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.

 Adalimumab Inj 40 mg per 0.8 ml syringe Humira 2 1799.92 Inj 40 mg per 0.8 ml pen HumiraPen 2 1799.92 Inj 20 mg per 0.4 ml syringe Humira 2 1799.92

Initiation - juvenile idiopathic arthritis

Rheumatologist or named specialist

Re-assessment required after 4 months

Either:
  1. Either:
    1. Both:

      1. The patient has had an initial Special Authority approval for etanercept for juvenile idiopathic arthritis (JIA); and

      2. Either:

        1. The patient has experienced intolerable side effects from etanercept; or

        2. The patient has received insufficient benefit from etanercept to meet the renewal criteria for etanercept for JIA; or

  2. All of the following:

    1. Patient diagnosed with Juvenile Idiopathic Arthritis (JIA); and

    2. To be used as an adjunct to methotrexate therapy or monotherapy where use of methotrexate is limited by toxicity or intolerance; and

    3. Patient has had severe active polyarticular course JIA for 6 months duration or longer; and

    4. Patient has tried and not responded to at least three months of oral or parenteral methotrexate (at a dose of 10-20 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

    5. Both:
      1. Either:

        1. Patient has persistent symptoms of poorly-controlled and active disease in at least 20 swollen, tender joints; or

        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. Physician's global assessment indicating severe disease.

Continuation - juvenile idiopathic arthritis

Rheumatologist or named specialist

Re-assessment required after 6 months

Both:

  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:

    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. 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:

    1. Patient has one or more complex externally draining enterocutaneous fistula(e); or

    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

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:

    1. Patient has a Crohn's Disease Activity Index (CDAI) score of greater than or equal to 300; or

    2. Patient has extensive small intestine disease affecting more than 50 cm of the small intestine; or

    3. Patient has evidence of short gut syndrome or would be at risk of short gut syndrome with further bowel resection; or

    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. Either:

      1. CDAI score has reduced by 100 points from the CDAI score when the patient was initiated on adalimumab; or

      2. CDAI score is 150 or less; or

    2. Both:

      1. The patient has demonstrated an adequate response to treatment but CDAI score cannot be assessed; and

      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. The patient has had an initial Special Authority approval for etanercept for rheumatoid arthritis; and

    2. Either:

      1. The patient has experienced intolerable side effects from etanercept; or

      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:

    1. Patient has had severe and active erosive rheumatoid arthritis for six months duration or longer; and

    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

    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

    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:

      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 ciclosporin; or

      2. Patient has tried and not responded to at least three months of oral or parenteral methotrexate in combination with intramuscular gold; or

      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:

      1. Patient has persistent symptoms of poorly controlled and active disease in at least 20 swollen, tender joints; or

      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:

      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. 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:

    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. 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. The patient has had an initial Special Authority approval for etanercept for ankylosing spondylitis; and

    2. Either:

      1. The patient has experienced intolerable side effects from etanercept; or

      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:

    1. Patient has a confirmed diagnosis of ankylosing spondylitis present for more than six months; and

    2. Patient has low back pain and stiffness that is relieved by exercise but not by rest; and

    3. Patient has bilateral sacroiliitis demonstrated by plain radiographs, CT or MRI scan; and

    4. Patient's ankylosing spondylitis has not responded adequately to treatment with two or more non-steroidal anti-inflammatory 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

    5. Either:

      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. 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

    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 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. The patient has had an initial Special Authority approval for etanercept for psoriatic arthritis; and

    2. Either:

      1. The patient has experienced intolerable side effects from etanercept; or

      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:

    1. Patient has had severe active psoriatic arthritis for six months duration or longer; and

    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

    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

    4. Either:

      1. Patient has persistent symptoms of poorly controlled and active disease in at least 15 swollen, tender joints; or

      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

    5. Any of the following:

      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. Patient has an elevated erythrocyte sedimentation rate (ESR) greater than 25 mm per hour; or

      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:
  1. Either:

    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. 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:

    1. The patient has experienced intolerable side effects from etanercept; or

    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. 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

    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, ciclosporin, 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. Both:

      1. Patient had "whole body" severe chronic plaque psoriasis at the start of treatment; and

      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

    2. Both:

      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

      2. Either:

        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

        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.

Indication - pyoderma gangrenosum

Dermatologist

All of the following:

  1. Patient has pyoderma gangrenosum*; and

  2. Patient has received three months of conventional therapy including a minimum of three pharmaceuticals (e.g. prednisone, ciclosporin, azathioprine, or methotrexate) and not received an adequate response; and

  3. A maximum of 4 doses.

Note: Indications marked with * are Unapproved Indications (refer to Section A: General Rules, Part I (Interpretations and Definitions) and Part V (Miscellaneous Provisions) rule 5.5).

Renewal - pyoderma gangrenosum

Dermatologist

All of the following:

  1. Patient has shown clinical improvement; and

  2. Patient continues to require treatment; and

  3. A maximum of 4 doses

Initiation - adult-onset Still’s disease

Rheumatologist

Re-assessment required after 6 months

Either:
  1. Both:
    1. Either:

      1. The patient has had an initial Special Authority approval for etanercept for adult-onset Still’s disease (AOSD); or

      2. The patient has been started on tocilizumab for AOSD in a DHB hospital in accordance with the HML rules; and

    2. Either:

      1. The patient has experienced intolerable side effects from etanercept and/or tocilizumab; or

      2. The patient has received insufficient benefit from at least a three-month trial of etanercept and/or tocilizumab such that they do not meet the renewal criteria for AOSD; or

  2. All of the following:

    1. Patient diagnosed with AOSD according to the Yamaguchi criteria (J Rheumatol 1992;19:424-430); and

    2. Patient has tried and not responded to at least 6 months of glucocorticosteroids, non-steroidal antiinflammatory drugs (NSAIDs) and methotrexate; and

    3. Patient has persistent symptoms of disabling poorly controlled and active disease.

Continuation - adult-onset Still’s disease

Rheumatologist

Re-assessment required after 6 months

The patient has a sustained improvement in inflammatory markers and functional status.

 Abciximab Inj 2 mg per ml, 5 ml vial ReoPro 1 579.53
Either:

  1. For use in patients with acute coronary syndromes undergoing percutaneous coronary intervention; or

  2. For use in patients undergoing intra-cranial intervention.

 Other Immunosuppressants Antithymocyte globulin (rabbit) Inj 25 mg vial Any 0 Picibanil Inj 100 mg vial Any 0 Everolimus Tab 5 mg Afinitor 30 4555.76 Tab 10 mg Afinitor 30 6512.29

Initiation

Neurologist or oncologist

Re-assessment required after 3 months

Both:

  1. Patient has tuberous sclerosis; and

  2. Patient has progressively enlarging sub-ependymal giant cell astrocytomas (SEGAs) that require treatment.

Continuation

Neurologist or oncologist

Re-assessment required after 12 months

All of the following:

  1. Documented evidence of SEGA reduction or stabilisation by MRI within the last 3 months; and

  2. The treatment remains appropriate and the patient is benefiting from treatment; and

  3. Everolimus to be discontinued at progression of SEGAs.

Note: MRI should be performed at minimum once every 12 months, more frequent scanning should be performed with new onset of symptoms such as headaches, visual complaints, nausea or vomiting, or increase in seizure activity.

Mycophenolate mofetil Inj 500 mg vial CellCept 4 133.33 Cap 250 mg CellCept 100 25.00 Tab 500 mg CellCept 50 25.00 Powder for oral liq 1 g per 5 ml CellCept 165 187.25 Antithymocyte globulin (equine) Inj 50 mg per ml, 5 ml ampoule ATGAM 5 2351.25 Sirolimus Tab 1 mg Rapamune 100 813.00 Tab 2 mg Rapamune 100 1626.00 Oral liq 1 mg per ml Rapamune 60 487.80

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:

  • GFR < 30 ml/min; or

  • Rapidly progressive transplant vasculopathy; or

  • Rapidly progressive obstructive bronchiolitis; or

  • HUS or TTP; or

  • Leukoencepthalopathy; or

  • Significant malignant disease

 Azathioprine Inj 50 mg vial Imuran 1 126.00 Tab 50 mg Azamun 100 13.22 Tab 25 mg Azamun 60 8.28 Bacillus calmette-guerin (BCG) Inj 2-8 x 10^8 CFU vial OncoTICE 1 149.37 Inj 40 mg per ml, vial SII-Onco-BCG 3 149.37

For use in bladder cancer

 Respiratory System and Allergies Antiallergy Preparations Allergy Desensitisation Bee venom Inj 550 mcg vial with diluent Any 0
Both:

  1. RAST or skin test positive; and

  2. Patient has had severe generalised reaction to the sensitising agent.

 Paper wasp venom Inj 550 mcg vial with diluent Any 0
Both:

  1. RAST or skin test positive; and

  2. Patient has had severe generalised reaction to the sensitising agent.

 Yellow jacket wasp venom Inj 550 mcg vial with diluent Any 0
Both:

  1. RAST or skin test positive; and

  2. Patient has had severe generalised reaction to the sensitising agent.

 Allergy Prophylactics Sodium cromoglycate Nasal spray 4% Any 0 Beclomethasone dipropionate Nasal spray 50 mcg per dose Alanase 200 4.85 Nasal spray 100 mcg per dose Alanase 200 5.75 Budesonide Nasal spray 50 mcg per dose Butacort Aqueous 200 4.85 Nasal spray 100 mcg per dose Butacort Aqueous 200 5.75 Ipratropium bromide Aqueous nasal spray 0.03% Univent 15 3.95 Fluticasone propionate Nasal spray 50 mcg per dose Flixonase Hayfever & Allergy 120 2.18 Antihistamines Chlorpheniramine maleate Inj 10 mg per ml, 1 ml ampoule Any 0 Oral liq 0.4 mg per ml Any 0 Cyproheptadine hydrochloride Tab 4 mg Any 0 Fexofenadine hydrochloride Tab 120 mg Any 0 Tab 180 mg Any 0 Tab 60 mg Any 0 Trimeprazine tartrate Oral liq 6 mg per ml Any 0 Promethazine hydrochloride Inj 25 mg per ml, 2 ml ampoule Hospira 5 11.99 Tab 10 mg Allersoothe 50 1.78 Tab 25 mg Allersoothe 50 1.99 Oral liq 1 mg per ml Allersoothe 100 2.59 Cetirizine hydrochloride Oral liq 1 mg per ml Histaclear 200 2.99 Tab 10 mg Zetop 100 1.59 Loratadine Oral liq 1 mg per ml LoraPaed 200 4.25 Tab 10 mg Lorafix 100 1.30 Anticholinergic Agents Anticholinergic Agents Ipratropium bromide Aerosol inhaler 20 mcg per dose Any 0 Nebuliser soln 250 mcg per ml, 1 ml ampoule Univent 20 3.26 Nebuliser soln 250 mcg per ml, 2 ml ampoule Univent 20 3.37 Anticholinergic Agents with Beta-Adrenoceptor Agonists Salbutamol with ipratropium bromide Aerosol inhaler 100 mcg with ipratropium bromide 20 mcg per dose Any 0 Nebuliser soln 2.5 mg with ipratropium bromide 0.5 mg per 2.5 ml ampoule Duolin 20 3.59 Long-Acting Muscarinic Agents Glycopyrronium Powder for inhalation 50 mcg per dose Seebri Breezhaler 30 61.00

Note: glycopyrronium treatment must not be used if the patient is also receiving treatment with subsidised tiotropium.

