Hospital Medicines List New Zealand April 2026 14 2 2026-04-01
Preferred Medicines List Alimentary Tract and Metabolism Antacids and Antiflatulents Antacids and Reflux Barrier Agents Aluminium hydroxide with magnesium hydroxide and simeticone Tab 200 mg with magnesium hydroxide 200 mg and simeticone 20 mg e.g. Mylanta 0 Oral liq 400 mg with magnesium hydroxide 400 mg and simeticone 30 mg per 5 ml e.g. Mylanta Double Strength 0 Simeticone Oral drops 100 mg per ml Any 0 Oral drops 20 mg per 0.3 ml Any 0 1 Oral drops 40 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) Biomed 90 25.00 Sodium alginate with sodium bicarbonate and calcium carbonate Tab 500 mg with sodium bicarbonate 267 mg and calcium carbonate 160 mg e.g. Gaviscon Extra Strength 0 Oral liq 500 mg with sodium bicarbonate 267 mg and calcium carbonate 160 mg per 10 ml Acidex 500 7.50 Phosphate Binding Agents Aluminium hydroxide Tab 600 mg Any 0 Calcium carbonate <range>Calcium carbonate</range> Only when prescribed for patients unable to swallow calcium carbonate tablets or where calcium carbonate tablets are inappropriate. medical practitioner 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 Nodia 400 10.75 Cap 2 mg Diamide Relief 400 12.00 Rectal and Colonic Anti-Inflammatories Olsalazine Cap 250 mg Dipentum 100 53.00 Tab 500 mg Dipentum 100 93.37 Sodium cromoglicate Cap 100 mg Any 0 Hydrocortisone acetate with pramoxine hydrochloride Topical Aerosol foam, 1% with pramoxine hydrochloride 1% Any 0 1 Budesonide <range>Budesonide</range> Mild to moderate ileal, ileocaecal or proximal Crohn's disease Diabetes Cushingoid habitus Osteoporosis where there is significant risk of fracture Severe acne following treatment with conventional corticosteroid therapy History of severe psychiatric problems associated with corticosteroid treatment History of major mental illness (such as bipolar affective disorder) where the risk of conventional corticosteroid treatment causing relapse is considered to be high Relapse during pregnancy (where conventional corticosteroids are considered to be contraindicated) medical practitioner Patient has a diagnosis of microscopic colitis (collagenous or lymphocytic colitis) by colonoscopy with biopsies medical practitioner Patient has gut Graft versus Host disease following allogenic bone marrow transplantation medical practitioner Patient has autoimmune hepatitis* Patient does not have cirrhosis Diabetes Cushingoid habitus Osteoporosis where there is significant risk of fracture Severe acne following treatment with conventional corticosteroid therapy History of severe psychiatric problems associated with corticosteroid treatment History of major mental illness (such as bipolar affective disorder) where the risk of conventional corticosteroid treatment causing relapse is considered to be high Relapse during pregnancy (where conventional corticosteroids are considered to be contraindicated) Adolescents with poor linear growth (where conventional corticosteroid use may limit further growth) medical practitioner 6

Indications marked with * are unapproved indications.

 Treatment remains appropriate and the patient is benefitting from the treatment medical practitioner 6 Mesalazine Enema 1 g per 100 ml Pentasa 7 41.30 Suppos 500 mg Asacol 20 22.80 20 22.80 Suppos 1 g Pentasa 28 50.96 Tab EC 400 mg Asacol 100 49.50 100 49.50 Octasa 90 71.00 Tab long-acting 500 mg Pentasa 100 56.10 Modified release granules 1 g Pentasa 100 118.10 Tab 800 mg Asacol 90 85.50 90 85.50 90 85.50 Tab 1,600 mg Asacol 60 85.50 Hydrocortisone acetate Rectal foam 10%, CFC free (14 applications) Colifoam 15 57.09 Sulfasalazine Tab 500 mg Salazopyrin 100 19.49 Tab EC 500 mg Salazopyrin EN 100 20.54 Local Preparations for Anal and Rectal Disorders Antihaemorrhoidal Preparations Prednisolone hexanoate with cinchocaine hydrochoride Suppos 1.3 mg with cinchocaine hydrochloride 1 mg per g Scheriproct 12 8.61 Fluocortolone caproate with fluocortolone pivalate and cinchocaine Oint 950 mcg with fluocortolone pivalate 920 mcg and cinchocaine hydrochloride 5 mg per g Ultraproct 30 13.05 Suppos 630 mcg with fluocortolone pivalate 610 mcg and cinchocaine hydrochloride 1 mg Ultraproct 12 8.61 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 Spazmol 5 1.91 Tab 10 mg Hyoscine Butylbromide (Adiramedica) 20 2.25 Glycopyrronium bromide Inj 200 mcg per ml, 1 ml ampoule Robinul 5 19.00 Glycopyrronium-AFT 10 11.99 Mebeverine hydrochloride Tab 135 mg Colofac 90 8.50 Antiulcerants Antisecretory and Cytoprotective Misoprostol Tab 200 mcg Cytotec 120 47.73 H2 Antagonists Cimetidine Tab 200 mg Any 0 Tab 400 mg Any 0 Famotidine Tab 20 mg Any 0 Tab 40 mg Famotidine Hovid MY 100 10.27 Inj 10 mg per ml, 4 ml vial Any 0 Inj 10 mg per ml, 2 ml vial Any 0 Ranitidine <range>Ranitidine</range> For continuation use Routine prevention of allergic reactions. medical practitioner Proton Pump Inhibitors Omeprazole Cap 10 mg Omeprazole actavis 10 90 2.06 Omeprazole Teva 90 2.06 Cap 20 mg Omeprazole actavis 20 90 2.02 Omeprazole Teva 90 2.02 Cap 40 mg Omeprazole actavis 40 90 3.18 Omeprazole Teva 90 3.18 Inf 40 mg vial Omezol IV 5 14.50 Inj 40 mg ampoule with diluent Dr Reddy's Omeprazole 5 37.38 Tab dispersible 20 mg <range>Omeprazole - Tab dispersible 10 mg and 20 mg</range> Only for use in tube-fed patients medical practitioner Powder for oral liq Midwest 5 52.00 Tab dispersible 10 mg <range>Omeprazole - Tab dispersible 10 mg and 20 mg</range> Only for use in tube-fed patients medical practitioner Lansoprazole Cap 30 mg Lanzol Relief 100 5.43 Cap 15 mg Lanzol Relief 100 4.04 30 1.21 Pantoprazole Tab EC 20 mg Panzop Relief 90 1.81 Tab EC 40 mg Panzop Relief 90 2.70 Inj 40 mg vial Any 0 Site Protective Agents Sucralfate Tab 1 g Any 0 Colloidal bismuth subcitrate Tab 120 mg Gastrodenol 50 14.51 Bile and Liver Therapy Bile and Liver Therapy L-ornithine L-aspartate <range>L-ornithine L-aspartate</range> For patients with chronic hepatic encephalopathy who have not responded to treatment with, or are intolerant to lactulose, or where lactulose is contraindicated medical practitioner Rifaximin <range>Rifaximin</range> For patients with hepatic encephalopathy despite an adequate trial of maximum tolerated doses of lactulose medical practitioner Diabetes Alpha Glucosidase Inhibitors Acarbose Tab 50 mg Accarb 90 11.20 Tab 100 mg Accarb 90 17.38 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 Oral soln 15 g per 80 ml sachet HypoPak Glucose 50 70.00 Glucagon hydrochloride Inj 1 mg syringe kit Glucagen Hypokit 1 32.00 Diazoxide <range>Diazoxide</range> For patients with confirmed hypoglycaemia caused by hyperinsulinism medical practitioner 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 degludec with insulin aspart Inj degludec 70 u with insulin aspart 30 u, 100 u per ml, 3 ml Ryzodeg 70/30 Penfill 5 1 80.00 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 Daonil 100 7.50 Vildagliptin Tab 50 mg Galvus 60 35.00 Vildagliptin with metformin hydrochloride Tab 50 mg with 850 mg metformin hydrochloride Galvumet 60 35.00 Tab 50 mg with 1,000 mg metformin hydrochloride Galvumet 60 35.00 Metformin hydrochloride Tab immediate-release 500 mg Metformin Viatris 1000 14.74 Tab immediate-release 850 mg Metformin Viatris 500 11.28 Pioglitazone Tab 15 mg Vexazone 90 6.15 Tab 30 mg Vexazone 90 7.25 Tab 45 mg Vexazone 90 12.00 Gliclazide Tab 80 mg Glizide 500 20.10 Glipizide Tab 5 mg Minidiab 100 6.86 GLP-1 Agonists Dulaglutide

Note: Not to be given in combination with another funded GLP-1 agonist or empagliflozin / empagliflozin with metformin hydrochloride unless receiving empagliflozin / empagliflozin with metformin hydrochloride for the treatment of heart failure.

<range>Dulaglutide</range> For continuation use Patient has type 2 diabetes Target HbA1c (of 53 mmol/mol or less) has not been achieved despite the regular use of all of the following funded blood glucose lowering agents for a period of least 6 months, where clinically appropriate: empagliflozin, metformin, and vildagliptin Patient is Māori or any Pacific ethnicity* Patient has pre-existing cardiovascular disease or risk equivalent (see note a)* Patient has an absolute 5-year cardiovascular disease risk of 15% or greater according to a validated cardiovascular risk assessment calculator* Patient has a high lifetime cardiovascular risk due to being diagnosed with type 2 diabetes during childhood or as a young adult* Patient has diabetic kidney disease (see note b)* medical practitioner

* Criteria intended to describe patients at high risk of cardiovascular or renal complications of diabetes.

  1. Pre-existing cardiovascular disease or risk equivalent defined as: prior cardiovascular disease event (i.e. angina, myocardial infarction, percutaneous coronary intervention, coronary artery bypass grafting, transient ischaemic attack, ischaemic stroke, peripheral vascular disease), congestive heart failure or familial hypercholesterolaemia.

  2. Diabetic kidney disease defined as: persistent albuminuria (albumin:creatinine ratio greater than or equal to 3 mg/mmol, in at least two out of three samples over a 3-6 month period) and/or eGFR less than 60 mL/min/1.73m2 in the presence of diabetes, without alternative cause identified.

  3. Funded GLP-1a treatment is not to be given in combination with funded (empagliflozin / empagliflozin with metformin hydrochloride) unless receiving funded (empagliflozin or empagliflozin in combination with metformin hydrochloride) for the treatment of heart failure.

 Liraglutide

Note: Not to be given in combination with another funded GLP-1 agonist or empagliflozin / empagliflozin with metformin hydrochloride unless receiving empagliflozin / empagliflozin with metformin hydrochloride for the treatment of heart failure.

<range>Liraglutide</range> For continuation use Patient has type 2 diabetes Target HbA1c (of 53 mmol/mol or less) has not been achieved despite the regular use of all of the following funded blood glucose lowering agents for a period of least 6 months, where clinically appropriate: empagliflozin, metformin, and vildagliptin Patient is Māori or any Pacific ethnicity* Patient has pre-existing cardiovascular disease or risk equivalent (see note a)* Patient has an absolute 5-year cardiovascular disease risk of 15% or greater according to a validated cardiovascular risk assessment calculator* Patient has a high lifetime cardiovascular risk due to being diagnosed with type 2 diabetes during childhood or as a young adult* Patient has diabetic kidney disease (see note b)* medical practitioner

* Criteria intended to describe patients at high risk of cardiovascular or renal complications of diabetes.

  1. Pre-existing cardiovascular disease or risk equivalent defined as: prior cardiovascular disease event (i.e. angina, myocardial infarction, percutaneous coronary intervention, coronary artery bypass grafting, transient ischaemic attack, ischaemic stroke, peripheral vascular disease), congestive heart failure or familial hypercholesterolaemia.

  2. Diabetic kidney disease defined as: persistent albuminuria (albumin:creatinine ratio greater than or equal to 3 mg/mmol, in at least two out of three samples over a 3-6 month period) and/or eGFR less than 60 mL/min/1.73m2 in the presence of diabetes, without alternative cause identified.

  3. Funded GLP-1a treatment is not to be given in combination with funded (empagliflozin / empagliflozin with metformin hydrochloride) unless receiving funded (empagliflozin or empagliflozin in combination with metformin hydrochloride) for the treatment of heart failure.

 SGLT2 Inhibitors <range>Empagliflozin</range> <range>Empagliflozin with metformin hydrochloride</range> Patient has heart failure Patient is in NYHA functional class II or III or IV Patient has a documented left ventricular ejection fraction (LVEF) of less than or equal to 40% An ECHO is not reasonably practicable, and in the opinion of the treating practitioner the patient would benefit from treatment Patient is receiving concomitant optimal standard funded chronic heart failure treatment medical practitioner For continuation use Patient has previously had an initial approval for a GLP-1 agonist Patient has type 2 diabetes Patient is Māori or any Pacific ethnicity* Patient has pre-existing cardiovascular disease or risk equivalent (see note a)* Patient has an absolute 5-year cardiovascular disease risk of 15% or greater according to a validated cardiovascular risk assessment calculator* Patient has a high lifetime cardiovascular risk due to being diagnosed with type 2 diabetes during childhood or as a young adult* Patient has diabetic kidney disease (see note b)* Target HbA1c (of 53 mmol/mol or less) has not been achieved despite the regular use of at least one blood-glucose lowering agent (e.g. metformin, vildagliptin, or insulin) for at least 3 months medical practitioner

* Criteria intended to describe patients at high risk of cardiovascular or renal complications of diabetes.

  1. Pre-existing cardiovascular disease or risk equivalent defined as: prior cardiovascular disease event (i.e. angina, myocardial infarction, percutaneous coronary intervention, coronary artery bypass grafting, transient ischaemic attack, ischaemic stroke, peripheral vascular disease), congestive heart failure or familial hypercholesterolaemia.

  2. Diabetic kidney disease defined as: persistent albuminuria (albumin:creatinine ratio greater than or equal to 3 mg/mmol, in at least two out of three samples over a 3-6 month period) and/or eGFR less than 60 mL/min/1.73m2 in the presence of diabetes, without alternative cause.

  3. Funded [empagliflozin / empagliflozin with metformin hydrochloride] treatment is not to be given in combination with a funded GLP-1 unless receiving (empagliflozin / empagliflozin with metformin hydrochloride] for the treatment of heart failure.

 Digestives Including Enzymes Digestives Including Enzymes Pancreatic enzyme Cap pancreatin 150 mg (amylase 8,000 Ph Eur U, lipase 10,000 Ph Eur U, total protease 600 Ph Eur U) Creon 10000 100 34.93 Cap pancreatin 300 mg (amylase 18,000 Ph Eur U, lipase 25,000 Ph Eur U, total protease 1,000 Ph Eur U) Creon 25000 100 94.38 Cap pancreatin (175 mg (25,000 U lipase, 22,500 U amylase, 1,250 U protease)) Any 0 Powder pancreatin 60.12 mg (3,600 Ph. Eur. u/amylase, 5,000 Ph. Eur. u/lipase and 200 Ph. Eur. u/protease) Any 0 Modified release granules pancreatin 60.12 mg (amylase 3,600 Ph Eur U, lipase 5,000 Ph Eur U, protease 200 Ph Eur U) Creon Micro 20 34.93 Ursodeoxycholic acid <range>Ursodeoxycholic acid</range> Patient has been diagnosed with Alagille syndrome Patient has progressive familial intrahepatic cholestasis medical practitioner Patient has chronic severe drug induced cholestatic liver injury Cholestatic liver injury not due to Total Parenteral Nutrition (TPN) use in adults Treatment with ursodeoxycholic acid may prevent hospital admission or reduce duration of stay medical practitioner Primary biliary cholangitis 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 Patient not requiring a liver transplant (bilirubin > 100 umol/l; decompensated cirrhosis) medical practitioner Patient diagnosed with cholestasis of pregnancy medical practitioner 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 Treatment for up to 13 weeks medical practitioner Paediatric patient has developed abnormal liver function as indicated on testing which is likely to be induced by TPN Liver function has not improved with modifying the TPN composition medical practitioner The individual has leukaemia/lymphoma and requires prophylaxis for medications/therapies with a high risk of sinusoidal obstruction syndrome medical practitioner Laxatives Bowel-Cleansing Preparations Citric acid with magnesium carbonate hydrate and sodium picosulfate Powder for oral soln 12 g with magnesium carbonate hydrate 7.4 g and sodium picosulfate 10 mg per sachet e.g. PicoPrep Orange 0 Macrogol 3350 with potassium chloride and sodium chloride Powder for oral soln 755.68 mg with potassium chloride 10.55 mg, sodium chloride 37.33 mg and sodium sulphate 80.62 mg per g, 70 g sachet Glycoprep Orange 3 16.10 12 64.32 Powder for oral soln 755.68 mg with potassium chloride 10.55 mg, sodium chloride 37.33 mg and sodium sulphate 80.62 mg per g, 210 g sachet e.g. Glycoprep Orange 0 Macrogol 3350 with ascorbic acid, potassium chloride, sodium chloride and citric acid with magnesium carbonate hydrate and sodium picosulfate Powder for oral soln 52.9 g with ascorbic acid 6 g, potassium chloride 740 mg, sodium chloride 2.6 g and sodium sulphate 5.6 g per sachet (1) and powder for oral soln citric acid 12 g with magnesium carbonate hydrate 7.4 g and sodium picosulfate 10 mg per sachet (2) e.g. Prepkit Orange 0 Macrogol 3350 with potassium chloride and sodium chloride with/without sodium sulfate, sodium ascorbate, ascorbic acid Powd for oral soln 100g with potassium chloride 1g, sodium chloride 2g and sodium sulfate 9g per sach(1), powd for oral soln 40g with potassium chloride 1.2g and sodium chloride 3.2g per sach(1) and powd for oral soln ascorbic acid 7.54g and sodium ascorbate 48.11g per sach(1) Plenvu 3 18.52 Bulk-Forming Agents Ispaghula (psyllium) husk Powder for oral soln Konsyl-D 500 22.10 Sterculia with frangula

For continuation only

Powder for oral soln Any 0 Faecal Softeners Docusate sodium with sennosides Tab 50 mg with sennosides 8 mg Laxsol 200 3.50 Solax 100 1.50 Poloxamer Oral drops 10% Coloxyl 30 4.17 Paraffin Enema 133 ml Any 0 Oral liquid 1 mg per ml Any 0 Docusate sodium Tab 50 mg Coloxyl 100 3.20 Tab 120 mg Coloxyl 100 4.98 Opioid Receptor Antagonists - Peripheral Methylnaltrexone bromide <range>Methylnaltrexone bromide</range> The patient is receiving palliative care Oral and rectal treatments for opioid induced constipation are ineffective Oral and rectal treatments for opioid induced constipation are unable to be tolerated medical practitioner Individual has opioid induced constipation Oral and rectal treatments for opioid induced constipation, including bowel-cleansing preparations, are ineffective or inappropriate Mechanical bowel obstruction has been excluded medical practitioner 14 Osmotic Laxatives Sodium phosphate with phosphoric acid Enema 10% with phosphoric acid 6.58% Fleet Phosphate Enema 1 3.70 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 36.89 Glycerol Suppos 2.8/4.0 g

Note: DV limit applies to glycerol suppository presentations.

Lax-suppositories Glycerol 20 12.39 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 Movicol 30 12.19 Molaxole 30 10.15 30 10.15 Lactulose Oral liq 10 g per 15 ml Laevolac 500 6.16 Stimulant Laxatives Sennosides Tab 7.5 mg Any 0 Sodium picosulfate <range>sodium picosulfate</range> The patient is a child with problematic constipation despite an adequate trial of other oral pharmacotherapies including macrogol where practicable The patient would otherwise require a high-volume bowel cleansing preparation medical practitioner Bisacodyl Suppos 10 mg Lax-Suppositories 10 4.14 Tab 5 mg Bisacodyl Viatris 200 10.00 Bisacodyl-AFT 200 6.28 Metabolic Disorder Agents Metabolic Disorder Agents Arginine Inj 600 mg per ml, 25 ml vial Any 0 Powder Any 0 Inj 500 mg per ml, 10 ml vial Any 0 Tab 1,000 mg Any 0 Cap 500 mg Any 0 Betaine <range>Betaine</range> The patient has a confirmed diagnosis of homocystinuria A cystathionine beta-synthase (CBS) deficiency A 5,10-methylene-tetrahydrofolate reductase (MTHFR) deficiency A disorder of intracellular cobalamin metabolism An appropriate homocysteine level has not been achieved despite a sufficient trial of appropriate vitamin supplementation metabolic physician 12 The treatment remains appropriate and the patient is benefiting from treatment metabolic physician 12 Haem arginate Inj 25 mg per ml, 10 ml ampoule Any 0 Levocarnitine <range>Levocarnitine</range> No patient criteria neurologist metabolic physician metabolic disorders dietitian 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 <range>Sodium phenylbutyrate</range> For the chronic management of a urea cycle disorder involving a deficiency of carbamylphosphate synthetase, ornithine transcarbamylase or argininosuccinate synthetase metabolic physician 12 The treatment remains appropriate and the patient is benefiting from treatment metabolic physician 12 Biotin <range>Biotin</range> No patient criteria metabolic physician metabolic disorders dietitian Pyridoxal-5-phosphate <range>Pyridoxal-5-phosphate</range> No patient criteria neurologist metabolic physician metabolic disorders dietitian Galsulfase <range>Galsulfase</range> The patient has been diagnosed with mucopolysaccharidosis VI Diagnosis confirmed by demonstration of N-acetyl-galactosamine-4-sulfatase (arylsulfatase B) deficiency confirmed by either enzyme activity assay in leukocytes or skin fibroblasts Detection of two disease causing mutations and patient has a sibling who is known to have mucopolysaccharidosis VI metabolic physician 12 The treatment remains appropriate for the patient and the patient is benefiting from treatment Patient has not had severe infusion-related adverse reactions which were not preventable by appropriate pre-medication and/or adjustment of infusion rates Patient has not developed another life threatening or severe disease where the long term prognosis is unlikely to be influenced by Enzyme Replacement Therapy (ERT) Patient has not developed another medical condition that might reasonably be expected to compromise a response to ERT metabolic physician 12 Alglucosidase alfa <range>Alglucosidase Alfa</range> The patient is aged up to 24 months at the time of initial application and has been diagnosed with infantile Pompe disease Diagnosis confirmed by documented deficiency of acid alpha-glucosidase by prenatal diagnosis using chorionic villus biopsies and/or cultured amniotic cells Documented deficiency of acid alpha-glucosidase, and urinary tetrasaccharide testing indicating a diagnostic elevation of glucose tetrasaccharides Documented deficiency of acid alpha-glucosidase, and documented molecular genetic testing indicating a disease-causing mutation in the acid alpha-glucosidase gene (GAA gene) Documented urinary tetrasaccharide testing indicating a diagnostic elevation of glucose tetrasaccharides, and molecular genetic testing indicating a disease-causing mutation in the GAA gene Patient has not required long-term invasive ventilation for respiratory failure prior to starting enzyme replacement therapy (ERT) Patient does not have another life-threatening or severe disease where the prognosis is unlikely to be influenced by ERT or might be reasonably expected to compromise a response to ERT Alglucosidase alfa to be administered at doses no greater than 20 mg/kg every 2 weeks metabolic physician 12 The treatment remains appropriate for the patient and the patient is benefiting from treatment Alglucosidase alfa to be administered at doses no greater than 20 mg/kg every 2 weeks Patient has not had severe infusion-related adverse reactions which were not preventable by appropriate pre-medication and/or adjustment of infusion rates Patient has not developed another life threatening or severe disease where the long term prognosis is unlikely to be influenced by ERT Patient has not developed another medical condition that might reasonably be expected to compromise a response to ERT There is no evidence of life threatening progression of respiratory disease as evidenced by the needed for >14 days of invasive ventilation There is no evidence of new or progressive cardiomyopathy metabolic physician 12 Idursulfase <range>Idursulfase</range> The patient has been diagnosed with Hunter Syndrome (mucopolysacchardosis II) Diagnosis confirmed by demonstration of iduronate 2-sulfatase deficiency in white blood cells by either enzyme assay in cultured skin fibroblasts Detection of a disease causing mutation in the iduronate 2-sulfatase gene Patient is going to proceed with a haematopoietic stem cell transplant (HSCT) within the next 3 months and treatment with idursulfase would be bridging treatment to transplant Patient has not required long-term invasive ventilation for respiratory failure prior to starting Enzyme Replacement Therapy (ERT) Idursulfase to be administered for a total of 24 weeks (equivalent to 12 weeks pre- and 12 weeks post-HSCT) at doses no greater than 0.5 mg/kg every week metabolic physician 24 Laronidase <range>Laronidase</range> The patient has been diagnosed with Hurler Syndrome (mucopolysacchardosis I-H) Diagnosis confirmed by demonstration of alpha-L-iduronidase deficiency in white blood cells by either enzyme assay in cultured skin fibroblasts Detection of two disease causing mutations in the alpha-L-iduronidase gene and patient has a sibling who is known to have Hurler syndrome Patient is going to proceed with a haematopoietic stem cell transplant (HSCT) within the next 3 months and treatment with laronidase would be bridging treatment to transplant Patient has not required long-term invasive ventilation for respiratory failure prior to starting Enzyme Replacement Therapy (ERT) Laronidase to be administered for a total of 24 weeks (equivalent to 12 weeks pre- and 12 post-HSCT) at doses no greater than 100 units/kg every week metabolic physician 24 Taliglucerase alfa <range>Taliglucerase alfa</range> The patient has a diagnosis of symptomatic type 1 or type 3* Gaucher disease confirmed by the demonstration of specific deficiency of glucocerebrosidase in leukocytes or cultured skin fibroblasts, and genotypic analysis Patient does not have another life-threatening or severe disease where the prognosis is unlikely to be influenced by enzyme replacement therapy (ERT) or the disease might be reasonably expected to compromise a response to ERT Patient has haematological complications of Gaucher disease Patient has skeletal complications of Gaucher disease Patient has significant liver dysfunction or hepatomegaly attributable to Gaucher disease Patient has reduced vital capacity from clinically significant or progressive pulmonary disease due to Gaucher disease Patient is a child and has experienced growth failure with significant decrease in percentile linear growth over a 6-12 month period Taliglucerase alfa is to be administered at a dose no greater than 30 unit/kg every other week rounded to the nearest whole vial (200 units) metabolic physician 12

Indication marked with * is an unapproved indication

 Patient has demonstrated a symptomatic improvement and has maintained improvements in the main symptom or symptoms for which therapy was started Patient has demonstrated a clinically objective improvement or no deterioration in haemoglobin levels, platelet counts and liver and spleen size RRadiological (MRI) signs of bone activity performed at two years since initiation of treatment, and five yearly thereafter, demonstrate no deterioration shown by the MRI, compared with MRI taken immediately prior to commencement of therapy or adjusted dose Patient has not developed another medical condition that might reasonably be expected to compromise a response to ERT Patient is adherent with regular treatment and taliglucerase alfa is to be administered at a dose no greater than 30 unit/kg every other week rounded to the nearest whole vial (200 units) metabolic physician any relevant practitioner 3 Sapropterin Dihydrochloride <range>Sapropterin dihydrochloride</range> Patient has phenylketonuria (PKU) and is pregnant or actively planning to become pregnant Treatment with sapropterin is required to support management of PKU during pregnancy Sapropterin to be administered at doses no greater than a total daily dose of 20 mg/kg Sapropterin to be used alone or in combination with PKU dietary management Total treatment duration with sapropterin will not exceed 22 months for each pregnancy (includes time for planning and becoming pregnant) and treatment will be stopped after delivery metabolic physician 1 Following the initial one-month approval, the patient has demonstrated an adequate response to a 2 to 4 week trial of sapropterin with a clinically appropriate reduction in phenylalanine levels to support management of PKU during pregnancy On subsequent renewal applications, the patient has previously demonstrated response to treatment with sapropterin and maintained adequate phenylalanine levels to support management of PKU during pregnancy Patient continues to be pregnant and treatment with sapropterin will not continue after delivery Patient is actively planning a pregnancy and this is the first renewal for treatment with sapropterin Treatment with sapropterin is required for a second or subsequent pregnancy to support management of their PKU during pregnancy Sapropterin to be administered at doses no greater than a total daily dose of 20 mg/kg Sapropterin to be used alone or in combination with PKU dietary management Total treatment duration with sapropterin will not exceed 22 months for each pregnancy (includes time for planning and becoming pregnant) and treatment will be stopped after delivery metabolic physician 12 Carglumic acid <range>Carglumic Acid</range> For the acute in-patient treatment of organic acidaemias as an alternative to haemofiltration metabolic physician Coenzyme Q10 <range>Coenzyme Q10</range> The patient has a suspected inborn error of metabolism that may respond to coenzyme Q10 supplementation metabolic physician 6 The patient has a confirmed diagnosis of an inborn error of metabolism that responds to coenzyme Q10 supplementation The treatment remains appropriate and the patient is benefiting from treatment metabolic physician 24 Riboflavin <range>Riboflavin</range> The patient has a suspected inborn error of metabolism that may respond to riboflavin supplementation metabolic physician neurologist 6 The patient has a confirmed diagnosis of an inborn error of metabolism that responds to riboflavin supplementation The treatment remains appropriate and the patient is benefiting from treatment metabolic physician neurologist 24 Taurine <range>Taurine</range> The patient has a suspected specific mitochondrial disorder that may respond to taurine supplementation metabolic physician 6 The patient has a confirmed diagnosis of a specific mitochondrial disorder which responds to taurine supplementation The treatment remains appropriate and the patient is benefiting from treatment metabolic physician 24 Trientine <range>Trientine</range> Patient has confirmed Wilson disease Treatment with D-penicillamine has been trialled and discontinued because the person has experienced intolerable side effects or has not received sufficient benefit Treatment with zinc has been trialled and discontinued because the person has experienced intolerable side effects or has not received sufficient benefit, or zinc is considered clinically inappropriate as the person has symptomatic liver disease and requires copper chelation medical practitioner Nitisinone <range>Nitisinone</range> Patient requires nitisinone for the management of inherited metabolic disorders medical practitioner Minerals Calcium Calcium carbonate Tab eff 1.75 g (1 g elemental) Any 0 Tab 1.25 g (500 mg elemental) Calci-Tab 500 250 7.28 Tab eff 1.25 g (500 mg elemental) Any 0 Copper <range>Copper chloride</range> Patient has been hospitalised with moderate to severe burns Treatment is recommended by a National Burns Unit specialist medical practitioner 3 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 5.99 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 sulfate with ascorbic acid Tab long-acting 325 mg (105 mg elemental) with ascorbic acid 500 mg Any 0 Iron (as ferric carboxymaltose) <range>Ferric carboxymaltose</range> Treatment with oral iron has proven ineffective or is clinically inappropriate medical practitioner Ferric derisomaltose <range>Ferric derisomaltose</range> Patient had previously developed iron-infusion related hypophosphataemia or other severe adverse reaction medical practitioner Iron polymaltose Inj 50 mg per ml, 2 ml ampoule Ferrosig 5 41.75 Ferrous sulfate Oral liq 30 mg (6 mg elemental) per ml Ferro-Liquid 250 10.25 Ferrous fumarate Tab 200 mg (65.7 mg elemental) Ferro-tab 100 3.49 Ferrous fumarate with folic acid Tab 310 mg (100 mg elemental) with folic acid 350 mcg Ferro-F-Tabs 100 5.98 Iron (as sucrose) Inj 20 mg per ml, 5 ml ampoule Venofer 5 100.00 Magnesium Magnesium hydroxide Tab 311 mg (130 mg elemental) Any 0 Suspension 8% Any 0 1 Magnesium oxide Cap 663 mg (400 mg elemental) Any 0 Cap 696 mg (420 mg elemental) Any 0 1 Magnesium chloride Inj 1 mmol per 1 ml, 100 ml bag Any 0 1 Magnesium oxide with magnesium aspartate, magnesium amino acid chelate and magnesium citrate Cap 500 mg with magnesium aspartate 100 mg, magnesium amino acid chelate 100 mg and magnesium citrate 100 mg (360 mg elemental magnesium) Any 0 1 Magnesium amino acid chelate Cap 750 mg (150 mg elemental) Any 0 1 Magnesium sulphate Inj 0.4 mmol per ml, 250 ml bag Any 0 Inj 2 mmol per ml, 5 ml ampoule Martindale 10 37.53 Inj 100 mg per ml, 50 ml bag Any 0 Inj 100 mg per ml, 40 ml bag Any 0 Inj 2 mmol per ml, 10 ml ampoule Inresa 10 75.06 Selenium Selenium <range>Selenium</range> Patient has been hospitalised with moderate to severe burns Treatment is recommended by a National Burns Unit specialist medical practitioner 3 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 11.00 100 11.00 Cap 220 mg (50 mg elemental) Rugby 100 29.14 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 Carmellose sodium with pectin and gelatine Paste Any 0 Powder Any 0 Dichlorobenzyl alcohol with amylmetacresol Lozenge 1.2 mg with amylmetacresol 0.6 mg Any 0 Triamcinolone acetonide Paste 0.1% Kenalog in Orabase 5 5.49 Chlorhexidine gluconate Mouthwash 0.2% healthE 200 3.99 Oropharyngeal Anti-Infectives Amphotericin B Lozenge 10 mg Fungilin 20 5.86 Nystatin Oral liquid 100,000 u per ml Nilstat 24 2.22 Miconazole Oral gel 20 mg per g Decozol 40 5.19 Other Oral Agents Hyaluronic acid with lidocaine [lignocaine] Inj 20 mg per ml Any 0 1 Silver diamine fluoride Oral application 38% Topamine 5 139.00 Sodium hyaluronate [Hyaluronic acid] <range>Sodium hyaluronate</range> No patient criteria 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 <range>Multivitamins - Cap </range> Patient has cystic fibrosis with pancreatic insufficiency Patient is an infant or child with liver disease or short gut syndrome Patient has severe malabsorption syndrome medical practitioner 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) Any 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) Any 0 Tab (BPC cap strength) Mvite 1000 24.00 Powder vitamin A 3200 mcg with vitamin D 100 mcg, vitamin E 54.2 mg, vitamin C 400 mg, vitamin K1 108 mcg thiamine 3.2 mg, riboflavin 4.4 mg, niacin 41 mg, vitamin B6 3.6 mg, folic acid 600 mcg, vitamin B12 9 mcg, biotin 120 mcg, pantothenic acid 24 mg, choline 1250 mg and inositol 700 mg <range>Multivitamins – Powder</range> Patient has inborn errors of metabolism medical practitioner Multivitamin and mineral supplement <range>Multivitamin and mineral supplement</range> Patient was admitted to hospital with burns Burn size is greater than 15% of total body surface area (BSA) for all types of burns Burn size is greater than 10% of BSA for mid-dermal or deep dermal burns Nutritional status prior to admission or dietary intake is poor medical practitioner 3 Multivitamin renal <range>Multivitamin renal</range> The patient has chronic kidney disease and is receiving either peritoneal dialysis or haemodialysis 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) medical practitioner Vitamin A Retinol Cap 25,000 iu Any 0 Oral liq 150,000 iu per ml Any 0 Tab 10,000 iu Any 0 Oral liq 5,000 iu per drop, 30 ml Any 0 1 Oral liq 666.7 mcg per 2 drops, 10 ml Any 0 Vitamin B Thiamine hydrochloride Inj 100 mg per ml, 2 ml vial Any 0 Tab 100 mg Any 0 Tab 50 mg Thiamine multichem 100 4.65 Inj 100 mg per ml, 1 ml vial e.g. Benerva 0 Inj 125 mg per ml, 2 ml vial Any 0 Inj 50 mg per ml, 2 ml ampoule Thiamine Sterop 10 49.95 Vitamin B complex Tab strong, BPC Bplex 500 11.25 Hydroxocobalamin Inj 1 mg per ml, 1 ml ampoule Hydroxocobalamin Panpharma 3 3.95 Pyridoxine hydrochloride Inj 100 mg per ml, 1 ml ampoule Any 0 Tab 25 mg Vitamin B6 25 90 3.43 Tab 50 mg Pyridoxine multichem 500 23.45 Inj 100 mg per ml, 30 ml vial Any 0 1 Inj 100 mg per ml, 2 ml vial Any 0 1 Vitamin C Ascorbic acid Tab chewable 250 mg Any 0 Tab 100 mg Cvite 500 16.00 Vitamin D Alfacalcidol Oral drops 2 mcg per ml One-Alpha 20 60.68 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 7.89 Calcitriol XL 100 7.89 Cap 0.5 mcg Calcitriol-AFT 100 13.68 Calcitriol XL 100 13.68 Colecalciferol Cap 1.25 mg (50,000 iu) Vit.D3 12 3.65 Oral liq 188 mcg per ml (7,500 iu per ml) Clinicians 5 9.00 Vitamin E Alpha tocopheryl acetate <range>Alpha tocopheryl acetate</range> Cystic fibrosis patient Patient has tried and failed the other available funded fat soluble vitamin A,D,E,K supplement (Vitabdeck) The other available funded fat soluble vitamin A,D,E,K supplement (Vitabdeck) is contraindicated or clinically inappropriate for the patient medical practitioner For the treatment of osteoradionecrosis medical practitioner Infant or child with liver disease or short gut syndrome Requires vitamin supplementation Patient has tried and failed the other available funded fat soluble vitamin A,D,E,K supplements (Vitabdeck) The other available funded fat soluble vitamin A,D,E,K supplement (Vitabdeck) is contraindicated or clinically inappropriate for patient medical practitioner Alpha tocopheryl <range>Alpha tocopheryl</range> Cystic fibrosis patient Patient has tried and failed the other available funded fat soluble vitamin A,D,E,K supplement (Vitabdeck) The other available funded fat soluble vitamin A,D,E,K supplement (Vitabdeck) is contraindicated or clinically inappropriate for the patient medical practitioner For the treatment of osteoradionecrosis medical practitioner Infant or child with liver disease or short gut syndrome Requires vitamin supplementation Patient has tried and failed the other available funded fat soluble vitamin A,D,E,K supplements (Vitabdeck) The other available funded fat soluble vitamin A,D,E,K supplement (Vitabdeck) is contraindicated or clinically inappropriate for patient medical practitioner Blood and Blood Forming Organs Antianaemics Hypoplastic and Haemolytic Epoetin beta

Note: Epoetin beta is considered a Discretionary Variance Pharmaceutical for epoetin alfa.

<range>Epoetin beta</range> Patient in chronic renal failure Haemoglobin is less than or equal to 100g/L Patient does not have diabetes mellitus Glomerular filtration rate is less than or equal to 30ml/min Patient has diabetes mellitus Glomerular filtration rate is less than or equal to 45ml/min Patient is on haemodialysis or peritoneal dialysis medical practitioner Patient has a confirmed diagnosis of myelodysplasia (MDS) Has had symptomatic anaemia with haemoglobin < 100g/L and is red cell transfusion-dependent Patient has very low, low or intermediate risk MDS based on the WHO classification-based prognostic scoring system for myelodysplastic syndrome (WPSS) Other causes of anaemia such as B12 and folate deficiency have been excluded Patient has a serum epoetin level of < 500 IU/L The minimum necessary dose of epoetin would be used and will not exceed 80,000 iu per week medical practitioner 12 The patient's transfusion requirement continues to be reduced with epoetin treatment Transformation to acute myeloid leukaemia has not occurred The minimum necessary dose of epoetin would be used and will not exceed 80,000 iu per week medical practitioner 2 Haematologist For use in patients where blood transfusion is not a viable treatment alternative *Note: Indications marked with * are unapproved indications medical practitioner Epoetin alfa <range>Epoetin alfa</range> Patient in chronic renal failure Haemoglobin is less than or equal to 100g/L Patient does not have diabetes mellitus Glomerular filtration rate is less than or equal to 30ml/min Patient has diabetes mellitus Glomerular filtration rate is less than or equal to 45ml/min Patient is on haemodialysis or peritoneal dialysis medical practitioner Patient has a confirmed diagnosis of myelodysplasia (MDS) Has had symptomatic anaemia with haemoglobin < 100g/L and is red cell transfusion-dependent Patient has very low, low or intermediate risk MDS based on the WHO classification-based prognostic scoring system for myelodysplastic syndrome (WPSS) Other causes of anaemia such as B12 and folate deficiency have been excluded Patient has a serum epoetin level of < 500 IU/L The minimum necessary dose of epoetin would be used and will not exceed 80,000 iu per week medical practitioner 2 The patient's transfusion requirement continues to be reduced with epoetin treatment Transformation to acute myeloid leukaemia has not occurred The minimum necessary dose of epoetin would be used and will not exceed 80,000 iu per week medical practitioner 12 For use in patients where blood transfusion is not a viable treatment alternative haematologist

Indications marked with * are unapproved indications

 Megaloblastic Folic acid Inj 5 mg per ml, 10 ml vial Any 0 Tab 0.8 mg Folic Acid multichem 1000 26.60 Tab 5 mg Folic Acid Viatris 100 5.82 Oral liq 50 mcg per ml Biomed 25 31.77 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 <range>Aprotinin</range> Paediatric patient undergoing cardiopulmonary bypass procedure Adult patient undergoing cardiac surgical procedure where the significant risk of massive bleeding outweighs the potential adverse effects of the drug cardiac anaesthetist Eltrombopag <range>Eltrombopag</range> Patient has had a splenectomy Two immunosuppressive therapies have been trialled and failed after therapy of 3 months each (or 1 month for rituximab) Patient has a platelet count of 20,000 to 30,000 platelets per microlitre and has evidence of significant mucocutaneous bleeding Patient has a platelet count of less than or equal to 20,000 platelets per microlitre and has evidence of active bleeding Patient has a platelet count of less than or equal to 10,000 platelets per microlitre haematologist 6 The patient requires eltrombopag treatment as preparation for splenectomy haematologist 6 The patient has obtained a response (see Note) from treatment during the initial approval or subsequent renewal periods and further treatment is required haematologist 12

Response to treatment is defined as a platelet count of > 30,000 platelets per microlitre

 Patient has a significant and well-documented contraindication to splenectomy for clinical reasons Two immunosuppressive therapies have been trialled and failed after therapy of 3 months each (or 1 month for rituximab) Patient has immune thrombocytopenic purpura* with a platelet count of less than or equal to 20,000 platelets per microliter Patient has immune thrombocytopenic purpura* with a platelet count of 20,000 to 30,000 platelets per microlitre and significant mucocutaneous bleeding haematologist 3 The patient’s significant contraindication to splenectomy remains The patient has obtained a response from treatment during the initial approval period Patient has maintained a platelet count of at least 50,000 platelets per microlitre on treatment Further treatment with eltrombopag is required to maintain response haematologist 12 Two immunosuppressive therapies have been trialled and failed after therapy of at least 3 months duration Patient has severe aplastic anaemia with a platelet count of less than or equal to 20,000 platelets per microliter Patient has severe aplastic anaemia with a platelet count of 20,000 to 30,000 platelets per microlitre and significant mucocutaneous bleeding haematologist 3 The patient has obtained a response from treatment of at least 20,000 platelets per microlitre above baseline during the initial approval period Platelet transfusion independence for a minimum of 8 weeks during the initial approval period haematologist 12 Aluminium chloride <range>Aluminium chloride</range> For use as a haemostatis agent medical practitioner Emicizumab <range>Emicizumab</range> Patient has severe congenital haemophilia A with a severe bleeding phenotype (endogenous factor VIII activity less than or equal to 2%) Emicizumab is to be administered at a dose of no greater than 3 mg/kg weekly for 4 weeks followed by the equivalent of 1.5 mg/kg weekly haematologist Tranexamic acid Tab 500 mg Mercury Pharma 60 9.93 Inj 100 mg per ml, 5 ml ampoule Tranexamic-AFT 5 5.39 Inj 100 mg per ml, 10 ml ampoule Tranexamic-AFT 5 7.99 Anticoagulant Reversal Agents Idarucizumab <range>Idarucizumab</range> For the reversal of the anticoagulant effects of dabigatran when required in situations of life-threatening or uncontrolled bleeding, or for emergency surgery or urgent procedures medical practitioner Blood Factors Moroctocog alfa [Recombinant factor VIII] <range>Moroctocog alfa [Recombinant factor VIII]</range> For patients with haemophilia. Rare Clinical Circumstances Brand of short half-life recombinant factor VIII. Access to funded treatment is managed by the Haemophilia Treaters Group in conjunction with the National Haemophilia Management Group, subject to criteria medical practitioner Octocog alfa [Recombinant factor VIII] (Advate) <range>Octocog alfa [Recombinant factor VIII] (Advate)</range> For patients with haemophilia. Preferred Brand of short half-life recombinant factor VIII. Access to funded treatment is managed by the Haemophilia Treaters Group in conjunction with the National Haemophilia Management Group medical practitioner Octocog alfa [Recombinant factor VIII] (Kogenate FS) <range>Octocog alfa [Recombinant factor VIII] (Kogenate FS)</range> For patients with haemophilia. Rare Clinical Circumstances Brand of short half-life recombinant factor VIII. Access to funded treatment is managed by the Haemophilia Treaters Group in conjunction with the National Haemophilia Management Group, subject to criteria medical practitioner Nonacog gamma, [Recombinant factor IX] <range>Nonacog gamma</range> For patients with haemophilia. Access to funded treatment is managed by the Haemophilia Treaters Group in conjunction with the National Haemophilia Management Group medical practitioner Rurioctocog alfa pegol [Recombinant factor VIII] <range>Rurioctocog alfa pegol [Recombinant factor VIII]</range> For patients with haemophilia A receiving prophylaxis treatment. Access to funded treatment is managed by the Haemophilia Treaters Group in conjunction with the National Haemophilia Management Group medical practitioner Eftrenonacog alfa [Recombinant factor IX] <range>Eftrenonacog alfa</range> For patients with haemophilia B receiving prophylaxis treatment. Access to funded treatment is managed by the Haemophilia Treaters Group in conjunction with the National Haemophilia Management Group medical practitioner Factor eight inhibitor bypassing fraction <range>Factor eight inhibitor bypassing fraction</range> For patients with haemophilia. Preferred Brand of bypassing agent for >14 days predicted use. Access to funded treatment is managed by the Haemophilia Treaters Group in conjunction with the National Haemophilia Management Group medical practitioner Eptacog alfa [Recombinant factor VIIa] <range>Eptacog alfa</range> For patients with haemophilia. Access to funded treatment is managed by the Haemophilia Treaters Group in conjunction with the National Haemophilia Management Group. Rare Clinical Circumstances Brand of bypassing agent for >14 days predicted use. Access to funded treatment for >14 days predicted use is by named patient application to the Haemophilia Treaters Group, subject to access criteria medical practitioner Vitamin K Phytomenadione Inj 2 mg in 0.2 ml ampoule Konakion MM Paediatric 5 8.00 Inj 10 mg per ml, 1 ml ampoule Konakion MM 5 9.21 Antithrombotics Anticoagulants Bivalirudin <range>Bivalirudin</range> For use in heparin-induced thrombocytopaenia, heparin resistance or heparin intolerance For use in patients undergoing endovascular procedures medical practitioner Danaparoid <range>Danaparoid</range> For use in heparin-induced thrombocytopaenia, heparin resistance or heparin intolerance medical practitioner Defibrotide <range>Defibrotide</range> Patient has moderate or severe sinusoidal obstruction syndrome as a result of chemotherapy or regimen-related toxicities haematologist 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 <range>Fondaparinux sodium</range> For use in heparin-induced thrombocytopaenia, heparin resistance or heparin intolerance medical practitioner 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 Citrate sodium Inj 4% (200 mg per 5 ml), 5 ml ampoule Any 0 Inj 46.7% (2.36 g per 5 ml), 5 ml ampoule Any 0 Inj 46.7% (1.4 g per 3 ml), 3 ml syringe Any 0 1 Warfarin sodium Tab 1 mg Marevan 100 7.50 Tab 2 mg Any 0 Tab 3 mg Marevan 100 12.00 Tab 5 mg Marevan 100 13.50 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 96.91 Heparin sodium 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 70.33 Inj 1,000 iu per ml, 1 ml ampoule Hospira 50 362.98 Inj 1,000 iu per ml, 5 ml ampoule Pfizer 50 164.40 Inj 5,000 iu per ml, 5 ml ampoule Pfizer 50 406.15 Inj 5,000 iu per ml, 5 ml vial Heparin Sodium Panpharma 10 83.00 Inj 10 iu per ml, 5 ml ampoule (flushing solution) Wockhardt 10 19.38 Enoxaparin sodium Inj 20 mg in 0.2 ml syringe Clexane 10 21.90 Inj 40 mg in 0.4 ml syringe Clexane 10 29.74 Inj 60 mg in 0.6 ml syringe Clexane 10 42.47 Inj 80 mg in 0.8 ml syringe Clexane 10 56.62 Inj 100 mg in 1 ml syringe Clexane 10 70.91 Inj 120 mg in 0.8 ml syringe Clexane Forte 10 88.11 Inj 150 mg in 1 ml syringe Clexane Forte 10 100.70 Inj 40 mg in 0.4 ml ampoule Any 0 Rivaroxaban Tab 10 mg Xarelto 30 15.60 Tab 15 mg Xarelto 28 14.56 Tab 20 mg Xarelto 28 14.56 Dabigatran Cap 75 mg Pradaxa 60 27.99 Cap 110 mg Pradaxa 60 27.99 Cap 150 mg Pradaxa 60 27.99 Antiplatelets Aspirin Suppos 300 mg Any 0 Tab 100 mg Ethics Aspirin EC 990 12.65 Ticlopidine Tab 250 mg Any 0 Lysine acetylsalicylate [Lysine asprin] <range>Lysine acetylsalicylate</range> For use when an immediate antiplatelet effect is required prior to an urgent interventional neuro-radiology or interventional cardiology procedure Administration of oral aspirin would delay the procedure medical practitioner Dipyridamole

For continuation only

Inj 5 mg per ml, 2 ml ampoule Any 0 Tab 25 mg Any 0 Cap modified-release 200 mg Dipyridamole - Strides 60 55.13 Clopidogrel Tab 75 mg Arrow - Clopid 84 5.07 Eptifibatide <range>Eptifibatide</range> For use in patients with acute coronary syndromes undergoing percutaneous coronary intervention For use in patients with definite or strongly suspected intra-coronary thrombus on coronary angiography For use in patients undergoing intra-cranial intervention medical practitioner Ticagrelor <range>Ticagrelor</range> 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 medical practitioner Patient has had a neurological stenting procedure* in the last 60 days Patient is about to have a neurological stenting procedure performed* Patient has demonstrated clopidogrel resistance using the P2Y12 (VerifyNow) assay or another appropriate platelet function assay and requires antiplatelet treatment with ticagrelor Clopidogrel resistance has been demonstrated by the occurrence of a new cerebral ischemic event Clopidogrel resistance has been demonstrated by the occurrence of transient ischemic attack symptoms referable to the stent. medical practitioner 12 Patient is continuing to benefit from treatment Treatment continues to be clinically appropriate medical practitioner 12 Patient has undergone percutaneous coronary intervention Patient has had a stent deployed in the previous 4 weeks Patient is clopidogrel-allergic** medical practitioner 12 Patient has experienced cardiac stent thrombosis whilst on clopidogrel medical practitioner For short term use while in hospital following ST-elevated myocardial infarction medical practitioner 1 Patient has been diagnosed with a minor stroke (NIHSS† score 3 or less), high-risk TIA (ABCD2 score 4 or more) or Crescendo TIA Patient is expected to be a poor metaboliser of clopidogrel, with documented clinical rationale Patient is allergic to clopidogrel** Ticagrelor to be prescribed for a maximum of 21 days following minor stroke or TIA medical practitioner Patient has been diagnosed with a minor stroke (NIHSS score 3 or less), high-risk transient ischemic attack (ABCD2 score 4 or more) or Crescendo TIA medical practitioner 1

Indications marked with * are unapproved indications.