 Tiotropium bromide Powder for inhalation 18 mcg per dose Spiriva 30 70.00

Note: tiotropium treatment must not be used if the patient is also receiving treatment with subsidised glycopyrronium.

Initiation

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 dose of at least 40 µg ipratropium q.i.d for one month; and

  3. Either the patient’s breathlessness according to the Medical Research Council (UK) dyspnoea scale is:

    1. Grade 4 (stops for breath after walking about 100 meters or after a few minutes on the level); or

    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:

    1. Patient is not a smoker (for reporting purposes only); or

    2. Patient is a smoker and has been offered smoking cessation counselling; and

  6. The patient has been offered annual influenza immunization.

 Beta-Adrenoceptor Agonists Beta-Adrenoceptor Agonists Terbutaline sulphate Inj 0.5 mg per ml, 1 ml ampoule Any 0 Powder for inhalation 250 mcg per dose Any 0 Salbutamol Aerosol inhaler, 100 mcg per dose Ventolin 200 6.00 200 6.00 Salamol 200 4.00 SalAir 200 3.80 Inj 1 mg per ml, 5 ml ampoule Any 0 Inj 500 mcg per ml, 1 ml ampoule Any 0 Nebuliser soln 1 mg per ml, 2.5 ml ampoule Asthalin 20 3.19 Nebuliser soln 2 mg per ml, 2.5 ml ampoule Asthalin 20 3.29 Oral liq 400 mcg per ml Ventolin 150 2.06 Cough Suppressants Cough Suppressants Pholcodine Oral liq 1 mg per ml Any 0 Decongestants Decongestants Oxymetazoline hydrochloride Aqueous nasal spray 0.25 mg per ml Any 0 Aqueous nasal spray 0.5 mg per ml Any 0 Pseudoephedrine hydrochloride Tab 60 mg Any 0 Sodium chloride with sodium bicarbonate Soln for nasal irrigation Any 0 Xylometazoline hydrochloride Aqueous nasal spray 0.05% Any 0 Aqueous nasal spray 0.1% Any 0 Nasal drops 0.05% Any 0 Nasal drops 0.1% Any 0 Sodium chloride Aqueous nasal spray isotonic Any 0 Inhaled Corticosteroids Inhaled Corticosteroids Beclomethasone dipropionate Aerosol inhaler 50 mcg per dose Beclazone 50 200 8.54 Qvar 200 9.30 Aerosol inhaler 100 mcg per dose Beclazone 100 200 12.50 Qvar 200 15.50 Aerosol inhaler 250 mcg per dose Beclazone 250 200 22.67 Budesonide Nebuliser soln 250 mcg per ml, 2 ml ampoule Any 0 Nebuliser soln 500 mcg per ml, 2 ml ampoule Any 0 Powder for inhalation 100 mcg per dose Any 0 Powder for inhalation 200 mcg per dose Any 0 Powder for inhalation 400 mcg per dose Any 0 Fluticasone Aerosol inhaler 50 mcg per dose Flixotide 120 7.50 Floair 120 7.50 Aerosol inhaler 125 mcg per dose Flixotide 120 13.60 Floair 120 13.60 Aerosol inhaler 250 mcg per dose Flixotide 120 27.20 Floair 120 27.20 Powder for inhalation 50 mcg per dose Flixotide Accuhaler 60 8.67 Powder for inhalation 100 mcg per dose Flixotide Accuhaler 60 13.87 Powder for inhalation 250 mcg per dose Flixotide Accuhaler 60 24.51 Leukotriene Receptor Antagonists Leukotriene Receptor Antagonists Montelukast Tab 5 mg Singulair 28 18.48 Tab 4 mg Singulair 28 18.48 Tab 10 mg Singulair 28 18.48

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

All of the following:

  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 Long-Acting Beta-Adrenoceptor Agonists Eformoterol fumarate Powder for inhalation 12 mcg per dose Any 0 Powder for inhalation 6 mcg per dose Any 0 Indacaterol Powder for inhalation 150 mcg per dose Onbrez Breezhaler 30 61.00 Powder for inhalation 300 mcg per dose Onbrez Breezhaler 30 61.00 Salmeterol Powder for inhalation 50 mcg per dose Serevent Accuhaler 60 26.46 Aerosol inhaler 25 mcg per dose Serevent 120 26.46 Meterol 120 26.46 Inhaled Corticosteroids with Long-Acting Beta-Adrenoceptor Agonists Budesonide with eformoterol Aerosol inhaler 100 mcg with eformoterol fumarate 6 mcg Any 0 Aerosol inhaler 200 mcg with eformoterol fumarate 6 mcg Any 0 Powder for inhalation 100 mcg with eformoterol fumarate 6 mcg Any 0 Powder for inhalation 200 mcg with eformoterol fumarate 6 mcg Any 0 Powder for inhalation 400 mcg with eformoterol fumarate 12 mcg Any 0
Either:
  1. All of the following:

    1. Patient is a child under the age of 12; and

    2. Has been treated with inhaled corticosteroids of at least 400 mcg per day beclomethasone or budesonide, or 200 mcg per day fluticasone; and

    3. The prescriber considers that the patient would receive additional clinical benefit from switching to a combination product; or

  2. All of the following:

    1. Patient is over the age of 12; and

    2. Has been treated with inhaled corticosteroids of at least 800 mcg per day beclomethasone or budesonide, or 500 mcg per day fluticasone; and

    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 Seretide 120 37.48 RexAir 120 37.48 Aerosol inhaler 125 mcg with salmeterol 25 mcg Seretide 120 49.69 RexAir 120 49.69 Powder for inhalation 100 mcg with salmeterol 50 mcg Seretide Accuhaler 60 37.48 Powder for inhalation 250 mcg with salmeterol 50 mcg Seretide Accuhaler 60 49.69 Mast Cell Stabilisers Mast Cell Stabilisers Nedocromil Aerosol inhaler 2 mg per dose Any 0 Sodium cromoglycate Aerosol inhaler 5 mg per dose Any 0 Powder for inhalation 20 mg per dose Any 0 Methylxanthines Methylxanthines Theophylline Oral liq 80 mg per 15 ml Any 0 Tab long-acting 250 mg Any 0 Caffeine citrate Oral liq 20 mg per ml (caffeine 10 mg per ml) Biomed 25 14.85 Inj 20 mg per ml (caffeine 10 mg per ml), 2.5 ml ampoule Biomed 5 55.75 Aminophylline Inj 25 mg per ml, 10 ml ampoule DBL Aminophylline 5 118.25 Mucolytics and Expectorants Mucolytics and Expectorants Sodium chloride Nebuliser soln 7%, 90 ml bottle Biomed 90 23.50 Dornase alfa Nebuliser soln 2.5 mg per 2.5 ml ampoule Pulmozyme 6 250.00
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:

    1. Patient is an in-patient; and

    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.

 Pulmonary Surfactants Pulmonary Surfactants Beractant Soln 200 mg per 8 ml vial Survanta 1 550.00 Poractant alfa Soln 120 mg per 1.5 ml vial Curosurf 1 425.00 Soln 240 mg per 3 ml vial Curosurf 1 695.00 Respiratory Stimulants Respiratory Stimulants Doxapram Inj 20 mg per ml, 5 ml vial Any 0 Sclerosing Agents Sclerosing Agents Talc Powder Any 0 Soln (slurry) 100 mg per ml, 50 ml Any 0 Sensory Organs Anti-Infective Preparations Antibacterials Framycetin sulphate Ear/eye drops 0.5% Any 0 Propamidine isethionate Eye drops 0.1% Any 0 Sulphacetamide sodium Eye drops 10% Any 0 Gentamicin sulphate Eye drops 0.3% Genoptic 5 5 11.40 Chloramphenicol Ear drops 0.5% Any 0 Eye drops 0.5%, single dose Any 0 Eye drops 0.5% Chlorafast 10 0.98 Eye oint 1% Chlorsig 4 2.76 Ciprofloxacin Eye drops 0.3% Any 0 Fusidic acid Eye drops 1% Fucithalmic 5 4.50 Tobramycin Eye oint 0.3% Tobrex 3.50 10.45 Eye drops 0.3% Tobrex 5 11.48 Antifungals Natamycin Eye drops 5% Any 0 Antivirals Ganciclovir Eye gel 0.15% e.g. Virgan 0 Aciclovir Eye oint 3% Any 0 Combination Preparations Dexamethasone with framycetin and gramicidin Ear/eye drops 500 mcg with framycetin sulphate 5 mg and gramicidin 50 mcg per ml Any 0 Dexamethasone with neomycin sulphate and polymyxin B sulphate Eye drops 0.1% with neomycin sulphate 0.35% and polymyxin b sulphate 6,000 u per ml Maxitrol 5 4.50 Eye oint 0.1% with neomycin sulphate 0.35% and polymyxin b sulphate 6,000 u per g Maxitrol 3.50 5.39 Dexamethasone with tobramycin Eye drops 0.1% with tobramycin 0.3% Tobradex 5 12.64 Flumetasone pivalate with clioquinol Ear drops 0.02% with clioquinol 1% Any 0 Ciprofloxacin with hydrocortisone Ear drops ciprofloxacin 0.2% with 1% hydrocortisone Ciproxin HC Otic 10 16.30 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 Kenacomb 7.50 5.16 Anti-Inflammatory Preparations Corticosteroids Prednisolone acetate Eye drops 0.12% Any 0 Eye drops 1% Any 0 Fluorometholone Eye drops 0.1% FML 5 3.09 Prednisolone sodium phosphate Eye drops 0.5%, single dose (preservative free) Minims Prednisolone 20 38.50 Dexamethasone Eye drops 0.1% Maxidex 5 4.50 Eye oint 0.1% Maxidex 3.50 5.86 Non-Steroidal Anti-Inflammatory Drugs Ketorolac trometamol Eye drops 0.5% Any 0 Diclofenac sodium Eye drops 0.1% Voltaren Ophtha 5 13.80 Decongestants and Antiallergics Antiallergic Preparations Levocabastine Eye drops 0.05% Any 0 Lodoxamide Eye drops 0.1% Lomide 10 8.71 Olopatadine Eye drops 0.1% Any 0 Sodium cromoglycate Eye drops 2% Any 0 Decongestants Naphazoline hydrochloride Eye drops 0.1% Naphcon Forte 15 4.15 Diagnostic and Surgical Preparations Diagnostic Dyes Fluorescein sodium with lignocaine hydrochloride Eye drops 0.25% with lignocaine hydrochloride 4%, single dose Any 0 Lissamine green Ophthalmic strips 1.5 mg Any 0 Rose bengal sodium Ophthalmic strips 1% Any 0 Fluorescein sodium Eye drops 2%, single dose Any 0 Ophthalmic strips 1 mg Any 0 Inj 10%, 5 ml vial Fluorescite 12 125.00 Irrigation Solutions Mixed salt solution for eye irrigation Eye irrigation solution calcium chloride 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 dropper bottle Balanced Salt Solution 15 5.00 Eye irrigation solution calcium chloride 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 0 Eye irrigation solution calcium chloride 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 bottle Balanced Salt Solution 500 10.50 Ocular Anaesthetics Oxybuprocaine hydrochloride Eye drops 0.4%, single dose Any 0 Tetracaine [Amethocaine] hydrochloride Eye drops 0.5%, single dose Any 0 Eye drops 1%, single dose Any 0 Proxymetacaine hydrochloride Eye drops 0.5% Any 0 Viscoelastic Substances Sodium hyaluronate [Hyaluronic acid] 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 [hyaluronic acid] per ml, 0.4 ml syringe Duovisc 1 64.00 Inj 30 mg per ml with chondroitin sulphate 40 mg per ml, 0.5 ml syringe and inj 10 mg sodium hyaluronate [hyaluronic acid] per ml, 0.55 ml syringe Duovisc 1 74.00 Inj 30 mg with chondroitin sulphate 40 mg per ml, 0.75 ml syringe Any 0 Sodium hyaluronate [Hyaluronic acid] Inj 23 mg per ml, 0.6 ml syringe Any 0 Inj 10 mg per ml, 0.85 ml syringe Provisc 1 30.00 Inj 14 mg per ml, 0.55 ml syringe Healon GV 1 50.00 Inj 14 mg per ml, 0.85 ml syringe Healon GV 1 50.00 Hypromellose Inj 2%, 1 ml syringe Any 0 Inj 2%, 2 ml syringe Any 0 Other Disodium edetate Inj 150 mg per ml, 100 ml vial Any 0 Inj 150 mg per ml, 20 ml ampoule Any 0 Inj 150 mg per ml, 20 ml vial Any 0 Riboflavin 5-phosphate Inj 0.1% Any 0 1 Inj 0.1% plus 20% dextran T500 Any 0 1 Soln trans epithelial riboflavin Any 0 Glaucoma Preparations Beta Blockers Betaxolol Eye drops 0.25% Betoptic S 5 11.80 Eye drops 0.5% Betoptic 5 7.50 Timolol Eye drops 0.25% Arrow-Timolol 5 1.45 Eye drops 0.25%, gel forming Timoptol XE 2.50 3.30 Eye drops 0.5% Arrow-Timolol 5 1.45 Eye drops 0.5%, gel forming Timoptol XE 2.50 3.78 Levobunolol hydrochloride Eye drops 0.5% Betagan 5 7.00 Carbonic Anhydrase Inhibitors Brinzolamide Eye drops 1% Any 0 Dorzolamide Eye drops 2% Any 0 Acetazolamide Inj 500 mg Any 0 Tab 250 mg Diamox 100 17.03 Dorzolamide with timolol Eye drops 2% with timolol 0.5% Arrow-Dortim 5 3.45 Miotics Acetylcholine chloride Inj 20 mg vial with diluent Any 0 Pilocarpine hydrochloride Eye drops 1% Isopto Carpine 15 4.26 Eye drops 2% Isopto Carpine 15 5.35 Eye drops 2%, single dose Any 0 Eye drops 4% Isopto Carpine 15 7.99 Prostaglandin Analogues Bimatoprost Eye drops 0.03% Any 0 Travoprost Eye drops 0.004% Any 0 Latanoprost Eye drops 0.005% Hysite 2.50 1.50 Sympathomimetics Apraclonidine Eye drops 0.5% Iopidine 5 19.77 Brimonidine tartrate with timolol Eye drops 0.2% with timolol 0.5% Any 0 Brimonidine tartrate Eye drops 0.2% Arrow-Brimonidine 5 4.32 Mydriatics and Cycloplegics Anticholinergic Agents Cyclopentolate hydrochloride Eye drops 0.5%, single dose Any 0 Eye drops 1% Cyclogyl 15 8.76 Eye drops 1%, single dose Any 0 Atropine sulphate Eye drops 0.5% Any 0 Eye drops 1%, single dose Any 0 Eye drops 1% Atropt 15 17.36 Tropicamide Eye drops 0.5%, single dose Any 0 Eye drops 1%, single dose Any 0 Eye drops 0.5% Mydriacyl 15 7.15 Eye drops 1% Mydriacyl 15 8.66 Sympathomimetics Phenylephrine hydrochloride Eye drops 10%, single dose Any 0 Eye drops 2.5%, single dose Any 0 Ocular Lubricants Ocular Lubricants Carbomer Ophthalmic gel 0.2% Any 0 Ophthalmic gel 0.3%, single dose Poly Gel 30 8.25 Carmellose sodium Eye drops 0.5% Any 0 Eye drops 0.5%, single dose Any 0 Eye drops 1% Any 0 Eye drops 1%, single dose Any 0 Hypromellose with dextran Eye drops 0.3% with dextran 0.1% Poly-Tears 15 2.30 Eye drops 0.3% with dextran 0.1%, single dose Any 0 Paraffin liquid with wool fat Eye oint 3% with wool fat 3% Poly-Visc 3.50 3.63 Polyvinyl alcohol with povidone Eye drops 1.4% with povidone 0.6%, single dose Any 0 Retinol Palmitate Oint 138 mcg per g VitA-POS 5 3.80 Macrogol 400 and propylene glycol Eye drops 0.4% with propylene glycol 0.3% preservative free, single dose Systane Unit Dose 24 4.30 Sodium hyaluronate [Hyaluronic acid] Eye drops 1 mg per ml Hylo-Fresh 10 22.00 Polyvinyl alcohol Eye drops 1.4% Liquifilm Tears 15 3.62 Vistil 15 2.95 Eye drops 3% Liquifilm Forte 15 3.88 Vistil Forte 15 3.80 Hypromellose Eye drops 0.5% Methopt 15 3.92 Paraffin liquid with soft white paraffin Eye oint 42.5% with soft white paraffin 57.3% Any 0 Other Otological Preparations Other Otological Preparations Acetic acid with propylene glycol Ear drops 2.3% with propylene glycol 2.8% Any 0 Docusate sodium Ear drops 0.5% Any 0 Various Agents Used in the Treatment of Poisonings Antidotes Digoxin immune Fab Inj 38 mg vial Any 0 Inj 40 mg vial Any 0 Ethanol with glucose Inj 10% with glucose 5%, 500 ml bottle Any 0 Ethanol, dehydrated Inj 100%, 5 ml ampoule Any 0 Inj 96% Any 0 Pralidoxime iodide Inj 25 mg per ml, 20 ml ampoule Any 0 Sodium nitrite Inj 30 mg per ml, 10 ml ampoule Any 0 Sodium thiosulfate Inj 250 mg per ml, 10 ml vial Any 0 Inj 500 mg per ml, 10 ml vial Any 0 Inj 500 mg per ml, 20 ml ampoule Any 0 Soya oil Inj 20%, 500 ml bag Any 0 Inj 20%, 500 ml bottle Any 0 Ethanol Liq 96% Any 0 Flumazenil Inj 0.1 mg per ml, 5 ml ampoule Anexate 5 85.05 Naloxone hydrochloride Inj 400 mcg per ml, 1 ml ampoule Hospira 5 48.84 Hydroxocobalamin Inj 2.5 g vial Any 0 Inj 5 g vial Any 0 Acetylcysteine Tab eff 200 mg Any 0 Inj 200 mg per ml, 10 ml ampoule DBL Acetylcysteine 10 78.34 Antitoxins Botulism antitoxin Inj 250 ml vial Any 0 Diphtheria antitoxin Inj 10,000 iu vial Any 0 Antivenoms Red back spider antivenom Inj 500 u vial Any 0 Snake antivenom Inj 50 ml vial Any 0 Removal and Elimination Dicobalt edetate Inj 15 mg per ml, 20 ml ampoule Any 0 Dimercaprol Inj 50 mg per ml, 2 ml ampoule Any 0 Dimercaptosuccinic acid Cap 100 mg Any 0 Sodium calcium edetate Inj 200 mg per ml, 2.5 ml ampoule Any 0 Inj 200 mg per ml, 5 ml ampoule Any 0 Deferasirox Tab 125 mg dispersible Exjade 28 276.00 Tab 250 mg dispersible Exjade 28 552.00 Tab 500 mg dispersible Exjade 28 1105.00

Initiation

Haematologist

Re-assessment required after 2 years

All of the following:

  1. The patient has been diagnosed with chronic iron overload due to congenital inherited anaemia; and

  2. Deferasirox is to be given at a daily dose not exceeding 40 mg/kg/day; and

  3. Any of the following:

    1. Treatment with maximum tolerated doses of deferiprone monotherapy or deferiprone and desferrioxamine combination therapy have proven ineffective as measured by serum ferritin levels, liver or cardiac MRI T2*; or

    2. Treatment with deferiprone has resulted in severe persistent vomiting or diarrhoea; or

    3. Treatment with deferiprone has resulted in arthritis; or

    4. Treatment with deferiprone is contraindicated due to a history of agranulocytosis (defined as an absolute neutrophil count (ANC) of < 0.5 cells per µL) or recurrent episodes (greater than 2 episodes) of moderate neutropenia (ANC 0.5 - 1.0 cells per µL)

Continuation

Haematologist

Re-assessment required after 2 years

Either:

  1. For the first renewal following 2 years of therapy, the treatment has been tolerated and has resulted in clinical improvement in all three parameters namely serum ferritin, cardiac MRI T2* and liver MRI T2* levels; or

  2. For subsequent renewals, the treatment has been tolerated and has resulted in clinical stability or continued improvement in all three parameters namely serum ferritin, cardiac MRI T2* and liver MRI T2* levels.

Desferrioxamine mesilate Inj 500 mg vial Hospira 10 109.89 Desferal 10 51.52 Charcoal Oral liq 200 mg per ml Carbasorb-X 250 43.50 Deferiprone Tab 500 mg Ferriprox 100 533.17 Oral liq 100 mg per ml Ferriprox 250 266.59

Patient has been diagnosed with chronic iron overload due to congenital inherited anaemia or acquired red cell aplasia.

 Antiseptics and Disinfectants Antiseptics and Disinfectants Povidone-iodine with ethanol Soln 10% with ethanol 30% Betadine Skin Prep 500 10.00 Soln 10% with ethanol 70% Any 0 Sodium hypochlorite Soln Any 0 Chlorhexidine Soln 4% healthE 50 1.86 Soln 5% healthE 500 15.50 Povidone-iodine Pad 10% Any 0 Soln 5% Any 0 Soln 7.5% Any 0 Swab set 10% Any 0 Soln 10% Betadine 500 6.20 Riodine 100 2.95 500 6.20 Oint 10% Betadine 25 3.27 Vaginal tab 200 mg Any 0

Rectal administration pre-prostate biopsy.