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

Note:NIHSS† National Institutes of Health Stroke Scale.

 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 Inj 5,000 iu vial Any 0 Inj 250,000 iu vial Any 0 Colony-Stimulating Factors Drugs Used to Mobilise Stem Cells Plerixafor <range>Plerixafor</range> Patient is to undergo stem cell transplantation Patient is a donor for stem cell transplantation Patient has not had more than one previous unsuccessful mobilisation attempt with plerixafor Patient is undergoing G-CSF mobilisation Has a suboptimal peripheral blood CD34 count of less than or equal to 20 × 106/L on day 5 after 4 days of G-CSF treatment Efforts to collect > 1 × 106 CD34 cells/kg have failed after one apheresis procedure Patient is undergoing chemotherapy and G-CSF mobilisation Has rising white blood cell counts of > 2 × 109/L Has a suboptimal peripheral blood CD34 count of less than or equal to 20 × 106/L Efforts to collect > 1 × 106 CD34 cells/kg have failed after one apheresis procedure The peripheral blood CD34 cell counts are decreasing before the target has been received A previous mobilisation attempt with G-CSF or G-CSF plus chemotherapy has failed haematologist 3 Granulocyte Colony-Stimulating Factors Pegfilgrastim <range>Pegfilgrastim</range> For prevention of neutropenia in patients undergoing high risk chemotherapy for cancer (febrile neutropenia risk greater than or equal to 5%*) medical practitioner

*Febrile neutropenia risk greater than or equal to 5% after taking into account other risk factors as defined by the European Organisation for Research and Treatment of Cancer (EORTC) guidelines

 Filgrastim <range>Filgrastim</range> No patient criteria haematologist oncologist Fluids and Electrolytes Intravenous Administration Calcium chloride Inj 100 mg per ml, 10 ml vial Any 0 Inj 100 mg per ml, 50 ml syringe e.g. Baxter 0 1 Compound electrolytes Inj sodium 140 mmol/l, potassium 5 mmol/l, magnesium 1.5 mmol/l, chloride 98 mmol/l, acetate 27 mmol/l, gluconate 23 mmol/l, 500 ml bag Plasma-Lyte 148 18 62.82 Inj sodium 140 mmol/l, potassium 5 mmol/l, magnesium 1.5 mmol/l, chloride 98 mmol/l, acetate 27 mmol/l, gluconate 23 mmol/l, 1,000 ml bag Plasma-Lyte 148 12 30.72 Compound electrolytes with glucose [Dextrose] Inj sodium 140 mmol/l, 5 mmol/l potassium, 1.5 mmol/l magnesium, 98 mmol/l chloride, 27 mmol/l acetate and 23 mmol/l gluconate, glucose 23 mmol/l (5%), 1,000 ml bag Plasma-Lyte 148 & 5% Glucose 12 239.04 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, 500 ml bag Baxter 18 27.90 Inj sodium 131 mmol/l with potassium 5 mmol/l, calcium 2 mmol/l, bicarbonate 29 mmol/l, chloride 111 mmol/l, 1,000 ml bag Baxter 12 19.32 Potassium dihydrogen phosphate Inj 1 mmol per ml, 10 ml ampoule Hospira 10 174.57 Ringer's solution Inj sodium 147 mmol/l with potassium 4 mmol/l, calcium 2.2 mmol/l, chloride 156 mmol/l, 1,000 ml bag Baxter 12 227.52 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 Fresenius Kabi 50 7.50 Inj 0.9%, 5 ml ampoule Fresenius Kabi 20 4.12 Inj 1.8%, 500 ml bottle Any 0 Inj 23.4% (4 mmol/ml), 20 ml ampoule Biomed 5 40.15 Inj 0.9%, 20 ml ampoule Fresenius Kabi 20 5.20 Inj 0.9%, 3 ml, prefilled syringe, non-sterile pack <range>Sodium chloride – Inj</range> For use in flushing of in-situ vascular access devices only medical practitioner Inj 0.9%, 5 ml, prefilled syringe, non-sterile pack <range>Sodium chloride – Inj</range> For use in flushing of in-situ vascular access devices only medical practitioner Inj 0.9%, 10 ml, prefilled syringe, non-sterile pack <range>Sodium chloride – Inj</range> For use in flushing of in-situ vascular access devices only medical practitioner Inj 0.45%, 500 ml bag Baxter 18 84.42 Inj 0.9%, 50 ml bag Baxter 60 124.20 Baxter-Viaflo 75 147.75 Inj 0.9%, 100 ml bag Baxter 48 88.80 Baxter-Viaflo 60 105.60 Inj 0.9%, 250 ml bag Baxter 24 50.40 Inj 0.9%, 500 ml bag Baxter 18 27.54 Inj 0.9%, 1,000 ml bag Baxter 12 18.96 Inj 3%, 1,000 ml bag Baxter 12 165.84 Sodium bicarbonate Inj 8.4%, 10 ml vial Any 0 Inj 8.4%, 100 ml vial Biomed 1 25.31 Inj 8.4%, 50 ml vial Biomed 1 24.70 Calcium gluconate Inj 10%, 10 ml ampoule e.g. Max Health 0 1 Glucose [Dextrose] Inj 50%, 10 ml ampoule Biomed 5 34.75 Inj 50%, 90 ml bottle Biomed 1 17.50 Inj 5%, 50 ml bag Baxter Glucose 5% 60 162.00 Inj 10%, 500 ml bag Baxter Glucose 10% 18 126.00 Inj 10%, 1,000 ml bag Baxter Glucose 10% 12 162.00 Inj 50%, 500 ml bag Baxter Glucose 50% 18 423.00 Inj 5%, 100 ml bag Fresenius Kabi 50 97.00 Inj 5%, 250 ml bag Fresenius Kabi 30 63.00 Inj 5%, 500 ml bag Fresenius Kabi 20 67.40 Inj 5%, 1,000 ml bag Fresenius Kabi 10 53.10 Glucose with potassium chloride Inj 10% glucose with 20 mmol/l potassium chloride, 500 ml bag Any 0 1 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%, 1,000 ml bag Baxter 12 240.36 Inj 5% glucose with potassium chloride 20 mmol/l and sodium chloride 0.45%, 1,000 ml bag Baxter 12 189.00 Inj 5% glucose with potassium chloride 20 mmol/l and sodium chloride 0.9%, 1,000 ml bag Baxter 12 334.08 Potassium chloride with sodium chloride Inj 10 mmol potassium chloride with 0.29% sodium chloride, 100 ml bag Baxter 48 563.52 Inj 40 mmol potassium chloride with 0.9% sodium chloride, 100 ml bag Baxter 48 912.96 Inj 20 mmol potassium chloride with 0.9% sodium chloride, 1,000 ml bag Baxter 12 192.72 Inj 40 mmol potassium chloride with 0.9% sodium chloride, 1,000 ml bag Baxter 12 299.40 Glucose with sodium chloride Inj 4% glucose and sodium chloride 0.18%, 1,000 ml bag Baxter 12 192.96 Inj 5% glucose and sodium chloride 0.9%, 1,000 ml bag Baxter 12 204.84 Inj 5% glucose and sodium chloride 0.45%, 1,000 ml bag Baxter 12 192.84 Inj glucose 2.5% with sodium chloride 0.45%, 500 ml bag Baxter 18 318.78 Water Inj 250 ml bag Any 0 Inj 500 ml bag Any 0 Inj 10 ml ampoule Multichem 50 7.60 Fresenius Kabi 50 1 7.60 Inj 20 ml ampoule Fresenius Kabi 20 5.00 Inj, 1,000 ml bag Baxter 12 24.12 Sodium dihydrogen phosphate [Sodium acid phosphate] Inj 1 mmol per ml, 20 ml ampoule Biomed 5 59.10 Oral Administration Compound electrolytes Powder for oral soln Electral 50 9.50 Compound electrolytes with glucose [Dextrose] Soln with electrolytes Hydralyte - Lemonade 1 6.53 Soln with electrolytes (2 x 500 ml) Pedialyte 1 8.45 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 16.15 200 16.15 Sodium chloride Oral liq 2 mmol/ml Any 0 Tab 600 mg Any 0 Sodium bicarbonate Cap 840 mg Sodibic 100 8.52 100 8.52 Calcium polystyrene sulphonate Powder Calcium Resonium 300 169.85 Roma 300 169.85 Plasma Volume Expanders Gelatine, succinylated Inj 4%, 500 ml bag Gelofusine 10 139.10 Cardiovascular System Agents Affecting the Renin-Angiotensin System ACE Inhibitors Ramipril Cap 1.25 mg Tryzan 90 17.25 Cap 2.5 mg Tryzan 90 16.50 Cap 5 mg Tryzan 90 16.88 Cap 10 mg Tryzan 90 17.63 Quinapril Tab 5 mg Arrow-Quinapril 5 90 10.24 Tab 10 mg Arrow-Quinapril 10 90 12.51 Tab 20 mg Arrow-Quinapril 20 90 14.38 Captopril Oral liq 5 mg per ml <range>Captopril - Oral liq 5 mg per ml</range> For use in children under 12 years of age For use in tube-fed patients For management of rebound transient hypertension following cardiac surgery medical practitioner Lisinopril Tab 5 mg Teva Lisinopril 90 12.00 Tab 10 mg Teva Lisinopril 90 12.00 Tab 20 mg Teva Lisinopril 90 16.00 Enalapril maleate Tab 5 mg Acetec 90 4.25 Ipca-Enalapril 90 1.40 Tab 10 mg Acetec 90 5.50 Ipca-Enalapril 90 1.58 Tab 20 mg Acetec 90 6.50 Ipca-Enalapril 90 2.00 Perindopril Tab 2 mg Coversyl 30 1.79 Tab 4 mg Coversyl 30 2.44 Tab 8 mg Coversyl 30 3.94 Angiotensin II Antagonists Candesartan cilexetil Tab 4 mg Candestar 90 2.68 Candesartan Viatris Sante 90 2.68 Tab 8 mg Candestar 90 2.67 Candesartan Viatris Sante 90 2.67 Tab 16 mg Candestar 90 4.22 Candesartan Viatris Sante 90 4.22 Tab 32 mg Candestar 90 5.24 Candesartan Viatris Sante 30 1.75 Losartan potassium Tab 12.5 mg Losartan Actavis 84 2.00 Tab 25 mg Losartan Actavis 84 2.29 Tab 50 mg Losartan Actavis 84 2.86 Tab 100 mg Losartan Actavis 84 4.57 Angiotensin II Antagonists with Diuretics Losartan potassium with hydrochlorothiazide Tab 50 mg with hydrochlorothiazide 12.5 mg Arrow-Losartan & Hydrochlorothiazide 30 4.31 Losartan & Hydrochlorothiazide (Ipca) 90 7.25 Candesartan cilexetil with hydrochlorothiazide Tab 32 mg with hydrochlorothiazide 12.5 mg APO-Candesartan HCTZ 32/12.5 30 5.25 Tab 16 mg with hydrochlorothiazide 12.5 mg APO-Candesartan HCTZ 16/12.5 30 4.10 Angiotensin II Antagonists with Neprilysin Inhibitors Sacubitril with valsartan <range>Sacubitril with valsartan</range> Patient has heart failure Patient is in NYHA/WHO functional class II Patient is in NYHA/WHO functional class III Patient is in NYHA/WHO functional class IV Patient has a documented left ventricular ejection fraction (LVEF) of less than or equal to 35% An ECHO is not reasonably practical, and in the opinion of the treating practitioner the patient would benefit from treatment Patient is receiving concomitant optimal standard chronic heart failure treatments medical practitioner Alpha-Adrenoceptor Blockers Alpha-Adrenoceptor Blockers Phenoxybenzamine hydrochloride Cap 10 mg Any 0 Inj 50 mg per ml, 2 ml ampoule Any 0 Inj 50 mg per ml, 1 ml ampoule Any 0 1 Terazosin

For continuation only

Tab 1 mg Any 0 Phentolamine mesylate Inj 10 mg per ml, 1 ml ampoule Any 0 Inj 5 mg per ml, 1 ml ampoule Any 0 Doxazosin Tab 2 mg Doxazosin Clinect 500 17.35 Tab 4 mg Doxazosin Clinect 500 20.94 Prazosin Tab 1 mg Arrotex-Prazosin S29 100 5.53 Tab 2 mg Arrotex-Prazosin S29 100 7.00 Tab 5 mg Arrotex-Prazosin S29 100 11.70 Cap 1 mg Prazosin Mylan 100 15.40 Cap 2 mg Prazosin Mylan 100 15.58 Cap 5 mg Prazosin Mylan 100 23.32 Antiarrhythmics Antiarrhythmics Adenosine Inj 3 mg per ml, 10 ml vial <range>Adenosine - Inj 3 mg per ml, 10 ml vial</range> For use in cardiac catheterisation, myocardial perfusion scans, electrophysiology and MRI medical practitioner Inj 3 mg per ml, 2 ml vial Adsine 5 34.50 Ajmaline <range>Ajmaline</range> No patient criteria cardiologist Amiodarone hydrochloride Inj 50 mg per ml, 3 ml ampoule Max Health 10 17.96 Tab 100 mg Aratac 30 4.95 Tab 200 mg Aratac 30 5.86 Digoxin Inj 250 mcg per ml, 2 ml vial Any 0 Oral liq 50 mcg per ml Any 0 Tab 250 mcg Lanoxin 240 18.75 Tab 62.5 mcg Lanoxin PG 240 8.58 Disopyramide phosphate Cap 100 mg Any 0 Propafenone hydrochloride Tab 150 mg Any 0 Ivabradine <range>Ivabradine</range> Patient is indicated for computed tomography coronary angiography Patient has a heart rate of greater than 70 beats per minute while taking a maximally tolerated dose of beta blocker Patient is unable to tolerate beta blockers medical practitioner Atropine sulphate Inj 600 mcg per ml, 1 ml ampoule Martindale 10 16.10 Hikma 10 16.10 Flecainide acetate Tab 50 mg Flecainide BNM 60 19.95 Cap long-acting 100 mg Flecainide Controlled Release Teva 90 35.78 Cap long-acting 200 mg Flecainide Controlled Release Teva 90 54.28 Inj 10 mg per ml, 15 ml ampoule Tambocor 5 108.16 Almarytm 5 102.79 Tambocor German 5 108.16 Mexiletine hydrochloride Cap 150 mg Teva 100 162.00 Cap 250 mg Teva 100 202.00 Antihypotensives Antihypotensives Midodrine <range>Midodrine</range> Patient has disabling orthostatic hypotension not due to drugs medical practitioner 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 49.85 Tab 50 mg Viatris 500 11.00 Tab 100 mg Atenolol Viatris 500 18.50 Sotalol Tab 80 mg Mylan 500 40.00 Tab 160 mg Mylan 100 20.00 Labetalol Inj 5 mg per ml, 20 ml ampoule Any 0 Tab 50 mg Any 0 Tab 100 mg Trandate 100 14.50 Biocon 100 49.54 Tab 200 mg Presolol 100 42.07 Trandate 100 27.00 Carvedilol Tab 6.25 mg Carvedilol Sandoz 60 1.97 Tab 12.5 mg Carvedilol Sandoz 60 2.03 Tab 25 mg Carvedilol Sandoz 60 2.46 Metoprolol tartrate Tab long-acting 200 mg Slow-Lopresor 28 23.40 Inj 1 mg per ml, 5 ml vial Metoprolol IV Mylan 5 26.50 Metoprolol IV Viatris 5 26.50 Tab 50 mg IPCA-Metoprolol 100 5.66 Tab 100 mg IPCA-Metoprolol 60 7.55 Celiprolol

For continuation only

Tab 200 mg Any 0 Nadolol Tab 40 mg Nadolol BNM 100 19.19 100 19.19 Tab 80 mg Nadolol BNM 100 30.39 100 30.39 Propranolol Inj 1 mg per ml, 1 ml ampoule Any 0 Oral liq 4 mg per ml e.g. Hikma-Propranolol 0 Cap long-acting 160 mg Cardinol LA 100 18.17 Tab 10 mg Drofate 100 7.04 Tab 40 mg IPCA-Propranolol 100 8.75 Metoprolol succinate Tab long-acting 23.75 mg Myloc CR 90 4.20 Tab long-acting 47.5 mg Myloc CR 90 3.65 Tab long-acting 95 mg Myloc CR 90 5.24 Tab long-acting 190 mg Myloc CR 90 9.76 Bisoprolol fumarate Tab 5 mg Ipca-Bisoprolol 90 1.91 Tab 2.5 mg Ipca-Bisoprolol 90 1.36 Tab 10 mg Ipca-Bisoprolol 90 2.71 Calcium Channel Blockers Dihydropyridine Calcium Channel Blockers Isradipine Tab 2.5 mg Any 0 Cap 2.5 mg Any 0 Nimodipine Inj 0.2 mg per ml, 50 ml vial Nimotop 5 337.50 Tab 30 mg Nimotop 100 350.00 Nicardipine hydrochloride <range>Nicardipine hydrochloride</range> Patient has hypertension requiring urgent treatment with an intravenous agent Patient has excessive ventricular afterload Patient is awaiting or undergoing cardiac surgery using cardiopulmonary bypass anaesthetist intensivist cardiologist paediatric cardiologist Nifedipine Cap 5 mg Any 0 Tab long-acting 10 mg Tensipine MR10 56 19.42 Tab long-acting 20 mg Nyefax Retard 100 17.72 Valni Retard 56 9.92 Tab long-acting 30 mg Mylan (24 hr release) 100 34.10 Mylan Italy (24 hr release) 14 4.78 Tab long-acting 60 mg Mylan (24 hr release) 100 52.81 Felodipine Tab long-acting 5 mg Felo 5 ER 90 6.57 Tab long-acting 10 mg Felo 10 ER 90 6.95 Tab long-acting 2.5 mg Plendil ER 30 2.18 Amlodipine Tab 5 mg Vasorex 90 1.21 Tab 10 mg Vasorex 90 1.31 Tab 2.5 mg Vasorex 90 1.45 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 Isoptin SR 30 15.12 Inj 2.5 mg per ml, 2 ml ampoule Isoptin 5 25.00 Tab long-acting 120 mg Isoptin SR 100 36.02 Perhexiline maleate Tab 100 mg Pexsig 100 62.90 Diltiazem hydrochloride Inj 5 mg per ml, 5 ml vial Any 0 Tab 30 mg Any 0 Cap long-acting 120 mg Diltiazem CD Clinect 500 65.35 Cap long-acting 180 mg Cardizem CD 30 7.00 Cap long-acting 240 mg Cardizem CD 30 9.30 Centrally-Acting Agents Centrally-Acting Agents Clonidine hydrochloride Inj 150 mcg per ml, 1 ml ampoule Catapres 5 14.10 Tab 150 mcg Catapres 100 40.41 Tab 25 mcg Clonidine Teva 112 29.74 Methyldopa Tab 250 mg Methyldopa Viatris 100 15.10 Clonidine Patch 2.5 mg, 100 mcg per day Mylan 4 11.70 Patch 5 mg, 200 mcg per day Mylan 4 12.80 Patch 7.5 mg, 300 mcg per day Mylan 4 17.90 Diuretics Loop Diuretics Furosemide [Frusemide] Inj 10 mg per ml, 25 ml ampoule Lasix 6 60.65 Oral liq 10 mg per ml Lasix 30 11.20 Inj 10 mg per ml, 2 ml ampoule Furosemide-Baxter 5 2.40 Furosemide-AFT 10 3.97 Tab 40 mg IPCA-Frusemide 1000 12.80 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 20%, 500 ml bag Baxter 18 1296.00 Inj 10%, 1,000 ml bag Baxter 12 882.84 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 Eplerenone <range>Eplerenone</range> Patient has heart failure with ejection fraction less than 40% Patient is intolerant to optimal dosing of spironolactone Patient has experienced a clinically significant adverse effect while on optimal dosing of spironolactone medical practitioner Spironolactone Tab 25 mg Spiractin 100 4.20 Tab 100 mg Spiractin 100 11.40 Oral liq 5 mg per ml Biomed 25 35.70 Amiloride hydrochloride Tab 5 mg Any 0 1 Oral liq 1 mg per ml Biomed 25 35.40 Thiazide and Related Diuretics Metolazone Tab 5 mg Any 0 Indapamide Tab 2.5 mg Dapa-Tabs 90 16.00 Chlorothiazide Oral liq 50 mg per ml Biomed 25 30.67 Chlortalidone [Chlorthalidone] Tab 25 mg Hygroton 50 6.95 Bendroflumethiazide [Bendrofluazide] Tab 2.5 mg Arrow-Bendrofluazide 500 51.50 Tab 5 mg Arrow-Bendrofluazide 500 61.00 Vasopressin receptor antagonists Tolvaptan <range>Tolvaptan</range> Patient has a confirmed diagnosis of autosomal dominant polycystic kidney disease Patient has an estimated glomerular filtration rate (eGFR) of greater than or equal to 25 ml/min/1.73 m² at treatment initiation Patient’s disease is rapidly progressing, with a decline in eGFR of greater than or equal to 5 mL/min/1.73 m² within one-year Patient’s disease is rapidly progressing, with an average decline in eGFR of greater than or equal to 2.5 mL/min/1.73 m² per year over a five-year period renal physician any relevant practitioner 12 Patient has not developed end-stage renal disease, defined as an eGFR of less than 15 mL/min/1.73 m² Patient has not undergone a kidney transplant renal physician any relevant practitioner 12 Lipid-Modifying Agents Fibrates Bezafibrate Tab 200 mg Bezalip 90 22.65 Tab long-acting 400 mg Bezalip Retard 30 21.54 HMG CoA Reductase Inhibitors (Statins) Rosuvastatin <range>Rosuvastatin</range> Patient is considered to be at risk of cardiovascular disease Patient is Māori or any Pacific ethnicity Patient has a calculated risk of cardiovascular disease of at least 15% over 5 years LDL cholesterol has not reduced to less than 1.8 mmol/litre with treatment with the maximum tolerated dose of atorvastatin and/or simvastatin medical practitioner Patient has familial hypercholesterolemia (defined as a Dutch Lipid Criteria score greater than or equal to 6) LDL cholesterol has not reduced to less than 1.8 mmol/litre with treatment with the maximum tolerated dose of atorvastatin and/or simvastatin medical practitioner Patient has proven coronary artery disease (CAD) Patient has proven peripheral artery disease (PAD) Patient has experienced an ischaemic stroke LDL cholesterol has not reduced to less than 1.4 mmol/litre with treatment with the maximum tolerated dose of atorvastatin and/or simvastatin medical practitioner Patient has experienced a recurrent major cardiovascular event (defined as myocardial infarction, ischaemic stroke, coronary revascularisation, hospitalisation for unstable angina) in the last 2 years LDL cholesterol has not reduced to less than 1.0 mmol/litre with treatment with the maximum tolerated dose of atorvastatin and/or simvastatin medical practitioner Simvastatin Tab 10 mg Simvastatin Mylan 90 1.68 Simvastatin Viatris 90 1.68 Tab 20 mg Simvastatin Viatris 90 2.54 Tab 40 mg Simvastatin Viatris 90 4.11 Tab 80 mg Simvastatin Viatris 90 8.81 Atorvastatin Tab 10 mg Lorstat 500 5.16 30 0.31 Tab 20 mg Lorstat 500 8.12 Tab 40 mg Lorstat 500 13.79 Tab 80 mg Lorstat 500 25.39 30 1.52 Pravastatin Tab 10 mg Any 0 Tab 20 mg Clinect 100 7.16 Tab 40 mg Clinect 100 12.25 Resins Cholestyramine Powder for oral liq 4 g Any 0 Colestipol hydrochloride Grans for oral liq 5 g Any 0 Colestyramine Powder for oral suspension 4 g sachet Colestyramine - Mylan 50 61.50 Selective Cholesterol Absorption Inhibitors Ezetimibe Tab 10 mg Ezetimibe Sandoz 30 1.76 Ezetimibe with simvastatin Tab 10 mg with simvastatin 10 mg Zimybe 30 11.86 Tab 10 mg with simvastatin 20 mg Zimybe 30 12.55 Tab 10 mg with simvastatin 40 mg Zimybe 30 11.55 Tab 10 mg with simvastatin 80 mg Zimybe 30 14.27 30 14.27 Other Lipid-Modifying Agents Acipimox Cap 250 mg Any 0 Nitrates Nitrates Glyceryl trinitrate 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 5 118.00 Inj 1 mg per ml, 5 ml ampoule Any 0 1 Inj 1 mg per ml, 50 ml vial Any 0 Oral pump spray, 400 mcg per dose Nitrolingual Pump Spray 250 7.48 Inj 1 mg per ml, 10 ml ampoule Any 0 1 Isosorbide mononitrate Tab 20 mg Ismo 20 100 22.49 Tab long-acting 60 mg Duride 90 13.50 Tab long-acting 40 mg Ismo 40 Retard 30 9.80 Other Cardiac Agents Other Cardiac Agents Levosimendan <range>Levosimendan</range> For use as a bridge to heart transplant, in patients who have been accepted for transplant For the treatment of heart failure following heart transplant medical practitioner For the treatment of severe acute decompensated heart failure that is non-responsive to dobutamine cardiologist intensivist Sympathomimetics Sympathomimetics Dobutamine Inj 12.5 mg per ml, 20 ml ampoule Dobutamine-hameln 5 61.13 Isoprenaline [Isoproterenol] 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 Torbay 10 53.00 Inj 0.5 mg per ml, 5 ml syringe Any 0 Inj 0.5 mg per ml, 10 ml syringe 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 Noradrenaline Medsurge 10 32.78 Inj 0.1 mg per ml, 50 ml syringe Any 0 Phenylephrine hydrochloride Inj 10 mg per ml, 1 ml ampoule Neosynephrine HCL 25 310.42 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 DBL Adrenaline 5 17.78 Aspen Adrenaline 5 4.98 Inj 1 in 10,000, 10 ml ampoule Hospira 5 36.18 Aspen Adrenaline 10 49.00 Dopamine hydrochloride Inj 40 mg per ml, 5 ml ampoule Max Health Ltd 10 46.38 Dopamine Basi 10 46.38 Ephedrine Inj 3 mg per ml, 10 ml syringe Ephedrine Aguettant 10 142.00 Ephedrine Juno 10 1 142.00 Inj 30 mg per ml, 1 ml ampoule Max Health 10 34.31 Vasodilators Vasodilators Milrinone Inj 1 mg per ml, 10 ml ampoule Milrinone-Baxter 10 68.00 Pentoxifylline [Oxpentifylline] Tab 400 mg Any 0 Alprostadil <range>Alprostadil</range> Patient has erectile dysfunction Patient is to receive a penile Doppler ultrasonography medical practitioner Papaverine hydrochloride Inj 30 mg per ml, 1 ml vial Any 0 Inj 12 mg per ml, 10 ml ampoule Hospira 5 257.12 Hydralazine hydrochloride Tab 25 mg <range>Hydralazine hydrochloride - Tab 25 mg</range> For the treatment of refractory hypertension 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 medical practitioner Inj 20 mg ampoule Apresoline 5 25.90 5 25.90 Alprostadil hydrochloride Inj 500 mcg per ml, 1 ml ampoule Prostin VR 5 2030.33 Sodium nitroprusside Inj 50 mg vial Any 0 Nicorandil Tab 10 mg Max Health 60 27.81 Tab 20 mg Max Health 60 35.12 Minoxidil Tab 10 mg Loniten 100 78.40 Diazoxide Inj 15 mg per ml, 20 ml ampoule Any 0 Endothelin Receptor Antagonists Bosentan <range>Bosentan</range> Patient has pulmonary arterial hypertension (PAH)* PAH is in Group 1, 4 or 5 of the WHO (Venice 2003) clinical classifications PAH is in New York Heart Association/World Health Organization (NYHA/WHO) functional class II, III or IV PAH has been confirmed by right heart catheterisation A mean pulmonary artery pressure (PAPm) greater than 20 mmHg (unless peri Fontan repair) A pulmonary capillary wedge pressure (PCWP) less than or equal to 15 mmHg Pulmonary vascular resistance greater than 2 Wood Units or greater than 160 International Units (dyn s cm-5) PAH has been demonstrated to be non-responsive in vasoreactivity assessment using iloprost or nitric oxide, as defined in the 2022 ECS/ERS Guidelines for PAH Patient has not experienced an acceptable response to calcium antagonist treatment, according to a validated risk stratification tool** Patient has PAH other than idiopathic / heritable or drug-associated type Patient is a child with PAH secondary to congenital heart disease or PAH due to idiopathic, congenital or developmental lung disorders including severe chronic neonatal lung disease Patient has palliated single ventricle congenital heart disease and elevated pulmonary pressures or a major complication of the Fontan circulation requiring the minimising of pulmonary/venous filling pressures Bosentan is to be used as PAH monotherapy Patient has experienced intolerable side effects on sildenafil Patient has an absolute contraindication to sildenafil Patient is a child with idiopathic PAH or PAH secondary to congenital heart disease respiratory specialist cardiologist rheumatologist any relevant practitioner 6 Patient has pulmonary arterial hypertension (PAH)* PAH is in Group 1, 4 or 5 of the WHO (Venice 2003) clinical classifications PAH is in New York Heart Association/World Health Organization (NYHA/WHO) functional class II, III or IV PAH has been confirmed by right heart catheterisation A mean pulmonary artery pressure (PAPm) greater than 20 mmHg (unless peri Fontan repair) A pulmonary capillary wedge pressure (PCWP) less than or equal to 15 mmHg Pulmonary vascular resistance greater than 2 Wood Units or greater than 160 International Units (dyn s cm-5) PAH has been demonstrated to be non-responsive in vasoreactivity assessment using iloprost or nitric oxide, as defined in the 2022 ECS/ERS Guidelines for PAH Patient has not experienced an acceptable response to calcium antagonist treatment, according to a validated risk stratification tool** Patient has PAH other than idiopathic / heritable or drug-associated type Patient is a child with PAH secondary to congenital heart disease or PAH due to idiopathic, congenital or developmental lung disorders including severe chronic neonatal lung disease Patient has palliated single ventricle congenital heart disease and elevated pulmonary pressures or a major complication of the Fontan circulation requiring the minimising of pulmonary/venous filling pressures Bosentan is to be used as part of PAH dual therapy Patient has tried a PAH monotherapy (sildenafil) for at least three months and has experienced an inadequate therapeutic response to treatment according to a validated risk stratification tool** Patient is presenting in NYHA/WHO functional class III or IV, and in the opinion of the treating clinician would likely benefit from initial dual therapy respiratory specialist cardiologist rheumatologist any relevant practitioner 6 Patient has pulmonary arterial hypertension (PAH)* PAH is in Group 1, 4 or 5 of the WHO (Venice 2003) clinical classifications PAH is in New York Heart Association/World Health Organization (NYHA/WHO) functional class II, III or IV PAH has been confirmed by right heart catheterisation A mean pulmonary artery pressure (PAPm) greater than 20 mmHg (unless peri Fontan repair) A pulmonary capillary wedge pressure (PCWP) less than or equal to 15 mmHg Pulmonary vascular resistance greater than 2 Wood Units or greater than 160 International Units (dyn s cm-5) PAH has been demonstrated to be non-responsive in vasoreactivity assessment using iloprost or nitric oxide, as defined in the 2022 ECS/ERS Guidelines for PAH Patient has not experienced an acceptable response to calcium antagonist treatment, according to a validated risk stratification tool** Patient has PAH other than idiopathic / heritable or drug-associated type Patient is a child with PAH secondary to congenital heart disease or PAH due to idiopathic, congenital or developmental lung disorders including severe chronic neonatal lung disease Patient has palliated single ventricle congenital heart disease and elevated pulmonary pressures or a major complication of the Fontan circulation requiring the minimising of pulmonary/venous filling pressures Bosentan is to be used as part of PAH triple therapy Patient is on the lung transplant list Patient is presenting in NYHA/WHO functional class IV Patient has tried PAH dual therapy for at least three months and has not experienced an acceptable response to treatment according to a validated risk stratification tool** Patient does not have major life-threatening comorbidities and triple therapy is not being used in a palliative scenario respiratory specialist cardiologist rheumatologist any relevant practitioner 6 Patient is continuing to derive benefit from bosentan treatment according to a validated PAH risk stratification tool** respiratory specialist cardiologist rheumatologist any relevant practitioner 2

** the requirement to use a validated risk stratification tool to determine insufficient response applies to adults. Determining insufficient response in children does not require use of a validated PAH risk stratification tool, where currently no such validated tools exist for PAH risk stratification in children.

 Ambrisentan <range>Ambrisentan</range> Patient has pulmonary arterial hypertension (PAH) PAH is in Group 1, 4 or 5 of the WHO (Venice 2003) clinical classifications PAH is in New York Heart Association/World Health Organization (NYHA/WHO) functional class II, III or IV PAH has been confirmed by right heart catheterisation A mean pulmonary artery pressure (PAPm) greater than 20 mmHg (unless peri Fontan repair) A pulmonary capillary wedge pressure (PCWP) less than or equal to 15 mmHg Pulmonary vascular resistance greater than 2 Wood Units or greater than 160 International Units (dyn s cm-5) PAH has been demonstrated to be non-responsive in vasoreactivity assessment using iloprost or nitric oxide, as defined in the 2022 ECS/ERS Guidelines for PAH Patient has not experienced an acceptable response to calcium antagonist treatment, according to a validated risk stratification tool** Patient has PAH other than idiopathic / heritable or drug-associated type Patient is a child with PAH secondary to congenital heart disease or PAH due to idiopathic, congenital or developmental lung disorders including chronic neonatal lung disease Patient has palliated single ventricle congenital heart disease and elevated pulmonary pressures or a major complication of the Fontan circulation requiring the minimising of pulmonary/venous filling pressures Ambrisentan is to be used as PAH monotherapy Patient has experienced intolerable side effects with both sildenafil and bosentan Patient has an absolute contraindication to sildenafil and an absolute or relative contraindication to bosentan (e.g. due to current use of a combined oral contraceptive or liver disease) Patient is a child with idiopathic PAH or PAH secondary to congenital heart disease respiratory specialist cardiologist rheumatologist any relevant practitioner 6 Patient has pulmonary arterial hypertension (PAH) PAH is in Group 1, 4 or 5 of the WHO (Venice 2003) clinical classifications PAH is in New York Heart Association/World Health Organization (NYHA/WHO) functional class II, III or IV PAH has been confirmed by right heart catheterisation A mean pulmonary artery pressure (PAPm) greater than 20 mmHg (unless peri Fontan repair) A pulmonary capillary wedge pressure (PCWP) less than or equal to 15 mmHg Pulmonary vascular resistance greater than 2 Wood Units or greater than 160 International Units (dyn s cm-5) PAH has been demonstrated to be non-responsive in vasoreactivity assessment using iloprost or nitric oxide, as defined in the 2022 ECS/ERS Guidelines for PAH Patient has not experienced an acceptable response to calcium antagonist treatment, according to a validated risk stratification tool** Patient has PAH other than idiopathic / heritable or drug-associated type Patient is a child with PAH secondary to congenital heart disease or PAH due to idiopathic, congenital or developmental lung disorders including chronic neonatal lung disease Patient has palliated single ventricle congenital heart disease and elevated pulmonary pressures or a major complication of the Fontan circulation requiring the minimising of pulmonary/venous filling pressures Ambrisentan is to be used as PAH dual therapy Patient has tried bosentan (either as PAH monotherapy, or PAH dual therapy with sildenafil) for at least three months and has not experienced an acceptable response to treatment according to a validated risk stratification tool** Patient has experienced intolerable side effects on bosentan Patient has an absolute or relative contraindication to bosentan (e.g. due to current use of a combined oral contraceptive or liver disease) Patient is presenting in NYHA/WHO functional class III or IV, and would benefit from initial dual therapy in the opinion of the treating clinician and has an absolute or relative contraindication to bosentan (eg. due to current liver disease or use of a combined oral contraceptive) respiratory specialist cardiologist rheumatologist any relevant practitioner 6 Patient has pulmonary arterial hypertension (PAH) PAH is in Group 1, 4 or 5 of the WHO (Venice 2003) clinical classifications PAH is in New York Heart Association/World Health Organization (NYHA/WHO) functional class II, III or IV PAH has been confirmed by right heart catheterisation A mean pulmonary artery pressure (PAPm) greater than 20 mmHg (unless peri Fontan repair) A pulmonary capillary wedge pressure (PCWP) less than or equal to 15 mmHg Pulmonary vascular resistance greater than 2 Wood Units or greater than 160 International Units (dyn s cm-5) PAH has been demonstrated to be non-responsive in vasoreactivity assessment using iloprost or nitric oxide, as defined in the 2022 ECS/ERS Guidelines for PAH Patient has not experienced an acceptable response to calcium antagonist treatment, according to a validated risk stratification tool** Patient has PAH other than idiopathic / heritable or drug-associated type Patient is a child with PAH secondary to congenital heart disease or PAH due to idiopathic, congenital or developmental lung disorders including chronic neonatal lung disease Patient has palliated single ventricle congenital heart disease and elevated pulmonary pressures or a major complication of the Fontan circulation requiring the minimising of pulmonary/venous filling pressures Ambrisentan is to be used as PAH triple therapy Patient is on the lung transplant list Patient is presenting in NYHA/WHO functional class IV Patient has an absolute or relative contraindication to bosentan (e.g. due to current use of a combined oral contraceptive or liver disease) Patient has tried PAH dual therapy for at least three months and remains in an unacceptable risk category according to a validated risk stratification tool** Patient does not have major life-threatening comorbidities and triple therapy is not being used in a palliative scenario respiratory specialist cardiologist rheumatologist any relevant practitioner 6 The patient is continuing to derive benefit from ambrisentan treatment according to a validated PAH risk stratification tool** respiratory specialist cardiologist rheumatologist any relevant practitioner 2

** the requirement to use a validated risk stratification tool to determine insufficient response applies to adults. Determining insufficient response in children does not require use of a validated PAH risk stratification tool, where currently no such validated tools exist for PAH risk stratification in children.

 Phosphodiesterase Type 5 Inhibitors Sildenafil <range>Sildenafil (Vedafil)</range> Patient has Raynaud's phenomenon Patient has severe digital ischaemia (defined as severe pain requiring hospital admission or with a high likelihood of digital ulceration; digital ulcers; or gangrene) Patient is following lifestyle management (proper body insulation, avoidance of cold exposure, smoking cessation support, avoidance of sympathomimetic drugs) Patient has persisting severe symptoms despite treatment with calcium channel blockers and nitrates (unless contraindicated or not tolerated) medical practitioner Patient has pulmonary arterial hypertension (PAH)* PAH is in Group 1, 4 or 5 of the WHO (Venice 2003) clinical classifications PAH is in New York Heart Association/World Health Organization (NYHA/WHO) functional class II, III or IV PAH is confirmed by right heart catheterisation A mean pulmonary artery pressure (PAPm) of greater than 20 mmHg A pulmonary capillary wedge pressure (PCWP) that is less than or equal to 15 mmHg Pulmonary vascular resistance (PVR) of at least 2 Wood Units or at least 160 International Units (dyn s cm-5) PAH is non-responsive in vasoreactivity assessment using iloprost or nitric oxide, as defined in the 2022 ECS/ERS Guidelines for PAH Patient has not experienced an acceptable response to calcium antagonist treatment, according to a validated risk stratification tool** Patient has PAH other than idiopathic / heritable or drug-associated type Patient is a child with PAH secondary to congenital heart disease or PAH due to idiopathic, congenital or developmental lung disorders including severe chronic neonatal lung disease Patient has palliated single ventricle congenital heart disease and elevated pulmonary pressures or a major complication of the Fontan circulation requiring the minimising of pulmonary/venous filling pressures respiratory specialist cardiologist rheumatologist any relevant practitioner For use in weaning patients from inhaled nitric oxide For perioperative use in cardiac surgery patients For use in intensive care as an alternative to nitric oxide For use in the treatment of erectile dysfunction secondary to spinal cord injury in patients being treated in a spinal unit medical practitioner For use in the treatment of pulmonary hypertension in infants or children being treated in paediatric intensive care units and neonatal intensive care units when the enteral route is not accessible For perioperative use following cardiac surgery For use in persistent pulmonary hypertension of the newborn (PPHN) For use in congenital diaphragmatic hernia medical practitioner

** the requirement to use a validated risk stratification tool to determine insufficient response applies to adults. Determining insufficient response in children does not require use of a validated PAH risk stratification tool, where currently no such validated tools exist for PAH risk stratification in children.

 Prostacyclin Analogues Epoprostenol <range>Epoprostenol</range> Patient has pulmonary arterial hypertension (PAH) PAH is in Group 1, 4 or 5 of the WHO (Venice 2003) clinical classifications PAH is in New York Heart Association/World Health Organization (NYHA/WHO) functional class III or IV PAH has been confirmed by right heart catheterisation A mean pulmonary artery pressure (PAPm) greater than 20 mmHg (unless peri Fontan repair) A pulmonary capillary wedge pressure (PCWP) less than or equal to 15 mmHg A pulmonary vascular resistance greater than 2 Wood Units or greater than 160 International Units (dyn s cm-5) PAH has been demonstrated to be non-responsive in vasoreactivity assessment using iloprost or nitric oxide, as defined in the 2022 ECS/ERS Guidelines for PAH Patient has not experienced an acceptable response to calcium antagonist treatment, according to a validated risk stratification tool** Patient has PAH other than idiopathic / heritable or drug-associated type Patient is a child with PAH secondary to congenital heart disease or PAH due to idiopathic, congenital or developmental lung disorders including severe chronic neonatal lung disease Patient has palliated single ventricle congenital heart disease and elevated pulmonary pressures or a major complication of the Fontan circulation requiring the minimising of pulmonary/venous filling pressures Epoprostenol is to be used as part of PAH dual therapy with either sildenafil or an endothelin receptor antagonist Patient is presenting in NYHA/WHO functional class IV Patient has tried a PAH monotherapy for at least three months and remains in an unacceptable risk category according to a validated risk stratification tool respiratory specialist cardiologist rheumatologist any relevant practitioner 6 Patient has pulmonary arterial hypertension (PAH) PAH is in Group 1, 4 or 5 of the WHO (Venice 2003) clinical classifications PAH is in New York Heart Association/World Health Organization (NYHA/WHO) functional class III or IV PAH has been confirmed by right heart catheterisation A mean pulmonary artery pressure (PAPm) greater than 20 mmHg (unless peri Fontan repair) A pulmonary capillary wedge pressure (PCWP) less than or equal to 15 mmHg A pulmonary vascular resistance greater than 2 Wood Units or greater than 160 International Units (dyn s cm-5) PAH has been demonstrated to be non-responsive in vasoreactivity assessment using iloprost or nitric oxide, as defined in the 2022 ECS/ERS Guidelines for PAH Patient has not experienced an acceptable response to calcium antagonist treatment, according to a validated risk stratification tool** Patient has PAH other than idiopathic / heritable or drug-associated type Patient is a child with PAH secondary to congenital heart disease or PAH due to idiopathic, congenital or developmental lung disorders including severe chronic neonatal lung disease Patient has palliated single ventricle congenital heart disease and elevated pulmonary pressures or a major complication of the Fontan circulation requiring the minimising of pulmonary/venous filling pressures Epoprostenol is to be used as PAH triple therapy Patient is on the lung transplant list Patient is presenting in NYHA/WHO functional class IV Patient has tried PAH dual therapy for at least three months and has not experienced an acceptable response to treatment according to a validated risk stratification tool Patient does not have major life-threatening comorbidities and triple therapy is not being used in a palliative scenario respiratory specialist cardiologist rheumatologist any relevant practitioner 6 Patient is continuing to derive benefit from epoprostenol treatment according to a validated PAH risk stratification tool respiratory specialist cardiologist rheumatologist any relevant practitioner 2

** the requirement to use a validated risk stratification tool to determine insufficient response applies to adults. Determining insufficient response in children does not require use of a validated PAH risk stratification tool, where currently no such validated tools exist for PAH risk stratification in children.

 Iloprost Inj 50 mcg in 0.5 ml ampoule Ilomedin 5 380.00 Nebuliser soln 10 mcg per ml, 2 ml <range>Iloprost</range> Patient has pulmonary arterial hypertension (PAH) PAH is in Group 1, 4 or 5 of the WHO (Venice 2003) clinical classifications PAH is in New York Heart Association/World Health Organization (NYHA/WHO) functional class II, III or IV PAH has been confirmed by right heart catheterisation A mean pulmonary artery pressure (PAPm) greater than 20 mmHg (unless peri Fontan repair) A pulmonary capillary wedge pressure (PCWP) less than or equal to 15 mmHg A pulmonary vascular resistance greater than 2 Wood Units or greater than 160 International Units (dyn s cm-5) PAH has been demonstrated to be non-responsive in vasoreactivity assessment using iloprost or nitric oxide, as defined in the 2022 ECS/ERS Guidelines for PAH Patient has not experienced an acceptable response to calcium antagonist treatment, according to a validated risk stratification tool** Patient has PAH other than idiopathic / heritable or drug-associated type Patient is a child with PAH secondary to congenital heart disease or PAH due to idiopathic, congenital or developmental lung disorders including severe chronic neonatal lung disease Patient has palliated single ventricle congenital heart disease and elevated pulmonary pressures or a major complication of the Fontan circulation requiring the minimising of pulmonary/venous filling pressures Iloprost is to be used as PAH monotherapy Patient has experienced intolerable side effects on sildenafil and both the funded endothelin receptor antagonists (i.e. both bosentan and ambrisentan) Patient has an absolute contraindication to sildenafil and an absolute or relative contraindication to endothelin receptor antagonists respiratory specialist cardiologist rheumatologist any relevant practitioner 6 Patient has pulmonary arterial hypertension (PAH) PAH is in Group 1, 4 or 5 of the WHO (Venice 2003) clinical classifications PAH is in New York Heart Association/World Health Organization (NYHA/WHO) functional class II, III or IV PAH has been confirmed by right heart catheterisation A mean pulmonary artery pressure (PAPm) greater than 20 mmHg (unless peri Fontan repair) A pulmonary capillary wedge pressure (PCWP) less than or equal to 15 mmHg A pulmonary vascular resistance greater than 2 Wood Units or greater than 160 International Units (dyn s cm-5) PAH has been demonstrated to be non-responsive in vasoreactivity assessment using iloprost or nitric oxide, as defined in the 2022 ECS/ERS Guidelines for PAH Patient has not experienced an acceptable response to calcium antagonist treatment, according to a validated risk stratification tool** Patient has PAH other than idiopathic / heritable or drug-associated type Patient is a child with PAH secondary to congenital heart disease or PAH due to idiopathic, congenital or developmental lung disorders including severe chronic neonatal lung disease Patient has palliated single ventricle congenital heart disease and elevated pulmonary pressures or a major complication of the Fontan circulation requiring the minimising of pulmonary/venous filling pressures Iloprost is to be used as PAH dual therapy with either sildenafil or an endothelin receptor antagonist Patient has an absolute contraindication to or has experienced intolerable side effects on sildenafil Patient has an absolute or relative contraindication to or experienced intolerable side effects with a funded endothelin receptor antagonist Patient has tried a PAH monotherapy for at least three months and remains in an unacceptable risk category according to a validated risk stratification tool** Patient is presenting in NYHA/WHO functional class III or IV, and in the opinion of the treating clinician would benefit from initial dual therapy respiratory specialist cardiologist rheumatologist any relevant practitioner 6 Patient has pulmonary arterial hypertension (PAH) PAH is in Group 1, 4 or 5 of the WHO (Venice 2003) clinical classifications PAH is in New York Heart Association/World Health Organization (NYHA/WHO) functional class II, III or IV PAH has been confirmed by right heart catheterisation A mean pulmonary artery pressure (PAPm) greater than 20 mmHg (unless peri Fontan repair) A pulmonary capillary wedge pressure (PCWP) less than or equal to 15 mmHg A pulmonary vascular resistance greater than 2 Wood Units or greater than 160 International Units (dyn s cm-5) PAH has been demonstrated to be non-responsive in vasoreactivity assessment using iloprost or nitric oxide, as defined in the 2022 ECS/ERS Guidelines for PAH Patient has not experienced an acceptable response to calcium antagonist treatment, according to a validated risk stratification tool** Patient has PAH other than idiopathic / heritable or drug-associated type Patient is a child with PAH secondary to congenital heart disease or PAH due to idiopathic, congenital or developmental lung disorders including severe chronic neonatal lung disease Patient has palliated single ventricle congenital heart disease and elevated pulmonary pressures or a major complication of the Fontan circulation requiring the minimising of pulmonary/venous filling pressures Iloprost is to be used as PAH triple therapy Patient is on the lung transplant list Patient is presenting in NYHA/WHO functional class IV Patient has tried PAH dual therapy for at least three months and has not experienced an acceptable response to treatment according to a validated risk stratification tool** Patient does not have major life-threatening comorbidities and triple therapy is not being used in a palliative scenario respiratory specialist cardiologist rheumatologist any relevant practitioner 6 Patient is continuing to derive benefit from iloprost treatment according to a validated PAH risk stratification tool respiratory specialist cardiologist rheumatologist any relevant practitioner 2

** the requirement to use a validated risk stratification tool to determine insufficient response applies to adults. Determining insufficient response in children does not require use of a validated PAH risk stratification tool, where currently no such validated tools exist for PAH risk stratification in children.

 Dermatologicals Anti-Infective Preparations Antibacterials Mupirocin Oint 2% Any 0 Mafenide acetate <range>Mafenide acetate</range> For the treatment of burns patients medical practitioner Sodium fusidate [Fusidic acid] Crm 2% Foban 5 1.69 Oint 2% Foban 5 1.69 Hydrogen peroxide Soln 3% (10 vol) Any 0 Crm 1% Crystaderm 15 4.89 Sulfadiazine silver Crm 1% Flamazine 50 10.80 Antifungals Amorolfine Nail soln 5% MycoNail 5 21.87 Ciclopirox olamine Nail soln 8% Any 0 Soln 1%

For continuation only

Any 0 Econazole nitrate Crm 1% Pevaryl 20 8.04 Foaming soln 1% Any 0 Miconazole nitrate Lotn 2%

For continuation only

Any 0 Tinc 2% Any 0 Crm 2% Multichem 15 0.90 Nystatin Crm 100,000 u per g Any 0 Metronidazole Gel 0.75% Any 0 Clotrimazole Soln 1%

For continuation only

Any 0 Crm 1% Clomazol 20 1.15 Ketoconazole Shampoo 2% Sebizole 100 4.09 Antiparasitics Dimethicone Lotn 4% healthE Dimethicone 4% Lotion 200 4.60 Malathion [Maldison] Lotn 0.5% Any 0 Shampoo 1% Any 0 Phenothrin Shampoo 0.5% Any 0 Permethrin Lotn 5% A-Scabies 30 4.28 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 Oratane 120 18.75 Cap 20 mg Oratane 120 26.73 Cap 5 mg Oratane 60 11.26 Tretinoin Crm 0.05% ReTrieve 50 16.82 Antipruritic Preparations Antipruritic Preparations Crotamiton Crm 10% Itch-Soothe 20 3.49 Calamine Crm, aqueous, BP healthE Calamine Aqueous 100 3.45 Barrier Creams and Emollients Barrier Creams Dimethicone Crm 5% tube healthE Dimethicone 5% 100 1.52 Crm 5% pump bottle healthE Dimethicone 5% 460 4.30 Hydralock 460 4.14 Crm 10% pump bottle healthE Dimethicone 10% 460 4.52 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

Note: DV limit applies to the pack sizes of 30 g or less.

healthE 20 1.26 Crm Orion 20 1.63 Oint

Note: DV limit applies to the pack sizes of greater than 30 g.

Evara 500 4.25 Emollients Cetomacrogol with glycerol Crm 90% with glycerol 10%,

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

healthE 100 1.65 Crm 90% with glycerol 10%

Note: DV limit applies to the pack sizes of greater than 100 g.

Evara 460 1.92 920 3.25 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% healthE Urea Cream 100 1.37 Wool fat Crm Any 0 Aqueous cream Crm 500 g

Note: DV limit applies to the pack sizes of greater than 100 g.

Evara 500 1.65 Crm 100 g

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

Evara 100 1.25 Emulsifying ointment Oint BP

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

Jaychem 100 2.30 Oint BP, 500 g

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

Evara Emulsifying Ointment 500 3.13 Oil in water emulsion Crm, 500 g

Note: DV limit applies to the pack sizes of greater than 100 g.

Fatty Emulsion Cream (Evara) 500 2.10 Crm, 100 g

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

Fatty Emulsion Cream (Evara) 100 1.43 Paraffin Oint liquid paraffin 50% with white soft paraffin 50%

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

healthE 100 1.78 White Soft Liquid Paraffin AFT 100 1.84 Yellow soft Any 0 White soft

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

healthE 10 0.79 White soft,

Note: DV limit applies to the pack sizes of 500 g or less and greater than 30 g.

EVARA White Soft Paraffin 450 4.74 Lotn liquid paraffin 85% e.g QV Bath Oil 0 Cetomacrogol Crm BP, 100 g Cetomacrogol Cream AFT 100 0.99 Crm BP, 500 g Cetomacrogol-AFT 500 2.29 Corticosteroids Corticosteroids Betamethasone dipropionate Crm 0.05%

Note: DV limit applies to the pack sizes of greater than 30 g.

Diprosone 50 36.00 Oint 0.05%

Note: DV limit applies to the pack sizes of greater than 30 g.

Diprosone 50 36.00 Clobetasone butyrate Crm 0.05% Any 0 Diflucortolone valerate

For continuation only

Crm 0.1% Any 0 Fatty oint 0.1% Any 0 Hydrocortisone and paraffin liquid and lanolin Lotn 1% with paraffin liquid 15.9% and lanolin 0.6% DP Lotn HC 250 12.83 Hydrocortisone Crm 1%, 500 g

Note: DV limit applies to the pack sizes of greater than 100 g.

Noumed 500 20.40 Crm 1%, 30 g

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

Ethics 30 1.75 Triamcinolone acetonide Crm 0.02% Aristocort 100 6.49 Oint 0.02% Aristocort 100 6.54 Clobetasol propionate Crm 0.05% Dermol 30 3.75 Oint 0.05% Dermol 30 3.68 Hydrocortisone butyrate Crm 0.1% Locoid Lipocream 100 4.85 Oint 0.1% Locoid 100 10.28 Milky emul 0.1% Locoid Crelo 100 12.33 Methylprednisolone aceponate Crm 0.1% Advantan 15 4.95 Oint 0.1% Advantan 15 4.95 Betamethasone valerate Crm 0.1% Beta Cream 50 5.85 Lotn 0.1% Betnovate 50 30.00 Oint 0.1% Beta Ointment 50 7.90 Mometasone furoate Crm 0.1% Elocon Alcohol Free 15 2.25 50 3.50 Oint 0.1% Elocon 15 2.25 50 3.50 Lotn 0.1% Elocon 30 4.99 Corticosteroids with Anti-Infective Agents Betamethasone valerate with clioquinol <range>Betamethasone valerate with clioquinol</range> For the treatment of intertrigo For continuation use medical practitioner Betamethasone valerate with sodium fusidate [Fusidic acid] Crm 0.1% with sodium fusidate (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 Oint 1% with natamycin 1% and neomycin sulphate 0.5% Pimafucort 15 4.34 Hydrocortisone with miconazole Crm 1% with miconazole nitrate 2% Micreme H 15 2.85 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 Pimecrolimus <range>Pimecrolimus</range> Patient has atopic dermatitis on the eyelid Patient has at least one of the following contraindications to topical corticosteroids: periorificial dermatitis, rosacea, documented epidermal atrophy, documented allergy to topical corticosteroids, cataracts, glaucoma, or raised intraocular pressure dermatologist paediatrician ophthalmologist Tacrolimus Oint 0.1% <range>Tacrolimus Ointment</range> Patient has atopic dermatitis on the face Patient has at least one of the following contraindications to topical corticosteroids: periorificial dermatitis, rosacea, documented epidermal atrophy or documented allergy to topical corticosteroids dermatologist paediatrician Calcipotriol Oint 50 mcg per g Daivonex 120 40.00 Pine tar with trolamine laurilsulfate and fluorescein Soln 2.3% with trolamine laurilsulfate and fluorescein sodium Pinetarsol 500 5.41 Acitretin Cap 10 mg Novatretin 60 26.20 Cap 25 mg Novatretin 60 57.37 Betamethasone dipropionate with calcipotriol Oint 500 mcg with calcipotriol 50 mcg per g Daivobet 30 14.31 Gel 500 mcg with calcipotriol 50 mcg per g Daivobet 60 40.92 Foam spray 500 mcg with calcipotriol 50 mcg per g Enstilar 60 59.95 Scalp Preparations Scalp Preparations Clobetasol propionate Scalp app 0.05% Dermol 30 6.90 Hydrocortisone butyrate Scalp lotn 0.1% Locoid 100 6.57 Betamethasone valerate Scalp app 0.1% Beta Scalp 100 12.95 Wart Preparations Wart Preparations Silver nitrate Sticks with applicator Any 0 Podophyllotoxin Soln 0.5% Condyline 3 33.60 3.5 33.60 Other Skin Preparations Other Skin Preparations Diphemanil metilsulfate Powder 2% Any 0 Sunscreen, proprietary Lotn Marine Blue Lotion SPF 50+ 200 6.50 Imiquimod Crm 5%, 250 mg sachet Perrigo 24 21.72 Padagis 24 21.72 Antineoplastics Methyl aminolevulinate hydrochloride <range>Methyl aminolevulinate hydrochloride</range> No patient criteria dermatologist plastic surgeon Fluorouracil sodium Crm 5% Efudix 20 5.56 Wound Management Products Calcium gluconate Gel 2.5% e.g. Orion 0 1 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 6.89 Nystatin Vaginal crm 100,000 u per 5 g with applicator(s) Nilstat 75 5.70 Clotrimazole Vaginal crm 1% with applicator Clomazol 35 4.20 Vaginal crm 2% with applicator Clomazol 20 4.60 Chlorhexidine gluconate Crm 1% Any 0 Lotn 1% Any 0 Contraceptives Antiandrogen Oral Contraceptives Cyproterone acetate with ethinyloestradiol Tab 2 mg with ethinyloestradiol 35 mcg and 7 inert tablets Ginet 168 5.08 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 Tab 35 mcg with norethisterone 1 mg and 7 inert tab Brevinor 1/28 84 14.09 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 20 mcg with levonorgestrel 100 mcg and 7 inert tablets Lo-Oralcon 20 ED 84 2.00 Tab 30 mcg with levonorgestrel 150 mcg and 7 inert tablets Oralcon 30 ED 84 2.30 Contraceptive Devices Intra-uterine device IUD 29.1 mm length x 23.2 mm width Choice 380 7med Nsha Silver/copper Short 1 29.80 IUD 33.6 mm length x 29.9 mm width TCu 380 Plus Normal 1 26.80 IUD 35.5 mm length x 19.6 mm width Cu 375 Standard 1 33.00 Emergency Contraception Levonorgestrel Tab 1.5 mg Levonorgestrel BNM 1 1.75 Levonorgestrel -1 (Lupin) 1 1.31 Progestogen-Only Contraceptives Desogestrel Tab 75 mcg Cerazette 84 24.50 Medroxyprogesterone acetate Inj 150 mg per ml, 1 ml syringe Depo-Provera 1 10.56 Norethisterone Tab 350 mcg Noriday 28 84 13.23 Noriday 84 12.25 Levonorgestrel Intra-uterine device 52 mg Mirena 1 269.50 Tab 30 mcg Microlut 112 22.00 Intra-uterine device 13.5 mg Jaydess 1 215.60 Subdermal implant (2 x 75 mg rods) Jadelle 2 106.92 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 41.47 Oxytocin Inj 10 iu per ml, 1 ml ampoule Oxytocin BNM 5 7.18 Inj 5 iu per ml, 1 ml ampoule Oxytocin BNM 5 5.98 Dinoprostone Pessaries 10 mg Any 0 Vaginal gel 1 mg in 3 g Prostin E2 1 65.39 Vaginal gel 2 mg in 3 g Prostin E2 1 82.33 Ergometrine maleate Inj 500 mcg per ml, 1 ml ampoule DBL Ergometrine 5 160.00 Tocolytics Progesterone Cap 100 mg Utrogestan 30 14.85 Terbutaline <range>Terbutaline</range> No patient criteria obstetrician Oestrogens Oestrogens Oestriol Crm 1 mg per g with applicator Ovestin 15 6.95 Pessaries 500 mcg Ovestin 15 7.55 Urologicals 5-Alpha Reductase Inhibitors Finasteride <range>Finasteride</range> Patient has symptomatic benign prostatic hyperplasia The patient is intolerant of non-selective alpha blockers or these are contraindicated Symptoms are not adequately controlled with non-selective alpha blockers medical practitioner Alpha-1A Adrenoceptor Blockers Tamsulosin hydrochloride <range>Tamsulosin</range> Patient has symptomatic benign prostatic hyperplasia The patient is intolerant of non-selective alpha blockers or these are contraindicated medical practitioner Urinary Alkalisers Sodium citro-tartrate Grans eff 4 g sachets Ural 28 3.50 Potassium citrate <range>Potassium citrate</range> The patient has recurrent calcium oxalate urolithiasis The patient has had more than two renal calculi in the two years prior to the application medical practitioner Urinary Antispasmodics Oxybutynin Oral liq 5 mg per 5 ml Any 0 Tab 5 mg Alchemy Oxybutynin 100 5.42 Solifenacin succinate Tab 5 mg Solifenacin succinate Max Health 30 1.95 Tab 10 mg Solifenacin succinate Max Health 30 3.53 Hormone Preparations Anabolic Agents Anabolic Agents Oxandrolone Tab 2.5 mg <range>Oxandrolone - Tab 2.5 mg</range> For the treatment of burns patients medical practitioner 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 Siterone 50 17.05 Tab 100 mg Siterone 50 31.00 Testosterone Gel (transdermal) 16.2 mg per g, 88 g Testogel 60 52.00 Testosterone cipionate Inj 100 mg per ml, 10 ml vial Depo-Testosterone 1 97.75 Testosterone undecanoate Cap 40 mg

For continuation only

Any 0 Inj 250 mg per ml, 4 ml vial Reandron 1000 1 86.00 Calcium Homeostasis Calcium Homeostasis Cinacalcet <range>Cinacalcet</range> The patient has been diagnosed with a parathyroid carcinoma (see Note) The patient has persistent hypercalcaemia (serum calcium greater than or equal to 3 mmol/L) despite previous first-line treatments including sodium thiosulfate (where appropriate) and bisphosphonates The patient is symptomatic The patient has been diagnosed with calciphylaxis (calcific uraemic arteriolopathy) The patient has symptomatic (e.g. painful skin ulcers) hypercalcaemia (serum calcium greater than or equal to 3 mmol/L) The patient's condition has not responded to previous first-line treatments including bisphosphonates and sodium thiosulfate nephrologist endocrinologist 6 The patient's serum calcium level has fallen to < 3mmol/L The patient has experienced clinically significant symptom improvement nephrologist endocrinologist 1

This does not include parathyroid adenomas unless these have become malignant.

 Patient has primary hyperparathyroidism Patient has hypercalcaemia of more than 3 mmol/L with or without symptoms Patient has hypercalcaemia of more than 2.85 mmol/L with symptoms Surgery is not feasible or has failed Patient has other comorbidities, severe bone pain, or calciphylaxis medical practitioner 1 Patient has tertiary hyperparathyroidism and markedly elevated parathyroid hormone (PTH) with hypercalcaemia Patient has symptomatic secondary hyperparathyroidism and elevated PTH Patient is on renal replacement therapy Residual parathyroid tissue has not been localised despite repeat unsuccessful parathyroid explorations Parathyroid tissue is surgically inaccessible Parathyroid surgery is not feasible medical practitioner 6 The patient has had a kidney transplant, and following a treatment free interval of at least 12 weeks a clinically acceptable parathyroid hormone (PTH) level to support ongoing cessation of treatment has not been reached The patient has not received a kidney transplant and trial of withdrawal of cinacalcet is clinically inappropriate medical practitioner 12 Zoledronic acid Inj 4 mg per 5 ml, vial Zoledronic acid Viatris 1 15.65 Zoledronic Acid Injection Mylan 1 15.65 Calcitonin Inj 100 iu per ml, 1 ml ampoule Miacalcic 5 121.00 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 52.54 Inj 125 mg vial Solu-Medrol Act-O-Vial 1 34.10 Inj 40 mg vial Solu-Medrol Act-O-Vial 1 22.30 Inj 500 mg vial Solu-Medrol Act-O-Vial 1 43.01 Tab 100 mg Medrol 20 223.10 Tab 4 mg Medrol 100 112.00 Prednisolone Enema 200 mcg per ml, 100 ml Any 0 Oral liq 5 mg per ml Redipred 30 6.00 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 3.96 Triamcinolone acetonide Inj 10 mg per ml, 1 ml ampoule Kenacort-A 10 5 21.42 Inj 40 mg per ml, 1 ml ampoule Kenacort-A 40 5 52.63 Fludrocortisone acetate Tab 100 mcg Florinef 100 8.05 Dexamethasone Oral liq 1 mg per ml Biomed 25 53.86 Tab 4 mg Dexmethsone 30 3.18 Tab 0.5 mg Dexmethsone 30 1.80 Methylprednisolone acetate Inj 40 mg per ml, 1 ml vial Depo-Medrol 5 47.06 Dexamethasone phosphate Inj 4 mg per ml, 1 ml ampoule Dexamethasone Medsurge 10 6.88 Inj 4 mg per ml, 2 ml ampoule Dexamethasone Medsurge 10 10.98 Prednisone Tab 1 mg Prednisone Clinect 500 18.58 Tab 2.5 mg Prednisone Clinect 500 21.04 Tab 5 mg Prednisone Clinect 500 19.30 Tab 20 mg Prednisone Clinect 500 50.51 Hormone Replacement Therapy Oestrogens Oestradiol Patch 100 mcg per day Estradot 8 16.18 Estradiol TDP Mylan 8 10.59 Patch 25 mcg per day Estradot 8 16.23 Estradiol TDP Mylan 8 8.89 Patch 50 mcg per day Estradot 8 15.79 Estradiol TDP Mylan 8 9.26 Tab 1 mg Any 0 Patch 75 mcg per day Estradot 8 16.53 Estradiol TDP Mylan 8 10.33 Gel (transdermal) 0.06% (750 mcg/actuation) Estrogel 80 14.25 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 7.54 Tab 5 mg Provera 100 100 23.15 Tab 10 mg Provera 30 30 11.10 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 Clomifene citrate Tab 50 mg Mylan Clomiphen 10 29.84 Cabergoline <range>Cabergoline</range> Inhibition of lactation Patient has hyperprolactinemia Patient has acromegaly medical practitioner

Indication marked with * is an unapproved indication.

 Other Oestrogen Preparations Other Oestrogen Preparations Oestradiol Implant 50 mg Any 0 Oestriol Tab 2 mg Ovestin 30 7.70 Other Progestogen Preparations Other Progestogen Preparations Medroxyprogesterone Tab 100 mg Provera HD 100 153.60 Norethisterone Tab 5 mg Primolut N 30 5.49 Pituitary and Hypothalamic Hormones and Analogues Pituitary and Hypothalamic Hormones and Analogues Corticorelin (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 1 86.25 UK Synacthen 1 86.25 Inj 1 mg per ml, 1 ml ampoule Synacthen Depot 1 690.00 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, syringe Zoladex 1 138.23 Implant 3.6 mg, syringe Zoladex 1 66.48 Leuprorelin acetate Inj 3.75 mg prefilled dual chamber syringe Lucrin Depot 1-month 1 221.60 Inj 11.25 mg prefilled dual chamber syringe Lucrin Depot 3-month 1 591.68 Gonadotrophins Choriogonadotropin alfa Inj 250 mcg in 0.5 ml syringe Any 0 Growth Hormone Somatropin <range>Somatropin</range> 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) 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) A current bone age is < 14 years (female patients) or < 16 years (male patients) 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 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 Appropriate imaging of the pituitary gland has been obtained endocrinologist paediatric endocrinologist 12 A current bone age is 14 years or under (female patients) or 16 years or under (male patients) Height velocity is greater than or equal to 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) Height velocity is greater than or equal to 2.0 cm per year, as calculated over 6 months No serious adverse effect that the patients specialist considers is likely to be attributable to growth hormone treatment has occurred No malignancy has developed since starting growth hormone endocrinologist paediatric endocrinologist 12 The patient has a post-natal genotype confirming Turner Syndrome Height velocity is < 25th percentile over 6-12 months using the standards of Tanner and Davies (1985) A current bone age is < 14 years endocrinologist paediatric endocrinologist 12 Height velocity greater than or equal to 50th percentile for age (while on growth hormone calculated over 6 to 12 months using the Ranke’s Turner Syndrome growth velocity charts) Height velocity is greater than or equal to 2 cm per year, calculated over six months A current bone age is 14 years or under No serious adverse effect that the specialist considers is likely to be attributable to growth hormone treatment has occurred No malignancy has developed since starting growth hormone endocrinologist paediatric endocrinologist 12 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 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) A current bone age is < 14 years (female patients) or < 16 years (male patients) 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 endocrinologist paediatric endocrinologist 12 Height velocity is greater than or equal to 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) Height velocity is greater than or equal to 2 cm per year as calculated over six months Current bone age is 14 years or under (female patients) or 16 years or under (male patients) No serious adverse effect that the patient’s specialist considers is likely to be attributable to growth hormone treatment has occurred endocrinologist paediatric endocrinologist 12 The patient’s height is more than 2 standard deviations below the mean 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) A current bone age is to 14 years or under (female patients) or to 16 years or under (male patients) The patient is metabolically stable, has no evidence of metabolic bone disease and absence of any other severe chronic disease The patient is under the supervision of a specialist with expertise in renal medicine The patient has a GFR less than or equal to 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 The patient has received a renal transplant and has received < 5mg/ m² /day of prednisone or equivalent for at least 6 months endocrinologist paediatric endocrinologist renal physician 12 Height velocity is greater than or equal to 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) Height velocity is greater than or equal to 2 cm per year as calculated over six months A current bone age is 14 years or under (female patients) or 16 years or under (male patients) No serious adverse effect that the patients specialist considers is likely to be attributable to growth hormone has occurred No malignancy has developed after growth hormone therapy was commenced The patient has not experienced significant biochemical or metabolic deterioration confirmed by diagnostic results The patient has not received renal transplantation since starting growth hormone treatment 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 endocrinologist paediatric endocrinologist renal physician 12 The patient has a diagnosis of Prader-Willi syndrome that has been confirmed by genetic testing or clinical scoring criteria The patient is aged six months or older A current bone age is < 14 years (female patients) or < 16 years (male patients) 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 The patient is aged two years or older There is no evidence of type II diabetes or uncontrolled obesity defined by BMI that has increased by greater than or equal to 0.5 standard deviations in the preceding 12 months The patient is aged between six months and two years and a thorough upper airway assessment is planned to be undertaken prior to treatment commencement and at six to 12 weeks following treatment initiation endocrinologist paediatric endocrinologist 12 Height velocity is greater than or equal to 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) Height velocity is greater than or equal to 2 cm per year as calculated over six months A current bone age is 14 years or under (female patients) or 16 years or under (male patients) No serious adverse effect that the patient’s specialist con siders is likely to be attributable to growth hormone treatment has occurred No malignancy has developed after growth hormone therapy was commenced The patient has not developed type II diabetes or uncontrolled obesity as defined by BMI that has increased by greater than or equal to 0.5 standard deviations in the preceding 12 months endocrinologist paediatric endocrinologist 12 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) The patient has undergone appropriate treatment of other hormonal deficiencies and psychological illnesses The patient has severe growth hormone deficiency (see notes) The patient’s serum IGF-I is more than 1 standard deviation below the mean for age and sex 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®) endocrinologist paediatric endocrinologist 12

For the purposes of adults and adolescents, severe growth hormone deficiency is defined as a peak serum growth hormone level of less than or equal to 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 less than or equal to 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.

 The patient has been treated with somatropin for < 12 months 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 Serum IGF-I levels have increased to within ±1SD of the mean of the normal range for age and sex The dose of somatropin does not exceed 0.7 mg per day for male patients, or 1 mg per day for female patients The patient has been treated with somatropin for more than 12 months 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) 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) The dose of somatropin has not exceeded 0.7 mg per day for male patients or 1 mg per day for female patients The patient has had a Special Authority approval for somatropin for childhood deficiency in children and no longer meets the renewal criteria under this indication The patient has undergone appropriate treatment of other hormonal deficiencies and psychological illnesses The patient has severe growth hormone deficiency (see notes) The patient's serum IGF-I is more than 1 standard deviation below the mean for age and sex 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®) endocrinologist paediatric endocrinologist 12

For the purposes of adults and adolescents, severe growth hormone deficiency is defined as a peak serum growth hormone level of less than or equal to 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 less than or equal to 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 the serum IGF-I 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.

 Thyroid and Antithyroid Preparations Thyroid and Antithyroid Preparations Carbimazole Tab 5 mg Neo-Mercazole 100 7.56 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 <range>Liothyronine sodium - Tab 20 mcg</range> For a maximum of 14 days' treatment in patients with thyroid cancer who are due to receive radioiodine therapy medical practitioner Inj 100 mcg vial Any 0 Inj 10 mcg vial Any 0 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 <range>Propylthiouracil</range> The patient has hyperthyroidism The patient is intolerant of carbimazole or carbimazole is contraindicated medical practitioner Vasopressin Agents Vasopressin Agents Argipressin [Vasopressin] Inj 20 u per ml, 1 ml ampoule Any 0 Desmopressin Wafer 120 mcg Minirin Melt 30 47.00 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 25.00 Tab 200 mcg Minirin 30 54.45 Nasal spray 10 mcg per dose, 6 ml Desmopressin-PH&T 60 34.95 Terlipressin Inj 0.2 mg per ml, 5 ml vial Terlipressin Ever Pharma 5 110.00 Infections Antibacterials Aminoglycosides Streptomycin sulphate <range>Streptomycin sulphate</range> No patient criteria clinical microbiologist infectious disease specialist respiratory specialist Gentamicin sulphate Inj 40 mg per ml, 2 ml ampoule Pfizer 10 18.38 Inj 10 mg per ml, 1 ml ampoule DBL Gentamicin 5 102.60 Inj 10 mg per ml, 2 ml ampoule Any 0 Amikacin <range>Amikacin</range> No patient criteria clinical microbiologist infectious disease specialist respiratory specialist Tobramycin Inj 100 mg per ml, 5 ml vial <range>Tobramycin</range> No patient criteria clinical microbiologist infectious disease specialist respiratory specialist Inj 40 mg per ml, 2 ml vial <range>Tobramycin</range> No patient criteria clinical microbiologist infectious disease specialist respiratory specialist Solution for inhalation 60 mg per ml, 5 ml <range>Tobramycin Solution for inhalation 60 mg per ml, 5 ml</range> Patient has cystic fibrosis medical practitioner Powder <range>Tobramcyin</range> For addition to orthopaedic bone cement medical practitioner Paromomycin <range>Paromomycin</range> No patient criteria clinical microbiologist infectious disease specialist gastroenterologist Carbapenems Imipenem with cilastatin <range>Imipenem with cilastatin</range> No patient criteria clinical microbiologist infectious disease specialist Ertapenem <range>Ertapenem</range> No patient criteria clinical microbiologist infectious disease specialist Meropenem <range>Meropenem</range> No patient criteria clinical microbiologist infectious disease specialist Cephalosporins and Cephamycins - 1st Generation Cefazolin Inj 500 mg vial Cefazolin-AFT 5 3.39 Inj 1 g vial Cefazolin-AFT 5 3.59 Inj 2 g vial Cefazolin-AFT 5 7.09 Cefalexin Grans for oral liq 25 mg per ml Flynn 100 7.88 Grans for oral liq 50 mg per ml Cefalexin Sandoz 100 11.75 Flynn 100 10.38 Cap 500 mg Cephalexin ABM 20 5.85 Cefalexin Sandoz 20 3.33 Cap 250 mg Cephalexin ABM 20 3.85 Cefalexin Lupin 20 3.90 Cephalosporins and Cephamycins - 2nd Generation Cefuroxime Inj 1.5 g vial Cefuroxime Devatis 10 13.01 Inj 750 mg vial Cefuroxime Devatis 10 8.16 Tab 250 mg Any 0 Cefaclor Cap 250 mg Ranbaxy-Cefaclor 100 29.73 Grans for oral liq 25 mg per ml Ranbaxy-Cefaclor 100 5.83 Cefoxitin Inj 1 g vial Any 0 Cephalosporins and Cephamycins - 3rd Generation Ceftazidime with avibactam <range>Ceftazidime with avibactam</range> Prescribed by, or recommended by a clinical microbiologist or infectious disease specialist, or in accordance with a protocol or guideline that has been endorsed by the Health NZ Hospital Proven infection with a carbapenem-resistant micro-organism, based on microbiology report Probable infection with a carbapenem-resistant micro-organism, based on assessment by a clinical microbiologist or infectious disease specialist. medical practitioner Cefotaxime Inj 1 g vial DBL Cefotaxime 10 38.98 Inj 500 mg vial Cefotaxime Sandoz 1 1.90 Ceftazidime <range>Ceftazadime</range> No patient criteria clinical microbiologist infectious disease specialist respiratory specialist Ceftriaxone Inj 2 g vial Ceftriaxone-AFT 5 8.15 Inj 1 g vial Ceftriaxone-AFT 5 3.49 Inj 500 mg vial Ceftriaxone-AFT 1 0.94 Cephalosporins and Cephamycins - 4th Generation Cefepime <range>Cefepime</range> No patient criteria clinical microbiologist infectious disease specialist Cephalosporins and Cephamycins - 5th Generation Ceftaroline fosamil <range>Ceftaroline</range> for patients where alternative therapies have failed for patients who have a contraindication or hypersensitivity to standard current therapies clinical microbiologist infectious disease specialist Macrolides Erythromycin (as stearate)

For continuation only

Tab 250 mg Any 0 Tab 500 mg Any 0 Roxithromycin <range>Roxithromycin tab dispersible 50 mg</range> Only for use in patients under 12 years of age medical practitioner Erythromycin (as lactobionate) Inj 1 g vial Erythrocin IV 1 10.00 Clarithromycin <range>Clarithromycin</range> Atypical mycobacterial infection Mycobacterium tuberculosis infection where there is drug resistance or intolerance to standard pharmaceutical agents Helicobacter pylori eradication Prophylaxis of infective endocarditis associated with surgical or dental procedures if amoxicillin is contra-indicated medical practitioner Helicobacter pylori eradication medical practitioner Atypical mycobacterial infection Mycobacterium tuberculosis infection where there is drug resistance or intolerance to standard pharmaceutical agents Community-acquired pneumonia medical practitioner Erythromycin (as ethylsuccinate) Tab 400 mg E-Mycin 100 35.82 Grans for oral liq 200 mg per 5 ml E-Mycin 100 6.53 Grans for oral liq 400 mg per 5 ml E-Mycin 100 9.41 Azithromycin <range>Azithromycin</range> Patient has received a lung transplant, stem cell transplant or bone marrow transplant and requires treatment for bronchiolitis obliterans syndrome* Patient has received a lung transplant and requires prophylaxis for bronchiolitis obliterans syndrome* Patient has cystic fibrosis and has chronic infection with Pseudomonas aeruginosa or Pseudomonas related gram negative organisms* Patient has an atypical Mycobacterium infection medical practitioner

Indications marked with * are unapproved indications

 For prophylaxis of exacerbations of non-cystic fibrosis bronchiectasis* Patient is aged 18 and under Patient has had 3 or more exacerbations of their bronchiectasis, within a 12 month period Patient has had 3 acute admissions to hospital for treatment of infective respiratory exacerbations within a 12 month period respiratory specialist paediatrician 12

Indications marked with * are unapproved indications. A maximum of 24 months of azithromycin treatment for non-cystic fibrosis will be subsidised in the community.

 The patient has completed 12 months of azithromycin treatment for non-cystic fibrosis bronchiectasis Following initial 12 months of treatment, the patient has not received any further azithromycin treatment for non-cystic fibrosis bronchiectasis for a further 12 months, unless considered clinically inappropriate to stop treatment The patient will not receive more than a total of 24 months' azithromycin cumulative treatment (see note) respiratory specialist paediatrician 12

Indications marked with * are unapproved indications. A maximum of 24 months of azithromycin treatment for non-cystic fibrosis will be subsidised in the community.

 For any other condition medical practitioner 5 For any other condition medical practitioner 5 Penicillins Ticarcillin with clavulanic acid <range>Ticarcillin with clavulanic acid</range> No patient criteria clinical microbiologist infectious disease specialist respiratory specialist Amoxicillin with clavulanic acid Tab 500 mg with clavulanic acid 125 mg Curam Duo 500/125 10 1.59 Grans for oral liq 25 mg with clavulanic acid 6.25 mg per ml Augmentin 100 8.50 Grans for oral liq 50 mg with clavulanic acid 12.5 mg per ml Amoxiclav Devatis Forte 100 5.61 Inj 1,000 mg with clavulanic acid 200 mg vial Cerobact 10 26.90 Synermox 10 29.61 Inj 500 mg with clavulanic acid 100 mg vial Synermox 10 22.48 Amoxicillin Inj 250 mg vial Ibiamox 5 6.32 10 15.97 Inj 500 mg vial Ibiamox 5 7.23 10 17.43 Inj 1 g vial Ibiamox 5 11.00 10 21.64 Cap 250 mg Miro-Amoxicillin 500 54.00 Cap 500 mg Miro-Amoxicillin 500 41.00 Amoxycillin Sandoz 20 1.14 Grans for oral liq 250 mg per 5 ml Alphamox 250 100 2.81 Grans for oral liq 125 mg per 5 ml Alphamox 125 100 2.22 Benzylpenicillin sodium [Penicillin G] Inj 600 mg (1 million units) vial Sandoz 10 16.50 Flucloxacillin Cap 250 mg Staphlex 250 22.58 Cap 500 mg Staphlex 500 72.71 Inj 250 mg vial Flucloxin 10 42.60 Inj 500 mg vial Flucloxin 10 45.63 Inj 1 g vial Flucil 5 6.00 Grans for oral liq 25 mg per ml AFT 100 4.89 Grans for oral liq 50 mg per ml AFT 100 5.89 Procaine penicillin Inj 1.5 g in 3.4 ml syringe Any 0 Benzathine benzylpenicillin Inj 900 mg (1.2 million units) in 2.3 ml syringe Bicillin LA 10 432.37 Inj 900 mg (1.2 million units) vial Benzetacil 1 43.24 Phenoxymethylpenicillin [Penicillin V] Cap 250 mg Cilicaine VK 50 7.68 Cap 500 mg Cilicaine VK 50 13.72 Grans for oral liq 125 mg per 5 ml AFT 100 5.75 Grans for oral liq 250 mg per 5 ml AFT 100 5.89 Piperacillin with tazobactam <range>Piperacillin with tazobactam</range> No patient criteria clinical microbiologist infectious disease specialist respiratory specialist Quinolones Ciprofloxacin <range>Ciprofloxacin</range> No patient criteria clinical microbiologist infectious disease specialist Norfloxacin Tab 400 mg Arrow-Norfloxacin 100 245.00 Moxifloxacin <range>Moxifloxacin</range> Active tuberculosis Documented resistance to one or more first-line medications 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 Impaired visual acuity (considered to preclude ethambutol use) Significant pre-existing liver disease or hepatotoxicity from tuberculosis medications Significant documented intolerance and/or side effects following a reasonable trial of first-line medications Mycobacterium avium-intracellulare complex not responding to other therapy or where such therapy is contraindicated Patient is under five years of age and has had close contact with a confirmed multi-drug resistant tuberculosis case infectious disease specialist clinical microbiologist respiratory specialist Immunocompromised patient with pneumonia that is unresponsive to first-line treatment Pneumococcal pneumonia or other invasive pneumococcal disease highly resistant to other antibiotics infectious disease specialist clinical microbiologist Five days treatment for patients requiring prophylaxis following a penetrating eye injury ophthalmologist Has nucleic acid amplification test (NAAT) confirmed Mycoplasma genitalium and is symptomatic Has tried and failed to clear infection using azithromycin Has laboratory confirmed azithromycin resistance Treatment is only for 7 days medical practitioner Individual has a history of severe delayed beta-lactam allergy infectious disease specialist clinical microbiologist Tetracyclines Demeclocycline hydrochloride Cap 150 mg Any 0 Cap 300 mg Any 0 Tab 150 mg Any 0 Minocycline Cap 100 mg

For continuation only

Any 0 Tab 50 mg Any 0 Tigecycline <range>Tigecycline</range> No patient criteria clinical microbiologist infectious disease specialist Doxycycline Inj 5 mg per ml, 20 ml vial Any 0 Tab 50 mg

For continuation only

Any 0 Tab 100 mg Doxine 500 64.43 Tetracycline Tab 250 mg Accord 28 68.44 Cap 500 mg Any 0 Other Antibacterials Daptomycin <range>Daptomycin</range> No patient criteria clinical microbiologist infectious disease specialist Methenamine (Hexamine) hippurate Tab 1 g Hiprex 100 19.95 100 19.95 Lincomycin <range>Lincomycin</range> No patient criteria clinical microbiologist infectious disease specialist Linezolid <range>Linezolid</range> No patient criteria clinical microbiologist infectious disease specialist Nitrofurantoin Tab 100 mg Nifuran 100 37.50 Tab 50 mg Nifuran 100 22.20 Cap modified-release 100 mg Macrobid 100 81.20 Sulfadiazine sodium <range>Sulphadiazine</range> No patient criteria clinical microbiologist infectious disease specialist maternal-foetal medicine specialist Teicoplanin <range>Teicoplanin</range> No patient criteria clinical microbiologist infectious disease specialist Fosfomycin <range>Fosfomycin</range> No patient criteria clinical microbiologist infectious disease specialist Pivmecillinam <range>Pivmecillinam</range> No patient criteria clinical microbiologist infectious disease specialist Vancomycin <range>Vancomycin</range> No patient criteria clinical microbiologist infectious disease specialist Chloramphenicol <range>Aztreonam, Chloramphenicol</range> No patient criteria clinical microbiologist infectious disease specialist Clindamycin <range>Clindamycin</range> No patient criteria clinical microbiologist infectious disease specialist Sodium fusidate [Fusidic acid] <range>Fusidic acid</range> No patient criteria clinical microbiologist infectious disease specialist Colistin sulphomethate [Colestimethate] <range>Colistin sulphomethate [Colestimethate]</range> No patient criteria clinical microbiologist infectious disease specialist respiratory specialist Trimethoprim Tab 100 mg Any 0 Tab 300 mg TMP 50 27.83 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 Trisul 500 115.74 Oral liq 8 mg with sulphamethoxazole 40 mg per ml Deprim 100 4.95 Aztreonam <range>Aztreonam, Chloramphenicol</range> No patient criteria clinical microbiologist infectious disease specialist Antifungals Imidazoles Ketoconazole Tab 200 mg <range>Ketoconazole - Tab 200 mg</range> No patient criteria oncologist Polyene Antimycotics Amphotericin B Inj (liposomal) 50 mg vial <range>Amphotericin B - Inj (liposomal) 50 mg vial</range> Proven or probable invasive fungal infection, to be prescribed under an established protocol Possible invasive fungal infection A multidisciplinary team (including an infectious disease physician or a clinical microbiologist) considers the treatment to be appropriate clinical microbiologist haematologist infectious disease specialist oncologist respiratory specialist transplant specialist Inj 50 mg vial <range>Amphotericin B - Inj 50 mg vial</range> No patient criteria clinical microbiologist haematologist infectious disease specialist oncologist respiratory specialist transplant specialist Nystatin Tab 500,000 u Nilstat 50 17.09 Cap 500,000 u Nilstat 50 15.47 Triazoles Fluconazole <range>Fluconazole</range> No patient criteria consultant Itraconazole <range>Itraconazole</range> No patient criteria clinical immunologist clinical microbiologist dermatologist infectious disease specialist Voriconazole <range>Voriconazole</range> Patient is immunocompromised Patient has proven or probable invasive aspergillus infection clinical microbiologist haematologist infectious disease specialist Patient is immunocompromised Patient has possible invasive aspergillus infection A multidisciplinary team (including an infectious disease physician) considers the treatment to be appropriate clinical microbiologist haematologist infectious disease specialist Patient is immunocompromised Patient has fluconazole resistant candidiasis Patient has mould strain such as Fusarium spp. and Scedosporium spp A multidisciplinary team (including an infectious disease physician or clinical microbiologist) considers the treatment to be appropriate clinical microbiologist haematologist infectious disease specialist The patient is at risk of invasive fungal infection Voriconazole is prescribed by, or recommended by a haematologist, transplant physician, infectious disease specialist, paediatric haematologist or paediatric oncologist Prescribing voriconazole is in accordance with a protocol or guideline that has been endorsed by the Health New Zealand - Te Whatu Ora Hospital in the specific settings where there is a greater than 10% risk of invasive fungal infection (IFI) any relevant practitioner 6 The patient is at risk of invasive fungal infection Voriconazole is prescribed by, or recommended by a haematologist, transplant physician, infectious disease specialist, paediatric haematologist or paediatric oncologist Prescribing voriconazole is in accordance with a protocol or guideline that has been endorsed by the Health New Zealand - Te Whatu Ora Hospital in the specific settings where there is a greater than 10% risk of invasive fungal infection (IFI) any relevant practitioner 6 Posaconazole <range>Posaconazole</range> Patient has acute myeloid leukaemia Patient is planned to receive a stem cell transplant and is at high risk for aspergillus infection Patient is to be treated with high dose remission induction therapy or re-induction therapy haematologist infectious disease specialist 6 Patient has previously received posaconazole prophylaxis during remission induction therapy Patient is to be treated with high dose remission re-induction therapy Patient is to be treated with high dose consolidation therapy Patient is receiving a high risk stem cell transplant haematologist infectious disease specialist 6 The patient is at risk of invasive fungal infection Posaconazole is prescribed by, or recommended by a haematologist, transplant physician, infectious disease specialist, paediatric haematologist or paediatric oncologist Prescribing posaconazole is in accordance with a protocol or guideline that has been endorsed by the Health New Zealand - Te Whatu Ora Hospital in the specific settings where there is a greater than 10% risk of invasive fungal infection (IFI) any relevant practitioner 6 The patient is at risk of invasive fungal infection Posaconazole is prescribed by, or recommended by a haematologist, transplant physician, infectious disease specialist, paediatric haematologist or paediatric oncologist Prescribing posaconazole is in accordance with a protocol or guideline that has been endorsed by the Health New Zealand - Te Whatu Ora Hospital in the specific settings where there is a greater than 10% risk of invasive fungal infection (IFI) any relevant practitioner 6 Other Antifungals Flucytosine <range>Flucytosine</range> No patient criteria clinical microbiologist infectious disease specialist Terbinafine Tab 250 mg Deolate 84 8.97 Caspofungin <range>Caspofungin</range> Proven or probable invasive fungal infection, to be prescribed under an established protocol Possible invasive fungal infection A multidisciplinary team (including an infectious disease physician or a clinical microbiologist) considers the treatment to be appropriate clinical microbiologist haematologist infectious disease specialist oncologist respiratory specialist transplant specialist Antimycobacterials Antileprotics Clofazimine <range>Clofazimine</range> No patient criteria clinical microbiologist dermatologist infectious disease specialist Dapsone <range>Dapsone</range> No patient criteria clinical microbiologist dermatologist infectious disease specialist Antituberculotics Cycloserine <range>Cycloserine</range> No patient criteria clinical microbiologist infectious disease specialist respiratory specialist Isoniazid with rifampicin <range>Isoniazid with rifampicin</range> No patient criteria clinical microbiologist dermatologist paediatrician public health physician internal medicine physician Pyrazinamide <range>Pyrazinamide</range> No patient criteria clinical microbiologist infectious disease specialist respiratory specialist Rifampicin <range>Rifampicin</range> No patient criteria clinical microbiologist dermatologist internal medicine physician paediatrician public health physician Bedaquiline <range>Bedaquiline</range> The person has multi-drug resistant tuberculosis (MDR-TB) Ministry of Health’s Tuberculosis Clinical Network has reviewed the individual case and recommends bedaquiline as part of the treatment regimen medical practitioner 6 Isoniazid <range>Isoniazid</range> No patient criteria clinical microbiologist dermatologist paediatrician public health physician internal medicine physician Rifabutin <range>Rifabutin</range> No patient criteria clinical microbiologist gastroenterologist infectious disease specialist respiratory specialist Ethambutol hydrochloride <range>Ethambutol hydrochloride</range> No patient criteria clinical microbiologist infectious disease specialist respiratory specialist Para-aminosalicylic Acid <range>Para-aminosalicylic Acid</range> No patient criteria clinical microbiologist infectious disease specialist respiratory specialist Protionamide <range>Protionamide</range> No patient criteria clinical microbiologist infectious disease specialist respiratory specialist Antiparasitics Anthelmintics Albendazole <range>Albendazole</range> No patient criteria clinical microbiologist infectious disease specialist Praziquantel Tab 600 mg Any 0 Ivermectin <range>Ivermectin</range> No patient criteria clinical microbiologist dermatologist infectious disease specialist Mebendazole Oral liq 100 mg per 5 ml Any 0 Tab 100 mg Vermox 6 5.18 Antiprotozoals Artemether with lumefantrine <range>Artemether with lumefantrine</range> No patient criteria clinical microbiologist infectious disease specialist Artesunate <range>Artesunate</range> No patient criteria clinical microbiologist infectious disease specialist Atovaquone with proguanil hydrochloride <range>Atovaquone with proguanil hydrochloride</range> No patient criteria clinical microbiologist infectious disease specialist Chloroquine phosphate <range>Chloroquine phosphate</range> No patient criteria clinical microbiologist dermatologist infectious disease specialist rheumatologist Mefloquine <range>Mefloquine hydrochloride</range> No patient criteria clinical microbiologist dermatologist infectious disease specialist rheumatologist Pentamidine isethionate <range>Pentamidine isethionate</range> No patient criteria clinical microbiologist infectious disease specialist Primaquine <range>Primaquine phosphate</range> No patient criteria clinical microbiologist infectious disease specialist Pyrimethamine <range>Pyrimethamine</range> No patient criteria clinical microbiologist infectious disease specialist maternal-foetal medicine specialist Quinine dihydrochloride <range>Quinine dihydrochloride</range> No patient criteria clinical microbiologist infectious disease specialist Sodium stibogluconate <range>Sodium stibogluconate</range> No patient criteria clinical microbiologist infectious disease specialist Spiramycin <range>Spiramycin</range> No patient criteria maternal-foetal medicine specialist Metronidazole Inj 5 mg per ml, 100 ml bag Baxter 10 18.00 Tab 200 mg Metronidamed 250 25.86 Tab 400 mg Metronidamed 21 4.29 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 36.52 Nitazoxanide <range>Nitazoxanide</range> No patient criteria clinical microbiologist infectious disease specialist Antiretrovirals Non-Nucleoside Reverse Transcriptase Inhibitors <range>Non-Nucleoside Reverse Transcriptase Inhibitors</range> Patient has confirmed HIV infection medical practitioner Prevention of maternal foetal transmission Treatment of the newborn for up to eight weeks medical practitioner Treatment course to be initiated within 72 hours post exposure Patient has had condomless anal intercourse or receptive vaginal intercourse with a known HIV positive person with an unknown or detectable viral load greater than 200 copies per ml Patient has shared intravenous injecting equipment with a known HIV positive person Patient has had non-consensual intercourse and the clinician considers that the risk assessment indicates prophylaxis is required Patient has had condomless anal intercourse with a person from a high HIV prevalence country or risk group whose HIV status is unknown medical practitioner

Refer to local health pathways or the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine clinical guidelines for PEP (https://www.ashm.org.au/hiv/hiv-management/pep/).