 Chlorhexidine with cetrimide Crm 0.1% with cetrimide 0.5% Any 0 Foaming soln 0.5% with cetrimide 0.5% Any 0 Chlorhexidine with ethanol Soln 0.5% with ethanol 70%, non-staining (pink) 100 ml healthE 1 2.65 Soln 2% with ethanol 70%, non-staining (pink) 100 ml healthE 1 3.54 Soln 0.5% with ethanol 70%, staining (red) 100 ml healthE 1 2.90 Soln 0.5% with ethanol 70%, non-staining (pink) 500 ml healthE 1 5.45 Soln 0.5% with ethanol 70%, staining (red) 500 ml healthE 1 5.90 Soln 0.5% with ethanol 70%, non-staining (pink) 25 ml healthE 1 1.55 Soln 2% with ethanol 70%, staining (red) 100 ml healthE 1 3.86 Soln 2% with ethanol 70%, staining (red) 500 ml healthE 1 9.56 Iodine with ethanol Soln 1% with ethanol 70%, 100 ml healthE 1 9.30 Isopropyl alcohol Soln 70%, 500 ml healthE 1 5.65 PSM 12 60.00 1 5.00 Contrast Media Iodinated X-ray Contrast Media Iodised oil Inj 38% w/w (480 mg per ml), 10 ml ampoule Lipiodol Ultra Fluid 1 143.00 Iodixanol Inj 270 mg per ml (iodine equivalent), 50 ml bottle Visipaque 10 220.00 Inj 270 mg per ml (iodine equivalent), 100 ml bottle Visipaque 10 430.00 Inj 320 mg per ml (iodine equivalent), 50 ml bottle Visipaque 10 220.00 Inj 320 mg per ml (iodine equivalent), 100 ml bottle Visipaque 10 430.00 Inj 320 mg per ml (iodine equivalent), 200 ml bottle Visipaque 10 850.00 Iohexol Inj 240 mg per ml (iodine equivalent), 50 ml bottle Omnipaque 10 75.00 Inj 300 mg per ml (iodine equivalent), 20 ml bottle Omnipaque 10 57.00 Inj 300 mg per ml (iodine equivalent), 50 ml bottle Omnipaque 10 75.00 Inj 300 mg per ml (iodine equivalent), 100 ml bottle Omnipaque 10 150.00 Inj 350 mg per ml (iodine equivalent), 20 ml bottle Omnipaque 10 59.00 Inj 350 mg per ml (iodine equivalent), 50 ml bottle Omnipaque 10 75.00 Inj 350 mg per ml (iodine equivalent), 75 ml bottle Omnipaque 10 114.00 Inj 350 mg per ml (iodine equivalent), 100 ml bottle Omnipaque 10 150.00 Inj 350 mg per ml (iodine equivalent), 200 ml bottle Omnipaque 10 290.00 Diatrizoate meglumine with sodium amidotrizoate Inj 260 mg with sodium amidotrizoate 40 mg per ml, 250 ml bottle Urografin 1 80.00 Oral liq 660 mg per ml with sodium amidotrizoate 100 mg per ml, 100 ml bottle Gastrografin 100 22.50 Diatrizoate sodium Oral liq 370 mg per ml, 10 ml sachet Ioscan 50 156.12 Non-iodinated X-ray Contrast Media Citric acid with sodium bicarbonate Powder 382.2 mg per g with sodium bicarbonate 551.3 mg per g, 4 g sachet e.g. E-Z-GAS II 0 Barium sulphate with sodium bicarbonate Grans eff 382.2 mg per g with sodium bicarbonate 551.3 mg per g, 4 g sachet E-Z-Gas II 50 102.93 Barium sulphate Oral liq 22 mg per g (2.2% w/w), 250 ml bottle CT Plus+ 24 175.00 Oral liq 22 mg per g (2.2% w/w), 450 ml bottle CT Plus+ 24 220.00 Oral liq 1 mg per ml (0.1% w/v, 0.1% w/w), 450 ml bottle VoLumen 24 441.12 Oral liq 20.9 mg per ml (2.1% w/v, 2% w/w), 250 ml bottle Readi-CAT 2 24 140.94 Oral liq 400 mg per ml (40% w/v, 30% w/w), 20 ml bottle Tagitol V 3 52.35 Oral liq 400 mg per ml (40% w/v), bottle Varibar - Nectar 240 38.40 Varibar - Honey 250 155.35 Varibar - Pudding 230 145.04 Oral liq 400 mg per ml (40% w/v, 30% w/w), bottle Varibar - Thin Liquid 148 17.39 Oral liq 600 mg per g (60% w/w), tube E-Z-Paste 454 36.51 Oral liq 1,250 mg per ml (125% w/v), 2,000 ml bottle Liquibar 1 91.77 Powder for oral liq 20 mg per g (2% w/w), 22.1 g sachet E-Z-Cat Dry 50 507.50 Powder for oral soln 97.65% w/w, 300 g bottle X-Opaque-HD 24 237.76 Enema 1,250 mg per ml (125% w/v), 500 ml bag Liquibar 12 282.30 Paramagnetic Contrast Media Gadobenic acid Inj 334 mg per ml, 10 ml vial Multihance 10 324.74 Inj 334 mg per ml, 20 ml vial Multihance 10 636.28 Gadoteric acid Inj 279.32 mg per ml (0.5 mmol per ml), 10 ml bottle Dotarem 1 23.20 Inj 279.32 mg per ml (0.5 mmol per ml), 20 ml bottle Dotarem 1 46.30 Inj 279.32 mg per ml (0.5 mmol per ml), 5 ml bottle Dotarem 1 12.30 Inj 279.32 mg per ml (0.5 mmol per ml), 10 ml prefilled syringe Dotarem 1 24.50 Inj 279.32 mg per ml (0.5 mmol per ml), 20 ml prefilled syringe Dotarem 1 55.00 Inj 279.32 mg per ml (0.5 mmol per ml), 15 ml prefilled syringe Dotarem 1 41.00 Inj 279.32 mg per ml (0.5 mmol per ml), 15 ml bottle Dotarem 1 34.50 Gadoxetate disodium Inj 181.43 mg per ml (equivalent to 0.25 mmol per ml), 10 ml prefilled syringe Primovist 1 300.00 Meglumine iotroxate Inj 105 mg per ml, 100 ml bottle Biliscopin 100 150.00 Meglumine gadopentetate Inj 469 mg per ml, 10 ml prefilled syringe Magnevist 5 95.00 Inj 469 mg per ml, 10 ml vial Magnevist 10 185.00 Gadobutrol Inj 1 mmol per ml, 15 ml vial Any 0 Inj 604.72 mg per ml (equivalent to 1 mmol per ml), 7.5 ml prefilled syringe Gadovist 5 180.00 Inj 604.72 mg per ml (equivalent to 1 mmol per ml), 15 ml prefilled syringe Gadovist 10 700.00 Gadodiamide Inj 287 mg per ml, 5 ml vial Omniscan 10 120.00 Inj 287 mg per ml, 10 ml vial Omniscan 10 170.00 Inj 287 mg per ml, 10 ml prefilled syringe Omniscan 10 1 200.00 Inj 287 mg per ml, 15 ml prefilled syringe Omniscan 10 320.00 Ultrasound Contrast Media Perflutren Inj 1.1 mg per ml, 1.5 ml vial Definity 4 720.00 1 180.00 Diagnostic Agents Diagnostic Agents Arginine Inj 100 mg per ml, 300 ml bottle Any 0 Inj 50 mg per ml, 500 ml bottle Any 0 Histamine acid phosphate Nebuliser soln 0.6%, 10 ml vial Any 0 Nebuliser soln 2.5%, 10 ml vial Any 0 Nebuliser soln 5%, 10 ml vial Any 0 Secretin pentahydrochloride Inj 100 u ampoule Any 0 Tuberculin, purified protein derivative Inj 5 TU per 0.1 ml, 1 ml vial Any 0 Sincalide Inj 5 mcg per vial Any 0 Methacholine chloride Powder 100 mg Any 0 Mannitol Powder for inhalation e.g. Aridol 0 Diagnostic Dyes Bonney's blue dye Soln Any 0 Indigo carmine Inj 4 mg per ml, 5 ml ampoule Any 0 Inj 8 mg per ml, 5 ml ampoule Any 0 Indocyanine green Inj 25 mg vial Any 0 Methylthioninium chloride [Methylene blue] Inj 10 mg per ml, 10 ml ampoule Any 0 Inj 10 mg per ml, 5 ml ampoule Any 0 Patent blue V Inj 2.5%, 2 ml ampoule Obex Medical 5 440.00 Irrigation Solutions Irrigation Solutions Sodium chloride Irrigation soln 0.9%, bottle Baxter 500 2.88 1000 2.96 2000 10.00 3000 12.67 100 2.49 Irrigation soln 0.9%, 30 ml ampoule Pfizer 30 19.50 Chlorhexidine Irrigation soln 0.02%, 500 ml bottle Any 0 Irrigation soln 0.05%, bottle Baxter 100 3.02 500 3.63 Irrigation soln 0.1%, 30 ml ampoule Any 0 Irrigation soln 0.02%, bottle Baxter 100 2.92 Irrigation soln 0.1%, bottle Baxter 100 3.10 Irrigation soln 0.5%, bottle Baxter 500 4.69 Water Irrigation soln, bottle Baxter 1000 2.75 3000 15.80 2000 9.71 500 2.61 100 2.68 Chlorhexidine with cetrimide Irrigation soln 0.015% with cetrimide 0.15%, bottle Baxter 500 1 3.47 100 3.21 1000 4.17 Irrigation soln 0.015% with cetrimide 0.15%, 30 ml ampoule Any 0 Irrigation soln 0.05% with cetrimide 0.5%, bottle Baxter 100 4.20 500 3.87 Irrigation soln 0.1% with cetrimide 1%, bottle Baxter 500 5.81 100 4.38 Glycine Irrigation soln 1.5%, bottle Baxter 3000 14.44 2000 11.38 Surgical Preparations Surgical Preparations Bismuth subnitrate and iodoform paraffin Paste Any 0 Dimethyl sulfoxide Soln 50% Any 0 Soln 99% Any 0 Phenol Inj 6%, 10 ml ampoule Any 0 Phenol with ioxaglic acid Inj 12%, 10 ml ampoule Any 0 Trometamol Inj 36 mg per ml, 500 ml bottle Any 0 Cardioplegia Solutions Electrolytes 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 e.g. Cardioplegia Solution AHB7832 0 Inj 143 mmol/l sodium, 16 mmol/l potassium, 16 mmol/l magnesium and 1.2 mmol/l calcium, 1,000 ml bag e.g. Cardioplegia Electrolyte Solution 0 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. 0 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 e.g. Cardioplegia Enriched Solution 0 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 e.g. Cardioplegia Base Solution 0 Inj 15 mmol/l sodium chloride, 9 mmol/l potassium chloride, 1 mmol/l potassium hydrogen 2-ketoglutarate, 4 mmol/l magnesium chloride, 18 mmol/l histidine hydrochloride, 180 mmol/l histidine, 2 mmol/l tryptophan, 30 mmol/l mannitol, 0.015 mmol/l calcium chloride, 1,000 ml bag e.g. Custodiol-HTK 0 Monosodium glutamate with sodium aspartate Inj 42.68 mg with sodium aspartate 39.48 mg per ml, 250 ml bottle Any 0 Monosodium l-aspartate Inj 14 mmol per 10 ml, 10 ml Any 0 Cold Storage Solutions Sodium with potassium Inj 29 mmol/l with potassium 125 mmol/l, 1,000 ml bag Any 0 Extemporaneously Compounded Preparations Extemporaneously Compounded Preparations Extemporaneously Compounded Preparations Acetic acid Liq Any 0 Alum Powder BP Any 0 Arachis oil [Peanut oil] Liq Any 0 Benzoin Tincture compound BP Any 0 Bismuth subgallate Powder Any 0 Boric acid Powder Any 0 Carboxymethylcellulose Soln 1.5% Any 0 Cetrimide Soln 40% Any 0 Chloroform Liq BP Any 0 Citric acid Powder BP Any 0 Clove oil Liq Any 0 Coal tar Soln BP Any 0 Collodion flexible Liq Any 0 Compound hydroxybenzoate Soln Any 0 Cysteamine hydrochloride Powder Any 0 Disodium hydrogen phosphate with sodium dihydrogen phosphate Inj 37.46 mg with sodium dihydrogen phosphate 47.7 mg in 1.5 ml ampoule Any 0 Dithranol Powder Any 0 Lactose Powder Any 0 Magnesium hydroxide Paste Any 0 Menthol Crystals Any 0 Olive oil Liq Any 0 Phenobarbitone sodium Powder Any 0 Phenol Liq Any 0 Pilocarpine nitrate Powder Any 0 Polyhexamethylene biguanide Liq Any 0 Povidone K30 Powder Any 0 Silver nitrate Crystals Any 0 Sodium citrate Powder Any 0 Sodium metabisulfite Powder Any 0 Starch Powder Any 0 Tri-sodium citrate Crystals Any 0 Trichloracetic acid Grans Any 0 Urea Powder BP Any 0 Wool fat Oint, anhydrous Any 0 Xanthan Gum 1% Any 0 Zinc oxide Powder Any 0 Theobroma oil Oint Any 0 Hydrocortisone Powder ABM 25 59.50 Codeine phosphate Powder Any 0 Methadone hydrochloride Powder Any 0 Sodium bicarbonate Powder BP Any 0 Glucose [Dextrose] Powder Any 0 Glycerol Liq ABM 2000 19.80 Syrup Liq (pharmaceutical grade) Midwest 2000 21.75 Methyl hydroxybenzoate Powder Any 0 Methylcellulose Powder Any 0 Suspension Ora-Plus 473 35.50 Propylene glycol Liq ABM 500 12.00 Salicylic acid Powder Any 0 Sulphur Sublimed Any 0 Precipitated Any 0 Paraffin Liq Any 0 Chlorhexidine gluconate Soln 20 % Any 0 Ascorbic acid Powder Any 0 Glycerin with sucrose Suspension Ora-Sweet 473 35.50 Glycerin with sodium saccharin Suspension Ora-Sweet SF 473 35.50 Methylcellulose with glycerin and sucrose Suspension Ora-Blend 473 35.50 Methylcellulose with glycerin and sodium saccharin Suspension Ora-Blend SF 473 35.50 Special Foods Food Modules Carbohydrate Carbohydrate supplement Powder 95 g carbohydrate per 100 g, 368 g can Any 0 Powder 96 g carbohydrate per 100 g, 400 g can e.g. Polycal 0

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 made from at least one nutrient module and at least one further product listed in Section D of the Pharmaceutical Schedule or breast milk.

Notes: Patients are required to meet any Special Authority criteria associated with all of the products used in the modular formula.

Fat Long-chain triglyceride supplement Liquid 50 g fat per 100 ml, 200 ml bottle e.g. Calogen 0 Liquid 50 g fat per 100 ml, 500 ml bottle e.g. Calogen 0 Medium-chain triglyceride supplement Liquid 50 g fat per 100 ml, 250 ml bottle e.g. Liquigen 0 Liquid 95 g fat per 100 ml, 500 ml bottle e.g. MCT Oil 0 Walnut oil Liq Any 0

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 made from at least one nutrient module and at least one further product listed in Section D of the Pharmaceutical Schedule or breast milk.

Notes: Patients are required to meet any Special Authority criteria associated with all of the products used in the modular formula.

Protein Protein supplement Powder 6 g protein per 7 g, can Resource Beneprotein 227 8.95 Powder 5 g protein, 0.67 g carbohydrate and 0.6 g fat per 6.6 g, 275 g can e.g. Promod 0 Powder 89 g protein, <1.5 g carbohydrate and 2 g fat per 100 g, 225 g can e.g. Protifar 0

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 made from at least one nutrient module and at least one further product listed in Section D of the Pharmaceutical Schedule or breast milk.

Notes: Patients are required to meet any Special Authority criteria associated with all of the products used in the modular formula.

Other Supplements Breast milk fortifier Powder 0.2 g protein, 0.7 g carbohydrate and 0.02 g fat per 1 g sachet e.g. FM 85 0 Powder 0.6 g protein and 1.4 g carbohydrate per 2.2 g sachet e.g. Nutricia Breast Milk Fortifer 0 Powder 0.5 g protein, 1.2 g carbohydrate and 0.08 g fat per 2 g sachet e.g. S26 Human Milk Fortifier 0 Carbohydrate and fat supplement Powder 72.7 g carbohydrate and 22.3 g fat per 100 g, 400 g can e.g. Super Soluble Duocal 0
Both:

  1. Infant or child aged four years or under; and

  2. Any of the following:

    1. Cystic fibrosis; or

    2. Cancer in children; or

    3. Faltering growth; or

    4. Bronchopulmonary dysplasia; or

    5. Premature and post premature infants.

 Food/Fluid Thickeners Food/Fluid Thickeners Carob bean gum with maize starch and maltodextrin Powder e.g. Feed Thickener Karicare Aptamil 0 Guar gum Powder e.g. Guarcol 0 Maize starch Powder e.g. Resource Thicken Up; Nutilis 0 Maltodextrin with xanthan gum Powder e.g. Instant Thick 0 Maltodextrin with xanthan gum and ascorbic acid Powder e.g. Easy Thick 0

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:

  • use was established prior to 1 July 2013; and

  • the product has not been specifically considered and excluded by PHARMAC; and

  • 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.

 Metabolic Products Glutaric Aciduria Type 1 Products Amino acid formula (without lysine and low tryptophan) 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 0 Powder 25 g protein and 51 g carbohydrate per 100 g, 500 g can e.g. XLYS Low TRY Maxamaid 0 Homocystinuria Products Amino acid formula (without methionine) 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 Junior LQ 0 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. HCU Anamix Infant 0 Powder 25 g protein and 51 g carbohydrate per 100 g, 500 g can e.g. XMET Maxamaid 0 Powder 39 g protein and 34 g carbohydrate per 100 g, 500 g can e.g. XMET Maxamum 0 Isovaleric Acidaemia Products Amino acid formula (without leucine) 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. IVA Anamix Infant 0 Powder 25 g protein and 51 g carbohydrate per 100 g, 500 g can e.g. XLEU Maxamaid 0 Powder 39 g protein and 34 g carbohydrate per 100 g, 500 g can e.g. XLEU Maxamum 0 Maple Syrup Urine Disease Products Amino acid formula (without isoleucine, leucine and valine) 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 0 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 0 Powder 25 g protein and 51 g carbohydrate per 100 g, 500 g can e.g. MSUD Maxamaid 0 Powder 39 g protein and 34 g carbohydrate per 100 g, 500 g can e.g. MSUD Maxamum 0 Phenylketonuria Products Amino acid formula (without phenylalanine) Liquid 16 g protein, 7 g carbohydrate and 0.27 g fibre per 100 ml, 125 ml bottle e.g. PKU Lophlex LQ 20 0 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 0 Liquid 16 g protein, 7 g carbohydrate and 0.4 g fibre per 100 ml, 125 ml bottle e.g. PKU Lophlex LQ 20 0 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 0 Liquid 6.7 g protein, 5.1 g carbohydrate and 2 g fat per 100 ml, 250 ml carton e.g. Easiphen 0 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 0 Powder 25 g protein and 51 g carbohydrate per 100 g, 500 g can e.g. XP Maxamaid 0 Powder 39 g protein and 34 g carbohydrate per 100 g, 500 g can e.g. XP Maxamum 0 Powder 8.33 g protein and 8.8 g carbohydrate per 20 g sachet e.g. Phlexy-10 0 Tab 8.33 mg e.g. Phlexy-10 0 Liquid 8 g protein, 7 g carbohydrate, 3.8 g fat and 0.25 g fibre per 100 ml, bottle PKU Anamix Junior LQ (Unflavoured) 125 13.10 PKU Anamix Junior LQ (Orange) 125 13.10 PKU Anamix Junior LQ (Berry) 125 13.10 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 0 Powder 36 g protein, 32 g carbohydrate and 12.5 g fat per 100 g, 36 g sachet e.g. PKU Anamix Junior 0 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 0 Propionic Acidaemia and Methylmalonic Acidaemia Products Amino acid formula (without isoleucine, methionine, threonine and valine) 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 0 Powder 25 g protein and 51 g carbohydrate per 100 g, 500 g can e.g. XMTVI Maxamaid 0 Powder 39 g protein and 34 g carbohydrate per 100 g, 500 g can e.g. XMTVI Maxamum 0 Protein Free Supplements Protein free supplement Powder nil added protein and 67 g carbohydrate per 100 g, 400 g can e.g.Energivit 0 1 Tyrosinaemia Products Amino acid formula (without phenylalanine and tyrosine) 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 0 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 0 Powder 25 g protein and 51 g carbohydrate per 100 g, 400 g can e.g. XPHEN, TYR Maxamaid 0 Powder 36 g protein, 32 g carbohydrate and 12.5 g fat per 100 g, 36 g sachet e.g. TYR Anamix Junior 0 Urea Cycle Disorders Products Amino acid supplement Powder 25 g protein and 65 g carbohydrate per 100 g, 200 g can e.g. Dialamine 0 Powder 79 g protein per 100 g, 200 g can e.g. Essential Amino Acid Mix 0 X-Linked Adrenoleukodystrophy Products Glycerol trierucate Liquid, 1,000 ml bottle Any 0 Glycerol trioleate Liquid, 500 ml bottle Any 0
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.