 Patient has percutaneous exposure to blood known to be HIV positive medical practitioner Nucleoside Reverse Transcriptase Inhibitors <range>Nucleoside Reverse Transcriptase Inhibitors</range> Patient has confirmed HIV infection medical practitioner Prevention of maternal foetal transmission Treatment of the newborn for up to eight weeks medical practitioner Treatment course to be initiated within 72 hours post exposure Patient has had condomless anal intercourse or receptive vaginal intercourse with a known HIV positive person with an unknown or detectable viral load greater than 200 copies per ml Patient has shared intravenous injecting equipment with a known HIV positive person Patient has had non-consensual intercourse and the clinician considers that the risk assessment indicates prophylaxis is required Patient has had condomless anal intercourse with a person from a high HIV prevalence country or risk group whose HIV status is unknown medical practitioner

Refer to local health pathways or the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine clinical guidelines for PEP (https://www.ashm.org.au/hiv/hiv-management/pep/).

 Patient has percutaneous exposure to blood known to be HIV positive medical practitioner Protease Inhibitors <range>Protease Inhibitors</range> Patient has confirmed HIV infection medical practitioner Prevention of maternal foetal transmission Treatment of the newborn for up to eight weeks medical practitioner Treatment course to be initiated within 72 hours post exposure Patient has had condomless anal intercourse or receptive vaginal intercourse with a known HIV positive person with an unknown or detectable viral load greater than 200 copies per ml Patient has shared intravenous injecting equipment with a known HIV positive person Patient has had non-consensual intercourse and the clinician considers that the risk assessment indicates prophylaxis is required Patient has had condomless anal intercourse with a person from a high HIV prevalence country or risk group whose HIV status is unknown medical practitioner

Refer to local health pathways or the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine clinical guidelines for PEP (https://www.ashm.org.au/hiv/hiv-management/pep/).

 Patient has percutaneous exposure to blood known to be HIV positive medical practitioner Strand Transfer Inhibitors <range>Strand Transfer Inhibitors</range> Patient has confirmed HIV infection medical practitioner Prevention of maternal foetal transmission Treatment of the newborn for up to eight weeks medical practitioner Treatment course to be initiated within 72 hours post exposure Patient has had condomless anal intercourse or receptive vaginal intercourse with a known HIV positive person with an unknown or detectable viral load greater than 200 copies per ml Patient has shared intravenous injecting equipment with a known HIV positive person Patient has had non-consensual intercourse and the clinician considers that the risk assessment indicates prophylaxis is required Patient has had condomless anal intercourse with a person from a high HIV prevalence country or risk group whose HIV status is unknown medical practitioner

Refer to local health pathways or the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine clinical guidelines for PEP (https://www.ashm.org.au/hiv/hiv-management/pep/).

 Patient has percutaneous exposure to blood known to be HIV positive medical practitioner Antivirals Hepatitis B Tenofovir disoproxil Tab 245 mg (300 mg as a fumarate) Ricovir 30 13.80 Tab 245 mg (300 mg as a maleate) Tenofovir Disoproxil Viatris 30 13.80 Entecavir Tab 0.5 mg Entecavir (Rex) 30 12.04 Lamivudine Oral liq 5 mg per ml Zeffix 240 270.00 Tab 100 mg Zetlam 28 12.06 Hepatitis C Ledipasvir with sofosbuvir <range>Ledipasvir with sofosbuvir</range> No patient criteria medical practitioner

Only for use in patients with approval by the Hepatitis C Treatment Panel (HepCTP). Applications will be considered by HepCTP at its regular meetings and approved subject to eligibility according to the Access Criteria (set out in Section B of the Pharmaceutical Schedule).

 Glecaprevir with pibrentasvir

Note: the supply of treatment is via Pharmac’s approved direct distribution supply. Further details can be found on Pharmac’s website https://www.pharmac.govt.nz/maviret.

Tab 100 mg with pibrentasvir 40 mg Maviret 84 24750.00 Herpesviridae Cidofovir <range>Cidofovir</range> No patient criteria clinical microbiologist infectious disease specialist otolaryngologist oral surgeon Foscarnet sodium <range>Foscarnet sodium</range> No patient criteria clinical microbiologist infectious disease specialist Ganciclovir <range>Ganciclovir</range> No patient criteria clinical microbiologist infectious disease specialist Aciclovir Inj 250 mg vial Aciclovir-Baxter 5 13.75 Aciclovir Injection DBL 5 13.75 Tab dispersible 200 mg Lovir 25 2.05 Tab dispersible 400 mg Lovir 56 7.55 Tab dispersible 800 mg Lovir 35 7.43 Valaciclovir Tab 500 mg Vaclovir 30 9.64 Tab 1,000 mg Vaclovir 30 17.78 Valaciclovir Viatris 21 12.45 Valaciclovir Mylan 21 12.45 Valganciclovir <range>Valganciclovir</range> Patient has undergone a solid organ transplant and requires valganciclovir for CMV prophylaxis medical practitioner 3 Patient has undergone a solid organ transplant and received anti-thymocyte globulin and requires valganciclovir therapy for CMV prophylaxis Patient is to receive a maximum of 90 days of valganciclovir prophylaxis following anti-thymocyte globulin Patient has received pulse methylprednisolone for acute rejection and requires further valganciclovir therapy for CMV prophylaxis Patient is to receive a maximum of 90 days of valganciclovir prophylaxis following pulse methylprednisolone medical practitioner 3 Patient has undergone a lung transplant The donor was cytomegalovirus positive and the patient is cytomegalovirus negative The recipient is cytomegalovirus positive Patient has a high risk of CMV disease medical practitioner 12 Patient has undergone a lung re-transplant The donor was cytomegalovirus positive and the patient is cytomegalovirus negative The recipient is cytomegalovirus positive Patient has a high risk of CMV disease medical practitioner 12 Patient is immunocompromised Patient has cytomegalovirus syndrome or tissue invasive disease Patient has rapidly rising plasma CMV DNA in absence of disease Patient has cytomegalovirus retinitis medical practitioner HIV Prophylaxis and Treatment Emtricitabine with tenofovir disoproxil <range>Emtricitabine with tenofovir disoproxil</range> Patient has confirmed HIV infection medical practitioner Prevention of maternal foetal transmission Treatment of the newborn for up to eight weeks medical practitioner Treatment course to be initiated within 72 hours post exposure Patient has had unprotected receptive anal intercourse with a known HIV positive person Patient has shared intravenous injecting equipment with a known HIV positive person Patient has had non-consensual intercourse and the clinician considers that the risk assessment indicates prophylaxis is required medical practitioner Patient has percutaneous exposure to blood known to be HIV positive medical practitioner Patient has tested HIV negative, does not have signs or symptoms of acute HIV infection and has been assessed for HIV seroconversion The Practitioner considers the patient is at elevated risk of HIV exposure and use of PrEP is clinically appropriate medical practitioner 24

Refer to local health pathways or the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine clinical guidelines (https://ashm.org.au/HIV/PrEP/)

 Patient has tested HIV negative, does not have signs or symptoms of acute HIV infection and has been assessed for HIV seroconversion The Practitioner considers the patient is at elevated risk of HIV exposure and use of PrEP is clinically appropriate medical practitioner 24

Refer to local health pathways or the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine clinical guidelines (https://ashm.org.au/HIV/PrEP/)

 Influenza Oseltamivir

Note: The restriction on the use of oseltamivir to hospitalised patients means that supply into the community for a new course is not permitted. Supply of a part original pack on discharge where initiated as a hospital inpatient is permitted.

<range>Oseltamivir</range> Only for hospitalised patient with known or suspected influenza For prophylaxis of influenza in hospitalised patients as part of a Health NZ Hospital approved infections control plan medical practitioner Zanamivir

Note: The restriction on the use of zanamivir to hospitalised patients means that supply into the community for a new course is not permitted. Supply of a part original pack on discharge where initiated as a hospital inpatient is permitted.

Powder for inhalation 5 mg <range>Zanamivir - Powder for inhalation 5 mg</range> Only for hospitalised patient with known or suspected influenza For prophylaxis of influenza in hospitalised patients as part of a Health NZ Hospital approved infections control plan medical practitioner COVID-19 Treatments Nirmatrelvir with ritonavir <range>COVID-19 treatments</range> Only if patient meets access criteria (as per https://pharmac.govt.nz/covid-oral-antivirals). Note the supply of treatment is via Pharmac’s approved distribution process. Refer to the Pharmac website for more information about this and stock availability medical practitioner Remdesivir

Note: For patients meeting access criteria for oral antiviral treatments (as on Pharmac's website).

Inj 100 mg vial Veklury 1 615.23 Immune Modulators Immune Modulators 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 <range>Interferon gamma</range> Patient has chronic granulomatous disease and requires interferon gamma medical practitioner Pegylated interferon alfa-2a <range>Pegylated interferon alfa-2a</range> Patient has chronic hepatitis C, genotype 1, 4, 5 or 6 infection Patient has chronic hepatitis C and is co-infected with HIV Patient has chronic hepatitis C genotype 2 or 3 and has received a liver transplant medical practitioner 48

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.

 Patient has chronic hepatitis C, genotype 1 Patient has had previous treatment with pegylated interferon and ribavirin Patient has responder relapsed Patient was a partial responder Patient is to be treated in combination with boceprevir gastroenterologist infectious disease specialist general physician 48 Patient has chronic hepatitis C, genotype 1 Patient has had previous treatment with pegylated interferon and ribavirin Patient has responder relapsed Patient was a partial responder Patient received interferon treatment prior to 2004 Patient is to be treated in combination with boceprevir gastroenterologist infectious disease specialist general physician 48 Patient has chronic hepatitis C, genotype 2 or 3 infection medical practitioner 6 Patient has confirmed Hepatitis B infection (HBsAg positive for more than 6 months) Patient is Hepatitis B treatment-naive ALT > 2 times Upper Limit of Normal HBV DNA < 10 log10 IU/ml HBeAg positive Serum HBV DNA greater than or equal to 2,000 units/ml and significant fibrosis (greater than or equal to Metavir Stage F2 or moderate fibrosis) Compensated liver disease No continuing alcohol abuse or intravenous drug use Not co-infected with HCV, HIV or HDV Neither ALT nor AST > 10 times upper limit of normal No history of hypersensitivity or contraindications to pegylated interferon gastroenterologist infectious disease specialist general physician 48 Patient has a cutaneous T cell lymphoma* Patient has a myeloproliferative disorder* Patient is intolerant of hydroxyurea Treatment with anagrelide and busulfan is not clinically appropriate Patient has a myeloproliferative disorder Patient is pregnant, planning pregnancy or lactating medical practitioner 12 No evidence of disease progression The treatment remains appropriate and patient is benefitting from treatment Patient has a cutaneous T cell lymphoma* Patient has a myeloproliferative disorder* Remains intolerant of hydroxyurea and treatment with anagrelide and busulfan remains clinically inappropriate Patient is pregnant, planning pregnancy or lactating medical practitioner 12

Indications marked with * are unapproved indications

 Patient has ocular surface squamous neoplasia* ophthalmologist 12 The treatment remains appropriate and patient is benefitting from treatment ophthalmologist 12

Indications marked with * are unapproved indications

 Patient has received an allogeneic bone marrow transplant* and has evidence of disease relapse medical practitioner 3 Patient is responding and ongoing treatment remains appropriate medical practitioner 3

Indications marked with * are unapproved indications

 Musculoskeletal System Anticholinesterases Anticholinesterases Edrophonium chloride <range>Edrophonium chloride</range> For the diagnosis of myasthenia gravis medical practitioner Neostigmine metilsulfate with glycopyrronium bromide Inj 2.5 mg with glycopyrronium bromide 0.5 mg per ml, 1 ml ampoule Max Health 10 26.13 Neostigmine metilsulfate Inj 2.5 mg per ml, 1 ml ampoule Max Health 10 48.25 Pyridostigmine bromide Tab 60 mg Mestinon 100 50.28 Antirheumatoid Agents Antirheumatoid Agents 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 100 110.12 Tab 125 mg D-Penamine 100 67.23 Leflunomide Tab 10 mg Arava 30 6.00 Tab 20 mg Arava 30 6.00 Hydroxychloroquine sulphate Tab 200 mg Ipca-Hydroxychloroquine 100 7.80 Drugs Affecting Bone Metabolism Bisphosphonates Risedronate sodium Tab 35 mg Risedronate Sandoz 4 3.00 Pamidronate disodium Inj 3 mg per ml, 10 ml vial Pamisol 1 32.49 Inj 6 mg per ml, 10 ml vial Pamisol 1 88.11 Inj 9 mg per ml, 10 ml vial Pamisol 1 94.34 Zoledronic acid Inj 5 mg per 100 ml, bag Zoledronic Acid Viatris 1 19.45 Alendronate sodium Tab 70 mg Fosamax 4 3.10 Alendronate sodium with colecalciferol Tab 70 mg with colecalciferol 5,600 iu Fosamax Plus 4 1.99 Other Drugs Affecting Bone Metabolism Denosumab

Note: Denosumab inj 60 mg per 1 ml pre-filled syringe is Medsafe approved for use in osteoporosis. Denosumab inj 120 mg per 1.7 ml vial is Medsafe approved for use in hypercalcaemia of malignancy.

<range>Denosumab</range> The patient has established osteoporosis History of one significant osteoporotic fracture demonstrated radiologically, with a documented T-Score less than or equal to -2.5, that incorporates BMD measured using dual-energy x-ray absorptiometry (DEXA) History of one significant osteoporotic fracture, demonstrated radiologically, and either the patient is elderly, or densitometry scanning cannot be performed because of logistical, technical or pathophysiological reasons History of two significant osteoporotic fractures demonstrated radiologically Documented T-Score less than or equal to -3.0 A 10-year risk of hip fracture greater than or equal to 3%, calculated using a published risk assessment algorithm that incorporates BMD measured using DEXA Bisphosphonates are contraindicated because the patient’s creatinine clearance or eGFR is less than 35 mL/min The patient has experienced at least two symptomatic new fractures or a BMD loss greater than 2% per year, after at least 12 months’ continuous therapy with a funded antiresorptive agent Bisphosphonates result in intolerable side effects Intravenous bisphosphonates cannot be administered due to logistical or technical reasons medical practitioner Patient has hypercalcaemia of malignancy Patient has severe renal impairment medical practitioner Teriparatide <range>Teriparatide</range> The patient has severe, established osteoporosis The patient has a documented T-score less than or equal to -3.0 (see Notes) The patient has had two or more fractures due to minimal trauma 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) medical practitioner 18

  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 restriction are defined as: alendronate sodium tab 70 mg or tab 70 mg with colecalciferol 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 <range>Rasburicase</range> No patient criteria haematologist Benzbromarone

For continuation only

Tab 100 mg Benzbromaron AL 100 100 45.00 Tab 50 mg Any 0 Febuxostat <range>Febuxostat</range> Patient has been diagnosed with gout 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 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 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) The patient has previously had an initial Special Authority approval for benzbromarone for treatment of gout. medical practitioner Patient is scheduled to receive cancer therapy carrying an intermediate or high risk of tumour lysis syndrome Patient has a documented history of allopurinol intolerance haematologist oncologist 6 The treatment remains appropriate and patient is benefitting from treatment haematologist oncologist 6 Allopurinol Tab 100 mg Ipca-Allopurinol 1000 17.99 Tab 300 mg Ipca-Allopurinol 500 22.50 Colchicine Tab 500 mcg Colgout 100 6.30 Muscle Relaxants and Related Agents Muscle Relaxants and Related Agents Dantrolene Cap 25 mg Dantrium 100 145.77 Cap 50 mg Dantrium 100 77.00 Inj 20 mg vial Dantrium IV 6 1143.74 Orphenadrine citrate Tab 100 mg Norflex 100 23.25 Vecuronium bromide Inj 10 mg vial Vecure 10 380.00 Atracurium besylate Inj 10 mg per ml, 2.5 ml ampoule Medsurge 5 7.69 Inj 10 mg per ml, 5 ml ampoule Medsurge 5 9.86 Mivacurium chloride Inj 2 mg per ml, 10 ml ampoule Any 0 Pancuronium bromide Inj 2 mg per ml, 2 ml ampoule Any 0 Suxamethonium chloride Inj 50 mg per ml, 2 ml ampoule Martindale 10 35.40 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 3.70 Inj 2 mg per ml, 5 ml ampoule Sintetica Baclofen Intrathecal 10 490.91 Clostridium botulinum type A toxin Inj 100 u vial Botox 1 467.50 Inj 500 u vial Dysport 2 1295.00 Inj 300 u vial Dysport 1 388.50 Rocuronium bromide Inj 10 mg per ml, 5 ml vial Medsurge 10 28.96 Inj 10 mg per ml, 5 ml ampoule Hameln 10 37.06 Reversers of Neuromuscular Blockade Sugammadex <range>Sugammadex</range> Patient requires reversal of profound neuromuscular blockade following rapid sequence induction that has been undertaken using rocuronium (i.e. suxamethonium is contraindicated or undesirable) Severe neuromuscular degenerative disease where the use of neuromuscular blockade is required Patient has an unexpectedly difficult airway that cannot be intubated and requires a rapid reversal of anaesthesia and neuromuscular blockade The duration of the patient's surgery is unexpectedly short Neostigmine or a neostigmine/anticholinergic combination is contraindicated (for example the patient has ischaemic heart disease, morbid obesity or COPD) Patient has a partial residual block after conventional reversal medical practitioner Non-Steroidal Anti-Inflammatory Drugs Non-Steroidal Anti-Inflammatory Drugs Indometacin [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

For continuation only

Cap 250 mg Any 0 Sulindac Tab 100 mg Any 0 Tab 200 mg Any 0 Celecoxib Cap 100 mg Celebrex 60 3.60 Cap 200 mg Celecoxib Pfizer 30 3.20 Celostea 30 2.55 Etoricoxib <range>Etoricoxib</range> For in-vivo investigation of allergy only medical practitioner 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 Voltaren SR 100 10.00 Inj 25 mg per ml, 3 ml ampoule Voltaren 5 13.20 Tab EC 25 mg Diclofenac Sandoz 50 2.19 Tab EC 50 mg Diclofenac Sandoz 50 2.19 Ibuprofen Inj 5 mg per ml, 2 ml ampoule Any 0 Tab 200 mg - 1,000 tablet pack Relieve 1000 21.40 Tab 400 mg

For continuation only

Any 0 Tab 600 mg

For continuation only

Any 0 Oral liq 20 mg per ml Ethics 200 2.85 Tab long-acting 800 mg Ibuprofen SR BNM 30 3.65 Inj 10 mg per ml, 2 ml vial Any 0 Naproxen Tab long-acting 1 g Naprosyn SR 1000 28 11.50 Tab long-acting 750 mg Naprosyn SR 750 28 10.40 Tab 250 mg Noflam 250 500 39.23 90 7.06 Tab 500 mg Noflam 500 250 34.45 Tenoxicam Tab 20 mg Tilcotil 100 23.50 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 46.00 Parecoxib Juno 10 46.00 Topical Products for Joint and Muscular Pain Topical Products for Joint and Muscular Pain Capsaicin <range>Capsaicin</range> Patient has osteoarthritis that is not responsive to paracetamol and oral non-steroidal anti-inflammatories are contraindicated medical practitioner Nervous System Agents for Parkinsonism and Related Disorders Agents for Essential Tremor, Chorea and Related Disorders Riluzole <range>Riluzole</range> The patient has amyotrophic lateral sclerosis with disease duration of 5 years or less The patient has at least 60 percent of predicted forced vital capacity within 2 months prior to the initial application The patient has not undergone a tracheostomy The patient has not experienced respiratory failure The patient is ambulatory The patient is able to use upper limbs The patient is able to swallow neurologist respiratory specialist 6 The patient has not undergone a tracheostomy The patient has not experienced respiratory failure The patient is ambulatory The patient is able to use upper limbs The patient is able to swallow medical practitioner 18 Tetrabenazine Tab 25 mg Motetis 112 126.02 Anticholinergics Procyclidine hydrochloride Tab 5 mg Any 0 Benzatropine mesylate Tab 2 mg Benztrop 60 10.99 Inj 1 mg per ml, 2 ml ampoule Phebra 5 95.00 Dopamine Agonists and Related Agents Bromocriptine Cap 5 mg Any 0 Selegiline hydrochloride

For continuation only

Tab 5 mg Any 0 Rasagiline Tab 1 mg Azilect 30 53.50 Levodopa with carbidopa and entacapone Tab 50 mg with carbidopa 12.5 mg and entacapone 200 mg Stalevo 100 27.01 Tab 100 mg with carbidopa 25 mg and entacapone 200 mg Stalevo 100 34.18 Tab 150 mg with carbidopa 37.5 mg and entacapone 200 mg Stalevo 100 44.96 Tab 200 mg with carbidopa 50 mg and entacapone 200 mg Stalevo 100 51.23 Amantadine hydrochloride Cap 100 mg Symmetrel 60 38.24 Entacapone Tab 200 mg Entacapone Viatris 100 13.73 Ropinirole hydrochloride Tab 1 mg Ropin 84 10.09 Tab 2 mg Ropin 84 12.29 Tab 5 mg Ropin 84 25.94 Tab 0.25 mg Ropin 84 8.83 Apomorphine hydrochloride Inj 10 mg per ml, 2 ml ampoule Movapo 5 59.50 Inj 10 mg per ml, 5 ml ampoule Movapo 5 121.84 Levodopa with benserazide Cap 50 mg with benserazide 12.5 mg Madopar 62.5 100 13.75 Tab dispersible 50 mg with benserazide 12.5 mg Madopar Rapid 100 13.25 Cap 100 mg with benserazide 25 mg Madopar 125 100 15.80 Cap long-acting 100 mg with benserazide 25 mg Madopar HBS 100 22.85 Cap 200 mg with benserazide 50 mg Madopar 250 100 26.25 Levodopa with carbidopa Tab 100 mg with carbidopa 25 mg Sinemet 100 26.49 Tab 250 mg with carbidopa 25 mg Sinemet 100 39.49 Tab long-acting 200 mg with carbidopa 50 mg Sinemet CR 100 44.99 Tab long-acting 100 mg with carbipoda 25 mg Any 0 1 Tolcapone Tab 100 mg Tasmar 100 152.38 Pramipexole hydrochloride Tab 0.25 mg Ramipex 100 5.23 Tab 1 mg Ramipex 100 17.73 Anaesthetics General Anaesthetics Dexmedetomidine Inj 100 mcg per ml, 2 ml vial Dexmedetomidine Viatris 5 42.00 5 42.00 Etomidate Inj 2 mg per ml, 10 ml ampoule Any 0 Ketamine Inj 1 mg per ml, 100 ml bag Biomed 5 146.00 Inj 10 mg per ml, 10 ml syringe Biomed 5 76.00 Inj 100 mg per ml, 2 ml vial Ketalar 5 36.23 5 91.98 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 2730.00 Propofol Inj 10 mg per ml, 100 ml vial Fresofol 1% MCT/LCT 10 39.90 Inj 10 mg per ml, 50 ml vial Fresofol 1% MCT/LCT 10 27.50 Inj 10 mg per ml, 20 ml ampoule Fresofol 1% MCT/LCT 5 5.75 Sevoflurane Soln for inhalation 100%, 250 ml bottle Baxter 6 930.00 Desflurane Soln for inhalation 100%, 240 ml bottle Suprane 6 1350.00 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 Inj 4% with adrenaline 1:100,000, 1.8 ml dental cartridge Any 0 Inj 4% with adrenaline 1:200,000 1.8 ml dental cartridge Any 0 Bupivacaine hydrochloride with glucose Inj 0.5% with glucose 8%, 4 ml ampoule Marcain Heavy 5 21.40 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 20.50 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 30.00 5 7.60 Benzocaine with tetracaine hydrochloride Gel 18% with tetracaine hydrochloride 2% e.g. ZAP Topical Anaesthetic Gel 0 Mepivacaine hydrochloride with adrenaline Inj 2% with adrenaline 1:100,000, 1.8 ml dental cartridge Any 0 Inj 2% with adrenaline 1:100,000, 2.2 ml dental cartridge Any 0 Bupivacaine hydrochloride Inj 2.5 mg per ml, 20 ml ampoule sterile pack Marcain 5 28.00 Inj 5 mg per ml, 10 ml ampoule sterile pack Marcain 5 16.20 Inj 5 mg per ml, 4 ml ampoule Marcain Isobaric 5 62.50 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, 200 ml bag Any 0 Inj 5 mg per ml, 20 ml ampoule sterile pack Marcain 5 16.56 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 61.68 Inj 2.5 mg per ml with adrenaline 1:400,000, 20 ml vial Marcain with Adrenaline 5 57.00 Inj 2.5 mg per ml with adrenaline 1:200,000, 10 ml ampoule Any 0 Bupivacaine hydrochloride with fentanyl Inj 1.25 mg with fentanyl 2 mcg per ml, 100 ml bag Bupafen 5 135.00 Inj 1.25 mg with fentanyl 2 mcg per ml, 200 ml bag Bupafen 5 138.00 Inj 1.25 mg with fentanyl 2 mcg per ml, 20 ml syringe Biomed 5 57.35 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 Inj 0.625 mg with fentanyl 2 mcg per ml, 200 ml bag Biomed 5 165.00 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%, 5 ml ampoule Lidocaine-Baxter 25 15.00 Inj 2%, 5 ml ampoule Lidocaine-Baxter 25 27.50 Spray 10% Xylocaine 50 82.90 Gel 2% Orion 20 4.87 Soln 4% Any 0 Oral (gel) soln 2% Xylocaine Viscous 200 30.80 Inj 1%, 20 ml ampoule, sterile pack Any 0 Inj 2%, 20 ml ampoule, sterile pack Any 0 Inj 1%, 20 ml vial Lidocaine-Baxter 5 19.50 Inj 2%, 20 ml vial Lidocaine-Baxter 5 14.00 Gel 2%, 11 ml urethral syringe Instillagel Lido 10 65.45 Inj 10%, 5 ml ampoule Any 0 Lidocaine [Lignocaine] hydrochloride with adrenaline Inj 1% with adrenaline 1:100,000, 5 ml ampoule Xylocaine 10 32.00 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 Inj 2% with adrenaline 1:100,000, 1.7 ml dental cartridge Any 0 Inj 1% with adrenaline 1:100,000, 20 ml vial Any 0 Prilocaine hydrochloride Inj 0.5%, 50 ml vial Citanest 5 100.00 Inj 2%, 5 ml ampoule Any 0 Ropivacaine hydrochloride Inj 10 mg per ml, 10 ml ampoule Ropivacaine Kabi 5 11.75 Inj 2 mg per ml, 100 ml bag Ropivacaine Kabi 5 32.85 Inj 2 mg per ml, 20 ml ampoule Ropivacaine Kabi 5 10.25 Inj 2 mg per ml, 200 ml bag Ropivacaine Kabi 5 43.40 Inj 7.5 mg per ml, 10 ml ampoule Ropivacaine Kabi 5 11.00 Inj 7.5 mg per ml, 20 ml ampoule Ropivacaine Kabi 5 13.50 Inj 10 mg per ml, 20 ml ampoule Ropivacaine Kabi 5 17.60 Inj 2 mg per ml, 10 ml ampoule Ropivacaine Kabi 5 9.80 Cocaine hydrochloride Paste 5% Any 0 Soln 15%, 2 ml syringe Any 0 Soln 4%, 2 ml syringe Biomed 1 30.77 Analgesics Non-Opioid Analgesics Aspirin Tab dispersible 300 mg Ethics Aspirin 100 5.65 Nefopam hydrochloride Tab 30 mg Any 0 Sucrose Oral liq 25% Biomed 25 14.61 Oral liq 66.7% (preservative free) <range>Sucrose</range> For use in neonatal patients only medical practitioner Methoxyflurane <range>Methoxyflurane</range> Patient is undergoing a painful procedure with an expected duration of less than one hour Only to be used under supervision by a medical practitioner or nurse who is trained in the use of methoxyflurane medical practitioner Paracetamol <range>Paracetamol</range> 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 medical practitioner Capsaicin <range>Capsaicin</range> For post-herpetic neuralgia or diabetic peripheral neuropathy medical practitioner Opioid Analgesics Alfentanil Inj 0.5 mg per ml, 2 ml ampoule Medsurge 5 8.99 Morphine sulphate Inj 1 mg per ml, 10 ml syringe Biomed 5 27.25 Inj 1 mg per ml, 50 ml syringe Biomed 5 63.75 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 4.10 Cap long-acting 30 mg m-Eslon 10 6.05 Cap long-acting 60 mg m-Eslon 10 12.10 Cap long-acting 100 mg m-Eslon 10 14.50 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 Medsurge 5 4.99 Inj 30 mg per ml, 1 ml ampoule Medsurge 5 7.28 Inj 5 mg per ml, 1 ml ampoule Medsurge 5 5.96 Inj 15 mg per ml, 1 ml ampoule Medsurge 5 6.93 Inj 1 mg per ml, 100 ml bag Biomed 5 114.25 Oral liq 2 mg per ml Wockhardt 100 16.31 Oramorph 300 42.56 Oramorph CDC S29 100 29.80 Remifentanil Inj 1 mg vial Remifentanil-AFT 5 14.95 Inj 2 mg vial Remifentanil-AFT 5 20.95 Tramadol hydrochloride Inj 10 mg per ml, 100 ml bag Any 0 Cap 50 mg Arrow-Tramadol 100 3.33 Tab sustained-release 100 mg Tramal SR 100 20 1.95 20 1.95 Tab sustained-release 150 mg Tramal SR 150 20 2.95 20 2.95 Tab sustained-release 200 mg Tramal SR 200 20 3.80 20 3.80 Inj 50 mg per ml, 1 ml ampoule Tramal 50 5 10.00 5 10.00 Inj 50 mg per ml, 2 ml ampoule Tramal 100 5 9.00 5 9.00 Oral soln 10 mg per ml Any 0 Codeine phosphate Tab 15 mg Noumed 100 5.82 Tab 30 mg Noumed 100 6.88 Tab 60 mg Noumed 100 13.89 Methadone hydrochloride Inj 10 mg per ml, 1 ml vial AFT 10 72.99 Oral liq 2 mg per ml Biodone 200 7.80 Oral liq 5 mg per ml Biodone Forte 200 7.80 Oral liq 10 mg per ml Biodone Extra Forte 200 9.65 Tab 5 mg Methadone BNM 10 1.38 Morphine tartrate Inj 80 mg per ml, 1.5 ml ampoule Any 0 Oxycodone hydrochloride Inj 1 mg per ml, 100 ml bag Any 0 Oral liq 1 mg per ml Oxycodone Lucis S29 250 37.08 Rosemont 250 37.08 Tab controlled-release 10 mg Oxycodone Sandoz 20 2.49 Tab controlled-release 20 mg Oxycodone Sandoz 20 3.41 Tab controlled-release 40 mg Oxycodone Sandoz 20 6.67 Tab controlled-release 80 mg Oxycodone Sandoz 20 12.99 Tab controlled-release 5 mg Oxycodone Sandoz 20 2.49 Inj 10 mg per ml, 1 ml ampoule Hameln 5 4.37 Inj 10 mg per ml, 2 ml ampoule Hameln 5 8.62 Inj 50 mg per ml, 1 ml ampoule Hameln 5 14.90 Tab immediate-release 5 mg Oxycodone Amneal 100 13.77 Tab immediate-release 10 mg Oxycodone Amneal 100 18.77 Tab immediate-release 20 mg Oxycodone Amneal 100 26.77 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 29.88 Inj 50 mg per ml, 2 ml ampoule DBL Pethidine Hydrochloride 5 30.72 Tab 50 mg Noumed Pethidine 10 8.68 Morphine hydrochloride Oral liq 1 mg per ml RA-Morph 200 19.00 Oral liq 2 mg per ml RA-Morph 200 23.55 Oral liq 5 mg per ml RA-Morph 200 28.20 Oral liq 10 mg per ml RA-Morph 200 40.25 Dihydrocodeine tartrate Tab long-acting 60 mg DHC Continus 60 9.20 Fentanyl Inj 10 mcg per ml, 10 ml syringe Biomed Fentanyl 5 44.50 Inj 10 mcg per ml, 100 ml bag Biomed 5 114.25 Inj 20 mcg per ml, 100 ml bag Any 0 Inj 20 mcg per ml, 50 ml syringe Biomed 5 136.50 Inj 50 mcg per ml, 10 ml ampoule Boucher and Muir 10 9.41 Inj 50 mcg per ml, 2 ml ampoule Boucher and Muir 10 4.25 Patch 75 mcg per hour Fentanyl Sandoz 5 15.50 Patch 25 mcg per hour Fentanyl Sandoz 5 6.91 Patch 50 mcg per hour Fentanyl Sandoz 5 9.28 Patch 100 mcg per hour Fentanyl Sandoz 5 16.37 Patch 12 mcg per hour Fentanyl Sandoz 5 6.02 Paracetamol with codeine Tab paracetamol 500 mg with codeine phosphate 8 mg Paracetamol + Codeine (Relieve) 1000 31.95 Antidepressants Cyclic and Related Agents Doxepin hydrochloride

For continuation only

Cap 10 mg Any 0 Cap 25 mg Any 0 Cap 50 mg Any 0 Maprotiline hydrochloride

For continuation only

Tab 25 mg Any 0 Tab 75 mg Any 0 Mianserin hydrochloride

For continuation only

Tab 30 mg Any 0 Clomipramine hydrochloride Tab 25 mg APO Clomipramine 50 16.99 Amitriptyline Tab 10 mg Arrow-Amitriptyline 100 2.99 Tab 25 mg Arrow-Amitriptyline 100 1.99 Tab 50 mg Arrow-Amitriptyline 100 3.14 Imipramine hydrochloride Tab 10 mg Tofranil 50 5.48 60 6.58 Tab 25 mg Tofranil 50 8.80 Imipramine Crescent 28 4.93 Dosulepin [Dothiepin] hydrochloride

For continuation only

Cap 25 mg Dosulepin Viatris 50 7.83 Tab 75 mg Dosulepin Viatris 30 3.85 Nortriptyline hydrochloride Tab 10 mg Allegron 50 2.24 Tab 25 mg Allegron 50 2.95 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 Aurorix 60 23.60 Tab 300 mg Aurorix 60 38.50 Other Antidepressants Venlafaxine Cap 37.5 mg Enlafax XR 84 8.29 84 8.29 Cap 75 mg Enlafax XR 84 10.32 84 10.32 Cap 150 mg Enlafax XR 84 13.95 Mirtazapine Tab 30 mg Noumed 30 2.34 Tab 45 mg Noumed 30 3.10 Selective Serotonin Reuptake Inhibitors Citalopram hydrobromide Tab 20 mg Celapram 84 3.55 Fluoxetine hydrochloride Cap 20 mg Arrow-Fluoxetine 90 3.50 Tab dispersible 20 mg, scored Fluox 28 2.37 Paroxetine Tab 20 mg Loxamine 90 4.98 Escitalopram Tab 10 mg Ipca-Escitalopram 28 0.79 Tab 20 mg Ipca-Escitalopram 28 1.49 Sertraline Tab 50 mg Setrona 30 1.24 Tab 100 mg Setrona 30 2.00 Antiepilepsy Drugs Agents for the Control of Status Epilepticus Paraldehyde Inj 5 ml ampoule Any 0 Soln 97% Any 0 Phenytoin sodium Inj 50 mg per ml, 5 ml ampoule Hospira 5 154.01 Clonazepam Inj 1 mg per ml, 1 ml ampoule Any 0 Diazepam Rectal tubes 5 mg Stesolid 5 54.58 Rectal tubes 10 mg Any 0 Inj 5 mg per ml, 2 ml ampoule Hospira 5 27.92 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 Zarontin 100 140.88 Oral liq 50 mg per ml Zarontin 200 56.35 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 9.98 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 <range>Vigabatrin</range> Patient has infantile spasms Patient has epilepsy Seizures are not adequately controlled with optimal treatment with other antiepilepsy agents Seizures are controlled adequately but the patient has experienced unacceptable side effects from optimal treatment with other antiepilepsy agents Patient has tuberous sclerosis complex Patient is, or will be, receiving regular automated visual field testing (ideally before starting therapy and on a 6-monthly basis thereafter) It is impractical or impossible (due to comorbid conditions) to monitor the patient's visual fields medical practitioner 15 The patient has demonstrated a significant and sustained improvement in seizure rate or severity and or quality of life Patient is receiving regular automated visual field testing (ideally every 6 months) on an ongoing basis for duration of treatment with vigabatrin It is impractical or impossible (due to comorbid conditions) to monitor the patient's visual fields medical practitioner Pregabalin

Note: Pregabalin not to be given in combination with gabapentin

Cap 25 mg Pregabalin Pfizer 56 2.25 Lyrica 56 2.25 Cap 75 mg Pregabalin Pfizer 56 2.65 Lyrica 56 2.65 Cap 150 mg Pregabalin Pfizer 56 4.01 Lyrica 56 4.01 Cap 300 mg Pregabalin Pfizer 56 7.38 Lyrica 56 7.38 Clonazepam Oral drops 2.5 mg per ml Any 0 Gabapentin

Note: Gabapentin not to be given in combination with pregabalin

Cap 100 mg Nupentin 100 6.45 Cap 300 mg Nupentin 100 8.45 Cap 400 mg Nupentin 100 10.26 Lamotrigine Tab dispersible 5 mg Lamictal 30 50.00 Tab dispersible 25 mg Logem 56 4.20 Tab dispersible 50 mg Logem 56 5.11 Tab dispersible 100 mg Logem 56 6.75 Tab dispersible 2 mg Lamictal 30 55.00 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 Noumed Phenobarbitone 500 248.50 Tab 30 mg Noumed Phenobarbitone 500 398.50 Levetiracetam Inj 100 mg per ml, 5 ml vial Levetiracetam-AFT 10 38.95 Tab 250 mg Everet 60 5.84 Tab 500 mg Everet 60 10.51 Tab 750 mg Everet 60 16.71 Tab 1,000 mg Everet 60 21.82 Oral liq 100 mg per ml Levetiracetam-AFT 300 44.78 Lacosamide <range>Lacosamide</range> Patient has focal epilepsy 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) medical practitioner 15

Those of childbearing potential are not required to trial phenytoin sodium, sodium valproate, or topiramate. Those who can father children are not required to trial sodium valproate.

 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 medical practitioner Stiripentol <range>Stiripentol</range> Patient has confirmed diagnosis of Dravet syndrome Seizures have been inadequately controlled by appropriate courses of sodium valproate, clobazam and at least two of the following: topiramate, levetiracetam, ketogenic diet paediatric neurologist 6

Those of childbearing potential are not required to trial sodium valproate or topiramate. Those who can father children are not required to trial sodium valproate.