 Specialised Formulas Diabetic Products Low-GI oral feed 1 kcal/ml Liquid 5 g protein, 9.6 g carbohydrate and 5.4 g fat per 100 ml, 250 ml bottle Glucerna Select (Vanilla) 250 1.88 Liquid 4.9 g protein, 11.7 g carbohydrate, 3.8 g fat and 2 g fibre per 100 ml, 200 ml bottle e.g. Diasip 0 Liquid 6 g protein, 9.5 g carbohydrate, 4.7 g fat and 2.6 g fibre per 100 ml, can Resource Diabetic (Vanilla) 237 1 2.10 Liquid 4.5 g protein, 9.8 g carbohydrate, 4.4 g fat and 1.9 g fibre per 100 ml, can Sustagen Diabetic (Vanilla) 237 2.10 Low-GI enteral feed 1 kcal/ml Liquid 5 g protein, 9.6 g carbohydrate and 5.4 g fat per 100 ml, 1,000 ml bottle Glucerna Select RTH (Vanilla) 1000 7.50 Liquid 4.3 g protein, 11.3 g carbohydrate and 4.2 g fat per 100 ml, 1,000 ml bag e.g. Nutrison Advanced Diason 0
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

  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.

 Elemental and Semi-Elemental Products Amino acid oral feed Powder 11.5 g protein, 61.7 g carbohydrate and 0.8 g fat per sachet Vivonex TEN 80.40 4.50 Amino acid oral feed 0.8 kcal/ml Liquid 2.5 g protein, 11 g carbohydrate and 3.5 g fat per 100 ml, 250 ml carton e.g. Elemental 028 Extra 0 Peptide-based enteral feed 1 kcal/ml Liquid 4 g protein, 17.6 g carbohydrate and 1.7 g fat per 100 ml, 1,000 ml bag e.g. Nutrison Advanced Peptisorb 0 Peptide-based oral feed Powder 12.5 g protein, 55.4 g carbohydrate and 3.25 g fat per sachet Vital HN 79 4.40 Powder 13.7 g protein, 62.9 g carbohydrate and 17.5 g fat per 100 g, 400 g can e.g. Peptamen Junior 0 Powder 13.8 g protein, 59 g carbohydrate and 18 g fat per 100 g, 400 g can e.g. MCT Pepdite; MCT Pepdite 1+ 0 Powder 15.8 g protein, 49.5 g carbohydrate and 4.65 g fat per 76 g sachet Alitraq 76 7.50 Liquid 6.75 g protein, 18.4 g carbohydrate and 5.5 g fat per 100 ml, bottle Vital 1000 18.06 Peptide-based oral feed 1 kcal/ml Liquid 5 g protein, 16 g carbohydrate and 1.69 g fat per 100 ml, carton Peptamen OS 1.0 (Vanilla) 237 4.95
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.

 Fat Modified Products Fat-modified feed Powder 11.4 g protein, 68 g carbohydrate and 11.8 g fat per 100 g, 400 g can e.g. Monogen 0
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, made from at least one nutrient module and at least one further product listed in Section D of the Pharmaceutical Schedule, for adults.

Notes: Patients are required to meet any Special Authority criteria associated with all of the products used in the modular formula.

Hepatic Products Hepatic oral feed Powder 11 g protein, 64 g carbohydrate and 20 g fat per 100 g, can Heparon Junior 400 78.97

For children (up to 18 years) who require a liver transplant

 High Calorie Products Oral feed 2 kcal/ml Liquid 8.4 g protein, 22.4 g carbohydrate, 8.9 g fat and 0.8 g fibre per 100 ml, bottle Two Cal HN 200 1.90 Enteral Feed 2 kcal/ml Liquid 7.5 g protein, 20 g carbohydrate and 10 g fat per 100 ml, bottle Nutrison Concentrated 500 5.50 Liquid 8.4 g protein, 21.9 g carbohydrate, 9.1 g fat and 0.5 g fibre per 100 ml, bottle TwoCal HN RTH (Vanilla) 1000 11.00
Any of the following:

  1. Patient is fluid volume or rate restricted; or

  2. Patient requires low electrolyte; or

  3. Both:
    1. Any of the following:

      1. Cystic fibrosis; or

      2. Any condition causing malabsorption; or

      3. Faltering growth in an infant/child; or

      4. Increased nutritional requirements; and

    2. Patient has substantially increased metabolic requirements.

 High Protein Products High protein enteral feed 1.28 kcal/ml 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 e.g. Nutrison Protein Plus Multi Fibre 0
Both:

  1. The patient has a high protein requirement; and

  2. Any of the following:

    1. Patient has liver disease; or

    2. Patient is obese (BMI > 30) and is undergoing surgery; or

    3. Patient is fluid restricted; or

    4. Patient's needs cannot be more appropriately met using high calorie product.

 High protein enteral feed 1.25 kcal/ml Liquid 6.3 g protein, 14.2 g carbohydrate and 4.9 g fat per 100 ml, 1,000 ml bag e.g. Nutrison Protein Plus 0
Both:

  1. The patient has a high protein requirement; and

  2. Any of the following:

    1. Patient has liver disease; or

    2. Patient is obese (BMI > 30) and is undergoing surgery; or

    3. Patient is fluid restricted; or

    4. Patient's needs cannot be more appropriately met using high calorie product.

 Infant Formulas Extensively hydrolysed formula Powder 14 g protein, 53.4 g carbohydrate and 27.3 g fat per 100 g, 450 g can e.g. Aptamil Gold+ Pepti Junior 0

Initiation - new patients

Any of the following:
  1. Both:

    1. Cows' milk formula is inappropriate due to severe intolerance or allergy to its protein content; and

    2. Either:

      1. Soy milk formula has been reasonably trialled without resolution of symptoms; or

      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

  8. Proven fat malabsorption; or

  9. Severe intestinal motility disorders causing significant malabsorption; or

  10. Intestinal failure.

Note: A reasonable trial is defined as a 2-4 week trial.

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 0 Lactose-free formula Powder 1.5 g protein, 7.2 g carbohydrate and 3.6 g fat per 100 ml, 900 g can e.g. S26 Lactose Free 0 Powder 1.3 g protein, 7.3 g carbohydrate and 3.5 g fat per 100 ml, 900 g can e.g. Karicare Aptamil Gold De-Lact 0 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. Locasol 0 Preterm formula Liquid 2.2 g protein, 8.4 g carbohydrate and 4.4 g fat per 100 ml, bottle S26 LBW Gold RTF 100 0.75 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 0 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 0 Powder 1.9 g protein, 7.5 g carbohydrate and 3.9 g fat per 14 g, can S-26 Gold Premgro 400 15.25

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 0 Amino acid formula Powder 1.95 g protein, 8.1 g carbohydrate and 3.5 g fat per 100 ml, 400 g can e.g. Neocate 0 Powder 13 g protein, 52.5 g carbohydrate and 24.5 g fat per 100 g, 400 g can e.g. Neocate LCP 0 Powder 13.5 g protein, 52 g carbohydrate and 24.5 g fat per 100 g, can Neocate Gold (Unflavoured) 400 53.00 Powder 14 g protein, 50 g carbohydrate and 24.3 g fat per 100 g, 400 g can e.g. Neocate Advance 0 Powder 16 g protein, 51.4 g carbohydrate and 21 g fat per 100 g, can Neocate Advance (Vanilla) 400 53.00 Powder 2.2 g protein, 7.8 g carbohydrate and 3.4 g fat per 100 ml, can Elecare LCP (Unflavoured) 400 53.00 Powder 2.2 g protein, 7.8 g carbohydrate and 3.4 g fat per 100 ml, can Elecare (Unflavoured) 400 53.00 Elecare (Vanilla) 400 53.00 Powder 6 g protein, 31.5 g carbohydrate and 5.88 g fat per sachet Vivonex Paediatric 48.50 1 6.00

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.

Note: A reasonable trial is defined as a 2-4 week trial.

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.

 Paediatric oral feed 1 kcal/ml 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 0
Both:
  1. Either:

    1. The patient is fluid restricted; or

    2. The patient has increased nutritional requirements due to faltering growth;and

  2. Patient is under 18 months old and weighs less than 8kg.

 Ketogenic Diet Products High fat formula Powder 15.25 g protein, 3 g carbohydrate and 73 g fat per 100 g, can Ketocal 4:1 (Unflavoured) 300 35.50 Ketocal 4:1 (Vanilla) 300 35.50 Powder 15.3 g protein, 7.2 g carbohydrate and 67.7 g fat per 100 g, can Ketocal 3:1 (Unflavoured) 300 35.50

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

 Paediatric Products Paediatric oral feed 1.5 kcal/ml Liquid 3.4 g protein, 18.8 g carbohydrate and 6.8 g fat per 100 ml, 200 ml bottle e.g. Fortini 0 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 Multifibre 0 Paediatric enteral feed 1 kcal/ml Liquid 2.8 g protein, 11.2 g carbohydrate and 5 g fat per 100 ml, bag Pediasure RTH 500 2.68 Liquid 2.8 g protein, 12.3 g carbohydrate and 4.4 g fat per 100 ml, 500 ml bag e.g. Nutrini RTH 0 Paediatric oral feed 1 kcal/ml Liquid 4.2 g protein, 16.7 g carbohydrate and 7.5 g fat per 100 ml, bottle Pediasure (Chocolate) 200 1.07 Pediasure (Strawberry) 200 1.07 Pediasure (Vanilla) 200 1.07 Liquid 4.2 g protein, 16.7 g carbohydrate and 7.5 g fat per 100 ml, can Pediasure (Vanilla) 250 1.34 Paediatric enteral feed 0.76 kcal/ml Liquid 2.5 g protein, 12.5 g carbohydrate, 3.3 g fat and 0.7 g fibre per 100 ml, bag Nutrini Low Energy Multifibre RTH 500 4.00 Paediatric enteral feed 1.5 kcal/ml Liquid 4.1 g protein, 18.5 g carbohydrate and 6.7 g fat per 100 ml, 500 ml bag e.g. Nutrini Energy RTH 0 Liquid 4.1 g protein, 18.5 g carbohydrate, 6.7 g fat and 0.8 g fibre per 100 ml, bag Nutrini Energy Multi Fibre 500 6.00 Paediatric Oral Feed Powder 14.9 g protein, 54.3 g carbohydrate and 24.7 g fat per 100 g, can Pediasure (Vanilla) 850 20.00
Both:

  1. Child is aged one to ten years; and

  2. Any of the following:

    1. The child is being fed via a tube or a tube is to be inserted for the purposes of feeding; or

    2. Any condition causing malabsorption; or

    3. Faltering growth in an infant/child; or

    4. Increased nutritional requirements; or

    5. The child is being transitioned from TPN or tube feeding to oral feeding; or

    6. The child has eaten, or is expected to eat, little or nothing for 3 days.

 Renal Products Low electrolyte oral feed Powder 7.5 g protein, 59 g carbohydrate and 26.3 g fat per 100 g, 400 g can e.g. Kindergen 0

For children (up to 18 years) with acute or chronic kidney disease

 Low electrolyte enteral feed 1.8 kcal/ml Liquid 8.1 g protein, 14.74 g carbohydrate, 9.77 g fat and 1.26 g fibre per 100 ml, bottle Nepro HP RTH 500 6.08

For patients with acute or chronic kidney disease.