 Patient continues to benefit from treatment as measured by reduced seizure frequency from baseline paediatric neurologist Antimigraine Preparations Acute Migraine Treatment Dihydroergotamine mesylate Inj 1 mg per ml, 1 ml ampoule Any 0 Metoclopramide hydrochloride with paracetamol Tab 5 mg with paracetamol 500 mg Any 0 Sumatriptan Tab 50 mg Sumagran 90 14.41 Tab 100 mg Sumagran 90 22.68 Inj 12 mg per ml, 0.5 ml prefilled pen Clustran 2 29.80 Rizatriptan Tab orodispersible 10 mg Rizamelt 30 4.84 Prophylaxis of Migraine Pizotifen Tab 500 mcg Sandomigran 100 23.21 Antinausea and Vertigo Agents Antinausea and Vertigo Agents Droperidol Inj 2.5 mg per ml, 1 ml ampoule Droperidol Medsurge 10 28.68 Granisetron Inj 1 mg per ml, 3 ml ampoule Deva 1 1.20 Metoclopramide hydrochloride Inj 5 mg per ml, 2 ml ampoule Medsurge 10 5.48 Oral liq 5 mg per 5 ml Any 0 Tab 10 mg Metoclopramide Actavis 10 100 1.57 Ondansetron Inj 2 mg per ml, 2 ml ampoule Ondansetron-AFT 5 1.54 Inj 2 mg per ml, 4 ml ampoule Ondansetron-AFT 5 2.14 Tab 4 mg Periset 50 1.95 Tab 8 mg Periset 50 3.50 Tab dispersible 4 mg Periset ODT 10 0.56 Tab dispersible 8 mg Periset ODT 10 0.90 Tropisetron Inj 1 mg per ml, 2 ml ampoule Any 0 Inj 1 mg per ml, 5 ml ampoule Any 0 Betahistine dihydrochloride Tab 16 mg Serc 100 3.70 Cyclizine lactate Inj 50 mg per ml, 1 ml ampoule Hameln 10 16.36 Hyoscine hydrobromide Patch 1 mg per 72 hours <range>Hyoscine hydrobromide - Patch 1.5 mg</range> 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 Control of clozapine-induced hypersalivation where trials of at least two other alternative treatments have proven ineffective For treatment of post-operative nausea and vomiting where cyclizine, droperidol and a 5HT3 antagonist have proven ineffective, are not tolerated or are contraindicated medical practitioner Inj 400 mcg per ml, 1 ml ampoule Any 0 Cyclizine hydrochloride Tab 50 mg Nausicalm 10 0.66 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 Nausafix 250 25.00 Aprepitant <range>Aprepitant</range> Patient is undergoing highly emetogenic chemotherapy and/or anthracycline-based chemotherapy for the treatment of malignancy medical practitioner Domperidone Tab 10 mg Domperidone Viatris 100 3.80 Antipsychotic Agents General Chlorpromazine hydrochloride Inj 25 mg per ml, 2 ml ampoule Largactil 10 30.79 Oral liq 10 mg per ml Any 0 Tab 100 mg Largactil 100 36.73 Tab 25 mg Largactil 100 15.62 Oral liq 20 mg per ml Any 0 Levomepromazine Tab 100 mg Nozinan 100 41.75 Tab 25 mg Nozinan 100 16.10 Pericyazine Tab 10 mg Any 0 Tab 2.5 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 Levomepromazine hydrochloride Inj 25 mg per ml, 1 ml ampoule Wockhardt 10 23.26 Clozapine Tab 100 mg Clozaril 50 17.33 100 34.65 50 17.33 Clopine 100 34.65 50 17.33 Tab 25 mg Clozaril 50 6.69 100 13.37 50 6.69 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 Versacloz 100 173.30 Quetiapine Tab 100 mg Quetapel 90 6.40 Tab 200 mg Quetapel 90 10.97 Tab 25 mg Quetapel 90 2.36 Quetiapine Viatris 30 0.79 500 13.11 Tab 300 mg Quetapel 90 15.83 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, 1 ml ampoule Serenace 10 12.93 Olanzapine Inj 10 mg vial Any 0 Tab 2.5 mg Zypine 30 1.40 Tab 5 mg Zypine 30 1.93 Tab 10 mg Zypine 28 1.80 30 1.93 Tab orodispersible 10 mg Zypine ODT 28 2.89 Olanzapina Mylan Pharma 28 2.89 Olanzapina Mylan 28 2.89 Tab orodispersible 5 mg Zypine ODT 28 2.42 Risperidone Oral liq 1 mg per ml Risperon 30 10.29 100 34.30 Tab 0.5 mg Risperidone (Teva) 60 2.17 Tab 1 mg Risperidone (Teva) 60 2.44 Tab 2 mg Risperidone (Teva) 60 2.72 Tab 3 mg Risperidone (Teva) 60 4.50 Tab 4 mg Risperdal 60 6.25 Risperidone (Teva) 60 6.25 Ziprasidone Cap 20 mg Zusdone 60 17.90 Cap 40 mg Zusdone 60 27.41 Cap 60 mg Zusdone 60 38.39 Cap 80 mg Zusdone 60 46.55 Aripiprazole Tab 10 mg Aripiprazole Sandoz 30 10.50 Tab 30 mg Aripiprazole Sandoz 30 10.50 Tab 15 mg Aripiprazole Sandoz 30 10.50 Tab 20 mg Aripiprazole Sandoz 30 10.50 Tab 5 mg Aripiprazole Sandoz 30 10.50 Amisulpride Tab 100 mg Sulprix 30 5.84 Tab 200 mg Sulprix 60 14.47 Oral liq 100 mg per ml Any 0 Tab 400 mg Sulprix 60 35.06 Zuclopenthixol hydrochloride Tab 10 mg Clopixol 100 31.45 Lithium carbonate Tab long-acting 400 mg Priadel 100 82.80 Cap 250 mg Douglas 100 35.78 Depot Injections Pipothiazine palmitate

For continuation only

Inj 50 mg per ml, 1 ml ampoule Any 0 Inj 50 mg per ml, 2 ml ampoule Any 0 Paliperidone <range>Paliperidone</range> The patient has had an initial Special Authority approval for risperidone depot injection or olanzapine depot injection or aripiprazole depot injection The patient has schizophrenia or other psychotic disorder The patient has been unable to adhere to treatment using oral atypical antipsychotic agents 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 medical practitioner 12 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 medical practitioner 12 Paliperidone palmitate <range>Paliperidone palmitate</range> The patient has schizophrenia The patient has had an initial Special Authority approval for paliperidone once-monthly depot injection medical practitioner 12 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 medical practitioner 12 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 <range>Olanzapine</range> The patient has had an initial Special Authority approval for paliperidone depot injection or risperidone depot injection The patient has schizophrenia or other psychotic disorder The patient has tried but failed to comply with treatment using oral atypical antipsychotic agents 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 The patient has trialled other funded depot antipsychotics (aripiprazole, risperidone, and paliperidone) unless it is considered clinically inappropriate to use these The patient continues to have difficulties with adherence on oral antipsychotic treatments Prescribing clinician has relevant Clinical Director (Mental Health and Addiction services) approval medical practitioner 12 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 medical practitioner 12 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 <range>Risperidone</range> The patient has had an initial Special Authority approval for paliperidone depot injection or olanzapine depot injection or aripiprazole depot injection The patient has schizophrenia or other psychotic disorder The patient has not been able to adhere to treatment using oral atypical antipsychotic agents 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 medical practitioner 12 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 medical practitioner 12 Aripiprazole <range>Aripiprazole</range> The patient has had an initial Special Authority approval for risperidone depot injection or paliperidone depot injection or olanzapine depot injection The patient has schizophrenia or other psychotic disorder The patient has received treatment with oral atypical antipsychotic agents but has been unable to adhere 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 last 12 months Patient has been unable to access olanzapine depot injection due to supply issues with olanzapine depot injection, or otherwise would have been initiated on olanzapine depot injection but has been unable to due to supply issues with olanzapine depot injection. (see Note below for the olanzapine Special Authority criteria for new olanzapine depot injection patients prior to 1 April 2024) medical practitioner

The Olanzapine depot injection Special Authority criteria that apply to criterion 2 in this Aripiprazole Special Authority application are as follows:

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

  • All of the following:

    • The patient has schizophrenia; and

    • The patient has tried but has not been able to adhere with treatment using oral atypical antipsychotic agents; and

    • 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.

 Anxiolytics Anxiolytics Oxazepam Tab 10 mg Any 0 Tab 15 mg Any 0 Clonazepam Tab 500 mcg Paxam 100 5.64 Tab 2 mg Paxam 100 10.78 Diazepam Tab 2 mg Arrow-Diazepam 500 95.00 Tab 5 mg Arrow-Diazepam 500 115.00 Oral liq 10 mg per 10 ml <range>Diazepam</range> Only for use in children where diazepam tablets are not appropriate relevant specialist Lorazepam Tab 1 mg Ativan 250 10.20 Tab 2.5 mg Ativan 100 13.13 Buspirone hydrochloride Tab 5 mg Buspirone Viatris 100 13.95 Tab 10 mg Buspirone Viatris 100 12.50 Multiple Sclerosis Treatments Multiple Sclerosis Treatments <range>Multiple Sclerosis</range> Diagnosis of multiple sclerosis (MS) meets the McDonald 2017 diagnostic criteria for MS and has been confirmed by a neurologist Patient has an EDSS score between 0 – 6.0 Patient has had at least one significant attack of MS in the previous 12 months or two significant attacks in the past 24 months Each significant attack must be confirmed by the applying neurologist or general physician (the patient may not necessarily have been seen by them during the attack, but the neurologist/physician must be satisfied that the clinical features were characteristic) Each significant attack is associated with characteristic new symptom(s)/sign(s) or substantially worsening of previously experienced symptoms(s)/sign(s) Each significant attack has lasted at least one week and has started at least one month after the onset of a previous attack (where relevant) Each significant attack can be distinguished from the effects of general fatigue; and is not associated with a fever (T> 37.5°C) Each significant attack is severe enough to change either the EDSS or at least one of the Kurtze Functional System scores by at least 1 point Each significant attack is a recurrent paroxysmal symptom of multiple sclerosis (tonic seizures/spasms, trigeminal neuralgia, Lhermitte’s symptom) Evidence of new inflammatory activity on an MRI scan within the past 24 months A sign of that new inflammatory activity on MRI scanning (in criterion 5 immediately above) is a gadolinium enhancing lesion A sign of that new inflammatory activity is a lesion showing diffusion restriction A sign of that new inflammatory is a T2 lesion with associated local swelling A sign of that new inflammatory activity is a prominent T2 lesion that clearly is responsible for the clinical features of a recent attack that occurred within the last 2 years A sign of that new inflammatory activity is new T2 lesions compared with a previous MRI scan Patient has an active approval for ocrelizumab and does not have primary progressive MS any relevant practitioner 12

Treatment on two or more funded multiple sclerosis treatments simultaneously is not permitted.

 Patient has had an EDSS score of 0 to 6.0 (inclusive) with or without the use unilateral or bilateral aids at any time in the last six months (ie the patient has walked 100 metres or more with or without aids in the last six months) any relevant practitioner

Treatment on two or more funded multiple sclerosis treatments simultaneously is not permitted.

 Multiple Sclerosis Treatments - Other Ocrelizumab

Note: Treatment on two or more funded multiple sclerosis treatments simultaneously is not permitted.

<range>Multiple Sclerosis</range> Diagnosis of multiple sclerosis (MS) meets the McDonald 2017 diagnostic criteria for MS and has been confirmed by a neurologist Patient has an EDSS score between 0 – 6.0 Patient has had at least one significant attack of MS in the previous 12 months or two significant attacks in the past 24 months Each significant attack must be confirmed by the applying neurologist or general physician (the patient may not necessarily have been seen by them during the attack, but the neurologist/physician must be satisfied that the clinical features were characteristic) Each significant attack is associated with characteristic new symptom(s)/sign(s) or substantially worsening of previously experienced symptoms(s)/sign(s) Each significant attack has lasted at least one week and has started at least one month after the onset of a previous attack (where relevant) Each significant attack can be distinguished from the effects of general fatigue; and is not associated with a fever (T> 37.5°C) Each significant attack is severe enough to change either the EDSS or at least one of the Kurtze Functional System scores by at least 1 point Each significant attack is a recurrent paroxysmal symptom of multiple sclerosis (tonic seizures/spasms, trigeminal neuralgia, Lhermitte’s symptom) Evidence of new inflammatory activity on an MRI scan within the past 24 months A sign of that new inflammatory activity on MRI scanning (in criterion 5 immediately above) is a gadolinium enhancing lesion A sign of that new inflammatory activity is a lesion showing diffusion restriction A sign of that new inflammatory is a T2 lesion with associated local swelling A sign of that new inflammatory activity is a prominent T2 lesion that clearly is responsible for the clinical features of a recent attack that occurred within the last 2 years A sign of that new inflammatory activity is new T2 lesions compared with a previous MRI scan Patient has an active Special Authority approval for either dimethyl fumarate, fingolimod, glatiramer acetate, interferon beta-1-alpha, interferon beta-1-beta, natalizumab or teriflunomide any relevant practitioner 12

Treatment on two or more funded multiple sclerosis treatments simultaneously is not permitted.

 Patient has had an EDSS score of 0 to 6.0 (inclusive) with or without the use unilateral or bilateral aids at any time in the last six months (ie the patient has walked 100 metres or more with or without aids in the last six months) any relevant practitioner

Treatment on two or more funded multiple sclerosis treatments simultaneously is not permitted.

 Diagnosis of primary progressive multiple sclerosis (PPMS) meets the 2017 McDonald criteria and has been confirmed by a neurologist Patient has an EDSS 2.0 (score equal to or greater than 2 on pyramidal functions) to EDSS 6.5 Patient has no history of relapsing remitting multiple sclerosis any relevant practitioner 12 Patient has had an EDSS score of less than or equal to 6.5 at any time in the last six months (ie patient has walked 20 metres with bilateral assistance/aids, without rest in the last six months) any relevant practitioner 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

For continuation only

Tab 1 mg Any 0 Triazolam

For continuation only

Tab 125 mcg Any 0 Tab 250 mcg Any 0 Melatonin <range>Melatonin</range> Patient has been diagnosed with persistent and distressing insomnia secondary to a neurodevelopmental disorder (including, but not limited to, autism spectrum disorder or attention deficit hyperactivity disorder) Behavioural and environmental approaches have been tried or are inappropriate Funded modified-release melatonin is to be given at doses no greater than 10 mg per day Patient is aged 18 years or under psychiatrist paediatrician neurologist respiratory specialist 12 Patient is aged 18 years or under Patient has demonstrated clinically meaningful benefit from funded modified-release melatonin (clinician determined) Patient has had a trial of funded modified-release melatonin discontinuation within the past 12 months and has had a recurrence of persistent and distressing insomnia Funded modified-release melatonin is to be given at doses no greater than 10 mg per day psychiatrist paediatrician neurologist respiratory specialist 12 Patient has insomnia and benzodiazepines and zopiclone are contraindicated For in-hospital use only medical practitioner Midazolam Inj 1 mg per ml, 5 ml ampoule Midazolam-Baxter 10 7.80 Inj 5 mg per ml, 3 ml ampoule Midazolam-Baxter 5 4.75 Oral liq 2 mg per ml Any 0 Tab 7.5 mg Any 0 1 Inj 5 mg per ml, 1 ml plastic ampoule Midazolam-Pfizer 10 22.50 Temazepam Tab 10 mg Normison 25 1.40 Zopiclone Tab 7.5 mg Zopiclone Actavis 500 21.85 Phenobarbitone Inj 200 mg per ml, 1 ml ampoule Any 0 Inj 130 mg per ml, 1 ml vial Any 0 Spinal Muscular Atrophy Spinal Muscular Atrophy Nusinersen <range>Nusinersen</range> Patient has genetic documentation of homozygous SMN1 gene deletion, homozygous SMN1 point mutation, or compound heterozygous mutation Patient is 18 years of age or under Patient has experienced the defined signs and symptoms of SMA type I, II or IIIa prior to three years of age Patient is pre-symptomatic Patient has three or less copies of SMN2 medical practitioner 12 There has been demonstrated maintenance of motor milestone function since treatment initiation Patient does not require invasive permanent ventilation (at least 16 hours per day), in the absence of a potentially reversible cause while being treated with nusinersen Nusinersen not to be administered in combination other SMA disease modifying treatments or gene therapy medical practitioner 12 Risdiplam

Note: the supply of risdiplam is via Pharmac's approved direct distribution supply. Further details can be found on Pharmac's website https://pharmac.govt.nz/risdiplam

<range>Risdiplam</range> Patient has genetic documentation of homozygous SMN1 gene deletion, homozygous SMN1 point mutation, or compound heterozygous mutation Patient is 18 years of age or under Patient has experienced the defined signs and symptoms of SMA type I, II or IIIa prior to three years of age Patient is pre-symptomatic Patient has three or less copies of SMN2 medical practitioner 12 There has been demonstrated maintenance of motor milestone function since treatment initiation Patient does not require invasive permanent ventilation (at least 16 hours per day), in the absence of a potentially reversible cause while being treated with risdiplam Risdiplam not to be administered in combination other SMA disease modifying treatments or gene therapy medical practitioner 12 Stimulants / ADHD Treatments Stimulants / ADHD Treatments Caffeine Tab 100 mg Any 0 Modafinil <range>Modafinil</range> The patient has a diagnosis of narcolepsy and has excessive daytime sleepiness associated with narcolepsy occurring almost daily for three months or more 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 The patient has at least one of: cataplexy, sleep paralysis or hypnagogic hallucinations An effective dose of a listed formulation of methylphenidate or dexamphetamine has been trialled and discontinued because of intolerable side effects Methylphenidate and dexamphetamine are contraindicated Patient meets the Hospital Restriction criteria for methylphenidate hydrochloride for narcolepsy Patient is unable to access methylphenidate hydrochloride presentations due to an out of stock (see note) neurologist respiratory specialist

Criterion 2 is to permit short-term funding to cover an out-of-stock of methylphenidate hydrochloride.

 Lisdexamfetamine dimesilate <range>Lisdexamfetamine dimesilate</range> Patient is currently on treatment with lisdexamfetamine dimesilate and met all the following criteria prior to commencing treatment ADHD (Attention Deficit and Hyperactivity Disorder) Diagnosed according to DSM-5 or ICD 11 criteria Patient is taking a currently subsidised formulation of atomoxetine or methylphenidate hydrochloride (extended-release) for ADHD and has not received sufficient clinical benefit or has experienced intolerable side effects Patient is taking a currently subsidised formulation of dexamfetamine sulfate (immediate-release) which has not been effective due to significant administration and/or treatment adherence difficulties There is significant concern regarding the risk of diversion or abuse of immediate release dexamfetamine sulfate Patient is taking a currently subsidised formulation of methylphenidate hydrochloride (immediate-release or sustained release) which has not been effective due to significant administration and/or treatment adherence difficulties There is significant concern regarding the risk of diversion or abuse of immediate release methylphenidate hydrochloride Patient would have been prescribed a subsidised formulation of methylphenidate hydrochloride (extended-release) but has been unable to access due to supply issues with methylphenidate hydrochloride (extended-release) Other alternative stimulant presentations (methylphenidate or dexamfetamine) are not appropriate Lisdexamfetamine dimesilate is not to be used in combination with another funded methylphenidate presentation medical practitioner

Prescribing practitioner detail is in the relevant approval notice published in the New Zealand Gazette. Approval notices are located through the ‘Medicines (controlled drugs) with restrictions under regulation 22 of the Misuse of Drugs Regulations 1977’ section of the Medsafe ‘Restrictions on the Supply, Prescribing or Administration of Medicines under the Medicines Act 1981 and Misuse of Drugs Regulations 1977’ webpage (https://www.medsafe.govt.nz/profs/riss/restrict.asp#MedicinesReg22 as of April 2025).

 Methylphenidate hydrochloride <range>Methylphenidate hydrochloride</range> Patient has ADHD (Attention Deficit and Hyperactivity Disorder), diagnosed according to DSM-IV or ICD 10 criteria medical practitioner Patient has ADHD (Attention Deficit and Hyperactivity Disorder), diagnosed according to DSM-IV or ICD 10 criteria 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 treatment adherence difficulties There is significant concern regarding the risk of diversion or abuse of immediate-release methylphenidate hydrochloride medical practitioner

Prescribing practitioner detail is in the relevant approval notice published in the New Zealand Gazette. Approval notices are located through the ‘Medicines (controlled drugs) with restrictions under regulation 22 of the Misuse of Drugs Regulations 1977’ section of the Medsafe ‘Restrictions on the Supply, Prescribing or Administration of Medicines under the Medicines Act 1981 and Misuse of Drugs Regulations 1977’ webpage (https://www.medsafe.govt.nz/profs/riss/restrict.asp#MedicinesReg22 as of April 2025).

 Patient suffers from narcolepsy neurologist respiratory specialist Patient suffers from narcolepsy neurologist respiratory specialist

*narcolepsy is not a registered indication for Concerta, Ritalin LA or Methylphenidate Sandoz XR.

 Dexamfetamine sulfate <range>Dexamphetamine sulphate</range> Patient has ADHD (Attention Deficit and Hyperactivity Disorder), diagnosed according to DSM-IV or ICD 10 criteria medical practitioner

Prescribing practitioner detail is in the relevant approval notice published in the New Zealand Gazette. Approval notices are located through the ‘Medicines (controlled drugs) with restrictions under regulation 22 of the Misuse of Drugs Regulations 1977’ section of the Medsafe ‘Restrictions on the Supply, Prescribing or Administration of Medicines under the Medicines Act 1981 and Misuse of Drugs Regulations 1977’ webpage (https://www.medsafe.govt.nz/profs/riss/restrict.asp#MedicinesReg22 as of April 2025).

 Patient suffers from narcolepsy neurologist respiratory specialist Atomoxetine Cap 10 mg APO-Atomoxetine 28 43.02 Cap 18 mg APO-Atomoxetine 28 45.57 Cap 25 mg APO-Atomoxetine 28 44.30 Cap 40 mg APO-Atomoxetine 28 46.21 Cap 60 mg APO-Atomoxetine 28 51.31 Cap 80 mg APO-Atomoxetine 28 65.20 Cap 100 mg APO-Atomoxetine 28 65.71 Treatments for Dementia Treatments for Dementia Rivastigmine <range>Rivastigmine</range> The patient has been diagnosed with dementia The patient is contraindicated to or has experienced intolerable side effects from donepezil tablets medical practitioner 6 The treatment remains appropriate The patient has demonstrated a significant and sustained benefit from treatment medical practitioner 12 Donepezil hydrochloride Tab 5 mg Ipca-Donepezil 84 3.70 Tab 10 mg Ipca-Donepezil 84 5.50 Treatments for Substance Dependence Treatments for Substance Dependence Disulfiram Tab 200 mg Antabuse 100 236.40 Naltrexone hydrochloride <range>Naltrexone hydrochloride</range> Patient is currently enrolled, or is planned to be enrolled, in a recognised comprehensive treatment programme for alcohol dependence Naltrexone is to be prescribed by, or on the recommendation of, a physician working in an Alcohol and Drug Service medical practitioner For the treatment of opioid-induced constipation medical practitioner Nicotine <range>Nicotine</range> For perioperative use in patients who have a 'nil by mouth' instruction For use within mental health inpatient units Patient would be admitted to a mental health inpatient unit, but is unable to due to COVID-19 self-isolation requirement For acute use in agitated patients who are unable to leave the hospital facilities medical practitioner Bupropion hydrochloride Tab modified-release 150 mg Zyban 30 15.00 Varenicline <range>Varenicline</range> Short-term therapy as an aid to achieving abstinence in a patient who has indicated that they are ready to cease smoking 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 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 The patient has tried but failed to quit smoking using bupropion or nortriptyline The patient has not had a Special Authority for varenicline approved in the last 6 months Varenicline is not to be used in combination with other pharmacological smoking cessation treatments and the patient has agreed to this The patient is not pregnant The patient will not be prescribed more than 12 weeks' funded varenicline in a 12 month period medical practitioner Buprenorphine with naloxone <range>Buprenorphine with naloxone</range> Patient is opioid dependent Patient is currently engaged with an opioid treatment service approved by the Ministry of Health Prescriber works in an opioid treatment service approved by the Ministry of Health medical practitioner Patient is opioid dependent Patient will not be receiving methadone Patient is currently enrolled in an opioid substitution treatment program in a service approved by the Ministry of Health Prescriber works in an opioid treatment service approved by the Ministry of Health medical practitioner Oncology Agents and Immunosuppressants Chemotherapeutic Agents Alkylating Agents Carmustine Inj 100 mg vial BiCNU 1 710.00 BiCNU S29 1 710.00 Novadoz 1 710.00 Chlorambucil Tab 2 mg Any 0 Melphalan Inj 50 mg vial Melpha 1 48.25 Tab 2 mg Any 0 Thiotepa Inj 15 mg vial Tepadina 1 398.00 Inj 100 mg vial Tepadina 1 1800.00 Bendamustine hydrochloride <range>Bendamustine hydrochloride</range> The patient has chronic lymphocytic leukaemia requiring treatment Patient has ECOG performance status 0-2 Bendamustine is to be administered at a maximum dose of 100 mg/m² on days 1 and 2 every 4 weeks for a maximum of 6 cycles medical practitioner

Indication marked with a * includes indications that are unapproved. 'Chronic lymphocytic leukaemia (CLL)' includes small lymphocytic lymphoma (SLL).

 The patient has indolent low grade NHL requiring treatment Patient has ECOG performance status of 0-2 Patient is treatment naive Bendamustine is to be administered for a maximum of 6 cycles (in combination with rituximab when CD20+) Patient is refractory to or has relapsed within 12 months of a rituximab containing combined chemo-immunotherapy regimen Bendamustine is to be administered in combination with obinutuzumab for a maximum of 6 cycles The patient has not received prior bendamustine therapy Bendamustine is to be administered for a maximum of 6 cycles in relapsed patients (in combination with rituximab when CD20+) Patient has had a rituximab treatment-free interval of 12 months or more Bendamustine is to be administered as monotherapy for a maximum of 6 cycles in rituximab refractory patients medical practitioner 9 Patient is refractory to or has relapsed within 12 months of rituximab in combination with bendamustine Bendamustine is to be administered in combination with obinutuzumab for a maximum of 6 cycles Patients have not received a bendamustine regimen within the last 12 months Bendamustine is to be administered for a maximum of 6 cycles in relapsed patients (in combination with rituximab when CD20+) Patient has had a rituximab treatment-free interval of 12 months or more Bendamustine is to be administered as a monotherapy for a maximum of 6 cycles in rituximab refractory patients medical practitioner 9

'indolent, low-grade lymphomas' includes follicular, mantle cell, marginal zone and lymphoplasmacytic/ Waldenström's macroglobulinaemia.

 Patient has Hodgkin's lymphoma requiring treatment Patient has a ECOG performance status of 0-2 Patient has received one prior line of chemotherapy Patient's disease relapsed or was refractory following prior chemotherapy Bendamustine is to be administered in combination with gemcitabine and vinorelbine (BeGeV) at a maximum dose of no greater than 90 mg/m2 twice per cycle, for a maximum of four cycles relevant specialist medical practitioner 6

Indications marked with * are unapproved indications.

 Cyclophosphamide Tab 50 mg Cyclonex 50 145.00 Inj 1 g vial Endoxan 1 47.46 Inj 2 g vial Endoxan 1 95.06 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 40 mg Medac 20 880.00 Anthracyclines and Other Cytotoxic Antibiotics Dactinomycin [Actinomycin D] Inj 0.5 mg vial Cosmegen 1 255.00 Bleomycin sulphate Inj 15,000 iu vial DBL Bleomycin Sulfate 1 185.16 Daunorubicin Inj 20 mg vial Cerubidine 1 171.93 Inj 18.7 mg vial Pfizer 1 160.75 Doxorubicin hydrochloride Inj 2 mg per ml, 25 ml vial Doxorubicin Ebewe 1 11.50 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 69.99 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, 100 ml vial Epirubicin Ebewe 1 99.99 Idarubicin hydrochloride Inj 5 mg vial Zavedos 1 109.74 Inj 10 mg vial Zavedos 1 233.64 Mitozantrone Inj 2 mg per ml, 10 ml vial Mitozantrone Ebewe 1 97.50 Mitomycin C Inj 5 mg vial Any 0 Inj 20 mg vial Teva 1 1129.94 Antimetabolites Fluorouracil Inj 50 mg per ml, 100 ml vial Fluorouracil Accord 1 19.36 Inj 50 mg per ml, 20 ml vial Fluorouracil Accord 1 10.51 Inj 50 mg per ml, 50 ml vial Fluorouracil Accord 1 14.72 Thioguanine Tab 40 mg Any 0 Azacitidine <range>Azacitidine</range> The individual has intermediate or high risk MDS based on an internationally recognised scoring system The individual has chronic myelomonocytic leukaemia (based on an intermediate or high risk score from an internationally recognised scoring system or 10%-29% marrow blasts without myeloproliferative disorder) The individual has acute myeloid leukaemia according to World Health Organisation (WHO) Classification The individual has an estimated life expectancy of at least 3 months medical practitioner 12 No evidence of disease progression medical practitioner 12 Pemetrexed Inj 100 mg vial Pemetrexed-AFT 1 8.99 Inj 500 mg vial Pemetrexed-AFT 1 29.99 Capecitabine Tab 150 mg Capecitabine Viatris 60 10.92 Tab 500 mg Capecitabine Viatris 120 50.96 Cladribine Inj 1 mg per ml, 10 ml vial Leustatin 1 749.96 Inj 2 mg per ml, 5 ml vial Any 0 Cytarabine Inj 100 mg per ml, 20 ml vial Cytarabine DBL 1 48.80 Pfizer 1 48.80 Inj 20 mg per ml, 5 ml vial Pfizer 5 472.00 5 472.00 Fludarabine phosphate Tab 10 mg Fludara Oral 20 412.00 Inj 50 mg vial Fludarabine Ebewe 5 634.00 Gemcitabine Hydrochloride Inj 43.3 mg per ml (equivalent to 38 mg per ml gemcitabine), 26.3 ml vial DBL Gemcitabine 1 18.94 Methotrexate Tab 2.5 mg Trexate 90 7.80 Tab 10 mg Trexate 90 26.40 Inj 100 mg per ml, 10 ml vial Methotrexate Ebewe 1 25.00 Inj 100 mg per ml, 50 ml vial Methotrexate Ebewe 1 67.99 Inj 2.5 mg per ml, 2 ml vial Any 0 Inj 25 mg per ml, 2 ml vial Methotrexate DBL Onco-Vial 5 30.00 Inj 25 mg per ml, 20 ml vial DBL Methotrexate Onco-Vial 1 45.00 Inj 7.5 mg prefilled syringe Methotrexate Sandoz 1 29.17 Inj 10 mg prefilled syringe Methotrexate Sandoz 1 19.09 Inj 15 mg prefilled syringe Methotrexate Sandoz 1 24.53 Inj 20 mg prefilled syringe Methotrexate Sandoz 1 16.64 Inj 25 mg prefilled syringe Methotrexate Sandoz 1 20.72 Inj 30 mg prefilled syringe Methotrexate Sandoz 1 55.00 Mercaptopurine Tab 50 mg Puri-nethol 25 19.50 Oral suspension 20 mg per ml <range>Mercaptopurine</range> The patient requires a total dose of less than one full 50 mg tablet per day paediatric haematologist paediatric oncologist 12 The patient requires a total dose of less than one full 50 mg tablet per day paediatric haematologist paediatric oncologist 12 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 Venetoclax <range>Venetoclax</range> Individual has chronic lymphocytic leukaemia requiring treatment Individual has received at least one prior therapy for chronic lymphocytic leukaemia Individual has not previously received funded venetoclax The individual’s disease has relapsed Venetoclax to be used in combination with six 28-day cycles of rituximab commencing after the 5-week dose titration schedule with venetoclax Individual has an ECOG performance status of 0-2 medical practitioner 7 Treatment remains clinically appropriate and the individual is benefitting from and tolerating treatment Venetoclax is to be discontinued after a maximum of 24 months of treatment following the titration schedule unless earlier discontinuation is required due to disease progression or unacceptable toxicity medical practitioner 6 Individual has previously untreated chronic lymphocytic leukaemia There is documentation confirming that the individual has 17p deletion by FISH testing or TP53 mutation by sequencing Individual has an ECOG performance status of 0-2 medical practitioner 6 No evidence of disease progression medical practitioner 6

‘Chronic lymphocytic leukaemia (CLL)’ includes small lymphocytic lymphoma (SLL)* and B-cell prolymphocytic leukaemia (B-PLL)*. Indications marked with * are unapproved indications

 The individual is currently on treatment with venetoclax and met all remaining special authority criteria prior to commencing treatment Individual has previously untreated acute myeloid leukaemia (see note a), according to World Health Organization (WHO) Classification Venetoclax not to be used in combination with standard intensive remission induction chemotherapy Venetoclax to be used in combination with azacitidine or low dose cytarabine medical practitioner 6 No evidence of disease progression medical practitioner 6

  1. ‘Acute myeloid leukaemia’ includes myeloid sarcoma*

  2. Indications marked with * are Unapproved indications

 Olaparib <range>Olaparib</range> Patient has a high-grade serous* epithelial ovarian, fallopian tube, or primary peritoneal cancer There is documentation confirming pathogenic germline BRCA1 or BRCA2 gene mutation Patient has newly diagnosed, advanced disease Patient has received one line** of previous treatment with platinum-based chemotherapy Patient’s disease must have experienced a partial or complete response to the first-line platinum-based regimen Patient has received at least two lines** of previous treatment with platinum-based chemotherapy Patient has platinum sensitive disease defined as disease progression occurring at least 6 months after the last dose of the penultimate line** of platinum-based chemotherapy Patient’s disease must have experienced a partial or complete response to treatment with the immediately preceding platinum-based regimen Patient has not previously received funded olaparib treatment Treatment will be commenced within 12 weeks of the patient’s last dose of the immediately preceding platinum-based regimen Treatment to be administered as maintenance treatment Treatment not to be administered in combination with other chemotherapy medical oncologist 12 Treatment remains clinically appropriate and patient is benefitting from treatment No evidence of progressive disease Evidence of residual (not progressive) disease and the patient would continue to benefit from treatment in the clinician’s opinion Treatment to be administered as maintenance treatment Treatment not to be administered in combination with other chemotherapy Patient has received one line** of previous treatment with platinum-based chemotherapy Documentation confirming that the patient has been informed and acknowledges that the funded treatment period of olaparib will not be continued beyond 2 years if the patient experiences a complete response to treatment and there is no radiological evidence of disease at 2 years Patient has received at least two lines** of previous treatment with platinum-based chemotherapy medical oncologist 12

*Note “high-grade serous” includes tumours with high-grade serous features or a high-grade serous component.

**A line of chemotherapy treatment is considered to comprise a known standard therapeutic chemotherapy regimen and supportive treatments.

 Ibrutinib <range>Ibrutinib</range> Individual has chronic lymphocytic leukaemia (CLL) requiring therapy Individual has not previously received funded ibrutinib Ibrutinib is to be used as monotherapy There is documentation confirming that the individual has 17p deletion or TP53 mutation Individual has experienced intolerable side effects with venetoclax monotherapy Individual has received at least one prior immunochemotherapy for CLL Individual’s CLL has relapsed Individual has experienced intolerable side effects with venetoclax in combination with rituximab regimen Individual’s CLL is refractory to or has relapsed following a venetoclax regimen medical practitioner 6 No evidence of clinical disease progression medical practitioner 12

‘Chronic lymphocytic leukaemia (CLL)’ includes small lymphocytic lymphoma (SLL) and B-cell prolymphocytic leukaemia (B-PLL)*. Indications marked with * are Unapproved indications.

 Niraparib <range>Niraparib</range> Patient has advanced high-grade serous* epithelial ovarian, fallopian tube, or primary peritoneal cancer Patient has received at least one line** of treatment with platinum-based chemotherapy Patient has experienced a partial or complete response to the preceding treatment with platinum-based chemotherapy Patient has not previously received funded treatment with a PARP inhibitor Treatment will be commenced within 12 weeks of the patient's last dose of the preceding platinum-based regimen Patient commenced treatment with niraparib prior to 1 May 2024 Treatment to be administered as maintenance treatment Treatment not to be administered in combination with other chemotherapy medical practitioner 6 No evidence of progressive disease Treatment to be administered as maintenance treatment Treatment not to be administered in combination with other chemotherapy Treatment with niraparib to cease after a total duration of 36 months from commencement Treatment with niraparib is being used in the second-line or later maintenance setting medical practitioner 6

* "high-grade serous" includes tumours with high-grade serous features or a high-grade serous component.

**A line of chemotherapy treatment is considered to comprise a known standard therapeutic chemotherapy regimen and supportive treatments

 Lenalidomide (Viatris) <range>Lenalidomide</range> Patient has plasma cell dyscrasia, not including Waldenström macroglobulinaemia, requiring treatment Patient is not refractory to prior lenalidomide use any relevant practitioner Patient has low or intermediate-1 risk myelodysplastic syndrome (based on IPSS or an IPSS-R score of less than 3.5) associated with a deletion 5q cytogenetic abnormality Patient has transfusion-dependent anaemia any relevant practitioner 6 Patient has not needed a transfusion in the last 4 months No evidence of disease progression any relevant practitioner 12 Pomalidomide <range>Pomalidomide</range> Patient has relapsed or refractory plasma cell dyscrasia, not including Waldenström macroglobulinaemia, requiring treatment Patient has not received prior funded pomalidomide any relevant practitioner 6 Patient has no evidence of disease progression any relevant practitioner 12 Dacarbazine Inj 200 mg vial DBL Dacarbazine 1 72.11 Etoposide Cap 50 mg Vepesid 20 340.73 Cap 100 mg Vepesid 10 340.73 Inj 20 mg per ml, 5 ml vial Rex Medical 1 7.90 Irinotecan hydrochloride Inj 20 mg per ml, 5 ml vial Accord 1 52.57 Inj 20 mg per ml, 25 ml vial Accord 1 262.85 Procarbazine hydrochloride Cap 50 mg Natulan 50 980.00 Hydroxyurea [hydroxycarbamide] Cap 500 mg Devatis 100 20.72 Tretinoin Cap 10 mg Vesanoid 100 479.50 Temozolomide <range>Temozolomide</range> Patient has a glioma medical practitioner 12 Treatment remains appropriate and patient is benefitting from treatment medical practitioner 12 Patient has been diagnosed with metastatic or unresectable well-differentiated neuroendocrine tumour* Temozolomide is to be given in combination with capecitabine Temozolomide is to be used in 28 day treatment cycles for a maximum of 5 days treatment per cycle at a maximum dose of 200 mg/m² per day Temozolomide to be discontinued at disease progression medical practitioner 9 No evidence of disease progression The treatment remains appropriate and the patient is benefitting from treatment medical practitioner 6 Patient has relapse or refractory Ewing’s sarcoma medical practitioner 9 No evidence of disease progression The treatment remains appropriate and the patient is benefitting from treatment medical practitioner 6 Patient has neuroblastoma medical practitioner 12 Patient has no evidence of disease progression medical practitioner 12

Indication marked with a * is an unapproved indication. Temozolomide is not funded for the treatment of relapsed high grade glioma.

 Arsenic trioxide Inj 1 mg per ml, 10 ml vial Phenasen 10 4817.00 Thalidomide <range>Thalidomide</range> The patient has plasma cell dyscrasia, not including Waldenström macroglobulinaemia, requiring treatment The patient has erythema nodosum leprosum medical practitioner 12 Patient has obtained a response from treatment during the initial approval period medical practitioner

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

 Bortezomib <range>Bortezomib</range> The patient has plasma cell dyscrasia, not including Waldenström macroglobulinaemia, requiring treatment medical practitioner The patient has Waldenström Macroglobulinaemia/Lymphoplasmacytic Lymphoma requiring treatment The patient has not received prior bortezomib treatment medical practitioner 12 Patient has no evidence of clinical disease progression during bortezomib use medical practitioner 12 Etoposide (as phosphate) Inj 100 mg vial Etopophos 1 40.00 Pegaspargase <range>Pegaspargase</range> The patient has newly diagnosed acute lymphoblastic leukaemia Pegaspargase to be used with a contemporary intensive multi-agent chemotherapy treatment protocol medical practitioner 15 The patient has relapsed acute lymphoblastic leukaemia Pegaspargase to be used with a contemporary intensive multi-agent chemotherapy treatment protocol medical practitioner 12 Patient has lymphoma requiring L-asparaginase containing protocol (e.g. SMILE) medical practitioner 12 Platinum Compounds Carboplatin Inj 10 mg per ml, 45 ml vial Carboplatin Accord 1 25.73 Cisplatin Inj 1 mg per ml, 50 ml vial Cisplatin Accord 1 9.45 Inj 1 mg per ml, 100 ml vial Cisplatin Accord 1 18.90 Oxaliplatin Inj 5 mg per ml, 20 ml vial Alchemy Oxaliplatin 1 33.35 Protein-Tyrosine Kinase Inhibitors Nilotinib <range>Nilotinib</range> Patient has a diagnosis of chronic myeloid leukaemia (CML) in blast crisis, high risk chronic phase, or in chronic phase Patient has documented CML treatment failure* with a tyrosine kinase inhibitor (TKI) Patient has experienced treatment limiting toxicity with a tyrosine kinase inhibitor (TKI) precluding further treatment Maximum nilotinib dose of 800 mg/day Subsidised for use as monotherapy only haematologist 6

*treatment failure as defined by Leukaemia Net Guidelines.

 Lack of treatment failure while on nilotinib as defined by Leukaemia Net Guidelines Nilotinib treatment remains appropriate and the patient is benefiting from treatment Maximum nilotinib dose of 800 mg/day Subsidised for use as monotherapy only haematologist 6 Ruxolitinib <range>Ruxolitinib</range> The patient has primary myelofibrosis or post-polycythemia vera myelofibrosis or post-essential thrombocythemia myelofibrosis A classification of risk of intermediate-2 or high-risk myelofibrosis according to either the International Prognostic Scoring System (IPSS), Dynamic International Prognostic Scoring System (DIPSS), or the Age-Adjusted DIPSS A classification of risk of intermediate-1 myelofibrosis according to either the International Prognostic Scoring System (IPSS), Dynamic International Prognostic Scoring System (DIPSS), or the Age-Adjusted DIPSS Patient has severe disease-related symptoms that are resistant, refractory or intolerant to available therapy A maximum dose of 20 mg twice daily is to be given haematologist 12 The treatment remains appropriate and the patient is benefiting from treatment A maximum dose of 20 mg twice daily is to be given relevant specialist medical practitioner 12 Alectinib <range>Alectinib</range> Patient has locally advanced, or metastatic, unresectable, non-small cell lung cancer There is documentation confirming that the patient has an ALK tyrosine kinase gene rearrangement using an appropriate ALK test Patient has an ECOG performance score of 0-2 medical practitioner 6 No evidence of progressive disease according to RECIST criteria The patient is benefitting from and tolerating treatment medical practitioner 6 Palbociclib <range>Palbociclib (Ibrance)</range> Patient has unresectable locally advanced or metastatic breast cancer There is documentation confirming disease is hormone-receptor positive and HER2-negative Patient has an ECOG performance score of 0-2 Disease has relapsed or progressed during prior endocrine therapy Patient is amenorrhoeic, either naturally or induced, with endocrine levels consistent with a postmenopausal or without menstrual-potential state Patient has not received prior systemic treatment for metastatic disease Treatment must be used in combination with an endocrine partner Patient has not received prior funded treatment with a CDK4/6 inhibitor Patient has an active Special Authority approval for ribociclib Patient has experienced a grade 3 or 4 adverse reaction to ribociclib that cannot be managed by dose reductions and requires treatment discontinuation Treatment must be used in combination with an endocrine partner There is no evidence of progressive disease since initiation of ribociclib medical practitioner 6 Treatment must be used in combination with an endocrine partner There is no evidence of progressive disease since initiation of palbociclib medical practitioner 12 Midostaurin <range>Midostaurin</range> Patient has a diagnosis of acute myeloid leukaemia Condition must be FMS tyrosine kinase 3 (FLT3) mutation positive Patient must not have received a prior line of intensive chemotherapy for acute myeloid leukaemia Patient is to receive standard intensive chemotherapy in combination with midostaurin only Midostaurin to be funded for a maximum of 4 cycles medical practitioner Ribociclib <range>Ribociclib</range> Patient has unresectable locally advanced or metastatic breast cancer There is documentation confirming disease is hormone-receptor positive and HER2-negative Patient has an ECOG performance score of 0-2 Disease has relapsed or progressed during prior endocrine therapy Patient is amenorrhoeic, either naturally or induced, with endocrine levels consistent with a postmenopausal or without menstrual-potential state Patient has not received prior systemic endocrine treatment for metastatic disease Treatment to be used in combination with an endocrine partner Patient has not received prior funded treatment with a CDK4/6 inhibitor Patient has an active Special Authority approval for palbociclib Patient has experienced a grade 3 or 4 adverse reaction to palbociclib that cannot be managed by dose reductions and requires treatment discontinuation Treatment must be used in combination with an endocrine partner There is no evidence of progressive disease since initiation of palbociclib medical practitioner 6 Treatment must be used in combination with an endocrine partner There is no evidence of progressive disease since initiation of ribociclib medical practitioner 12 Lenvatinib <range>Lenvatinib</range> Patient is currently on treatment with lenvatinib and met all remaining criteria prior to commencing treatment The patient has locally advanced or metastatic differentiated thyroid cancer Patient must have symptomatic progressive disease prior to treatment Patient must progressive disease at critical anatomical sites with a high risk of morbidity or mortality where local control cannot be achieved by other measures A lesion without iodine uptake in a RAI scan Receiving cumulative RAI greater than or equal to 600 mCi Experiencing disease progression after a RAI treatment within 12 months Experiencing disease progression after two RAI treatments administered within 12 months of each other Patient has thyroid stimulating hormone (TSH) adequately supressed Patient is not a candidate for radiotherapy with curative intent Surgery is clinically inappropriate Patient has an ECOG performance status of 0-2 medical practitioner 6 there is no evidence of disease progression medical practitioner 6 Patient has unresectable hepatocellular carcinoma Patient has preserved liver function (Childs-Pugh A) Transarterial chemoembolisation (TACE) is unsuitable Patient has an ECOG performance status of 0-2 Patient has not received prior systemic therapy for their disease in the palliative setting Patient has experienced treatment-limiting toxicity from treatment with atezolizumab with bevacizumab No disease progression since initiation of atezolizumab with bevacizumab medical practitioner 6 there is no evidence of disease progression medical practitioner 6 The patient has metastatic renal cell carcinoma The disease is of predominant clear-cell histology The patient has documented disease progression following one previous line of treatment The patient has an ECOG performance status of 0-2 Lenvatinib is to be used in combination with everolimus Patient has received funded treatment with nivolumab for the second line treatment of metastatic renal cell carcinoma Patient has experienced treatment limiting toxicity from treatment with nivolumab Lenvatinib is to be used in combination with everolimus There is no evidence of disease progression medical practitioner 4 there is no evidence of disease progression medical practitioner 4 Osimertinib <range>Osimertinib</range> Patient has locally advanced or metastatic, incurable, non-squamous non-small cell lung cancer (NSCLC) Patient is treatment naïve Patient has received prior treatment in the adjuvant setting and/or while awaiting EGFR results The patient has discontinued gefitinib or erlotinib due to intolerance The cancer did not progress while on gefitinib or erlotinib There is documentation confirming that the cancer expresses activating mutations of EGFR Patient has an ECOG performance status 0-3 Baseline measurement of overall tumour burden is documented clinically and radiologically medical practitioner 4 response to or stable disease with treatment in target lesions has been determined by comparable radiologic assessment following the most recent treatment period medical practitioner 6 Patient has locally advanced or metastatic, incurable, non-squamous non-small cell lung cancer (NSCLC) Patient has an ECOG performance status 0-3 The patient must have received previous treatment with erlotinib or gefitinib There is documentation confirming that the cancer expresses T790M mutation of EGFR following progression on or after erlotinib or gefitinib The treatment must be given as monotherapy Baseline measurement of overall tumour burden is documented clinically and radiologically medical practitioner 4 response to treatment in target lesions has been determined by comparable radiologic assessment following the most recent treatment period medical practitioner 6 Axitinib <range>Axitinib</range> The patient has metastatic renal cell carcinoma The disease is of predominant clear cell histology The patient has documented disease progression following one previous line of treatment The patient has ECOG performance status of 0-2 medical practitioner 4 No evidence of disease progression. medical practitioner 4 Crizotinib <range>Crizotinib</range> Individual has locally advanced or metastatic, unresectable, non-squamous non-small cell lung cancer The individual has not received entrectinib The individual has received treatment with entrectinib and has discontinued entrectinib due to intolerance The cancer did not progress while the individual was on entrectinib There is documentation confirming that the patient has a ROS1 rearrangement using an appropriate ROS1 test Individual has ECOG performance score of 0-3 Baseline measurement of overall tumour burden is documented clinically and radiologically medical practitioner 6 Response to treatment has been determined by comparable radiological assessment following the most recent treatment period No evidence of disease progression medical practitioner 6 Dabrafenib <range>Dabrafenib</range> The individual has resected stage IIIB, IIIC, IIID or IV melanoma (excluding uveal) (see note a) The individual has received neoadjuvant treatment with a PD-1/PD-L1 inhibitor Adjuvant treatment with dabrafenib is required The individual has not received prior funded systemic treatment in the adjuvant setting for stage IIIB, IIIC, IIID or IV melanoma Treatment must be adjuvant to complete surgical resection Treatment must be initiated within 13 weeks of surgical resection, unless delay is necessary due to post-surgery recovery (see note b) The individual has a confirmed BRAF mutation Dabrafenib must be administered in combination with trametinib The individual has ECOG performance score 0-2 any relevant practitioner 4

  1. Stage IIIB, IIIC, IIID or IV melanoma defined as per American Joint Committee on Cancer (AJCC) 8th Edition

  2. Initiating treatment within 13 weeks of complete surgical resection means 13 weeks after resection (primary or lymphadenectomy)

 No evidence of disease recurrence Dabrafenib must be administered in combination with trametinib Treatment to be discontinued at signs of disease recurrence or at completion of 12 months’ total treatment course, including any systemic neoadjuvant treatment The individual has received adjuvant treatment with a BRAF/MEK inhibitor The individual has metastatic or unresectable melanoma (excluding uveal) stage III or IV The individual meets initiation criteria for dabrafenib for unresectable or metastatic melanoma The individual has received adjuvant treatment with a BRAF/MEK inhibitor The individual has received a BRAF/MEK inhibitor for unresectable or metastatic melanoma The individual meets continuation criteria for dabrafenib for unresectable or metastatic melanoma any relevant practitioner 4 The individual has metastatic or unresectable melanoma (excluding uveal) stage III or IV Baseline measurement of overall tumour burden is documented clinically and radiologically The individual has ECOG performance score 0-2 The individual has confirmed BRAF mutation Dabrafenib must be administered in combination with trametinib The individual has been diagnosed in the metastatic or unresectable stage III or IV setting The individual did not receive treatment in the adjuvant setting with a BRAF/MEK inhibitor The individual received treatment in the adjuvant setting with a BRAF/MEK inhibitor The individual did not experience disease recurrence while on treatment with that BRAF/MEK inhibitor The individual did not experience disease recurrence within six months of completing adjuvant treatment with a BRAF/MEK inhibitor any relevant practitioner 4 The individual’s disease has had a complete response to treatment The individual’s disease has had a partial response to treatment The individual has stable disease with treatment Response to treatment in target lesions has been determined by comparable radiologic assessment following the most recent treatment period any relevant practitioner 4 Trametinib <range>Trametinib</range> The individual has resected stage IIIB, IIIC, IIID or IV melanoma (excluding uveal) (see note a) The individual has received neoadjuvant treatment with a PD-1/PD-L1 inhibitor Adjuvant treatment with trametinib is required The individual has not received prior funded systemic treatment in the adjuvant setting for stage IIIB, IIIC, IIID or IV melanoma Treatment must be adjuvant to complete surgical resection Treatment must be initiated within 13 weeks of surgical resection, unless delay is necessary due to post-surgery recovery (see note b) The individual has a confirmed BRAF mutation Trametinib must be administered in combination with dabrafenib The individual has ECOG performance score 0-2 any relevant practitioner 4

  1. Stage IIIB, IIIC, IIID or IV melanoma defined as per American Joint Committee on Cancer (AJCC) 8th Edition

  2. Initiating treatment within 13 weeks of complete surgical resection means 13 weeks after resection (primary or lymphadenectomy)

 No evidence of disease recurrence Trametinib must be administered in combination with dabrafenib Treatment to be discontinued at signs of disease recurrence or at completion of 12 months’ total treatment course, including any systemic neoadjuvant treatment The individual has received adjuvant treatment with a BRAF/MEK inhibitor The individual has metastatic or unresectable melanoma (excluding uveal) stage III or IV The individual meets initiation criteria for trametinib for unresectable or metastatic melanoma The individual has received adjuvant treatment with a BRAF/MEK inhibitor The individual has received a BRAF/MEK inhibitor for unresectable or metastatic melanoma The individual meets continuation criteria for trametinib for unresectable or metastatic melanoma any relevant practitioner 4 The individual has metastatic or unresectable melanoma (excluding uveal melanoma) stage III or IV Baseline measurement of overall tumour burden is documented clinically and radiologically The individual has ECOG performance score 0-2 The individual has confirmed BRAF mutation Trametinib must be administered in combination with dabrafenib The individual has been diagnosed in the metastatic or unresectable stage III or IV setting The individual did not receive treatment in the adjuvant setting with a BRAF/MEK inhibitor The individual received treatment in the adjuvant setting with a BRAF/MEK inhibitor The individual did not experience disease recurrence while on treatment with that BRAF/MEK inhibitor The individual did not experience disease recurrence within six months of completing adjuvant treatment with a BRAF/MEK inhibitor any relevant practitioner 4 The individual’s disease has had a complete response to treatment The individual’s disease has had a partial response to treatment The individual has stable disease with treatment Response to treatment in target lesions has been determined by comparable radiologic assessment following the most recent treatment period any relevant practitioner 4 Entrectinib <range>Entrectinib</range> Individual has locally advanced or metastatic, unresectable, non-squamous non-small cell lung cancer The individual has not received crizotinib The individual has received an initial Special Authority approval for crizotinib and has discontinued crizotinib due to intolerance The cancer did not progress while the individual was on crizotinib There is documentation confirming that the patient has a ROS1 rearrangement using an appropriate ROS1 test Individual has ECOG performance score of 0-3 Baseline measurement of overall tumour burden is documented clinically and radiologicallyy medical practitioner 6 Response to treatment has been determined by comparable radiological assessment following the most recent treatment period No evidence of disease progression medical practitioner 6 Imatinib mesilate Cap 100 mg Imatinib-Rex 60 44.93 Cap 400 mg Imatinib-Rex 30 69.76 Dasatinib <range>Dasatinib</range> The patient has a diagnosis of chronic myeloid leukaemia (CML) in blast crisis or accelerated phase The patient has a diagnosis of Philadelphia chromosome-positive acute lymphoid leukaemia (Ph+ ALL) The patient has a diagnosis of CML in chronic phase Patient has documented treatment failure* with imatinib Patient has experienced treatment-limiting toxicity with imatinib precluding further treatment with imatinib Patient has high-risk chronic-phase CML defined by the Sokal or EURO scoring system haematologist any relevant practitioner 6 Lack of treatment failure while on dasatinib* Dasatinib treatment remains appropriate and the patient is benefiting from treatment haematologist any relevant practitioner 6

*treatment failure for CML as defined by Leukaemia Net Guidelines.

 Erlotinib <range>Erlotinib</range> Patient has locally advanced or metastatic, unresectable, non-squamous Non Small Cell Lung Cancer (NSCLC) There is documentation confirming that the disease expresses activating mutations of EGFR Patient is treatment naive Patient has received prior treatment in the adjuvant setting and/or while awaiting EGFR results The patient has discontinued osimertinib or getitinib due to intolerance The cancer did not progress while on osimertinib or gefitinib medical practitioner 4 Radiological assessment (preferably including CT scan) indicates NSCLC has not progressed medical practitioner 6 Sunitinib <range>Sunitinib</range> The patient has metastatic renal cell carcinoma The patient has not previously received funded sunitinib medical practitioner 4 No evidence of disease progression medical practitioner 4 The patient has unresectable or metastatic malignant gastrointestinal stromal tumour (GIST) The patient's disease has progressed following treatment with imatinib The patient has documented treatment-limiting intolerance, or toxicity to, imatinib medical practitioner 3 The patient has responded to treatment or has stable disease as determined by Choi's modified CT response evaluation criteria as follows: The patient has had a complete response (disappearance of all lesions and no new lesions) The patient has had a partial response (a decrease in size of 10% or more or decrease in tumour density in Hounsfield Units (HU) of 15% or more on CT and no new lesions and no obvious progression of non-measurable disease) 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 The treatment remains appropriate and the patient is benefiting from treatment medical practitioner 6 The patient has unresectable or metastatic malignant gastrointestinal stromal tumour (GIST) The patient is clinically benefiting from treatment and continued treatment remains appropriate Sunitinib is to be discontinued at progression The regular renewal requirements cannot be met due to COVID-19 constraints on the health sector medical practitioner 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% or more 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 <range>Lapatinib</range> For continuation use only medical practitioner The patient has metastatic breast cancer expressing HER-2 IHC 3+ or ISH+ (including FISH or other current technology) The cancer has not progressed at any time point during the previous 12 months whilst on lapatinib Lapatinib not to be given in combination with trastuzumab Lapatinib to be discontinued at disease progression medical practitioner 12 Pazopanib <range>Pazopanib</range> The patient has metastatic renal cell carcinoma of predominantly clear cell histology The patient is treatment naive The patient has only received prior cytokine treatment The patient has an ECOG performance score of 0-2 The patient has intermediate or poor prognosis defined as: Lactate dehydrogenase level > 1.5 times upper limit of normal Haemoglobin level < lower limit of normal Corrected serum calcium level > 10 mg/dL (2.5 mmol/L) Interval of < 1 year from original diagnosis to the start of systemic therapy Karnofsky performance score of less than or equal to 70 2 or more sites of organ metastasis The patient has metastatic renal cell carcinoma The patient has discontinued sunitinib within 3 months of starting treatment due to intolerance The cancer did not progress whilst on sunitinib Pazopanib to be used for a maximum of 3 months medical practitioner 3 No evidence of disease progression medical practitioner 3 Gefitinib <range>Gefitinib</range> Patient has locally advanced, or metastatic, unresectable, non-squamous Non Small Cell Lung Cancer (NSCLC) Patient is treatment naive Patient has received prior treatment in the adjuvant setting and/or while awaiting EGFR results The patient has discontinued osimertinib or erlotinib due to intolerance The cancer did not progress whilst on osimertinib or erlotinib There is documentation confirming that disease expresses activating mutations of EGFR medical practitioner 4 Radiological assessment (preferably including CT scan) indicates NSCLC has not progressed medical practitioner 6 Taxanes Docetaxel Inj 10 mg per ml, 8 ml vial DBL Docetaxel 1 24.91 Paclitaxel Inj 6 mg per ml, 16.7 ml vial Anzatax 1 19.59 Inj 6 mg per ml, 50 ml vial Anzatax 1 37.89 Treatment of Cytotoxic-Induced Side Effects Dexrazoxane <range>Dexrazoxane</range> Patient is to receive treatment with high dose anthracycline given with curative intent Based on current treatment plan, patient’s cumulative lifetime dose of anthracycline will exceed 250mg/m2 doxorubicin equivalent or greater Dexrazoxane to be administered only whilst on anthracycline treatment Treatment to be used as a cardioprotectant for a child or young adult Treatment to be used as a cardioprotectant for secondary malignancy medical oncologist paediatric oncologist haematologist paediatric haematologist Mesna Tab 400 mg Uromitexan 50 314.00 Tab 600 mg Uromitexan 50 448.50 Inj 100 mg per ml, 4 ml ampoule Uromitexan 15 177.45 Inj 100 mg per ml, 10 ml ampoule Uromitexan 15 407.40 Calcium folinate Inj 3 mg per ml, 1 ml ampoule Any 0 Inj 10 mg per ml, 30 ml vial Any 0 Tab 15 mg DBL Leucovorin Calcium 10 135.33 Inj 10 mg per ml, 10 ml vial Eurofolic 5 1 163.35 Inj 10 mg per ml, 100 ml vial Eurofolic 1 139.48 Inj 10 mg per ml, 5 ml vial Eurofolic 5 1 112.20 Inj 10 mg per ml, 35 ml vial Any 0 Vinca Alkaloids Vinblastine sulphate Inj 1 mg per ml, 10 ml vial Hospira 5 270.37 Vincristine sulphate Inj 1 mg per ml, 1 ml vial DBL Vincristine Sulfate 5 74.52 Inj 1 mg per ml, 2 ml vial DBL Vincristine Sulfate 5 102.73 Vinorelbine Inj 10 mg per ml, 1 ml vial Any 0 Inj 10 mg per ml, 5 ml vial Any 0 Cap 20 mg Vinorelbine Te Arai 1 32.10 Cap 30 mg Vinorelbine Te Arai 1 42.80 Cap 80 mg Vinorelbine Te Arai 1 80.00 Endocrine Therapy Endocrine Therapy Abiraterone acetate <range>Abiraterone acetate</range> Patient has prostate cancer Patient has metastases Patient's disease is castration resistant Patient is symptomatic Patient has disease progression (rising serum PSA) after second line anti-androgen therapy Patient has ECOG performance score of 0-1 Patient has not had prior treatment with taxane chemotherapy Patient's disease has progressed following prior chemotherapy containing a taxane Patient has ECOG performance score of 0-2 Patient has not had prior treatment with abiraterone medical oncologist radiation oncologist urologist 6 Significant decrease in serum PSA from baseline No evidence of clinical disease progression No initiation of taxane chemotherapy with abiraterone The treatment remains appropriate and the patient is benefiting from treatment medical oncologist radiation oncologist urologist 6 The patient is clinically benefiting from treatment and continued treatment remains appropriate Abiraterone acetate to be discontinued at progression No initiation of taxane chemotherapy with abiraterone The regular renewal requirements cannot be met due to COVID-19 constraints on the health sector medical practitioner 6 Fulvestrant <range>Fulvestrant</range> Patient has oestrogen-receptor positive locally advanced or metastatic breast cancer Patient has disease progression following prior treatment with an aromatase inhibitor or tamoxifen for their locally advanced or metastatic disease Treatment to be given at a dose of 500 mg monthly following loading doses Treatment to be discontinued at disease progression medical oncologist 6 Treatment remains appropriate and patient is benefitting from treatment Treatment to be given at a dose of 500 mg monthly No evidence of disease progression medical oncologist 6 Octreotide Inj 100 mcg per ml, 1 ml ampoule Max Health 5 32.71 Inj 50 mcg per ml, 1 ml ampoule Max Health 5 27.58 Inj 500 mcg per ml, 1 ml ampoule Max Health 5 113.10 Inj 100 mcg per ml, 1 ml vial Omega 5 48.50 Inj 50 mcg per ml, 1 ml vial Omega 5 27.58 Inj 500 mcg per ml, 1 ml vial Omega 5 113.10 Flutamide Tab 250 mg Flutamin 100 100 119.50 Tamoxifen citrate Tab 10 mg Tamoxifen Sandoz 60 15.00 Tab 20 mg Tamoxifen Sandoz 60 5.32 Bicalutamide Tab 50 mg Binarex 28 4.18 Aromatase Inhibitors Letrozole Tab 2.5 mg Letrole 30 4.67 Accord 28 4.36 Exemestane Tab 25 mg Pfizer Exemestane 30 9.86 Anastrozole Tab 1 mg Anatrole 30 4.39 Long-acting Somatostatin Analogues <range>Long-acting Somatostatin Analogues</range> The patient has nausea* and vomiting* due to malignant bowel obstruction* Treatment with antiemetics, rehydration, antimuscarinic agents, corticosteroids and analgesics for at least 48 hours has not been successful Treatment to be given for up to 4 weeks medical practitioner

Indications marked with * are unapproved indications

 The patient has acromegaly Treatment with surgery and radiotherapy is not suitable or was unsuccessful Treatment is for an interim period while awaiting the beneficial effects of radiotherapy Treatment with a dopamine agonist has been unsuccessful medical practitioner 3 Without reassessment for applications where IGF1 levels have decreased since starting treatment medical practitioner

In patients with acromegaly, treatment should be discontinued if IGF1 levels have no decreased 3 months after treatment. In patients treated with radiotherapy treatment should be withdrawn every 2 years, for 1 month, for assessment of remission. Treatment should be stopped where there is biochemical evidence of remission (normal IGF1 levels) following treatment withdrawal for at least 4 weeks.

 VIPomas and glucagonomas - for patients who are seriously ill in order to improve their clinical state prior to definitive surgery Gastrinoma Surgery has been unsuccessful Patient has metastatic disease after treatment with H2 antagonist or proton pump inhibitors has been unsuccessful Insulinomas Surgery is contraindicated or has not been successful For pre-operative control of hypoglycaemia and for maintenance therapy Carcinoid syndrome (diagnosed by tissue pathology and/or urinary 5HIAA analysis) Disabling symptoms not controlled by maximal medical therapy medical practitioner Patient has acromegaly Patient has a large pituitary tumour, greater than 10 mm at its widest Patient is scheduled to undergo pituitary surgery in the next six months medical practitioner 12

Indications marked with * are unapproved indications

The use of a long-acting somatostatin analogue in patients with fistulae, oesophageal varices, miscellaneous diarrhoea and hypotension will not be funded under Special Authority

 Imaging Agents Imaging Agents Aminolevulinic acid hydrochloride <range>Aminolevulinic acid hydrochloride</range> Patient has newly diagnosed, untreated, glioblastoma multiforme Treatment to be used as adjuvant to fluorescence-guided resection Patient's tumour is amenable to complete resection medical practitioner 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 <range>Tacrolimus</range> For use in organ transplant recipients The individual is receiving induction therapy for an organ transplant medical practitioner Patient requires long-term systemic immunosuppression Ciclosporin has been trialled and discontinued treatment because of unacceptable side effects or inadequate clinical response Patient is a child with nephrotic syndrome* any specialist

Indications marked with * are unapproved indications

 Fusion Proteins Etanercept <range>Etanercept</range> Patient has had a Special Authority approval for adalimumab for polyarticular course juvenile idiopathic arthritis (JIA) Patient has experienced intolerable side effects Patient has received insufficient benefit to meet the renewal criteria for polyarticular course JIA At least 5 active joints and at least 3 joints with pain, tenderness or a limited range of motion after a 3-month trial of methotrexate at the maximum tolerated dose, unless contraindicated Moderate or high disease activity (cJADAS10 score of at least 2.5) after a 3-month trial of methotrexate at the maximum tolerated dose, unless contraindicated Low disease activity (cJADAS10 score between 1.1 and 2.5) after a 6-month trial of methotrexate medical practitioner 6 Following initial treatment, at least a 50% decrease in active joint count from baseline On subsequent reapplications, at least a continuing 30% improvement in active joint count from baseline medical practitioner 2 Patient has had a Special Authority approval for adalimumab for oligoarticular course juvenile idiopathic arthritis (JIA) Patient has experienced intolerable side effects Patient has received insufficient benefit to meet the renewal criteria for oligoarticular course JIA At least 2 active joints with pain, tenderness or a limited range of motion, after a 3-month trial of methotrexate at the maximum tolerated dose, unless contraindicated Moderate or high disease activity (cJADAS10 score greater than 1.5) with poor prognostic features after a 3-month trial of methotrexate at the maximum tolerated dose, unless contraindicated medical practitioner 6 Following initial treatment, at least a 50% decrease in active joint count from baseline On subsequent reapplications, at least a continuing 30% improvement in active joint count from baseline medical practitioner 2 Patient has had a Special Authority approval for adalimumab for rheumatoid arthritis Patient has experienced intolerable side effects Patient has received insufficient benefit to meet the renewal criteria for rheumatoid arthritis Patient has had rheumatoid arthritis (either confirmed by radiologic imaging, or the patient is cyclic citrullinated peptide (CCP) antibody positive) Patient has received insufficient benefit from at least 3 months of methotrexate at a maximum tolerated dose (unless contraindicated) Patient has received insufficient benefit from at least 3 months of methotrexate in combination with sulfasalazine and hydroxychloroquine sulphate (at maximum tolerated doses unless contraindicated) Patient has received insufficient benefit from at least 3 months of methotrexate in combination with the maximum tolerated dose of ciclosporin, unless contraindicated Patient has received insufficient benefit from at least 3 months of therapy at the maximum tolerated dose of leflunomide alone or in combination with methotrexate, unless contraindicated Patient has persistent symptoms of poorly controlled and active disease in at least 15 joints Patient has persistent symptoms of poorly controlled and active disease in at least 4 joints from the following: wrist, elbow, knee, ankle, and either shoulder or hip medical practitioner 6 Following initial treatment, at least a 50% decrease in active joint count from baseline On subsequent reapplications, at least a continuing 30% improvement in active joint count from baseline Maximum dose 50 mg every 7 days medical practitioner 2 Patient has had a Special Authority approval for adalimumab for ankylosing spondylitis Patient has experienced intolerable side effects Patient has received insufficient benefit to meet the renewal criteria for ankylosing spondylitis Patient has a confirmed diagnosis of ankylosing spondylitis Patient has low back pain and stiffness that is relieved by exercise but not by rest Patient has bilateral sacroiliitis demonstrated by radiologic imaging Disease has not responded adequately to treatment with two or more NSAID (unless contraindicated) while patient was undergoing at least 3 months of a regular exercise regimen for ankylosing spondylitis Patient has limitation of motion of the lumbar spine in the sagittal and the frontal planes as determined by the following 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) Patient has limitation of chest expansion by at least 2.5 cm below the average normal values corrected for age and gender BASDAI score of at least 6 on a 10-point scale completed after 3-month exercise trial before ceasing any previous pharmacological treatment and not more than 1 month before the application medical practitioner 6 BASDAI has improved from pre-treatment baseline either by at least 4 points on a 10-point scale, or by at least 50% Maximum dose 50 mg every 7 days medical practitioner 2 Patient has had a Special Authority approval for adalimumab or secukinumab for psoriatic arthritis Patient has experienced intolerable side effects Patient has received insufficient benefit to meet the renewal criteria for psoriatic arthritis Patient has received insufficient benefit from at least 3 months of methotrexate at maximum tolerated dose unless contraindicated Patient received insufficient benefit from at least 3 months of sulfasalazine or leflunomide at maximum tolerated dose unless contraindicated Patient has persistent symptoms of poorly controlled and active disease in at least 15 joints Patient has persistent symptoms of poorly controlled and active disease in at least 4 joints from the following: wrist, elbow, knee, ankle, and either shoulder or hip Patient has CRP greater than 15 mg/L measured within one month before the application Patient has an ESR greater than 25 mm per hour measured within one month before the application ESR and CRP not measured as patient is receiving prednisone therapy greater than 5 mg per day received for more than 3 months medical practitioner 6 Following initial treatment, at least a 50% decrease in active joint count from baseline At least a continuing 30% improvement in active joint count from baseline Maximum dose 50 mg every 7 days medical practitioner 2 Patient has had a Special Authority approval for adalimumab for plaque psoriasis Patient has experienced intolerable side effects Patient has received insufficient benefit to meet the renewal criteria for adalimumab for plaque psoriasis Patient must be reassessed for continuation after 3 doses medical practitioner 6 Patient has "whole body" severe chronic plaque psoriasis with a PASI score of greater than 10 Patient has plaque psoriasis of the face, or palm of a hand, or sole of a foot Patient has localised genital or flexural plaque psoriasis with a DLQI score greater than 10 Patient has received insufficient benefit from (see Note), or has experienced intolerable side effects from, at least 3 of the following at maximum tolerated doses (unless contraindicated): phototherapy, methotrexate, ciclosporin, or acitretin A PASI assessment or DLQI assessment has been completed for the most recent prior treatment course within 1 month of stopping that treatment The most recent PASI or DLQI assessment is within 1 month of before the applicattion medical practitioner 6

"Insufficient benefit" is defined as: for whole body plaque psoriasis, a PASI score of greater than 10, for plaque psoriasis of the face, hand, foot, genital or flexural areas at least 2 of the 3 PASI symptom subscores for erythema, thickness and scaling are rated as severe or very severe, and for the face, palm of a hand or sole of a foot 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.

 Patient had "whole body" plaque psoriasis at the start of treatment Patient has a PASI score which is reduced by 75% or more, or is sustained at this level, compared with the pre-treatment baseline Patient has a DLQI improvement of 5 or more, compared with the pre-treatment baseline Patient had plaque psoriasis of the face, or palm of a hand or sole of a foot at the start of treatment 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, compared to the pre-treatment baseline Patient has a reduction of 75% or more in the skin area affected, or sustained at this level, compared to the pre-treatment baseline Patient had localised genital or flexural plaque psoriasis at the start of treatment Patient has experienced a reduction of 75% or more in the skin area affected, or sustained at this level, compared to the pre-treatment baseline Patient has a DLQI improvement of 5 or more, compared to the pretreatment baseline Maximum 50 mg every 7 days medical practitioner 2 Patient has received insufficient benefit from 3 months of conventional therapy including a minimum of 3 pharmaceuticals (e.g. prednisone, ciclosporin, azathioprine, or methotrexate). Where conventional pharmaceuticals are contraindicated, a 3-month trial has occurred of those that are not contraindicated Maximum of 8 doses every 4 months medical practitioner

Indications marked with * are unapproved indications.

 Patient has had a Special Authority approval for adalimumab or tocilizumab for AOSD Patient has experienced intolerable side effects Patient has received insufficient benefit to meet the new renewal criteria from at least a 3-month trial of adalimumab or tocilizumab Patient diagnosed with AOSD according to the Yamaguchi criteria Patient has tried and received insufficient benefit from at least 6 months of corticosteroids at a dose of at least 0.5 mg/kg prednisone-equivalents, NSAIDs and methotrexate, unless contraindicated Patient has persistent symptoms of disabling poorly controlled and active disease medical practitioner Patient has undifferentiated peripheral spondyloarthritis* with active peripheral joint arthritis in at least 4 joints from the following: wrist, elbow, knee, ankle, and either shoulder or hip Patient has received insufficient benefit from at least 3 months of each of methotrexate, sulfasalazine, and leflunomide at maximum tolerated doses, unless contraindicated Patient has a CRP level greater than 15 mg/L measured within one month before the application Patient has an ESR greater than 25 mm per hour measured within one month before the application ESR and CRP not measured as patient is currently receiving prednisone therapy greater than 5 mg per day received for more than three months medical practitioner 6

Indications marked with * are unapproved indications.

 Following initial treatment, the patient has experienced at least a 50% decrease in active joint count from baseline Patient has experienced at least a continuing 30% improvement in active joint count from baseline Maximum 50 mg dose every 7 days medical practitioner 2 Monoclonal Antibodies Bevacizumab (Ocular) <range>Bevacizumab</range> Ocular neovascularisation Exudative ocular angiopathy medical practitioner Ranibizumab <range>Ranibizumab</range> Wet age-related macular degeneration (wet AMD) Polypoidal choroidal vasculopathy Choroidal neovascular membrane from causes other than wet AMD The patient has developed severe endophthalmitis or severe posterior uveitis following treatment with bevacizumab There is worsening of vision or failure of retina to dry despite three intraocular injections of bevacizumab four weeks apart There is no structural damage to the central fovea of the treated eye Patient has not previously been treated with aflibercept or faricimab for longer than 3 months Patient has current approval to use aflibercept or faricimab for treatment of wAMD and was found to be intolerant within 3 months medical practitioner 3 Documented benefit must be demonstrated to continue Patient’s vision is 6/36 or better on the Snellen visual acuity score There is no structural damage to the central fovea of the treated eye medical practitioner 12 Infliximab <range>Infliximab</range> Patient has steroid-refractory acute graft vs. host disease of the gut medical practitioner Patient has had a Special Authority approval for adalimumab or etanercept for rheumatoid arthritis Patient has experienced intolerable side effects Patient has received insufficient benefit to meet the renewal criteria for rheumatoid arthritis Following initial induction doses, maximum dose 3mg/kg every 8 weeks medical practitioner 6 Following initial treatment, the patient has experienced at least a 50% decrease in active joint count from baseline Patient has experienced at least a continuing 30% improvement in active joint count from baseline Maximum dose 3 mg/kg every 8 weeks medical practitioner 2 Patient has had a Special Authority approval for adalimumab or etanercept for ankylosing spondylitis Patient has experienced intolerable side effects Patient has received insufficient benefit to meet the renewal criteria for ankylosing spondylitis Following initial induction doses, maximum dose 5mg/kg every 6-8 weeks medical practitioner 6 BASDAI has improved from pre-treatment baseline either by at least 4 points on a 10-point scale, or by at least 50% Maximum dose 5 mg/kg every 6-8 weeks medical practitioner 2 Patient has had a Special Authority approval for adalimumab or etanercept or secukinumab for psoriatic arthritis Patient has experienced intolerable side effects Patient has received insufficient benefit to meet the renewal criteria for psoriatic arthritis Following initial induction doses, maximum dose 5mg/kg every 8 weeks medical practitioner 6 Following initial treatment, at least a 50% decrease in active joint count from baseline At least a continuing 30% improvement in active joint count from baseline Maximum dose 5 mg/kg every 8 weeks medical practitioner 2 Patient has had an initial Special Authority approval for adalimumab for severe ocular inflammation Patient has experienced intolerable side effects Patient has received insufficient benefit to meet the renewal criteria for severe ocular inflammation Patient has severe, vision-threatening ocular inflammation requiring rapid control Treatment with high-dose IV corticosteroids followed by high dose oral corticosteroids has been ineffective at controlling symptoms Patient developed new inflammatory symptoms while receiving high dose corticosteroids Patient is aged under 8 years and treatment with high dose oral corticosteroids and other immunosuppressants has been ineffective at controlling symptoms High dose corticosteroids are contraindicated medical practitioner 4

Indications marked with * are unapproved indications.

 Patient has received a good clinical response following 3 initial doses Following each 2 year treatment period, the patient has experienced a sustained reduction in inflammation (Standardisation of Uveitis Nomenclature (SUN) criteria < ½+ anterior chamber or vitreous cells, absence of active vitreous or retinal lesions, or resolution of uveitic cystoid macular oedema) Following each 2 year treatment period, the patient has a sustained corticosteroid sparing effect, allowing reduction in prednisone to <10mg daily, or corticosteroid drops less than twice daily if under 18 years old medical practitioner 2

A trial withdrawal should be considered after every 24 months of stability, unless the patient is deemed to have extremely high risk of irreversible vision loss if infliximab is withdrawn.

Indications marked with * are unapproved indications.

 Patient has had a Special Authority approval for adalimumab for chronic ocular inflammation Patient has experienced intolerable side effects Patient has received insufficient benefit to meet the renewal criteria for chronic ocular inflammation Patient has severe uveitis with a severe risk of vision loss uncontrolled by treatment with corticosteroids and other immunosuppressants Patient is 18 years or older and treatment with at least two other immunomodulatory agents has been ineffective or are contraindicated Patient is under 18 years and treatment with methotrexate has been ineffective, is contraindicated or is not tolerated at a therapeutic dose Patient is under 8 years and treatment with corticosteroids or methotrexate has been ineffective, is contraindicated or is not tolerated at a therapeutic dose; or disease requires control to prevent irreversible vision loss prior to achieving a therapeutic dose of methotrexate medical practitioner 4

Indications marked with * are unapproved indications.

 Patient has received a good clinical response following 3 initial doses Following each 2 year treatment period, the patient has experienced a sustained reduction in inflammation (Standardisation of Uveitis Nomenclature (SUN) criteria < ½+ anterior chamber or vitreous cells, absence of active vitreous or retinal lesions, or resolution of uveitic cystoid macular oedema) Following each 2 year treatment period, the patient has a sustained corticosteroid sparing effect, allowing reduction in prednisone to <10mg daily, or corticosteroid drops less than twice daily if under 18 years old medical practitioner 2

A trial withdrawal should be considered after every 24 months of stability, unless the patient is deemed to have extremely high risk of irreversible vision loss if infliximab is withdrawn.

Indications marked with * are unapproved indications.

 Patient has life-threatening pulmonary sarcoidosis that is refractory to other treatments Treatment is to be prescribed by, or has been recommended by, a physician with expertise in the treatment of pulmonary sarcoidosis medical practitioner Patient has active Crohn's disease Patient has a CDAI score of greater than or equal to 300, or HBI score of greater than or equal to 10 Patient has extensive small intestine disease affecting more than 50 cm of the small intestine Patient has evidence of short gut syndrome or would be at risk of short gut syndrome with further bowel resection Patient has an ileostomy or colostomy, and has intestinal inflammation Patient has tried but had an inadequate response to, or has experienced intolerable side effects from, prior therapy with immunomodulators and corticosteroids any relevant practitioner 6 CDAI score has reduced by 100 points from the CDAI score, or HBI score has reduced by 3 points, from when the patient was initiated on infliximab CDAI score is 150 or less, or HBI is 4 or less The patient has demonstrated an adequate response to treatment but CDAI score and/or HBI score cannot be assessed 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 any relevant practitioner 2 Paediatric patient has active Crohn's disease Patient has a PCDAI score of greater than or equal to 30 Patient has extensive small intestine disease Patient has tried but experienced an inadequate response to, or intolerable side effects from, prior therapy with immunomodulators and corticosteroids any relevant practitioner 6 PCDAI score has reduced by 10 points from the PCDAI score when the patient was initiated on infliximab PCDAI score is 15 or less The patient has demonstrated an adequate response to treatment but PCDAI score cannot be assessed 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 any relevant practitioner 2 Patient has confirmed Crohn's disease Patient has one or more complex externally draining enterocutaneous fistula(e) Patient has one or more rectovaginal fistula(e) Patient has complete peri-anal fistula gastroenterologist 6 The number of open draining fistulae have decreased from baseline by at least 50% 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 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 any relevant practitioner 2 Patient has acute, fulminant ulcerative colitis Treatment with intravenous or high dose oral corticosteroids has not been successful gastroenterologist 6 Where maintenance treatment is considered appropriate, infliximab should be used in combination with immunomodulators and reassessed every 6 months 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 any relevant practitioner 2 Patient has active ulcerative colitis Patients SCCAI is greater than or equal to 4 Patients PUCAI score is greater than or equal to 20 Patient has experienced an inadequate response to, or intolerable side effects from, prior therapy with immunomodulators and systemic corticosteroids any relevant practitioner 6 The SCCAI score has reduced by 2 points or more from the SCCAI score when the patient was initiated on infliximab The PUCAI score has reduced by 30 points or more from the PUCAI score when the patient was initiated on infliximab 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 any relevant practitioner 2 Patient had a Special Authority approval for adalimumab, etanercept or secukinumab for plaque psoriasis Patient has experienced intolerable side effects Patient has received insufficient benefit to meet the renewal criteria for plaque psoriasis Patient has "whole body" plaque psoriasis with a PASI score of greater than 10 Patient has plaque psoriasis of the face, or palm of a hand or sole of a foot Patient has localised genital or flexural plaque psoriasis with a DLQI score greater than 10 Patient has received insufficient benefit (see Note) or has experienced intolerable side effects from at least 3 of the following (at maximum tolerated doses unless contraindicated): phototherapy, methotrexate, ciclosporin, or acitretin A PASI assessment has been completed for the most recent prior treatment course within 1 month of stopping that treatment The most recent PASI assessment is within 1 month before the application medical practitioner 6

"Insufficient benefit" is defined as: for whole body plaque psoriasis, a PASI score of greater than 10, for plaque psoriasis of the face, hand, foot, genital or flexural areas at least 2 of the 3 PASI symptom subscores for erythema, thickness and scaling are rated as severe or very severe, and for the face, palm of a hand or sole of a foot 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.

 Patient had "whole body" plaque psoriasis at the start of treatment Patient has a PASI score which is reduced by 75% or more, or is sustained at this level, when compared with the pre-infliximab baseline Patient had plaque psoriasis of the face, or palm of a hand or sole of a foot at the start of treatment 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 pre-infliximab baseline Patient has a reduction of 75% or more in the skin area affected, or sustained at this level, as compared to the pre-infliximab baseline Patient had localised genital or flexural plaque psoriasis at the start of treatment Patient has experienced a reduction of 75% or more in the skin area affected, or sustained at this level, as compared to the pre-treatment baseline Patient has a DLQI improvement of 5 or more, as compared to the pre-infliximab baseline Maximum dose 5 mg/kg every 8 weeks medical practitioner 2 Biopsy consistent with diagnosis of neurosarcoidosis Patient has CNS involvement Patient has steroid-refractory disease IV cyclophosphamide has been tried Treatment with IV cyclophosphamide is clinically inappropriate neurologist 18 A withdrawal period has been tried and the patient has relapsed A withdrawal period has been considered but would not be clinically appropriate There has been a marked reduction in prednisone dose There has been an improvement in MRI appearances Marked improvement in other symptomology neurologist 18 Patient has severe Behcet disease which is significantly impacting their quality of life Patient has severe ocular, neurological and/or vasculitic symptoms and has received insufficient benefit from 1 or more treatment(s) appropriate for the particular symptom(s) Patient has severe gastrointestinal, rheumatologic and/or mucocutaneous symptoms and has received insufficient benefit from 2 or more treatments appropriate for the particular symptom(s) Following initial loading doses, maximum dose 5mg/kg every 8 weeks medical practitioner Patient has received insufficient benefit from 3 months of conventional therapy including a minimum of 3 pharmaceuticals (e.g. prednisone, ciclosporin, azathioprine, or methotrexate). Where conventional pharmaceuticals are contraindicated, a 3-month trial has occurred of those that are not contraindicated Maximum of 8 doses every 4 months medical practitioner

Indications marked with * are unapproved indications.

 Patient has a diagnosis of active ulcerative colitis or active Crohn's disease Patient has had axial inflammatory pain for six months or more Patient is unable to take NSAIDs Patient has unequivocal sacroiliitis demonstrated by radiological imaging or MRI Patient has not experienced an adequate response to prior treatment consisting of at least 3 months of an exercise regime supervised by a physiotherapist Patient has a BASDAI of at least 6 on a 0-10 scale completed after the 3 month exercise trial, but prior to ceasing any previous pharmacological treatment medical practitioner 6 Where treatment has resulted in an improvement in BASDAI of 4 or more points from pre-treatment baseline on a 10-point scale, or an improvement in BASDAI of 50%, whichever is less medical practitioner 2 Patient has a diagnosis of active ulcerative colitis or active Crohn’s disease Patient has active arthritis in at least four joints from the following: hip, knee, ankle, subtalar, tarsus, forefoot, wrist, elbow, shoulder, sternoclavicular Patient has tried and not experienced a response to at least three months of methotrexate or azathioprine at a maximum tolerated dose (unless contraindicated) Patient has tried and not experienced a response to at least three months of sulfasalazine at a maximum tolerated dose (unless contraindicated) Patient has a CRP level greater than 15 mg/L measured no more than one month prior to the date of this application Patient has an ESR greater than 25 mm per hour measured no more than one month prior to the date of this application 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 medical practitioner 6 Following initial treatment, patient has experienced at least a 50% decrease in active joint count from baseline and a clinically significant response to treatment in the opinion of the physician Patient has experienced at least a continuing 30% improvement in active joint count from baseline in the opinion of the treating physician medical practitioner 2 The individual requires treatment for moderate to severe autoimmune toxicity following immune checkpoint inhibitor treatment for malignancy The individual has received insufficient benefit from use of corticosteroids Infliximab is to be administered at up to 5mg/kg for up to four doses any relevant practitioner 4 The individual has shown clinical improvement and ongoing treatment is required Infliximab is to be administered at up to 5mg/kg for up to a total of 8 doses any relevant practitioner 4

Indications marked with * are unapproved indications.

 Tocilizumab <range>Tocilizumab</range> The patient has developed grade 3 or 4 cytokine release syndrome associated with the administration of blinatumomab for the treatment of acute lymphoblastic leukaemia Tocilizumab is to be administered at doses no greater than 8 mg/kg IV for a maximum of 3 doses (if less than 30kg, maximum of 12 mg/kg) The patient is enrolled in the Malaghan Institute of Medical Research ENABLE trial programme The patient has developed CRS or Immune Effector Cell-Associated Neurotoxicity Syndrome (ICANS) following CAR T-Cell therapy for the treatment of relapsed or refractory B-cell non-Hodgkin lymphoma Tocilizumab is to be administered according to the consensus guidelines for CRS or ICANS for CAR T-cell therapy at doses no greater than 8 mg/kg IV for a maximum of 3 doses medical practitioner 3 Patient was being treated with tocilizumab prior to 1 February 2019 rheumatoid arthritis systemic juvenile idiopathic arthritis adult-onset Still's disease polyarticular juvenile idiopathic arthritis idiopathic multicentric Castleman's disease any relevant practitioner 6 The patient has had an initial Special Authority approval for adalimumab and/or etanercept for rheumatoid arthritis The patient has experienced intolerable side effects from adalimumab and/or etanercept 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 The patient is seronegative for both anti-cyclic citrullinated peptide (CCP) antibodies and rheumatoid factor The patient has been started on rituximab for rheumatoid arthritis in a Health NZ Hospital The patient has experienced intolerable side effects from rituximab 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 rheumatologist Practitioner 6 Patient has had severe and active erosive rheumatoid arthritis (either confirmed by radiology imaging, or the patient is cyclic citrullinated peptide (CCP) antibody positive) for six months duration or longer Tocilizumab is to be used as monotherapy Treatment with methotrexate is contraindicated Patient has tried and did not tolerate oral and/or parenteral methotrexate 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 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 Patient has persistent symptoms of poorly controlled and active disease in at least 20 active, swollen, tender joints 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 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 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 rheumatologist Practitioner 6 Patient diagnosed with systemic juvenile idiopathic arthritis 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 rheumatologist Practitioner 6 The patient has had an initial Special Authority approval for adalimumab and/or etanercept for adult-onset Still's disease (AOSD) The patient has been started on tocilizumab for AOSD in a Health NZ Hospital The patient has experienced intolerable side effects from adalimumab and/or etanercept 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 Patient diagnosed with AOSD according to the Yamaguchi criteria (J Rheumatol 1992;19:424-430) Patient has tried and not responded to at least 6 months of glucocorticosteroids at a dose of at least 0.5 mg/kg, non-steroidal antiinflammatory drugs (NSAIDs) and methotrexate Patient has persistent symptoms of disabling poorly controlled and active disease rheumatologist Practitioner 6 The patient has had an initial Special Authority approval for both etanercept and adalimumab for polyarticular course juvenile idiopathic arthritis (JIA) The patient has experienced intolerable side effects, or has received insufficient benefit from, both etanercept and adalimumab Treatment with a tumour necrosis factor alpha inhibitor is contraindicated Patient has had polyarticular course JIA for 6 months duration or longer To be used as an adjunct to methotrexate therapy or monotherapy where use of methotrexate is limited by toxicity or intolerance At least 5 active joints and at least 3 joints with limited range of motion, pain or tenderness after a 3-month trial of methotrexate (at the maximum tolerated dose) Moderate or high disease activity (cJADAS10 score of at least 2.5) after a 3-month trial of methotrexate (at the maximum tolerated dose) Low disease activity (cJADAS10 score between 1.1 and 2.5) after a 6-month trial of methotrexate rheumatologist Practitioner 4 Patient has severe HHV-8 negative idiopathic multicentric Castleman's disease Treatment with an adequate trial of corticosteroids has proven ineffective Tocilizumab to be administered at doses no greater than 8 mg/kg IV every 3-4 weeks haematologist rheumatologist Practitioner 6 Patient has confirmed (or probable) COVID-19 Oxygen saturation of <92% on room air, or requiring supplemental oxygen Patient is receiving adjunct systemic corticosteroids, or systemic corticosteroids are contraindicated Tocilizumab is to be administered at doses no greater than 8mg/kg IV for a maximum of one dose Tocilizumab is not to be administered in combination with barcitinib medical practitioner 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 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 rheumatologist Practitioner 6 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 On subsequent reapplications, the patient demonstrates at least a continuing ACR Pedi 30 response from baseline rheumatologist Practitioner 6 the patient has a sustained improvement in inflammatory markers and functional status rheumatologist Practitioner 6 Treatment is to be used as an adjunct to methotrexate therapy or monotherapy where use of methotrexate is limited by toxicity or intolerance 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 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 rheumatologist Practitioner 6 the treatment remains appropriate and the patient has a sustained improvement in inflammatory markers and functional status haematologist rheumatologist Practitioner 12 The individual requires treatment for moderate to severe autoimmune toxicity following immune checkpoint inhibitor treatment for malignancy The individual has received insufficient benefit from use of corticosteroids Tocilizumab is to be administered at a maximum dose of 8 mg/kg fortnightly any relevant practitioner 4 The individual has shown clinical improvement and ongoing treatment is required Tocilizumab is to be administered at a maximum dose of 8 mg/kg fortnightly any relevant practitioner 4

Indications marked with * are unapproved indications.

 Omalizumab <range>Omalizumab</range> Patient must be aged 6 years or older Patient has a diagnosis of severe asthma Past or current evidence of atopy, documented by skin prick testing or RAST Total serum human immunoglobulin E (IgE) between 76 IU/mL and 1300 IU/ml at baseline Proven adherence with optimal inhaled therapy including high dose inhaled corticosteroid (budesonide 1,600 mcg per day or fluticasone propionate 1,000 mcg per day or equivalent), plus long-acting beta-2 agonist therapy (at least salmeterol 50 mcg bd or eformoterol 12 mcg bd) for at least 12 months, unless contraindicated or not tolerated Patient has received courses of systemic corticosteroids equivalent to at least 28 days treatment in the past 12 months, unless contraindicated or not tolerated Patient has had at least 4 exacerbations needing systemic corticosteroids in the previous 12 months, where an exacerbation is defined as either documented use of oral corticosteroids for at least 3 days or parenteral steroids Patient has an Asthma Control Test (ACT) score of 10 or less Baseline measurements of the patient’s asthma control using the ACT and oral corticosteroid dose must be made at the time of application, and again at around 26 weeks after the first dose to assess response to treatment clinical immunologist respiratory specialist 6 An increase in the Asthma Control Test (ACT) score of at least 5 from baseline A reduction in the maintenance oral corticosteroid dose or number of exacerbations of at least 50% from baseline respiratory specialist 6 Patient must be aged 12 years or older Patient is symptomatic with Urticaria Activity Score 7 (UAS7) of 20 or above Patient has a Dermatology life quality index (DLQI) of 10 or greater Patient has been taking high dose antihistamines (e.g. 4 times standard dose) and ciclosporin (>3 mg/kg day) for at least 6 weeks Patient has been taking high dose antihistamines (e.g. 4 times standard dose) and at least 3 courses of systemic corticosteroids (>20 mg prednisone per day for at least 5 days) in the previous 6 months Patient has developed significant adverse effects whilst on corticosteroids or ciclosporin Treatment to be stopped if inadequate response* following 4 doses Complete response* to 6 doses of omalizumab clinical immunologist dermatologist 6 Patient has previously had a complete response* to 6 doses of omalizumab Patient has previously had a complete response* to 6 doses of omalizumab Patient has relapsed after cessation of omalizumab therapy clinical immunologist dermatologist 6

*Inadequate response defined as less than 50% reduction in baseline UAS7 and DLQI score, or an increase in Urticaria Control Test (UCT) score of less than 4 from baseline. Patient is to be reassessed for response after 4 doses of omalizumab. Complete response is defined as UAS7 less than or equal to 6 and DLQI less than or equal to 5; or UCT of 16. Relapse of chronic urticaria on stopping prednisone/ciclosporin does not justify the funding of omalizumab.

 Siltuximab <range>Siltuximab</range> Patient has severe HHV-8 negative idiopathic multicentric Castleman's Disease Treatment with an adequate trial of corticosteroids has proven ineffective Siltuximab is to be administered at doses no greater than 11 mg/kg every 3 weeks haematologist rheumatologist 6 The treatment remains appropriate and the patient has sustained improvement in inflammatory markers and functional status haematologist rheumatologist 12 Obinutuzumab <range>Obinutuzumab </range> The patient has progressive Binet stage A, B or C CD20+ chronic lymphocytic leukaemia requiring treatment The patient is obinutuzumab treatment naive The patient is not eligible for full dose FCR due to comorbidities with a score > 6 on the Cumulative Illness Rating Scale (CIRS) or reduced renal function (creatinine clearance <70mL/min) Patient has adequate neutrophil and platelet counts* unless the cytopenias are a consequence of marrow infiltration by CLL Patient has good performance status Obinutuzumab to be administered at a maximum cumulative dose of 8,000 mg and in combination with chlorambucil for a maximum of 6 cycles medical practitioner 6

Chronic lymphocytic leukaemia includes small lymphocytic lymphoma. Comorbidity refers only to illness/impairment other than CLL induced illness/impairment in the patient. ’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 obinutuzumab is expected to improve symptoms and improve ECOG score to <2.