 Low electrolyte oral feed 1.8 kcal/ml Liquid 8 g protein, 14.74 g carbohydrate, 9.77 g fat and 1.26 g fibre per 100 ml, carton Nepro HP (Vanilla) 220 2.67 Nepro HP (Strawberry) 220 2.67

For patients with acute or chronic kidney disease.

 Low electrolyte oral feed 2 kcal/ml Liquid 3 g protein, 25.5 g carbohydrate and 9.6 g fat per 100 ml, 237 ml bottle Any 0 Liquid 9.1 g protein, 19 g carbohydrate and 10 g fat per 100 ml, carton Novasource Renal (Vanilla) 237 3.31 Liquid 7.5 g protein, 20 g carbohydrate and 10 g fat per 100 ml, 125 ml carton e.g. Renilon 7.5 0

For patients with acute or chronic kidney disease.

 Respiratory Products Low carbohydrate oral feed 1.5 kcal/ml Liquid 6.2 g protein, 10.5 g carbohydrate and 9.32 g fat per 100 ml, bottle Pulmocare (Vanilla) 237 1.66

For patients with CORD and hypercapnia, defined as a CO2 value exceeding 55 mmHg

 Surgical Products Preoperative carbohydrate feed 0.5 kcal/ml Oral liq 0 g protein, 12.6 g carbohydrate and 0 g fat per 100 ml, 200 ml bottle preOp 4 6.80

Maximum of 400 ml as part of an Enhanced Recovery After Surgery (ERAS) protocol 2 to 3 hours before major abdominal surgery.

 High arginine oral feed 1.4 kcal/ml Liquid 7.6 g protein, 18.9 g carbohydrate, 3.9 g fat and 1.4 g fibre per 100 ml, carton Impact Advanced Recovery (Chocolate) 237 4.00 Impact Advanced Recovery (Vanilla) 237 1 4.00

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

 Standard Feeds Standard Feeds Enteral feed 1.2 kcal/ml 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 0 Oral feed 1 kcal/ml Liquid 3.8 g protein, 23 g carbohydrate and 12.7 g fibre per 100 ml, 237 ml carton e.g. Resource Fruit Beverage 0 Enteral feed 1 kcal/ml Liquid 4 g protein, 12.3 g carbohydrate and 3.9 g fat per 100 ml, 1,000 ml bag e.g. NutrisonStdRTH; NutrisonLowSodium 0 Liquid 4 g protein, 12.3 g carbohydrate, 3.9 g fat and 1.5 g fibre per 100 ml, 1000 ml bag e.g. Nutrison Multi Fibre 0 Liquid 4 g protein, 13.6 g carbohydrate and 3.4 g fat per 100 ml, bottle Osmolite RTH 1000 5.29 500 2.65 Liquid 4 g protein, 13.6 g carbohydrate and 3.4 g fat per 100 ml, can Osmolite 250 1.24 Liquid 4 g protein, 14.1 g carbohydrate, 3.47 g fat and 1.76 g fibre per 100 ml, bottle Jevity RTH 1000 5.29 500 2.65 Liquid 4 g protein, 14.1 g carbohydrate, 3.47 g fat and 1.76 g fibre per 100 ml, can Jevity 237 1.32 Oral feed 1.5 kcal/ml Liquid 4 g protein and 33.5 g carbohydrate per 100 ml, 200 ml bottle e.g. Fortijuice 0 Liquid 5.5 g protein, 21.1 g carbohydrate and 4.81 g fat per 100 ml, can Ensure Plus (Chocolate) 237 1.33 Ensure Plus (Vanilla) 237 1.33 Liquid 6 g protein, 18.4 g carbohydrate and 5.8 g fat per 100 ml, 200 ml bottle e.g. Fortisip 0 Liquid 6 g protein, 18.4 g carbohydrate, 5.8 g fat and 2.3 g fibre per 100 ml, 200 ml bottle e.g. Fortisip Multi Fibre 0 Liquid 6.25 g protein, 20.2 g carbohydrate and 4.92 g fat per 100 ml, carton Ensure Plus (Banana) 200 1.26 Ensure Plus (Chocolate) 200 1.26 Ensure Plus (Fruit of the Forest) 200 1.26 Ensure Plus (Vanilla) 200 1.26 Oral feed Powder 16 g protein, 59.8 g carbohydrate and 14 g fat per 100 g, can Ensure (Chocolate) 850 13.00 Ensure (Vanilla) 850 13.00 Powder 23 g protein, 65 g carbohydrate and 2.5 g fat per 100 g, can Sustagen Hospital Formula (Chocolate) 900 14.90 840 14.90 Sustagen Hospital Formula (Vanilla) 900 14.90 840 14.90

Note: Community subsidy of Sustagen Hospital Formula is subject to both Special Authority criteria and a manufacturer’s surcharge. Higher subsidy by endorsement is available for patients meeting the following endorsement criteria; fat malabsorption, fat intolerance or chyle leak.

 Powder 21.9 g protein, 53.5 g carbohydrate and 14.5 g fat per 100 g, can Fortisip (Vanilla) 350 3.67 Enteral Feed 1.5 kcal/ml Liquid 6 g protein, 18.3 g carbohydrate and 5.8 g fat per 100 ml, bag Nutrison Energy 1000 7.00 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 0 Liquid 6.25 g protein, 20 g carbohydrate and 5 g fat per 100 ml, can Ensure Plus HN 250 1.75 Liquid 6.27 g protein, 20.4 g carbohydrate and 4.9 g fat per 100 ml, bag Ensure Plus HN RTH 1000 7.00 Liquid 6.38 g protein, 21.1 g carbohydrate, 4.9 g fat and 1.2 g fibre per 100 ml, bag Jevity HiCal RTH 1000 7.00 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 0
Any of the following:
  1. For patients with malnutrition, defined as any of the following:

    1. BMI < 18.5; or

    2. Greater than 10% weight loss in the last 3-6 months; or

    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.

 Vaccines Bacterial and Viral Vaccines Bacterial and Viral Vaccines Diphtheria, tetanus, pertussis and polio vaccine Inj 30 IU diphtheria toxoid with 30IU 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 syringe Infanrix IPV 10 0.00
Funded for any of the following:

  1. A single dose for children up to the age of 7 who have completed primary immunisation; or

  2. A course of up to four vaccines is funded for catch up programmes for children (to the age of 10 years) to complete full primary immunisation; or

  3. An additional four doses (as appropriate) are funded for (re-)immunisation for patients post HSCT, or chemotherapy; pre- or post splenectomy; pre- or post solid organ transplant, renal dialysis and other severely immunosuppressive regimens; or

  4. Five doses will be funded for children requiring solid organ transplantation.

Note: Please refer to the Immunisation Handbook for appropriate schedule for catch up programmes

 Diphtheria, tetanus, pertussis, polio, hepatitis B and haemophilus influenzae type B vaccine 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 Infanrix-hexa 10 0.00
Funded for patients meeting any of the following criteria:

  1. Up to four doses for children up to and under the age of 10 for primary immunisation; or

  2. An additional four doses (as appropriate) are funded for (re-)immunisation for children up to and under the age of 10 who are patients post haematopoietic stem cell transplantation, or chemotherapy; pre or post splenectomy; pre- or post solid organ transplant, renal dialysis and other severely immunosuppressive regimens; or

  3. Up to five doses for children up to and under the age of 10 receiving solid organ transplantation.

Note: A course of up-to four vaccines is funded for catch up programmes for children (up to and under the age of 10 years) to complete full primary immunisation. Please refer to the Immunisation Handbook for the appropriate schedule for catch up programmes.

 Bacterial Vaccines Bacterial Vaccines Bacillus calmette-guerin vaccine Inj Mycobacterium bovis BCG (Bacillus Calmette-Guerin), Danish strain 1331, live attenuated, vial Danish strain 1331, live attenuated, vial with diluent BCG Vaccine 10 0.00

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.

Note: A list of countries with high rates of TB are available at http://www.health.govt.nz/tuberculosis (Search for Downloads) or www.bcgatlas.org/index.php

 Adult diphtheria and tetanus vaccine Inj 2 IU diphtheria toxoid with 20 IU tetanus toxoid in 0.5 ml syringe ADT Booster 5 0.00
Any of the following:

  1. For vaccination of patients aged 45 and 65 years old; or

  2. For vaccination of previously unimmunised or partially immunised patients; or

  3. For revaccination following immunosuppression; or

  4. For boosting of 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.

Note: Please refer to the Immunisation Handbook for the appropriate schedule for catch up programmes.

 Diphtheria, tetanus and pertussis vaccine 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 Boostrix 1 0.00 10 0.00
Funded for any of the following:

  1. A single vaccine for pregnant woman between gestational weeks 28 and 38; or

  2. A course of up to four vaccines is funded for children from age 7 up the age of 18 years inclusive to complete full primary immunisation; or

  3. An additional four doses (as appropriate) are funded for (re-)immunisation for patients post haematopoietic stem cell transplantation or chemotherapy; pre or post splenectomy; pre- or post solid organ transplant, renal dialysis and other severely immunosuppressive regimens

Note: Tdap is not registered for patients aged less than 10 years. Please refer to the Immunisation Handbook for the appropriate schedule for catch up programmes.

 Haemophilus influenzae type B vaccine Inj 10 mcg vial with diluent syringe Act-HIB 1 0.00
One dose for patients meeting any of the following:

  1. For primary vaccination in children; or

  2. An additional dose (as appropriate) is funded for (re-)immunisation for patients post haematopoietic stem cell transplantation, or chemotherapy; pre or post splenectomy; pre- or post solid organ transplant, pre- or post cochlear implants, renal dialysis and other severely immunosuppressive regimens; or

  3. 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 Inj 4 mcg or each meningococcal polysaccharide conjugated to a total of approximately 48 mcg of diphtheria toxoid carrier per 0.5 ml vial Menactra 1 0.00
Any of the following:

  1. Up to three doses and a booster every five years for patients pre- and post splenectomy and for patients with functional or anatomic asplenia, HIV, complement deficiency (acquired or inherited), or pre or post solid organ transplant; or

  2. One dose for close contacts of meningococcal cases; or

  3. A maximum of two doses for bone marrow transplant patients; or

  4. A maximum of two doses for patients following immunosuppression*.

Note: children under seven years of age require two doses 8 weeks apart, a booster dose three years after the primary series and then five yearly.

*Immunosuppression due to steroid or other immunosuppressive therapy must be for a period of greater than 28 days.

 Meningococcal C conjugate vaccine Inj 10 mcg in 0.5 ml syringe Neisvac-C 10 0.00 1 0.00
Any of the following:

  1. Up to three doses and a booster every five years for patients pre- and post splenectomy and for patients with functional or anatomic asplenia, HIV, complement deficiency (acquired or inherited), or pre or post solid organ transplant; or

  2. One dose for close contacts of meningococcal cases; or

  3. A maximum of two doses for bone marrow transplant patients; or

  4. A maximum of two doses for patients following immunosuppression*.

Note: children under seven years of age require two doses 8 weeks apart, a booster dose three years after the primary series and then five yearly.

*Immunosuppression due to steroid or other immunosuppressive therapy must be for a period of greater than 28 days.