* greater than or equal to 1.5 x 109/L and platelets greater than or equal to 75 x 109/L

 Patient has follicular lymphoma Patient has marginal zone lymphoma Patient is refractory to or has relapsed within 12 months of a rituximab containing combined chemo-immunotherapy regimen* Patient has an ECOG performance status of 0-2 Patient has been previously treated with no more than four chemotherapy regimens Obinutuzumab to be administered at a maximum dose of 1000 mg for a maximum of 6 cycles in combination with chemotherapy* medical practitioner 9

* includes unapproved indications

 Patient has no evidence of disease progression following obinutuzumab induction therapy Obinutuzumab to be administered at a maximum of 1000 mg every 2 months for a maximum of 2 years Obinutuzumab to be discontinued at disease progression medical practitioner 24 Pertuzumab <range>Pertuzumab </range> The patient has metastatic breast cancer expressing HER-2 IHC 3+ or ISH+ (including FISH or other current technology) Patient is chemotherapy treatment naive Patient has not received prior treatment for their metastatic disease and has had a treatment free interval of at least 12 months between prior (neo)adjuvant chemotherapy treatment and diagnosis of metastatic breast cancer The patient has good performance status (ECOG grade 0-1) Pertuzumab to be administered in combination with trastuzumab Pertuzumab maximum first dose of 840 mg, followed by maximum of 420 mg every 3 weeks Pertuzumab to be discontinued at disease progression medical practitioner 12 The patient has metastatic breast cancer expressing HER-2 IHC 3+ or ISH+ (including FISH or other current technology) The cancer has not progressed at any time point during the previous 12 months whilst on pertuzumab and trastuzumab Patient has previously discontinued treatment with pertuzumab and trastuzumab for reasons other than severe toxicity or disease progression Patient has signs of disease progression Disease has not progressed during previous treatment with pertuzumab and trastuzumab medical practitioner 12 Cetuximab <range>Cetuximab</range> Patient has locally advanced, non-metastatic, squamous cell cancer of the head and neck Cisplatin is contraindicated or has resulted in intolerable side effects Patient has an ECOG performance score of 0-2 To be administered in combination with radiation therapy medical practitioner Patient has metastatic colorectal cancer located on the left side of the colon (see Note) There is documentation confirming disease is RAS and BRAF wild-type Patient has an ECOG performance score of 0-2 Patient has not received prior funded treatment with cetuximab Cetuximab is to be used in combination with chemotherapy Chemotherapy is determined to not be in the best interest of the patient based on clinician assessment medical practitioner 6 No evidence of disease progression medical practitioner 6

Left-sided colorectal cancer comprises of the distal one-third of the transverse colon, the splenic flexure, the descending colon, the sigmoid colon, or the rectum.

 Aflibercept <range>Aflibercept</range> Wet age-related macular degeneration (wet AMD) Polypoidal choroidal vasculopathy Choroidal neovascular membrane from causes other than wet AMD The patient has developed severe endophthalmitis or severe posterior uveitis following treatment with bevacizumab There is worsening of vision or failure of retina to dry despite three intraocular injections of bevacizumab four weeks apart There is no structural damage to the central fovea of the treated eye Patient has not previously been treated with ranibizumab or faricimab for longer than 3 months Patient has current approval to use ranibizumab or faricimab for treatment of wAMD and was found to be intolerant within 3 months Patient has previously* (*before June 2018) received treatment with ranibizumab for wAMD and disease was stable while on treatment medical practitioner 3 Documented benefit must be demonstrated to continue Patient’s vision is 6/36 or better on the Snellen visual acuity score There is no structural damage to the central fovea of the treated eye medical practitioner 12 Patient has centre involving diabetic macular oedema (DMO) Patient’s disease is non responsive to 4 doses of intravitreal bevacizumab when administered 4-6 weekly Patient has reduced visual acuity between 6/9 – 6/36 with functional awareness of reduction in vision Patient has DMO within central OCT (ocular coherence tomography) subfield >350 micrometers There is no centre-involving sub-retinal fibrosis or foveal atrophy Patient has not previously been treated with faricimab for longer than 3 months medical practitioner 4 There is stability or two lines of Snellen visual acuity gain There is structural improvement on OCT scan (with reduction in intra-retinal cysts, central retinal thickness, and sub-retinal fluid) Patient’s vision is 6/36 or better on the Snellen visual acuity score There is no centre-involving sub-retinal fibrosis or foveal atrophy medical practitioner 12 Secukinumab <range>Secukinumab</range> Patient has "whole body" plaque psoriasis with a PASI score of greater than 10, where lesions have been present for at least 6 months from the time of initial diagnosis Patient has 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 Patient has localised genital or flexural plaque psoriasis where the plaques or lesions have been present for at least 6 months from the time of initial diagnosis, and with a DLQI score greater than 10 Patient has received insufficient benefit (see Note) or has experienced intolerable side effects from at least 3 of the following (at maximum tolerated doses unless contraindicated): phototherapy, methotrexate, ciclosporin, or acitretin A PASI assessment or DLQI assessment has been completed for the most recent prior treatment course, within 1 month of stopping that treatment The most recent PASI or DQLI assessment is within 1 month before the application Patient has had a Special Authority approval for adalimumab, etanercept, or infliximab, for plaque psoriasis Patient has experienced intolerable side effects Patient has received insufficient benefit to meet the renewal criteria for plaque psoriasis A PASI assessment or DLQI assessment has been completed for the most recent prior treatment within 1 month of stopping that treatment The most recent PASI or DQLI assessment is within 1 month before the application medical practitioner 6

A treatment course is defined as a minimum of 12 weeks of treatment. "Insufficient benefit" is defined as: for whole body plaque psoriasis, a PASI score of greater than 10; for plaque psoriasis of the face, hand, foot, genital or flexural areas, at least 2 of the 3 PASI symptom sub scores for erythema, thickness and scaling are rated as severe or very severe, and for the face, palm of a hand or sole of a foot 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.

 Patient’s PASI score has reduced by 75% or more compared to pre-secukinumab baseline Patient has a DLQI improvement of 5 or more compared to pre-secukinumab baseline Patient had localised genital or flexural plaque psoriasis at the start of treatment Patient has experienced a reduction of 75% or more in the skin area affected, or sustained at this level, compared to the pre-secukinumab baseline Patient has a DLQI improvement of 5 or more, compared to pre-secukinumab baseline Maximum dose 300 mg monthly medical practitioner 6 Patient has had a Special Authority approval for adalimumab or etanercept for ankylosing spondylitis Patient has experienced intolerable side effects Patient has received insufficient benefit to meet the renewal criteria for ankylosing spondylitis medical practitioner 3 BASDAI has improved from the pre-secukinumab baseline either by at least 4 points on a 10-point scale, or by at least 50%, whichever is less Maximum dose 300 mg monthly medical practitioner 6 Patient has had a Special Authority approval for adalimumab, etanercept or infliximab for psoriatic arthritis Patient has experienced intolerable side effects Patient has received insufficient benefit to meet the renewal criteria for psoriatic arthritis Patient has received insufficient benefit from at least 3 months of methotrexate at a maximum tolerated dose unless contraindicated Patient has received insufficient benefit from at least 3 months of sulfasalazine or leflunomide at maximum tolerated doses unless contraindicated Patient has persistent symptoms of poorly controlled and active disease in at least 15 joints Patient has persistent symptoms of poorly controlled and active disease in at least 4 joints from the following: wrist, elbow, knee, ankle, and either shoulder or hip CRP greater than 15 mg/L measured within one month before the application ESR greater than 25 mm per hour measured within one month before the application ESR and CRP not measured as patient is receiving prednisone therapy greater than 5 mg per day received for more than 3 months medical practitioner 6 Following initial treatment, at least a 50% decrease in active joint count from baseline At least a continuing 30% improvement in active joint count from baseline Maximum dose 300 mg monthly medical practitioner 6 Trastuzumab emtansine <range>Trastuzumab emtansine</range> Patient has early breast cancer expressing HER2 IHC3+ or ISH+ Documentation of pathological invasive residual disease in the breast and/or axiliary lymph nodes following completion of surgery Patient has completed systemic neoadjuvant therapy with trastuzumab and chemotherapy prior to surgery Disease has not progressed during neoadjuvant therapy Patient has left ventricular ejection fraction of 45% or greater Adjuvant treatment with trastuzumab emtansine to be commenced within 12 weeks of surgery Trastuzumab emtansine to be discontinued at disease progression Total adjuvant treatment duration must not exceed 42 weeks (14 cycles) medical practitioner Patient has metastatic breast cancer expressing HER-2 IHC 3+ or ISH+ (including FISH or other current technology) Patient has previously received trastuzumab and chemotherapy, separately or in combination The patient has received prior therapy for metastatic disease* The patient developed disease recurrence during, or within six months of completing adjuvant therapy* Patient has a good performance status (ECOG 0-1) Patient does not have symptomatic brain metastases Patient has brain metastases and has received prior local CNS therapy Patient has not received prior funded trastuzumab emtansine or trastuzumab deruxtecan treatment Patient has discontinued trastuzumab deruxtecan due to intolerance The cancer did not progress while on trastuzumab deruxtecan Treatment to be discontinued at disease progression medical practitioner 6 The cancer has not progressed at any time point during the previous approval period whilst on trastuzumab emtansine Treatment to be discontinued at disease progression medical practitioner 6

*Note: Prior or adjuvant therapy includes anthracycline, other chemotherapy, biological drugs, or endocrine therapy.

 Rituximab (riximyo) <range>Rituximab<instance>Riximyo</instance></range> Patient has mild congenital haemophilia complicated by inhibitors Patient has severe congenital haemophilia complicated by inhibitors and has failed immune tolerance therapy Patient has acquired haemophilia haematologist Patient was previously treated with rituximab for haemophilia with inhibitors An initial response lasting at least 12 months was demonstrated Patient now requires repeat treatment haematologist The patient has B-cell post-transplant lymphoproliferative disorder* To be used for a maximum of 8 treatment cycles medical practitioner

Indications marked with * are unapproved indications.

 The patient has had a rituximab treatment-free interval of 12 months or more The patient has B-cell post-transplant lymphoproliferative disorder* To be used for no more than 6 treatment cycles medical practitioner

Indications marked with * are unapproved indications.

 The patient has indolent low grade NHL or hairy cell leukaemia* with relapsed disease following prior chemotherapy To be used for a maximum of 6 treatment cycles The patient has indolent, low grade lymphoma or hairy cell leukaemia* requiring first-line systemic chemotherapy To be used for a maximum of 6 treatment cycles medical practitioner 9

'Indolent, low-grade lymphomas' includes follicular, mantle, marginal zone and lymphoplasmacytic/Waldenstrom macroglobulinaemia. *Unapproved indication. 'Hairy cell leukaemia' also includes hairy cell leukaemia variant.

 The patient has had a rituximab treatment-free interval of 12 months or more The patient has indolent, low-grade NHL or hairy cell leukaemia* with relapsed disease following prior chemotherapy To be used for no more than 6 treatment cycles medical practitioner 12

'Indolent, low-grade lymphomas' includes follicular, mantle, marginal zone and lymphoplasmacytic/Waldenstrom macroglobulinaemia. *Unapproved indication. 'Hairy cell leukaemia' also includes hairy cell leukaemia variant.

 The patient has treatment naive aggressive CD20 positive NHL To be used with a multi-agent chemotherapy regimen given with curative intent To be used for a maximum of 8 treatment cycles The patient has aggressive CD20 positive NHL with relapsed disease following prior chemotherapy To be used for a maximum of 6 treatment cycles medical practitioner

'Aggressive CD20 positive NHL' includes large B-cell lymphoma and Burkitt's lymphoma/leukaemia.

 The patient has had a rituximab treatment-free interval of 12 months or more The patient has relapsed refractory/aggressive CD20 positive NHL To be used with a multi-agent chemotherapy regimen given with curative intent To be used for a maximum of 4 treatment cycles medical practitioner

'Aggressive CD20 positive NHL' includes large B-cell lymphoma and Burkitt's lymphoma/leukaemia.

 The patient has progressive Binet stage A, B or C chronic lymphocytic leukaemia (CLL) requiring treatment The patient is rituximab treatment naive The patient is chemotherapy treatment naive The patient's disease has relapsed following no more than three prior lines of chemotherapy treatment The patient has had a treatment-free interval of 12 months or more if previously treated with fludarabine and cyclophosphamide chemotherapy The patient’s disease has relapsed and rituximab treatment is to be used in combination with funded venetoclax The patient has good performance status The patient does not have chromosome 17p deletion CLL Rituximab treatment is to be used in combination with funded venetoclax for relapsed/refractory chronic lymphocytic leukaemia Rituximab to be administered in combination with fludarabine and cyclophosphamide, bendamustine or venetoclax for a maximum of 6 treatment cycles It is planned that the patient receives full dose fludarabine and cyclophosphamide (orally or dose equivalent intravenous administration), bendamustine or venetoclax medical practitioner 12

'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.

 The patient’s disease has relapsed and rituximab treatment is to be used in combination with funded venetoclax The patient's disease has relapsed following no more than one prior line of treatment with rituximab for CLL The patient has had an interval of 36 months or more since commencement of initial rituximab treatment The patient does not have chromosome 17p deletion CLL It is planned that the patient receives full dose fludarabine and cyclophosphamide (orally or dose equivalent intravenous administration) or bendamustin Rituximab to be administered in combination with fludarabine and cyclophosphamide, bendamustine or venetoclax for a maximum of 6 treatment cycles medical practitioner 12

'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.

 Patient has cold haemagglutinin disease* Patient has severe disease which is characterized by symptomatic anaemia, transfusion dependence or disabling circulatory symptoms The total rituximab dose used would not exceed the equivalent of 375 mg/m² of body surface area per week for a total of 4 weeks haematologist 8

Indications marked with * are unapproved indications.

 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 Patient was previously treated with rituximab for severe cold haemagglutinin disease* An initial response lasting at least 12 months was demonstrated Patient now requires repeat treatment haematologist 8

Indications marked with * are unapproved indications.

 Patient has warm autoimmune haemolytic anaemia* 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 The total rituximab dose used would not exceed the equivalent of 375 mg/m² of body surface area per week for a total of 4 weeks haematologist 8

Indications marked with * are unapproved indications.

 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 Patient was previously treated with rituximab for warm autoimmune haemolytic anaemia* An initial response lasting at least 12 months was demonstrated Patient now requires repeat treatment haematologist 8

Indications marked with * are unapproved indications.

 Patient has immune thrombocytopenic purpura* with a platelet count of less than or equal to 20,000 platelets per microlitre Patient has immune thrombocytopenic purpura* with a platelet count of 20,000 to 30,000 platelets per microlitre and significant mucocutaneous bleeding Treatment with steroids and splenectomy have been ineffective Treatment with steroids has been ineffective and splenectomy is an absolute contraindication Other treatments including steroids have been ineffective and patient is being prepared for elective surgery (e.g. splenectomy) The total rituximab dose used would not exceed the equivalent of 375 mg/m² of body surface area per week for a total of 4 weeks haematologist 8

Indications marked with * are unapproved indications.

 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 Patient was previously treated with rituximab for immune thrombocytopenic purpura* An initial response lasting at least 12 months was demonstrated Patient now requires repeat treatment haematologist 8

Indications marked with * are unapproved indications.

 The total rituximab dose per cycle would not exceed the equivalent of 375 mg/m² of body surface area per week for a total of 4 weeks Each treatment cycle at least 6 months apart Patient has experienced progression of clinical symptoms or persistent thrombocytopenia despite plasma exchange Patient has acute idiopathic TTP* with neurological or cardiovascular pathology haematologist

Indications marked with * are unapproved indications.

 Patient has autoimmune pure red cell aplasia* associated with a demonstrable B-cell lymphoproliferative disorder haematologist 6

Indications marked with * are unapproved indications.

 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 haematologist 6

Indications marked with * are unapproved indications.

 Patient has been diagnosed with ANCA associated vasculitis* 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 Induction therapy with daily oral or pulse intravenous cyclophosphamide has failed to achieve significant improvement of disease after at least 3 months 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 Cyclophosphamide and methotrexate are contraindicated Patient is a female of child-bearing potential Patient has a previous history of haemorrhagic cystitis, urological malignancy or haematological malignancy medical practitioner 8

Indications marked with * are unapproved indications.

 Patient has been diagnosed with ANCA associated vasculitis* Patient has previously responded to treatment with rituximab but is now experiencing an acute flare of vasculitis 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 medical practitioner 8

Indications marked with * are unapproved indications.

 Patient has severe, immediately life- or organ-threatening SLE* The condition has been refractory to treatment with corticosteroids at a dose of at least 1 mg/kg unless contraindicated The condition 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 Initial treatment maximum of four 1000 mg infusions Treatment for relapse following initial partial response to rituximab up to a maximum of two 1000 mg infusions every 6 months rheumatologist nephrologist

Indications marked with * are unapproved indications.

 Patient has been diagnosed with antibody-mediated organ transplant rejection* medical practitioner

Indications marked with * are unapproved indications.

 Patient is to undergo an ABO-incompatible solid organ transplant* medical practitioner

Indications marked with * are unapproved indications.

 Patient is a child with SDNS* or FRNS* Treatment with corticosteroids, ciclosporin, and mycophenolate for at least 3 months for each agent has been ineffective, not tolerated, or is contraindicated The total rituximab dose used would not exceed the equivalent of 375 mg/m² of body surface area per week for a total of 4 weeks medical practitioner 8

Indications marked with * are unapproved indications.

 Patient who was previously treated with rituximab for nephrotic syndrome* Treatment with rituximab was previously successful and has demonstrated sustained response for >6 months, but the condition has relapsed and the patient now requires repeat treatment The total rituximab dose used would not exceed the equivalent of 375 mg/m² of body surface area per week for a total of 4 weeks medical practitioner 8

Indications marked with * are unapproved indications.

 Patient is a child with SRNS* and treatment with corticosteroids, ciclosporin and tacrolimus for at least 3 months for each agent has been ineffective, not tolerated, or is contraindicated Genetic causes of nephrotic syndrome have been excluded The total rituximab dose per cycle would not exceed the equivalent of 375 mg/m² of body surface area per week for a total of 4 weeks medical practitioner 8

Indications marked with * are unapproved indications.

 Patient who was previously treated with rituximab for nephrotic syndrome* Treatment with rituximab was previously successful and has demonstrated sustained response for greater than 6 months, but the condition has relapsed and the patient now requires repeat treatment The total rituximab dose used would not exceed the equivalent of 375 mg/m² of body surface area per week for a total of 4 weeks medical practitioner 8

Indications marked with * are unapproved indications.

 Cumulative dose up to 1500 mg/m² body surface area up to 2000 mg total per cycle Patient has experienced a severe episode or attack of NMOSD (rapidly progressing symptoms with supporting clinical investigations) Patient has experienced a breakthrough attack of NMOSD Patient is receiving treatment with mycophenolate unless contraindicated or not tolerated Patient is receiving treatment with corticosteroids unless contraindicated or not tolerated Each treatment cycle at least 6 months apart medical practitioner

Indications marked with * are unapproved indications.

 Cumulative dose up to 1500 mg/m² body surface area up to 2000 mg total per cycle Treatment with corticosteroids and at least one other immunosuppressant for a minimum period of 12 months has been ineffective Treatment with at least one other immunosuppressant for a period of at least 12 months Corticosteroids have been trialed for at least 12 months and have been discontinued due to unacceptable side effects medical practitioner 2

Indications marked with * are unapproved indications.

 Cumulative dose up to 1500 mg/m² body surface area up to 2000 mg total per cycle An initial response lasting at least 12 months was demonstrated Patient has relapsed despite treatment with corticosteroids and at least one other immunosuppressant for a period of at least 12 months Patient’s myasthenia gravis has relapsed despite treatment with at least one immunosuppressant for a period of at least 12 months Corticosteroids have been trialed for at least 12 months and have been discontinued due to unacceptable side effects medical practitioner 2

Indications marked with * are unapproved indications.

 Patient has severe, immediately life- or organ-threatening disease, including interstitial lung disease Treatment with at least 3 immunosuppressants (oral corticosteroids, cyclophosphamide, methotrexate, mycophenolate, ciclosporin, azathioprine) has been ineffective controlling active disease Rapid treatment is required for life threatening complications Maximum of two 1000 mg infusions every 6 months medical practitioner Patient has refractory graft versus host disease following transplant Treatment with at least 3 immunosuppressants (oral steroids, ciclosporin, tacrolimus, mycophenolate, sirolimus) has not be effective at controlling active disease The total rituximab dose used would not exceed the equivalent of 375 mg/m² of body surface area per week for a total of 4 weeks medical practitioner Treatment with corticosteroids and intravenous immunoglobulin and/or plasma exchange has been ineffective controlling active disease, is not tolerated, or is contraindicated At least one other immunosuppressant (cyclophosphamide, ciclosporin, tacrolimus, mycophenolate) is not tolerated or has been ineffective controlling active disease. If an immunosuppressant is contraindicated, a trial has occurred of one of those which is not contraindicated (unless all are contraindicated) Rapid treatment is required for life threatening complications Cumulative dose up to 1500 mg/m² body surface area up to 2000 mg total per cycle Each treatment cycle at least 6 months apart neurologist

Indications marked with * are unapproved indications.

 Treatment with corticosteroids and intravenous immunoglobulin and/or plasma exchange has been ineffective controlling active disease, is not tolerated or is contraindicated At least one other immunosuppressant (cyclophosphamide, ciclosporin, tacrolimus, mycophenolate) has been ineffective controlling active disease, is not tolerated or is contraindicated Rapid treatment is required for life threatening complications Cumulative dose up to 1500 mg/m² body surface area up to 2000 mg total per cycle Each treatment cycle at least 6 months apart medical practitioner

Indications marked with * are unapproved indications.

 The patient has CD20+ low grade or follicular B-cell NHL with relapsed disease following prior chemotherapy To be used for a maximum of 6 treatment cycles The patient has CD20+ low grade or follicular B-cell NHL requiring first-line systemic chemotherapy To be used for a maximum of 6 treatment cycles medical practitioner 9 Rituximab is to be used for maintenance in CD20+ low grade or follicular B-cell NHL following induction with first-line systemic chemotherapy Patient is intended to receive rituximab maintenance therapy for 2 years at a dose of 375 mg/m² every 8 weeks (maximum of 12 cycles) medical practitioner 24 Patient has biopsy-proven primary/idiopathic membranous nephropathy* Patient has PLA2 antibodies with no evidence of secondary cause, and an eGFR of >60ml/min/1.73m² Patient remains at high risk of progression to end-stage kidney disease despite more than 3 months of treatment with conservative measures that include (unless contraindicated or the patient has experienced intolerable side effects) renin-angiotensin system blockade, blood-pressure management, dietary sodium and protein restriction, treatment of dyslipidaemia, and anticoagulation agents The total rituximab dose per cycle would not exceed the equivalent of 375mg/m² of body surface area per week for a total of 4 weeks Subsequent retreatment only for disease relapse or after partial response medical practitioner

Indications marked with * are unapproved indications.

 Patient has newly diagnosed B-cell acute lymphoblastic leukaemia/lymphoma* Treatment must be in combination with an intensive chemotherapy protocol with curative intent The total rituximab dose would not exceed the equivalent of 375 mg/m² per dose for a maximum of 18 doses medical practitioner 2

Indications marked with * are unapproved indications.

 Patient requires desensitisation prior to mismatched allogenic stem cell transplant* Patient would receive no more than two doses at 375 mg/m² of body-surface area medical practitioner 6

Indications marked with * are unapproved indications.

 Patient has severe rapidly progressive pemphigus Is used in combination with systemic corticosteroids (20 mg/day) Skin involvement is at least 5% body surface area Significant mucosal involvement (10 or more mucosal erosions) or diffuse gingivitis or confluent large erosions Involvement of two or more mucosal sites Patient has pemphigus Patient has not experienced adequate clinical benefit from systemic corticosteroids (20 mg/day) in combination with a steroid sparing agent, unless contraindicated dermatologist relevant specialist 6

Indications marked with * are unapproved indications.

 Patient has experienced adequate clinical benefit from rituximab treatment, with improvement in symptoms and healing of skin ulceration and reduction in corticosteroid requirement Patient has not received rituximab in the previous 6 months dermatologist relevant specialist 6

Indications marked with * are unapproved indications.

 Patient has confirmed diagnosis of IgG4-RD* Treatment with corticosteroids and/or disease modifying anti-rheumatic drugs for at least 3 months has been ineffective in lowering corticosteroid dose below 5 mg per day (prednisone equivalent) without relapse Treatment with corticosteroids and/or disease modifying anti-rheumatic drugs is contraindicated or associated with evidence of toxicity or intolerance Total rituximab dose used should not exceed a maximum of two 1000 mg infusions of rituximab given two weeks apart medical practitioner 6

Indications marked with * are unapproved indications.

 Treatment with rituximab for IgG4-RD* was previously successful and patient’s disease has demonstrated sustained response, but the condition has relapsed Patient is receiving maintenance treatment for IgG4-RD* Rituximab re-treatment not to be given within 6 months of previous course of treatment Maximum of two 1000 mg infusions of rituximab given two weeks apart medical practitioner 12

Indications marked with * are unapproved indications.

 Mepolizumab <range>Mepolizumab</range> Patient must be aged 12 years or older Patient must have a diagnosis of severe eosinophilic asthma documented by a respiratory physician or clinical immunologist Conditions that mimic asthma eg. vocal cord dysfunction, central airway obstruction, bronchiolitis etc. have been excluded Patient has a blood eosinophil count of greater than 0.5 x 10^9 cells/L in the last 12 months Patient must be adherent to optimised asthma therapy including inhaled corticosteroids (equivalent to at least 1000 mcg per day of fluticasone propionate) plus long acting beta-2 agonist, or budesonide/formoterol as part of the single maintenance and reliever therapy regimen, unless contraindicated or not tolerated Patient has had at least 4 exacerbations needing systemic corticosteroids in the previous 12 months, where an exacerbation is defined as either documented use of oral corticosteroids for at least 3 days or parenteral corticosteroids Patient has received continuous oral corticosteroids of at least the equivalent of 10 mg per day over the previous 3 months Treatment is not to be used in combination with subsidised benralizumab Patient has an Asthma Control Test (ACT) score of 10 or less. Baseline measurements of the patient’s asthma control using the ACT and oral corticosteroid dose must be made at the time of application, and again at around 52 weeks after the first dose to assess response to treatment Patient has not previously received an anti-IL5 biological therapy for their severe eosinophilic asthma Patient was refractory or intolerant to previous anti-IL5 biological therapy Patient was not eligible to continue treatment with previous anti-IL5 biological therapy and discontinued within 12 months of commencing treatment respiratory physician clinical immunologist 12 An increase in the Asthma Control Test (ACT) score of at least 5 from baseline Exacerbations have been reduced from baseline by 50% as a result of treatment with mepolizumab Reduction in continuous oral corticosteroid use by 50% or by 10 mg/day while maintaining or improving asthma control respiratory physician clinical immunologist 2 The patient has eosinophilic granulomatosis with polyangiitis The patient has trialled and not received adequate benefit from at least one of the following for at least three months (unless contraindicated to all): azathioprine, cyclophosphamide, leflunomide, methotrexate, mycophenolate, or rituximab The patient has trialled prednisone for a minimum of three months and is unable to maintain disease control at doses below 7.5 mg per day Corticosteroids are contraindicated medical practitioner 12 Patient has no evidence of clinical disease progression medical practitioner 12 Adalimumab (Amgevita) <range>Adalimumab (Amgevita)</range> The patient has severe Behcet's disease* that is significantly impacting the patient's quality of life The patient has severe ocular, neurological, and/or vasculitic symptoms and has not responded adequately to one or more treatment(s) appropriate for the particular symptom(s) The patient has severe gastrointestinal, rheumatological and/or mucocutaneous symptoms and has not responded adequately to two or more treatments appropriate for the particular symptom(s) any relevant practitioner

Indications marked with * are unapproved indications.

 Patient has hidradenitis suppurativa Hurley Stage II or Hurley Stage III lesions in distinct anatomic areas Patient has tried, but had an inadequate response to at least a 90 day trial of systemic antibiotics or patient has demonstrated intolerance to or has contraindications for systemic antibiotics Patient has 3 or more active lesions The patient has a DLQI of 10 or more and the assessment is no more than 1 month old at time of application dermatologist 4 The patient has a reduction in active lesions (e.g. inflammatory nodules, abscesses, draining fistulae) of 25% or more from baseline The patient has a DLQI improvement of 4 or more from baseline any relevant practitioner 2 Patient has had an initial Special Authority approval for etanercept for severe chronic plaque psoriasis Patient has experienced intolerable side effects Patient has received insufficient benefit to meet the renewal criteria for etanercept for severe chronic plaque psoriasis Patient has "whole body" severe chronic plaque psoriasis with a (PASI) score of greater than 10, where lesions have been present for at least 6 months from the time of initial diagnosis 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 Patient has severe chronic localised genital or flexural plaque psoriasis where the plaques or lesions have been present for at least 6 months from the time of initial diagnosis, and with a Dermatology Life Quality Index (DLQI) score greater than 10 Patient has tried, but had an inadequate response 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 A PASI assessment or (DLQI) assessment has been completed for at least the most recent prior treatment course but no longer than 1 month following cessation of each prior treatment course and is no more than 1 month old at the time of application dermatologist 4 Patient had "whole body" severe chronic plaque psoriasis at the start of treatment The patient has experienced a 75% or more reduction in PASI score, or is sustained at this level, when compared with the pre-treatment baseline value The patient has a DLQI improvement of 5 or more, when compared with the pre-treatment baseline value Patient had severe chronic plaque psoriasis of the face, or palm of a hand or sole of a foot at the start of treatment The patient has experienced 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 The patient has experienced a reduction of 75% or more in the skin area affected, or sustained at this level, as compared to the pre-treatment baseline value Patient had severe chronic localised genital or flexural plaque psoriasis at the start of treatment The patient has experienced a reduction of 75% or more in the skin area affected, or sustained at this level, as compared to the pre-treatment baseline value Patient has a Dermatology Quality of Life Index (DLQI) improvement of 5 or more, as compared to baseline DLQI prior to commencing adalimumab medical practitioner 2 Patient has pyoderma gangrenosum* 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 dermatologist

Indications marked with * are unapproved indications.

 Patient has severe active Crohn's disease Patient has a CDAI score of greater than or equal to 300 or HBI score of greater than or equal to 10 Patient has extensive small intestine disease affecting more than 50 cm of the small intestine Patient has evidence of short gut syndrome or would be at risk of short gut syndrome with further bowel resection Patient has an ileostomy or colostomy and has intestinal inflammation Patient has tried but had an inadequate response to, or has experienced intolerable side effects from, prior therapy with immunomodulators and corticosteroids any relevant practitioner 6 CDAI score has reduced by 100 points from the CDAI score, or HBI score has reduced 3 points, from when the patient was initiated on adalimumab CDAI score is 150 or less, or HBI is 4 or less The patient has demonstrated an adequate response to treatment, but CDAI score and/or HBI score cannot be assessed any relevant practitioner 2 Paediatric patient has active Crohn's disease Patient has a PCDAI score of greater than or equal to 30 Patient has extensive small intestine disease Patient has tried but had an inadequate response to, or has experienced intolerable side effects from, prior therapy with immunomodulators and corticosteroids any relevant practitioner 6 PCDAI score has reduced by 10 points from the PCDAI score when the patient was initiated on adalimumab PCDAI score is 15 or less The patient has demonstrated an adequate response to treatment but PCDAI score cannot be assessed any relevant practitioner 2 Patient has confirmed Crohn's disease Patient has one or more complex externally draining enterocutaneous fistula(e) Patient has one or more rectovaginal fistula(e) Patient has complex peri-anal fistula A Baseline Fistula Assessment has been completed and is no more than 1 month old at the time of application any relevant practitioner 6 The number of open draining fistulae have decreased from baseline by at least 50% 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 any relevant practitioner 2 The patient has had an initial Special Authority approval for infliximab for chronic ocular inflammation Patient has severe uveitis uncontrolled with treatment of steroids and other immunosuppressants with a severe risk of vision loss Patient is 18 years or older and treatment with at least two other immunomodulatory agents has proven ineffective Patient is under 18 years and treatment with methotrexate has proven ineffective or is not tolerated at a therapeutic dose Patient is under 8 years and treatment with steroids or methotrexate has proven ineffective or is not tolerated at a therapeutic dose; or disease requires control to prevent irreversible vision loss prior to achieving a therapeutic dose of methotrexate any relevant practitioner 4 The patient has had a good clinical response following 12 weeks' initial treatment Following each 2 year treatment period, the patient has had a sustained reduction in inflammation (Standardisation of Uveitis Nomenclature (SUN) criteria < ½+ anterior chamber or vitreous cells, absence of active vitreous or retinal lesions, or resolution of uveitic cystoid macular oedema) Following each 2 year treatment period, the patient has a sustained steroid sparing effect, allowing reduction in prednisone to < 10mg daily, or steroid drops less than twice daily if under 18 years old any relevant practitioner 2 Patient has had an initial Special Authority approval for infliximab for severe ocular inflammation Patient has severe, vision-threatening ocular inflammation requiring rapid control Treatment with high-dose steroids (intravenous methylprednisolone) followed by high dose oral steroids has proven ineffective at controlling symptoms Patient developed new inflammatory symptoms while receiving high dose steroids Patient is aged under 8 years and treatment with high dose oral steroids and other immunosuppressants has proven ineffective at controlling symptoms any relevant practitioner 4 The patient has had a good clinical response following 3 initial doses Following each 2 year treatment period, the patient has had a sustained reduction in inflammation (Standardisation of Uveitis Nomenclature (SUN) criteria <½+ anterior chamber or vitreous cells, absence of active vitreous or retinal lesions, or resolution of uveitic cystoid macular oedema) Following each 2 year treatment period, the patient has a sustained steroid sparing effect, allowing reduction in prednisone to <10mg daily, or steroid drops less than twice daily if under 18 years old any relevant practitioner 2 Patient has had an initial Special Authority approval for etanercept for ankylosing spondylitis The patient has experienced intolerable side effects The patient has received insufficient benefit to meet the renewal criteria for ankylosing spondylitis Patient has a confirmed diagnosis of ankylosing spondylitis for more than six months Patient has low back pain and stiffness that is relieved by exercise but not by rest Patient has bilateral sacroiliitis demonstrated by radiology imaging Patient has not responded adequately to treatment with two or more NSAIDs, while patient was undergoing at least 3 months of a regular exercise regimen for ankylosing spondylitis Patient has limitation of motion of the lumbar spine in the sagittal and the frontal planes as determined by the following 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) Patient has limitation of chest expansion by at least 2.5 cm below the average normal values corrected for age and gender A BASDAI of at least 6 on a 0-10 scale completed after the 3 month exercise trial, but prior to ceasing any previous pharmacological treatment and is no more than 1 month old at the time of application rheumatologist 6 For applications where treatment has resulted in an improvement in BASDAI of 4 or more points from pre-treatment baseline on a 10 point scale, or an improvement in BASDAI of 50%, whichever is less any relevant practitioner 2 The patient has had an initial Special Authority approval for etanercept for oligoarticular course juvenile idiopathic arthritis (JIA) Patient has experienced intolerable side effects Patient has received insufficient benefit to meet the renewal criteria for oligoarticular course JIA To be used as an adjunct to methotrexate therapy or monotherapy where use of methotrexate is limited by toxicity or intolerance Patient has had oligoarticular course JIA for 6 months duration or longer At least 2 active joints with limited range of motion, pain or tenderness after a 3-month trial of methotrexate (at the maximum tolerated dose) Moderate or high disease activity (cJADAS10 score greater than 1.5) with poor prognostic features after a 3-month trial of methotrexate (at the maximum tolerated dose) named specialist rheumatologist 6 Following initial treatment, the patient has at least a 50% decrease in active joint count and an improvement in physician's global assessment from baseline 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 any relevant practitioner 2 Patient has had an initial Special Authority approval for etanercept for polyarticular course juvenile idiopathic arthritis (JIA) Patient has experienced intolerable side effects Patient has received insufficient benefit to meet the renewal criteria for polyarticular course JIA To be used as an adjunct to methotrexate therapy or monotherapy where use of methotrexate is limited by toxicity or intolerance Patient has had polyarticular course JIA for 6 months duration or longer At least 5 active joints and at least 3 joints with limited range of motion, pain or tenderness after a 3-month trial of methotrexate (at the maximum tolerated dose) Moderate or high disease activity (cJADAS10 score of at least 2.5) after a 3-month trial of methotrexate (at the maximum tolerated dose) Low disease activity (cJADAS10 score between 1.1 and 2.5) after a 6-month trial of methotrexate named specialist rheumatologist 6 Following initial treatment, the patient has at least a 50% decrease in active joint count and an improvement in physician's global assessment from baseline 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 any relevant practitioner 2 Patient has had an initial Special Authority approval for etanercept or secukinumab for psoriatic arthritis Patient has experienced intolerable side effects Patient has received insufficient benefit to meet the renewal criteria for psoriatic arthritis Patient has had active psoriatic arthritis for six months duration or longer Patient has tried and not responded to at least three months of methotrexate at a maximum tolerated dose (unless contraindicated) Patient has tried and not responded to at least three months of sulfasalazine or leflunomide at maximum tolerated doses (unless contraindicated) Patient has persistent symptoms of poorly controlled and active disease in at least 15 swollen joints 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 Patient has CRP level greater than 15 mg/L measured no more than one month prior to the date of this application Patient has an elevated ESR greater than 25 mm per hour 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 rheumatologist 6 Following initial treatment, the patient has at least a 50% decrease in swollen joint count from baseline and a clinically significant response in the opinion of the physician Patient demonstrates at least a continuing 30% improvement in swollen joint count from baseline and a clinically significant response in the opinion of the treating physician any relevant practitioner 2 The patient has had an initial Special Authority approval for etanercept for rheumatoid arthritis The patient has experienced intolerable side effects The patient has received insufficient benefit from etanercept to meet the renewal criteria for rheumatoid arthritis Patient has had rheumatoid arthritis (either confirmed by radiology imaging, or the patient is cyclic citrullinated peptide (CCP) antibody positive) for six months duration or longer Treatment is to be used as an adjunct to methotrexate therapy or monotherapy where use of methotrexate is limited by toxicity or intolerance Patient has tried and not responded to at least three months of methotrexate at a maximum tolerated dose (unless contraindicated) Patient has tried and not responded to at least three months of methotrexate in combination with sulfasalazine and hydroxychloroquine sulphate at maximum tolerated doses (unless contraindicated) Patient has tried and not responded to at least three months of methotrexate in combination with the maximum tolerated dose of ciclosporin (unless contraindicated) Patient has tried and not responded to at least three months of therapy at the maximum tolerated dose of leflunomid (unless contraindicated) alone or in combination with methotrexate Patient has persistent symptoms of poorly controlled and active disease in at least 15 swollen joints 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 rheumatologist 6 Following 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 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 any relevant practitioner 2 The patient has had an initial Special Authority approval for etanercept and/or tocilizumab for (AOSD) Patient has experienced intolerable side effects from etanercept and/or tocilizumab Patient has received insufficient benefit from at least a three-month trial of etanercept and/or tocilizumab Patient diagnosed with AOSD according to the Yamaguchi criteria Patient has tried and not responded to at least 6 months of glucocorticosteroids at a dose of at least 0.5 mg/kg, NSAIDs and methotrexate Patient has persistent symptoms of disabling poorly controlled and active disease rheumatologist Patient has active ulcerative colitis Patient's SCCAI score is greater than or equal to 4 Patient's PUCAI score is greater than or equal to 20 Patient has tried but had an inadequate response to, or has experienced intolerable side effects from, prior therapy with immunomodulators and systemic corticosteroids Surgery (or further surgery) is considered to be clinically inappropriate any relevant practitioner 6 The SCCAI score has reduced by 2 points or more from the SCCAI score when the patient was initiated on biologic therapy The PUCAI score has reduced by 10 points or more from the PUCAI score when the patient was initiated on biologic therapy any relevant practitioner 2 Patient has undifferentiated peripheral spondyloarthritis* with active peripheral joint arthritis in at least four joints from the following: wrist, elbow, knee, ankle, and either shoulder or hip Patient has tried and not responded to at least three months of each of methotrexate, sulphasalazine and leflunomide, at maximum tolerated doses (unless contraindicated) Patient has a CRP level greater than 15 mg/L measured no more than one month prior to the date of this application Patient has an ESR greater than 25 mm per hour measured no more than one month prior to the date of this application 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 rheumatologist 6

Indications marked with * are unapproved indications.

 Following 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 The patient demonstrates at least a continuing 30% improvement in active joint count from baseline and a clinically significant response in the opinion of the treating physician any relevant practitioner 2 Patient has a diagnosis of active ulcerative colitis or active Crohn's disease Patient has axial inflammatory pain for six months or more Patient is unable to take NSAIDs Patient has unequivocal sacroiliitis demonstrated by radiological imaging or MRI Patient has not responded adequately to prior treatment consisting of at least 3 months of an exercise regime supervised by a physiotherapist A BASDAI of at least 6 on a 0-10 scale completed after the 3 month exercise trial, but prior to ceasing any previous pharmacological treatment rheumatologist 6 Where treatment has resulted in an improvement in BASDAI of 4 or more points from pre-treatment baseline on a 10 point scale, or an improvement in BASDAI of 50%, whichever is less any relevant practitioner 2 Patient has a diagnosis of active ulcerative colitis or active Crohn's disease Patient has active arthritis in at least four joints from the following: hip, knee, ankle, subtalar, tarsus, forefoot, wrist, elbow, shoulder, sternoclavicular Patient has tried and not experienced a response to at least three months of methotrexate, or azathioprine at a maximum tolerated dose (unless contraindicated) Patient has tried and not experienced a response to at least three months of sulphasalazine at a maximum tolerated dose (unless contraindicated) Patient has a CRP level greater than 15 mg/L measured no more than one month prior to the date of this application Patient has an ESR greater than 25 mm per hour 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 rheumatologist 6 Following 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 Patient demonstrates at least a continuing 30% improvement in active joint count from baseline in the opinion of the treating physician any relevant practitioner 2 Palivizumab <range>Palivizumab</range> Palivizumab to be administered during the annual RSV season Infant was born in the last 12 months Infant was born at less than 32 weeks zero days’ gestation Child was born in the last 24 months Child has severe lung, airway, neurological or neuromuscular disease that requires ongoing ventilatory/respiratory support (see Note A) in the community Child has haemodynamically significant heart disease Child has unoperated simple congenital heart disease with significant left to right shunt (see Note B) Child has unoperated or surgically palliated complex congenital heart disease Child has severe pulmonary hypertension (see Note C) Child has moderate or severe left ventricular (LV) failure (see Note D) Child has severe combined immune deficiency, confirmed by an immunologist, but has not received a stem cell transplant Child has inborn errors of immunity (see Note E) that increase susceptibility to life-threatening viral respiratory infections, confirmed by an immunologist medical practitioner 12 Palivizumab to be administered during the annual RSV season Child was born in the last 24 months Child has severe lung, airway, neurological or neuromuscular disease that requires ongoing ventilatory/respiratory support (see Note A) in the community Child has haemodynamically significant heart disease Child has unoperated simple congenital heart disease with significant left to right shunt (see Note B) Child has unoperated or surgically palliated complex congenital heart disease Child has severe pulmonary hypertension (see Note C) Child has moderate or severe left ventricular (LV) failure (see Note D) Child has severe combined immune deficiency, confirmed by an immunologist, but has not received a stem cell transplant Child has inborn errors of immunity (see Note E) that increase susceptibility to life-threatening viral respiratory infections, confirmed by an immunologist medical practitioner 6

  1. Ventilatory/respiratory support includes those on home oxygen, CPAP/VPAP and those with tracheostomies in situ managed at home

  2. Child requires/will require heart failure medication, and/or child has significant pulmonary hypertension, and/or infant will require surgical palliation/definitive repair within the next 3 months

  3. Mean pulmonary artery pressure more than 25 mmHg

  4. LV Ejection Fraction less than 40%

  5. Inborn errors of immunity include, but are not limited to, IFNAR deficiencies

 Gemtuzumab ozogamicin <range>Gemtuzumab ozogamicin</range> Patient has not received prior chemotherapy for this condition Patient has de novo CD33-positive acute myeloid leukaemia Patient does not have acute promyelocytic leukaemia Gemtuzumab ozogamicin will be used in combination with standard anthracycline and cytarabine (AraC) Patient is being treated with curative intent Patient’s disease risk has been assessed by cytogenetic testing to be good or intermediate Patient must be considered eligible for standard intensive remission induction chemotherapy with standard anthracycline and cytarabine (AraC) Gemtuzumab ozogamicin to be funded for one course only (one dose at 3 mg per m² body surface area or up to 2 vials of 5 mg as separate doses) medical practitioner

Acute myeloid leukaemia excludes acute promyelocytic leukaemia and acute myeloid leukaemia that is secondary to another haematological disorder (eg myelodysplasia or myeloproliferative disorder).

 Benralizumab <range>Benralizumab</range> Patient must be aged 12 years or older Patient must have a diagnosis of severe eosinophilic asthma documented by a respiratory physician or clinical immunologist Conditions that mimic asthma eg. vocal cord dysfunction, central airway obstruction, bronchiolitis etc. have been excluded Patient has a blood eosinophil count of greater than 0.5 × 10^9 cells/L in the last 12 months Patient must be adherent to optimised asthma therapy including inhaled corticosteroids (equivalent to at least 1000 mcg per day of fluticasone propionate) plus long-acting beta-2 agonist, or budesonide/formoterol as part of the anti-inflammatory reliever therapy plus maintenance regimen, unless contraindicated or not tolerated Patient has had at least 4 exacerbations needing systemic corticosteroids in the previous 12 months, where an exacerbation is defined as either documented use of oral corticosteroids for at least 3 days or parenteral corticosteroids Patient has received continuous oral corticosteroids of at least the equivalent of 10 mg per day over the previous 3 months Treatment is not to be used in combination with subsidised mepolizumab Patient has an Asthma Control Test (ACT) score of 10 or less. Baseline measurements of the patient’s asthma control using the ACT and oral corticosteroid dose must be made at the time of application, and again at around 52 weeks after the first dose to assess response to treatment Patient has not previously received an anti-IL5 biological therapy for their severe eosinophilic asthma Patient was refractory or intolerant to previous anti-IL5 biological therapy Patient was not eligible to continue treatment with previous anti-IL5 biological therapy and discontinued within 12 months of commencing treatment respiratory physician clinical immunologist 12 An increase in the Asthma Control Test (ACT) score of at least 5 from baseline Exacerbations have been reduced from baseline by 50% as a result of treatment with benralizumab Reduction in continuous oral corticosteroid use by 50% or by 10 mg/day while maintaining or improving asthma control respiratory physician clinical immunologist 2 Ustekinumab <range>Ustekinumab</range> Patient is currently on treatment with ustekinumab commenced prior to 1 February 2023 and met all remaining criteria (criterion 2) below at the time of commencing treatment Patient has active Crohn's disease Patient has had an initial approval for prior biologic therapy for Crohn’s disease and has experienced intolerable side effects or insufficient benefit to meet renewal criteria Patient meets the initiation criteria for prior biologic therapies for Crohn’s disease Other biologics for Crohn’s disease are contraindicated medical practitioner 6 CDAI score has reduced by 100 points, or HBI score has reduced by 3 points, from when the patient was initiated on biologic therapy CDAI score is 150 or less, or HBI is 4 or less The patient has experienced an adequate response to treatment, but CDAI score and/or HBI score cannot be assessed Ustekinumab to be administered at a dose no greater than 90 mg every 8 weeks medical practitioner 12 Patient is currently on treatment with ustekinumab commenced prior to 1 February 2023 and met all remaining criteria (criterion 2) below at the time of commencing treatment Patient has active Crohn's disease Patient has had an initial approval for prior biologic therapy and has experienced intolerable side effects or insufficient benefit to meet renewal criteria Patient meets the initiation criteria for prior biologic therapies for Crohn’s disease Other biologics for Crohn’s disease are contraindicated medical practitioner 6

Indication marked with * is an unapproved indication.