 Pneumococcal (PCV13) conjugate vaccine Inj 30.8 mcg in 0.5 ml syringe Prevenar 13 1 0.00 10 0.00
Any of the following:

  1. A primary course of up to four doses for previously unvaccinated individuals up to the age of 59 months inclusive; or

  2. Up to three doses as appropriate to complete the primary course of immunisation for individuals under the age of 59 months who have received one to three doses of PCV10; or

  3. One dose is funded for high risk children (over the age of 17 months and up to the age of 18) who have previously received four doses of PCV10; or

  4. Up to an additional four doses (as appropriate) are funded for (re-)immunisation of patients with HIV, for patients post haematopoietic stem cell transplantation HSCT, or chemotherapy; pre- or post splenectomy; functional asplenia, pre- or post- solid organ transplant, renal dialysis, complement deficiency (acquired or inherited), cochlear implants, or primary immunodeficiency; or

  5. For use in testing for primary immunodeficiency diseases, on the recommendation of an internal medicine physician or paediatrician.

Note: Please refer to the Immunisation Handbook for the appropriate schedule for catch up programmes

 Pneumococcal (PPV23) polysaccharide vaccine Inj 575 mcg in 0.5 ml prefilled syringe (25 mcg of each 23 pneumococcal serotype) Pneumovax 23 1 0.00
Any of the following:

  1. Up to three doses for patients pre- or post-splenectomy or with functional asplenia; or

  2. Up to two doses are funded for high risk children to the age of 18; or

  3. For use in testing for primary immunodeficiency diseases, on the recommendation of an internal medicine physician or paediatrician.

 Salmonella typhi vaccine Inj 25 mcg in 0.5 ml syringe Any 0

For use during typhoid fever outbreaks

 Viral Vaccines Viral Vaccines Hepatitis A vaccine Inj 1440 ELISA units in 1 ml syringe Havrix 1 0.00 Inj 720 ELISA units in 0.5 ml syringe Havrix Junior 1 0.00
Funded for patients meeting any of the following criteria:

  1. Two vaccinations for use in transplant patients; or

  2. Two vaccinations for use in children with chronic liver disease; or

  3. One dose of vaccine for close contacts of known hepatitis A cases.

 Hepatitis B recombinant vaccine Inj 10 mcg in 1 ml vial HBvaxPRO 1 0.00
Funded for patients meeting any of the following criteria:

  1. For household or sexual contacts of known acute hepatitis B patients or hepatitis B carriers; or

  2. For children born to mothers who are hepatitis B surface antigen (HBsAg) positive; or

  3. For children up to and under the age of 18 years inclusive who are considered not to have achieved a positive serology and require additional vaccination; or

  4. For HIV positive patients; or

  5. For hepatitis C positive patients; or

  6. For patients following non-consensual sexual intercourse; or

  7. For patients following immunosuppression; or

  8. For transplant patients; or

  9. Following needle stick injury.

 Inj 5 mcg in 0.5 ml vial Any 0 HBvaxPRO 1 0.00
Funded for patients meeting any of the following criteria:

  1. For household or sexual contacts of known acute hepatitis B patients or hepatitis B carriers; or

  2. For children born to mothers who are hepatitis B surface antigen (HBsAg) positive; or

  3. For children up to and under the age of 18 years inclusive who are considered not to have achieved a positive serology and require additional vaccination; or

  4. For HIV positive patients; or

  5. For hepatitis C positive patients; or

  6. For patients following non-consensual sexual intercourse; or

  7. For patients following immunosuppression; or

  8. For transplant patients; or

  9. Following needle stick injury.

 Inj 40 mcg per 1 ml vial Any 0 1 HBvaxPRO 1 1 0.00
Funded for any of the following criteria:

  1. For dialysis patients; or

  2. For liver or kidney transplant patient.

 Human papillomavirus (6, 11, 16 and 18) vaccine [HPV] Inj 120 mcg in 0.5 ml syringe Gardasil 10 0.00
Maximum of three doses for patient meeting any of the following criteria:

  1. Females aged under 20 years old; or

  2. Patients aged under 26 years old with confirmed HIV infection; or

  3. For use in transplant (including stem cell) patients; or

  4. An additional dose for patients under 26 years of age post chemotherapy.

 Influenza vaccine Inj 45 mcg in 0.5 ml syringe Fluarix 10 90.00 Influvac 10 90.00
Any of the following:

  1. All people 65 years of age and over; or

  2. People under 65 years of age who:
    1. Have any of the following cardiovascular diseases:

      1. Ischaemic heart disease; or

      2. Congestive heart failure; or

      3. Rheumatic heart disease; or

      4. Congenital heart disease; or

      5. Cerebro-vascular disease; or

    2. Have any of the following chronic respiratory diseases:

      1. Asthma, if on a regular preventative therapy; or

      2. Other chronic respiratory disease with impaired lung function; or

    3. Have diabetes; or

    4. Have chronic renal disease; or

    5. Have any cancer, excluding basal and squamous skin cancers if not invasive; or

    6. Have any of the following other conditions:

      1. Autoimmune disease; or

      2. Immune suppression or immune deficiency; or

      3. HIV; or

      4. Transplant recipients; or

      5. Neuromuscular and CNS diseases/ disorders; or

      6. Haemoglobinopathies; or

      7. Are children on long term aspirin; or

      8. Have a cochlear implant; or

      9. Errors of metabolism at risk of major metabolic decompensation; or

      10. Pre and post splenectomy; or

      11. Down syndrome; or

    7. Are pregnant, or

    8. Are children aged four and under who have been hospitalised for respiratory illness or have a history of significant respiratory illness: or

  3. Patients who are compulsorily detained long-term in a forensic unit within a DHB hospital in the 2015 season.

Note: The following conditions are excluded from funding:

  • asthma not requiring regular preventative therapy; and

  • hypertension and/or dyslipidaemia without evidence of end-organ disease.

 Measles, mumps and rubella vaccine Inj 1000 TCID50 measles, 12500 TCID50 mumps and 1000 TCID50 rubella vial with diluent M-M-R-II 10 0.00
A maximum of two doses for any patient meeting the following criteria:

  1. For primary vaccination in children; or

  2. For revaccination following immunosuppression; or

  3. For any individual susceptible to measles, mumps or rubella; or

  4. A maximum of three doses for children who have had their first dose prior to 12 months.

Note: Please refer to the Immunisation Handbook for appropriate schedule for catch up programmes.

 Poliomyelitis vaccine Inj 80 D-antigen units in 0.5 ml syringe Any 0 IPOL 1 0.00
Up to three doses for patients meeting either of the following:

  1. For partially vaccinated or previously unvaccinated individuals; or

  2. For revaccination following immunosuppression.

Please refer to the Immunisation Handbook for the appropriate schedule for catch up programmes.

 Rabies vaccine Inj 2.5 IU vial with diluent Any 0 Varicella vaccine [Chicken pox vaccine] Inj 2,000 PFU vial with diluent Any 0 Varilrix 1 0.00
Maximum of two doses for any of the following:
  1. For non-immune patients:

    1. With chronic liver disease who may in future be candidates for transplantation; or

    2. With deteriorating renal function before transplantation; or

    3. Prior to solid organ transplant; or

    4. Prior to any elective immunosuppression*.

  2. For patients at least 2 years after bone marrow transplantation, on advice of their specialist.

  3. For patients at least 6 months after completion of chemotherapy, on advice of their specialist.

  4. For HIV positive non immune to varicella with mild or moderate immunosuppression on advice of HIV specialist.

  5. For patients with inborn errors of metabolism at risk of major metabolic decompensation, with no clinical history of varicella.

  6. For household contacts of paediatric patients who are immunocompromised, or undergoing a procedure leading to immune compromise where the household contact has no clinical history of varicella.

  7. For household contacts of adult patients who have no clinical history of varicella and who are severely immunocompromised, or undergoing a procedure leading to immune compromise where the household contact has no clinical history of varicella

* immunosuppression due to steroid or other immunosuppressive therapy must be for a treatment period of greater than 28 days

 Rotavirus live reassortant oral vaccine Oral susp G1, G2, G3, G4, P1(8) 11.5 million CCID50 units per 2 ml, tube Any 0 RotaTeq 10 0.00
Maximum of three doses for patients meeting the following:

  1. First dose to be administered in infants aged under 15 weeks of age; and

  2. No vaccination being administered to children aged 8 months or over.
Optional Pharmaceuticals Part III - OPTIONAL PHARMACEUTICALS Optional Pharmaceuticals Optional Pharmaceuticals Pregnancy test - hCG urine Cassette EasyCheck 40 17.60 Blood ketone diagnostic test meter Meter Freestyle Optium 1 40.00 Freestyle Optium Neo 1 40.00 Insulin pen needles 29 g x 12.7 mm B-D Micro-Fine 100 10.50 31 g x 6 mm ABM 100 10.50 31 g x 8 mm B-D Micro-Fine 100 10.50 31 g x 5 mm B-D Micro-Fine 100 11.75 32 g x 4 mm B-D Micro-Fine 100 10.50 Insulin syringes, disposable with attached needle Syringe 0.3 ml with 29 g x 12.7 mm needle B-D Ultra Fine 100 13.00 Syringe 0.3 ml with 31 g x 8 mm needle B-D Ultra Fine II 100 13.00 Syringe 0.5 ml with 29 g x 12.7 mm needle B-D Ultra Fine 100 13.00 Syringe 0.5 ml with 31 g x 8 mm needle B-D Ultra Fine II 100 13.00 Syringe 1 ml with 29 g x 12.7 mm needle B-D Ultra Fine 100 13.00 Syringe 1 ml with 31 g x 8 mm needle B-D Ultra Fine II 100 13.00 Blood glucose diagnostic test strip Blood glucose test strips FreeStyle Lite 50 21.65 Freestyle Optium 50 28.75 Accu-Chek Performa 50 28.75 CareSens N 50 10.56 CareSens 50 10.56 Blood glucose test strips x 50 and lancets x 5 On Call Advanced 50 19.10 Blood glucose diagnostic test meter Meter FreeStyle Lite 1 9.00 Accu-Chek Performa 1 19.00 On Call Advanced 1 9.00 1 meter with 50 lancets, a lancing device, and 10 diagnostic test strips Caresens II 1 20.00 Caresens N 1 20.00 Caresens N POP 1 20.00 Ketone blood beta-ketone electrodes Test strips Freestyle Optium Ketone 10 15.50 Spacer device 800 ml Volumatic 1 8.50 230 ml (single patient) Space Chamber Plus 1 4.72 220 ml (single patient) e-chamber Turbo 1 2.95 510 ml (single patient) e-chamber La Grande 1 5.12 Mask for spacer device Size 2 EZ-fit Paediatric Mask 1 2.99 Small e-chamber Mask 1 2.20 Peak flow meter Low Range Breath-Alert 1 11.44 Mini-Wright AFS Low Range 1 9.54 Normal Range Breath-Alert 1 11.44 Mini-Wright Standard 1 9.54 Sodium nitroprusside Test strip Accu-Chek Ketur-Test 50 6.00

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.