 PCDAI score has reduced by 10 points from when the patient was initiated on biologic therapy PCDAI score is 15 or less The patient has experienced an adequate response to treatment, but CDAI score cannot be assessed Ustekinumab to administered at a dose no greater than 90 mg every 8 weeks medical practitioner 12

Indication marked with * is an unapproved indication.

 Patient is currently on treatment with ustekinumab commenced prior to 1 February 2023 and met all remaining criteria (criterion 2) below at the time of commencing treatment Patient has active ulcerative colitis Patient has had an initial approval for prior biologic therapy for ulcerative colitis and has experienced intolerable side effects or insufficient benefit to meet renewal criteria Patient meets the initiation criteria for prior biologic therapies for ulcerative colitis Other biologics for ulcerative colitis are contraindicated medical practitioner 6 The SCCAI score has reduced by 2 points or more from the SCCAI score since initiation on biologic therapy PUCAI score has reduced by 10 points or more from the PUCAI score since initiation on biologic therapy* Ustekinumab will be used at a dose no greater than 90 mg intravenously every 8 weeks medical practitioner 12

Criterion marked with * is for an unapproved indication.

 Vedolizumab <range>Vedolizumab</range> Patient has active Crohn's disease Patient has had an initial approval for prior biologic therapy and has experienced intolerable side effects or insufficient benefit to meet renewal criteria (unless contraindicated) Patient has a CDAI score of greater than or equal to 300, or HBI score of greater than or equal to 10 Patient has extensive small intestine disease affecting more than 50 cm of the small intestine Patient has evidence of short gut syndrome or would be at risk of short gut syndrome with further bowel resection Patient has an ileostomy or colostomy, and has intestinal inflammation Patient has tried but experienced an inadequate response to (including lack of initial response and/or loss of initial response) from prior therapy with immunomodulators and corticosteroids Patient has experienced intolerable side effects from immunomodulators and corticosteroids Immunomodulators and corticosteroids are contraindicated medical practitioner 6 CDAI score has reduced by 100 points, or HBI score has reduced by 3 points, from when the patient was initiated on biologic therapy CDAI score is 150 or less, or HBI is 4 or less The patient has experienced an adequate response to treatment, but CDAI score and/or HBI score cannot be assessed Vedolizumab to administered at a dose no greater than 300 mg every 8 weeks medical practitioner 2 Paediatric patient has active Crohn’s disease Patient has had an initial approval for prior biologic therapy and has experienced intolerable side effects or insufficient benefit to meet renewal criteria (unless contraindicated) Patient has a Paediatric Crohn’s Disease Activity Index (PCDAI) score of greater than or equal to 30 Patient has extensive small intestine disease Patient has tried but experienced an inadequate response to (including lack of initial response and/or loss of initial response) from prior therapy with immunomodulators and corticosteroids Patient has experienced intolerable side effects from immunomodulators and corticosteroids Immunomodulators and corticosteroids are contraindicated medical practitioner 6

Indication marked with * is an unapproved indication.

 PCDAI score has reduced by 10 points from when the patient was initiated on biologic therapy PCDAI score is 15 or less The patient has experienced an adequate response to treatment, but CDAI score cannot be assessed Vedolizumab to administered at a dose no greater than 300mg every 8 weeks medical practitioner 2

Indication marked with * is an unapproved indication.

 Patient has active ulcerative colitis Patient has had an initial approval for prior biologic therapy and has experienced intolerable side effects or insufficient benefit to meet renewal criteria (unless contraindicated) Patient has a SCCAI score is greater than or equal to 4 Patient’s PUCAI score is greater than or equal to 20* Patient has tried but experienced an inadequate response to (including lack of initial response and/or loss of initial response) from prior therapy with immunomodulators and corticosteroids Patient has experienced intolerable side effects from immunomodulators and corticosteroids Immunomodulators and corticosteroids are contraindicated medical practitioner 6

Indication marked with * is an unapproved indication.

 The SCCAI score has reduced by 2 points or more from the SCCAI score since initiation on biologic therapy The PUCAI score has reduced by 10 points or more from the PUCAI score since initiation on biologic therapy * Vedolizumab will be used at a dose no greater than 300 mg intravenously every 8 weeks medical practitioner 2

Indication marked with * is an unapproved indication.

 Brentuximab vedotin <range>Brentuximab</range> Patient is currently on treatment with brentuximab vedotin and met all the following criteria prior to commencing treatment Patient has CD30 positive systemic anaplastic large-cell lymphoma Patient must have histological confirmation of CD30 expression Patient must not have received prior treatment with curative intent chemotherapy for this condition Treatment must be in combination with cyclophosphamide, anthracycline, and steroids for a maximum of 8 cycles Brentuximab vedotin is to be administered at doses no greater than 1.8 mg/kg every 3 weeks medical practitioner 12 Patient has relapsed/refractory CD30-positive Hodgkin lymphoma after two or more lines of chemotherapy Patient is ineligible for autologous stem cell transplant Patient has relapsed/refractory CD30-positive Hodgkin lymphoma Patient has previously undergone autologous stem cell transplant Patient has not previously received funded brentuximab vedotin Response to brentuximab vedotin treatment is to be reviewed after a maximum of 6 treatment cycles Brentuximab vedotin to be administered at doses no greater than 1.8 mg/kg every 3 weeks medical practitioner 6 Patient has achieved a partial or complete response to brentuximab vedotin after 6 treatment cycles Treatment remains clinically appropriate and the patient is benefitting from treatment and treatment is being tolerated Patient is to receive a maximum of 16 total cycles of brentuximab vedotin treatment medical practitioner 9 Patient has relapsed/refractory CD30-positive systemic anaplastic large cell lymphoma Patient has an ECOG performance status of 0-1 Patient has not previously received brentuximab vedotin Response to brentuximab vedotin treatment is to be reviewed after a maximum of 6 treatment cycles Brentuximab vedotin to be administered at doses no greater than 1.8 mg/kg every 3 weeks medical practitioner 9 Patient has experienced a partial or complete response to brentuximab vedotin after 6 treatment cycles Treatment remains clinically appropriate and the patient is benefitting from treatment and treatment is being tolerated Patient is to receive a maximum of 16 total cycles of brentuximab vedotin treatment medical practitioner 9 Trastuzumab (Herzuma) <range>Trastuzumab (Herzuma)</range> The patient has early breast cancer expressing HER-2 IHC 3+ or ISH + (including FISH or other current technology) Maximum cumulative dose of 106 mg/kg (12 months' treatment) medical practitioner 12 The patient has metastatic breast cancer expressing HER-2 IHC 3+ or ISH+ (including FISH or other current technology) The patient received prior adjuvant trastuzumab treatment for early breast cancer The patient has not previously received lapatinib treatment for HER-2 positive metastatic breast cancer The patient discontinued lapatinib within 3 months due to intolerable side effects and the cancer did not progress whilst on lapatinib he cancer has not progressed at any time point during the previous 12 months whilst on trastuzumab Trastuzumab will not be given in combination with pertuzumab Trastuzumab to be administered in combination with pertuzumab Patient has not received prior treatment for their metastatic disease and has had a treatment-free interval of at least 12 months between prior (neo)adjuvant chemotherapy treatment and diagnosis of metastatic breast cancer The patient has good performance status (ECOG grade 0-1) Trastuzumab to be discontinued at disease progression Patient has previously discontinued treatment with trastuzumab in the metastatic setting for reasons other than severe toxicity or disease progression Patient has signs of disease progression Disease has not progressed during previous treatment with trastuzumab medical practitioner 12

* For patients with relapsed HER-2 positive disease who have previously received adjuvant trastuzumab for early breast cancer

 The patient has metastatic breast cancer expressing HER-2 IHC 3+ or ISH+ (including FISH or other current technology) The patient has not previously received lapatinib treatment for HER-2 positive metastatic breast cancer The patient discontinued lapatinib within 3 months due to intolerable side effects and the cancer did not progress whilst on lapatinib Trastuzumab will not be given in combination with pertuzumab Trastuzumab to be administered in combination with pertuzumab Patient has not received prior treatment for their metastatic disease and has had a treatment-free interval of at least 12 months between prior (neo)adjuvant chemotherapy treatment and diagnosis of metastatic breast cancer The patient has good performance status (ECOG grade 0-1) Trastuzumab to be discontinued at disease progression medical practitioner 12 The patient has metastatic breast cancer expressing HER-2 IHC 3+ or ISH+ (including FISH or other current technology) The cancer has not progressed at any time point during the previous 12 months whilst on trastuzumab Trastuzumab to be discontinued at disease progression Patient has previously discontinued treatment with trastuzumab for reasons other than severe toxicity or disease progression Patient has signs of disease progression Disease has not progressed during previous treatment with trastuzumab medical practitioner 12 The patient has locally advanced or metastatic gastric, gastro-oesophageal junction or oesophageal cancer expressing HER-2 IHC 2+ FISH+ or IHC3+ (or other current technology) Patient has an ECOG score of 0-2 medical practitioner 12 The cancer has not progressed at any time point during the previous 12 months whilst on trastuzumab Trastuzumab to be discontinued at disease progression medical practitioner 12 Trastuzumab deruxtecan <range>Trastuzumab deruxtecan</range> Patient has metastatic breast cancer expressing HER-2 IHC3+ or ISH+ (including FISH or other current technology) Patient has previously received trastuzumab and chemotherapy, separately or in combination The patient has received prior therapy for metastatic disease The patient developed disease recurrence during, or within six months of completing adjuvant therapy Patient has a good performance status (ECOG 0-1) Patient has not received prior funded trastuzumab deruxtecan treatment Treatment to be discontinued at disease progression medical practitioner 6 The cancer has not progressed at any time point during the previous approval period whilst on trastuzumab deruxtecan Treatment to be discontinued at disease progression medical practitioner 6

Prior or adjuvant therapy includes anthracycline, other chemotherapy, biological drugs, or endocrine therapy.

 Bevacizumab <range>Bevacizumab</range> Patient is currently on treatment with bevacizumab, and met all remaining criteria prior to commencing treatment Patient has locally advanced or metastatic, unresectable hepatocellular carcinoma Patient has preserved liver function (Child-Pugh A) Transarterial chemoembolisation (TACE) is unsuitable Patient has not received prior systemic therapy for the treatment of hepatocellular carcinoma Patient received funded lenvatinib before 1 March 2025 Patient has experienced treatment-limiting toxicity from treatment with lenvatinib No disease progression since initiation of lenvatinib Patient has an ECOG performance status of 0-2 To be given in combination with atezolizumab medical practitioner 6 no evidence of disease progression medical practitioner 6 The patient has FIGO Stage IV epithelial ovarian, fallopian tube, or primary peritoneal cancer The patient has previously untreated advanced (FIGO Stage IIIB or IIIC) epithelial ovarian, fallopian tube, or primary peritoneal cancer Debulking surgery is inappropriate The cancer is sub-optimally debulked (maximum diameter of any gross residual disease greater than 1cm) Bevacizumab to be administered at a maximum dose of 15 mg/kg every three weeks 18 weeks concurrent treatment with chemotherapy is planned medical practitioner 4 no evidence of disease progression medical practitioner 4 Maximum of 6 doses The patient has recurrent respiratory papillomatosis The treatment is for intra-lesional administration medical practitioner 12 Maximum of 6 doses The treatment is for intra-lesional administration There has been a reduction in surgical treatments or disease regrowth as a result of treatment medical practitioner 12 Ocular neovascularisation Exudative ocular angiopathy medical practitioner Inotuzumab ozogamicin <range>Inotuzumab ozogamicin</range> Patient has relapsed or refractory CD22-positive B-cell acute lymphoblastic leukaemia/lymphoma, including minimal residual disease Patient has ECOG performance status of 0-2 Patient has Philadelphia chromosome positive B-Cell ALL Patient has previously received a tyrosine kinase inhibitor Patient has received one prior line of treatment involving intensive chemotherapy Treatment is to be administered for a maximum of 3 cycles medical practitioner 4 Patient is not proceeding to a stem cell transplant Patient has experienced complete disease response Patient has experienced complete remission with incomplete haematological recovery Treatment with inotuzumab ozogamicin is to cease after a total duration of 6 cycles medical practitioner 4 Faricimab <range>Faricimab</range> Patient has centre involving diabetic macular oedema (DMO) Patient’s disease is nonresponsive to 4 doses of intravitreal bevacizumab when administered 4-6 weekly Patient has reduced visual acuity between 6/9 – 6/36 with functional awareness of reduction in vision Patient has DMO within central OCT (ocular coherence tomography) subfield >350 micrometers There is no centre-involving sub-retinal fibrosis or foveal atrophy Patient has not previously been treated with aflibercept for longer than 3 months medical practitioner 4 There is stability or two lines of Snellen visual acuity gain There is structural improvement on OCT scan (with reduction in intra-retinal cysts, central retinal thickness, and sub-retinal fluid) Patient’s vision is 6/36 or better on the Snellen visual acuity score There is no centre-involving sub-retinal fibrosis or foveal atrophy medical practitioner 12 Wet age-related macular degeneration (wet AMD) Polypoidal choroidal vasculopathy Choroidal neovascular membrane from causes other than wet AMD The patient has developed severe endophthalmitis or severe posterior uveitis following treatment with bevacizumab There is worsening of vision or failure of retina to dry despite three intraocular injections of bevacizumab four weeks apart There is no structural damage to the central fovea of the treated eye Patient has not previously been treated with ranibizumab or aflibercept for longer than 3 months medical practitioner 3 Patient’s vision is 6/36 or better on the Snellen visual acuity score There is no structural damage to the central fovea of the treated eye medical practitioner 12 Pertuzumab with trastuzumab <range>Pertuzumab with trastuzumab</range> The individual has received an initial Special Authority approval for intravenous pertuzumab and trastuzumab for metastatic breast cancer Pertuzumab with trastuzumab to be administered subcutaneously at a maximum dose of 600 mg pertuzumab with 600 mg trastuzumab every three weeks (or equivalent) The patient has metastatic breast cancer expressing HER-2 IHC 3+ or ISH+ (including FISH or other current technology) Patient is chemotherapy treatment naïve Patient has not received prior treatment for their metastatic disease and has had a treatment free interval of at least 12 months between prior (neo)adjuvant chemotherapy treatment and diagnosis of metastatic breast cancer The patient has good performance status (ECOG grade 0-1) Loading dose of pertuzumab with trastuzumab to be administered subcutaneously at a maximum dose of 1200 mg pertuzumab with 600 mg trastuzumab, respectively Maintenance doses of pertuzumab with trastuzumab to be administered subcutaneously at a maximum dose of 600 mg pertuzumab with 600 mg trastuzumab every three weeks (or equivalent) Pertuzumab with trastuzumab to be discontinued at disease progression medical practitioner 12 The individual has metastatic breast cancer expressing HER-2 IHC 3+ or ISH+ (including FISH or other current technology) The cancer has not progressed at any time point during the previous 12 months whilst on pertuzumab and trastuzumab Individual has previously discontinued treatment with pertuzumab with trastuzumab for reasons other than severe toxicity or disease progression Individual has signs of disease progression Disease has not progressed during previous treatment with pertuzumab with trastuzumab medical practitioner 12 Basiliximab <range>Basiliximab</range> For use in solid organ transplants medical practitioner Rituximab (mabthera) <range>Rituximab<instance>Mabthera</instance></range> Patient has had a Special Authority approval for etanercept or adalimumab for rheumatoid arthritis Patient has experienced intolerable side effects Following at least a 4 month trial of adalimumab or etanercept, the renewal criteria for rheumatoid arthritis were not met Maximum of two 1000 mg infusions given two weeks apart medical practitioner 4 Treatment with a Tumour Necrosis Factor alpha inhibitor is contraindicated Patient has had rheumatoid arthritis (either confirmed by radiologic imaging, or the patient is CCP antibody positive) Disease has not responded to at least three months of methotrexate at a dose of at least 20 mg weekly or a maximum tolerated dose, unless contraindicated Disease has not responded to at least 3 months of methotrexate in combination with sulfasalazine and hydroxychloroquine sulphate (at maximum tolerated doses), unless contraindicated Disease has not responded to at least 3 months of methotrexate in combination with the maximum tolerated dose of cyclosporin, unless contraindicated Disease has not responded to at least 3 months of therapy at the maximum tolerated dose of leflunomide alone or in combination with methotrexate, unless contraindicated Patient has persistent symptoms of poorly controlled and active disease in at least 20 joints Patient has persistent symptoms of poorly controlled and active disease in at least 4 joints from the following: wrist, elbow, knee, ankle, shoulder, or hip Patient has CRP greater than 15 mg/L measured within one month before the application CRP not measured as patient is currently receiving prednisone therapy at a dose of greater than 5 mg per day received for more than 3 months Maximum of two 1000 mg infusions given two weeks apart medical practitioner 4 Following the initial course of rituximab the patient experienced between a 30% and 50% decrease in active joint count from baseline Following the second course of rituximab the patient experienced at least a 50% decrease in active joint count from baseline Following the third and subsequent courses of rituximab, the patient experienced at least a continuing 30% improvement in active joint count from baseline Rituximab re-treatment not to be given within 6 months of the previous course of treatment Maximum of two 1000 mg infusions given two weeks apart medical practitioner 12 Following the initial course of rituximab infusions the patient experienced at least a 50% decrease in active joint count from baseline Following the second and subsequent courses of rituximab, the patient experienced at least a continuing 30% improvement in active joint count from baseline Rituximab re-treatment not to be given within 6 months of the previous course of treatment Maximum of two 1000 mg infusions per course given two weeks apart medical practitioner 12 Adalimumab (Humira - alternative brand) <range>Adalimumab (Humira - Alternative brand)</range> The patient has experienced intolerable side effects from adalimumab (Amgevita) following a minimum of 4 weeks treatment Patient has developed symptoms of loss of disease control following a minimum of 4 weeks treatment with adalimumab (Amgevita) and clinician attributes this loss of disease response to a change in treatment regimen Patient has received a maximum of 6 months treatment with Amgevita Patient has previously had a Special Authority approval for the Humira brand of adalimumab for this indication Adalimumab to be administered at doses no greater than 40 mg every 14 days any relevant practitioner 6 The patient has had a good clinical response to treatment with measurably improved quality of life Adalimumab to be administered at doses no greater than 40 mg every 14 days any relevant practitioner 6 The patient has experienced intolerable side effects from adalimumab (Amgevita) following a minimum of 4 weeks treatment Patient has developed symptoms of loss of disease control following a minimum of 4 weeks treatment with adalimumab (Amgevita) and clinician attributes this loss of disease response to a change in treatment regimen Patient has received a maximum of 6 months treatment with Amgevita Patient has previously had a Special Authority approval for the Humira brand of adalimumab for this indication Adalimumab to be administered at doses no greater than 40 mg every 7 days. Fortnightly dosing has been considered dermatologist Practitioner 6 The patient has a reduction in active lesions (e.g. inflammatory nodules, abscesses, draining fistulae) of 25% or more from baseline The patient has a Dermatology Quality of Life Index improvement of 4 or more from baseline Adalimumab is to be administered at doses no greater than 40mg every 7 days. Fortnightly dosing has been considered dermatologist Practitioner 6 The patient has experienced intolerable side effects from adalimumab (Amgevita) following a minimum of 4 weeks treatment Patient has developed symptoms of loss of disease control following a minimum of 4 weeks treatment with adalimumab (Amgevita) and clinician attributes this loss of disease response to a change in treatment regimen Patient has received a maximum of 6 months treatment with Amgevita Patient has previously had a Special Authority approval for the Humira brand of adalimumab for this indication Adalimumab to be administered at doses no greater than 40 mg every 14 days dermatologist Practitioner 6 Patient had "whole body" severe chronic plaque psoriasis at the start of treatment 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 Following each prior adalimumab treatment course the patient has a Dermatology Quality of Life Index (DLQI) improvement of 5 or more, when compared with the pre-treatment baseline value Patient had severe chronic plaque psoriasis of the face, or palm of a hand or sole of a foot at the start of treatment 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 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-adalimumab treatment baseline value Adalimumab to be administered at doses no greater than 40 mg every 14 days dermatologist Practitioner 6 The patient has experienced intolerable side effects from adalimumab (Amgevita) following a minimum of 4 weeks treatment Patient has developed symptoms of loss of disease control following a minimum of 4 weeks treatment with adalimumab (Amgevita) and clinician attributes this loss of disease response to a change in treatment regimen Patient has received a maximum of 6 months treatment with Amgevita Patient has previously had a Special Authority approval for the Humira brand of adalimumab for this indication A maximum of 8 doses dermatologist 6 The patient has demonstrated clinical improvement and continues to require treatment A maximum of 8 doses dermatologist 6 The patient has experienced intolerable side effects from adalimumab (Amgevita) following a minimum of 4 weeks treatment, and a maximum of 6 months treatment with Amgevita Patient has developed symptoms of loss of disease control following a minimum of 4 weeks treatment, and a maximum of 6 months treatment with Amgevita and clinician attributes this loss of disease response to a change in treatment regimen Patient has Crohn’s and is considered to be at risk of disease destabilisation if there were to be a change to current treatment Patient has previously had a Special Authority approval for the Humira brand of adalimumab for this indication Adalimumab to be administered at doses no greater than 40 mg every 14 days gastroenterologist Practitioner 6 CDAI score has reduced by 100 points from the CDAI score when the patient was initiated on adalimumab CDAI score is 150 or less The patient has demonstrated an adequate response to treatment, but CDAI score cannot be assessed Adalimumab to be administered at doses no greater than 40 mg every 14 days gastroenterologist Practitioner 6 The patient has experienced intolerable side effects from adalimumab (Amgevita) following a minimum of 4 weeks treatment, and a maximum of 6 months treatment with Amgevita Patient has developed symptoms of loss of disease control following a minimum of 4 weeks treatment, and a maximum of 6 months treatment with Amgevita and clinician attributes this loss of disease response to a change in treatment regimen Patient has Crohn’s and is considered to be at risk of disease destabilisation if there were to be a change to current treatment Patient has previously had a Special Authority approval for the Humira brand of adalimumab for this indication Adalimumab to be administered at doses no greater than 40 mg every 14 days gastroenterologist Practitioner 6 PCDAI score has reduced by 10 points from the PCDAI score when the patient was initiated on adalimumab PCDAI score is 15 or less The patient has demonstrated an adequate response to treatment, but PCDAI score cannot be assessed Adalimumab to be administered at doses no greater than 40 mg every 14 days gastroenterologist Practitioner 6 The patient has experienced intolerable side effects from adalimumab (Amgevita) following a minimum of 4 weeks treatment, and a maximum of 6 months treatment with Amgevita Patient has developed symptoms of loss of disease control following a minimum of 4 weeks treatment, and a maximum of 6 months treatment with Amgevita and clinician attributes this loss of disease response to a change in treatment regimen Patient has Crohn’s and is considered to be at risk of disease destabilisation if there were to be a change to current treatment Patient has previously had a Special Authority approval for the Humira brand of adalimumab for this indication Adalimumab to be administered at doses no greater than 40 mg every 14 days gastroenterologist Practitioner 6 The number of open draining fistulae have decreased from baseline by at least 50% 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 Adalimumab to be administered at doses no greater than 40 mg every 14 days gastroenterologist Practitioner 6 The patient has experienced intolerable side effects from adalimumab (Amgevita) following a minimum of 4 weeks treatment, and a maximum of 6 months treatment with Amgevita Patient has developed symptoms of loss of disease control following a minimum of 4 weeks treatment with Amgevita, and a maximum of 6 months treatment with Amgevita and clinician attributes this loss of disease response to a change in treatment regimen Patient has uveitis and is considered to be at risk of vision loss if they were to change treatment Patient has previously had a Special Authority approval for the Humira brand of adalimumab for this indication Adalimumab to be administered at doses no greater than 40 mg every 14 days any relevant practitioner 12 The patient has had a good clinical response following 12 weeks' initial treatment Following each 12-month treatment period, the patient has had a sustained reduction in inflammation (Standardisation of Uveitis Nomenclature (SUN) criteria < ½+ anterior chamber or vitreous cells, absence of active vitreous or retinal lesions, or resolution of uveitic cystoid macular oedema) Following each 12-month treatment period, the patient has a sustained steroid sparing effect, allowing reduction in prednisone to < 10mg daily, or steroid drops less than twice daily if under 18 years old Adalimumab to be administered at doses no greater than 40 mg every 14 days any relevant practitioner 12 The patient has experienced intolerable side effects from adalimumab (Amgevita) following a minimum of 4 weeks treatment, and a maximum of 6 months treatment with Amgevita Patient has developed symptoms of loss of disease control following a minimum of 4 weeks treatment with Amgevita, and a maximum of 6 months treatment with Amgevita and clinician attributes this loss of disease response to a change in treatment regimen Patient has uveitis and is considered to be at risk of vision loss if they were to change treatment Patient has previously had a Special Authority approval for the Humira brand of adalimumab for this indication Adalimumab to be administered at doses no greater than 40 mg every 14 days any relevant practitioner 12 The patient has had a good clinical response following 3 initial doses Following each 12-month treatment period, the patient has had a sustained reduction in inflammation (Standardisation of Uveitis Nomenclature (SUN) criteria <½+ anterior chamber or vitreous cells, absence of active vitreous or retinal lesions, or resolution of uveitic cystoid macular oedema) Following each 12-month treatment period, the patient has a sustained steroid sparing effect, allowing reduction in prednisone to < 10mg daily, or steroid drops less than twice daily if under 18 years old Adalimumab to be administered at doses no greater than 40 mg every 14 days any relevant practitioner 12 The patient has experienced intolerable side effects from adalimumab (Amgevita) following a minimum of 4 weeks treatment Patient has developed symptoms of loss of disease control following a minimum of 4 weeks treatment with adalimumab (Amgevita) Patient has received a maximum of 6 months treatment with Amgevita Patient has previously had a Special Authority approval for the Humira brand of adalimumab for this indication Adalimumab to be administered at doses no greater than 40 mg every 14 days rheumatologist Practitioner 6 Treatment has resulted in an improvement in BASDAI of 4 or more points from pre-treatment baseline on a 10 point scale, or an improvement in BASDAI of 50%, whichever is less Adalimumab to be administered at doses no greater than 40 mg every 14 days rheumatologist Practitioner 6 The patient has experienced intolerable side effects from adalimumab (Amgevita) following a minimum of 4 weeks treatment Patient has developed symptoms of loss of disease control following a minimum of 4 weeks treatment with adalimumab (Amgevita) and clinician attributes this loss of disease response to a change in treatment regimen Patient has received a maximum of 6 months treatment with Amgevita Patient has previously had a Special Authority approval for the Humira brand of adalimumab for this indication named specialist rheumatologist 6 For patients that demonstrate at least a continuing 30% improvement in active joint count and continued improvement in physician's global assessment from baseline named specialist rheumatologist 6 The patient has experienced intolerable side effects from adalimumab (Amgevita) following a minimum of 4 weeks treatment Patient has developed symptoms of loss of disease control following a minimum of 4 weeks treatment with adalimumab (Amgevita) and clinician attributes this loss of disease response to a change in treatment regimen Patient has received a maximum of 6 months treatment with Amgevita Patient has previously had a Special Authority approval for the Humira brand of adalimumab for this indication named specialist rheumatologist 6 For patients that demonstrate at least a continuing 30% improvement in active joint count and continued improvement in physician's global assessment from baseline named specialist rheumatologist 6 The patient has experienced intolerable side effects from adalimumab (Amgevita) following a minimum of 4 weeks treatment Patient has developed symptoms of loss of disease control following a minimum of 4 weeks treatment with adalimumab (Amgevita) and clinician attributes this loss of disease response to a change in treatment regimen Patient has received a maximum of 6 months treatment with Amgevita Patient has previously had a Special Authority approval for the Humira brand of adalimumab for this indication Adalimumab to be administered at doses no greater than 40 mg every 14 days named specialist rheumatologist 6 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 Adalimumab to be administered at doses no greater than 40 mg every 14 days named specialist rheumatologist 6 The patient has experienced intolerable side effects from adalimumab (Amgevita) following a minimum of 4 weeks treatment Patient has developed symptoms of loss of disease control following a minimum of 4 weeks treatment with adalimumab (Amgevita) and clinician attributes this loss of disease response to a change in treatment regimen Patient has received a maximum of 6 months treatment with Amgevita Patient has previously had a Special Authority approval for the Humira brand of adalimumab for this indication Adalimumab to be administered at doses no greater than 40 mg every 14 days Patient cannot take concomitant methotrexate and requires doses of adalimumab higher than 40 mg every 14 days to maintain an adequate response rheumatologist Practitioner 6 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 Adalimumab to be administered at doses no greater than 40 mg every 14 days Patient cannot take concomitant methotrexate and requires doses of adalimumab higher than 40 mg every 14 days to maintain an adequate response rheumatologist Practitioner 6 The patient has experienced intolerable side effects from adalimumab (Amgevita) following a minimum of 4 weeks treatment Patient has developed symptoms of loss of disease control following a minimum of 4 weeks treatment with adalimumab (Amgevita) and clinician attributes this loss of disease response to a change in treatment regimen Patient has received a maximum of 6 months treatment with Amgevita Patient has previously had a Special Authority approval for the Humira brand of adalimumab for this indication rheumatologist Practitioner 6 the patient has demonstrated a sustained improvement in inflammatory markers and functional status rheumatologist Practitioner 6 Abciximab <range>Abciximab</range> For use in patients with acute coronary syndromes undergoing percutaneous coronary intervention For use in patients undergoing intra-cranial intervention medical practitioner Programmed Cell Death-1 (PD-1) Inhibitors Nivolumab <range>Nivolumab</range> The individual has metastatic or unresectable melanoma (excluding uveal) stage III or IV Baseline measurement of overall tumour burden is documented clinically and radiologically The individual has ECOG performance 0-2 The individual has not received funded pembrolizumab The individual has received an initial Special Authority approval for pembrolizumab and has discontinued pembrolizumab within 12 weeks of starting treatment due to intolerance The cancer did not progress while the individual was on pembrolizumab The individual has been diagnosed in the metastatic or unresectable stage III or IV setting The individual did not receive treatment in the perioperative setting with a PD-1/PD-L1 inhibitor The individual received treatment in the perioperative setting with a PD-1/PD-L1 inhibitor The individual did not experience disease recurrence while on treatment with that PD-1/PD-L1 inhibitor The individual did not experience disease recurrence within six months of completing perioperative treatment with a PD-1/PD-L1 inhibitor relevant specialist any relevant practitioner 4 The individual's disease has had a complete response to treatment The individual's disease has had a partial response to treatment The individual has stable disease Response to treatment in target lesions has been determined by comparable radiologic assessment following the most recent treatment period The individual has previously discontinued treatment with nivolumab for reasons other than severe toxicity or disease progression The individual has signs of disease progression Disease has not progressed during previous treatment with nivolumab relevant specialist any relevant practitioner 4 The individual has been on treatment for more than 24 months The individual's disease has had a complete response to treatment The individual's disease has had a partial response to treatment The individual has stable disease Response to treatment in target lesions has been determined by comparable radiologic or clinical assessment following the most recent treatment period The individual has previously discontinued treatment with nivolumab for reasons other than severe toxicity or disease progression The individual has signs of disease progression Disease has not progressed during previous treatment with nivolumab relevant specialist any relevant practitioner 4 Patient is currently on treatment with nivolumab and met all remaining criteria prior to commencing treatment The patient has metastatic renal cell carcinoma The patient is treatment naive The patient has ECOG performance status 0-2 The disease is predominantly of clear cell histology The patient has sarcomatoid histology Haemoglobin levels less than the lower limit of normal Corrected serum calcium level greater than 10 mg/dL (2.5 mmol/L) Neutrophils greater than the upper limit of normal Platelets greater than the upper limit of normal Interval of less than 1 year from original diagnosis to the start of systemic therapy Karnofsky performance score of less than or equal to 70 Nivolumab is to be used in combination with ipilimumab for the first four treatment cycles at a maximum dose of 3 mg/kg Nivolumab is to be used at a maximum maintenance dose of 240 mg every 2 weeks (or equivalent) medical practitioner 4 Patient has metastatic renal-cell carcinoma The disease is of predominant clear-cell histology Patient has ECOG performance status 0-2 Patient has documented disease progression following one or two previous regimens of antiangiogenic therapy Patient has not previously received a funded immune checkpoint inhibitor Nivolumab is to be used as monotherapy at a maximum dose of 240 mg every 2 weeks (or equivalent) and discontinued at disease progression medical practitioner 4 Patient’s disease has had a complete response to treatment Patient’s disease has had a partial response to treatment Patient has stable disease No evidence of disease progression Nivolumab is to be used as monotherapy at a maximum dose of 240 mg every 2 weeks (or equivalent) and discontinued at disease progression medical practitioner 4 Pembrolizumab <range>Pembrolizumab</range> The individual has resectable stage IIIB, IIIC, IIID or IV melanoma (excluding uveal) (see note) The individual has not received prior funded systemic treatment in the perioperative setting for their stage IIIB, IIIC, IIID or IV melanoma Treatment must be prior to complete surgical resection Pembrolizumab must be administered as monotherapy The individual has ECOG performance score 0-2 Pembrolizumab to be administered at a fixed dose of 200 mg every 3 weeks (or equivalent) relevant specialist any relevant practitioner 4 The individual has received neoadjuvant treatment with an immune checkpoint inhibitor The individual meets initiation criteria for pembrolizumab for stage III or IV resected melanoma – adjuvant The individual has received neoadjuvant and adjuvant treatment with an immune checkpoint inhibitor The individual meets continuation criteria for pembrolizumab for stage III or IV resected melanoma – adjuvant The individual has received neoadjuvant and adjuvant treatment with an immune checkpoint inhibitor The individual has metastatic or unresectable melanoma (excluding uveal) stage III or IV The individual meets initiation criteria for pembrolizumab for unresectable or metastatic melanoma The individual has received neoadjuvant and adjuvant treatment with an immune checkpoint inhibitor The individual has received treatment with an immune checkpoint inhibitor for unresectable or metastatic melanoma The individual meets continuation criteria for pembrolizumab for unresectable or metastatic melanoma relevant specialist any relevant practitioner 4

  1. Stage IIIB, IIIC, IIID or IV melanoma defined as per American Joint Committee on Cancer (AJCC) 8th Edition

  2. Initiating treatment within 13 weeks of complete surgical resection means either 13 weeks after resection (primary or lymphadenectomy) or 13 weeks prior to the scheduled date of the resection (primary or lymphadenectomy)

 The individual has resected stage IIIB, IIIC, IIID or IV melanoma (excluding uveal) (see note a) Adjuvant treatment with pembrolizumab is required The individual has not received prior funded systemic treatment in the adjuvant setting for stage IIIB, IIIC, IIID or IV melanoma Treatment must be in addition to complete surgical resection Treatment must be initiated within 13 weeks of complete surgical resection, unless delay is necessary due to post-surgery recovery (see note b) Pembrolizumab must be administered as monotherapy The individual has ECOG performance score 0-2 Pembrolizumab to be administered at a fixed dose of 200 mg every 3 weeks (or equivalent) relevant specialist any relevant practitioner 4

  1. Stage IIIB, IIIC, IIID or IV melanoma defined as per American Joint Committee on Cancer (AJCC) 8th Edition

  2. Initiating treatment within 13 weeks of complete surgical resection means 13 weeks after resection (primary or lymphadenectomy)

 No evidence of disease recurrence Pembrolizumab must be administered as monotherapy Pembrolizumab to be administered at a fixed dose of 200 mg every three weeks (or equivalent) for a maximum of 12 months total treatment course, including any systemic neoadjuvant treatment Treatment to be discontinued at signs of disease recurrence or at completion of 12 months total treatment course (equivalent to 18 cycles at a dose of 200 mg every 3 weeks), including any systemic neoadjuvant treatment The individual has received adjuvant treatment with an immune checkpoint inhibitor The individual has metastatic or unresectable melanoma (excluding uveal) stage III or IV The individual meets initiation criteria for pembrolizumab for unresectable or metastatic melanoma The individual has received adjuvant treatment with an immune checkpoint inhibitor The individual has received treatment with an immune checkpoint inhibitor for unresectable or metastatic melanoma The individual meets continuation criteria for pembrolizumab for unresectable or metastatic melanoma relevant specialist any relevant practitioner 4 The individual has metastatic or unresectable melanoma (excluding uveal) stage III or IV Baseline measurement of overall tumour burden is documented clinically and radiologically The individual has ECOG performance 0-2 The individual has not received funded nivolumab The individual has received an initial Special Authority approval for nivolumab and has discontinued nivolumab within 12 weeks of starting treatment due to intolerance The cancer did not progress while the individual was on nivolumab The individual has been diagnosed in the metastatic or unresectable stage III or IV setting The individual did not receive treatment in the perioperative setting with a PD-1/PD-L1 inhibitor The individual received treatment in the perioperative setting with a PD-1/PD-L1 inhibitor The individual did not experience disease recurrence while on treatment with that PD-1/PD-L1 inhibitor The individual did not experience disease recurrence within six months of completing perioperative treatment with a PD-1/PD-L1 inhibitor relevant specialist any relevant practitioner 4 The individual's disease has had a complete response to treatment The individual's disease has had a partial response to treatment The individual has stable disease Response to treatment in target lesions has been determined by comparable radiologic assessment following the most recent treatment period The individual has previously discontinued treatment with pembrolizumab for reasons other than severe toxicity or disease progression The individual has signs of disease progression Disease has not progressed during previous treatment with pembrolizumab relevant specialist any relevant practitioner 4 The individual has been on treatment for more than 24 months The individual's disease has had a complete response to treatment The individual's disease has had a partial response to treatment The individual has stable disease Response to treatment in target lesions has been determined by comparable radiologic or clinical assessment following the most recent treatment period The treatment remains clinically appropriate and the individual is benefitting from the treatment The individual has previously discontinued treatment with pembrolizumab for reasons other than severe toxicity or disease progression The individual has signs of disease progression Disease has not progressed during previous treatment with pembrolizumab relevant specialist any relevant practitioner 4 Patient has locally advanced or metastatic, unresectable, non-small cell lung cancer Patient has not had chemotherapy for their disease in the palliative setting Patient has not received prior funded treatment with an immune checkpoint inhibitor for NSCLC For patients with non-squamous histology there is documentation confirming that the disease does not express activating mutations of EGFR, ROS-1 or ALK tyrosine kinase unless not possible to ascertain Pembrolizumab to be used as monotherapy There is documentation confirming the disease expresses PD-L1 at a level greater than or equal to 50% as determined by a validated test unless not possible to ascertain There is documentation confirming the disease expresses PD-L1 at a level greater than or equal to 1% as determined by a validated test unless not possible to ascertain Chemotherapy is determined to be not in the best interest of the patient based on clinician assessment Patient has an ECOG 0-2 Pembrolizumab to be used at a maximum dose of 200 mg every three weeks (or equivalent) for a maximum of 16 weeks Baseline measurement of overall tumour burden is documented clinically and radiologically medical oncologist 4 Patient’s disease has had a complete response to treatment Patient’s disease has had a partial response to treatment Patient has stable disease Response to treatment in target lesions has been determined by comparable radiologic assessment following the most recent treatment period No evidence of disease progression The treatment remains clinically appropriate and patient is benefitting from treatment Pembrolizumab to be used at a maximum dose of 200 mg every three weeks (or equivalent) Treatment with pembrolizumab to cease after a total duration of 24 months from commencement (or equivalent of 35 cycles dosed every 3 weeks) medical oncologist any relevant practitioner 4 Patient has locally advanced or metastatic, unresectable, non-small cell lung cancer The patient has not had chemotherapy for their disease in the palliative setting Patient has not received prior funded treatment with an immune checkpoint inhibitor for NSCLC For patients with non-squamous histology there is documentation confirming that the disease does not express activating mutations of EGFR, ROS-1 or ALK tyrosine kinase unless not possible to ascertain Pembrolizumab to be used in combination with platinum-based chemotherapy Patient has an ECOG 0-2 Pembrolizumab to be used at a maximum dose of 200 mg every three weeks (or equivalent) for a maximum of 16 weeks Baseline measurement of overall tumour burden is documented clinically and radiologically medical oncologist 4 Patient’s disease has had a complete response to treatment Patient’s disease has had a partial response to treatment Patient has stable disease Response to treatment in target lesions has been determined by comparable radiologic assessment following the most recent treatment period No evidence of disease progression The treatment remains clinically appropriate and patient is benefitting from treatment Pembrolizumab to be used at a maximum dose of 200 mg every three weeks (or equivalent) Treatment with pembrolizumab to cease after a total duration of 24 months from commencement (or equivalent of 35 cycles dosed every 3 weeks) medical oncologist any relevant practitioner 4 Patient is currently on treatment with pembrolizumab and met all remaining criteria prior to commencing treatment Patient has recurrent or de novo unresectable, inoperable locally advanced triple-negative breast cancer (that does not express ER, PR or HER2 IHC3+ or ISH+ [including FISH or other technology]) Patient has recurrent or de novo metastatic triple-negative breast cancer (that does not express ER, PR or HER2 IHC3+ or ISH+ [including FISH or other technology]) Patient is treated with palliative intent Patient’s cancer has confirmed PD-L1 Combined Positive Score (CPS) is greater than or equal to 10 Patient has received no prior systemic therapy in the palliative setting Patient has an ECOG score of 0–2 Pembrolizumab is to be used in combination with chemotherapy Baseline measurement of overall tumour burden is documented clinically and radiologically Pembrolizumab is to be used at a maximum dose of 200 mg every three weeks (or equivalent) for a maximum of 16 weeks relevant specialist any relevant practitioner 6 Patient’s disease has had a complete response to treatment Patient’s disease has had a partial response to treatment Patient has stable disease No evidence of disease progression Response to treatment in target lesions has been determined by a comparable radiologic assessment following the most recent treatment period Pembrolizumab is to be used at a maximum dose of 200 mg every three weeks (or equivalent) Treatment with pembrolizumab is to cease after a total duration of 24 months from commencement (or equivalent of 35 cycles dosed every 3 weeks) any relevant practitioner 6 Patient is currently on treatment with pembrolizumab and met all remaining criteria prior to commencing treatment Patient has recurrent or metastatic head and neck squamous cell carcinoma of mucosal origin (excluding nasopharyngeal carcinoma) that is incurable by local therapies Patient has not received prior systemic therapy in the recurrent or metastatic setting Patient has a positive PD-L1 combined positive score (CPS) of greater than or equal to 1 Patient has an ECOG performance score of 0-2 Pembrolizumab to be used in combination with platinum-based chemotherapy Pembrolizumab to be used as monotherapy Pembrolizumab is to be used at a maximum dose of 200 mg every three weeks (or equivalent) for a maximum of 16 weeks relevant specialist any relevant practitioner 4 Patient’s disease has had a complete response to treatment Patient’s disease has had a partial response to treatment Patient has stable disease No evidence of disease progression Pembrolizumab is to be used at a maximum dose of 200 mg every three weeks (or equivalent) Treatment with pembrolizumab is to cease after a total duration of 24 months from commencement (or equivalent of 35 cycles dosed every 3 weeks) any relevant practitioner 4 Individual is currently on treatment with pembrolizumab and met all remaining criteria prior to commencing treatment Individual has deficient mismatch repair (dMMR) or microsatellite instability-high (MSI-H) metastatic colorectal cancer Individual has deficient mismatch repair (dMMR) or microsatellite instability-high (MSI-H) unresectable colorectal cancer Individual is treated with palliative intent Individual has not previously received funded treatment with pembrolizumab for MSI-H/dMMR advanced colorectal cancer Individual has an ECOG performance score of 0-2 Baseline measurement of overall tumour burden is documented clinically and radiologically Pembrolizumab to be used at a maximum dose of 200 mg every three weeks (or equivalent) for a maximum of 16 weeks relevant specialist any relevant practitioner 4 No evidence of disease progression Pembrolizumab to be used at a maximum dose of 200 mg every three weeks (or equivalent) Treatment with pembrolizumab is to cease after a total duration of 24 months from commencement (or equivalent of 35 cycles dosed every 3 weeks) any relevant practitioner 4 Patient is currently on treatment with pembrolizumab and met all remaining criteria prior to commencing treatment Patient has inoperable locally advanced (T4) or metastatic urothelial carcinoma Patient has an ECOG performance score of 0-2 Patient has documented disease progression following treatment with chemotherapy Pembrolizumab to be used as monotherapy at a maximum dose of 200 mg every three weeks (or equivalent) for a maximum of 16 weeks relevant specialist any relevant practitioner 4 Patient’s disease has had a complete response to treatment Patient’s disease has had a partial response to treatment Patient has stable disease No evidence of disease progression Pembrolizumab is to be used as monotherapy at a maximum dose of 200 mg every three weeks (or equivalent) Treatment with pembrolizumab is to cease after a total duration of 24 months from commencement (or equivalent of 35 cycles dosed every 3 weeks) any relevant practitioner 4 Individual is currently on treatment with pembrolizumab and met all remaining criteria prior to commencing treatment Individual has relapsed/refractory Hodgkin lymphoma after two or more lines of chemotherapy Individual is ineligible for autologous stem cell transplant Individual has relapsed/refractory Hodgkin lymphoma and has previously undergone an autologous stem cell transplant Individual has not previously received funded pembrolizumab for relapsed/refractory Hodgkin lymphoma Pembrolizumab to be administered at doses no greater than 200 mg once every 3 weeks relevant specialist any relevant practitioner 4 Patient has received a partial or complete response to pembrolizumab Treatment with pembrolizumab is to cease after a total duration of 24 months from commencement (or equivalent of 35 cycles dosed every 3 weeks) any relevant practitioner 6 Durvalumab <range>Durvalumab</range> Patient has histologically or cytologically documented stage III, locally advanced, unresectable non-small cell lung cancer (NSCLC) Patient has histologically or cytologically documented stage IIb (T1N2a only), locally advanced, unresectable non-small cell lung cancer (NSCLC) Patient has received two or more cycles of platinum-based chemotherapy concurrently with definitive radiation therapy Patient has no disease progression following the second or subsequent cycle of platinum-based chemotherapy with definitive radiation therapy treatment Patient has a ECOG performance status of 0 or 1 Patient has completed last radiation dose within 8 weeks of starting treatment with durvalumab Patient must not have received prior PD-1 or PD-L1 inhibitor therapy for this condition Durvalumab is to be used at a maximum dose of no greater than 10 mg/kg every 2 weeks Durvalumab is to be used at a flat dose of 1500 mg every 4 weeks Treatment with durvalumab to cease upon signs of disease progression medical practitioner 4 The treatment remains clinically appropriate and the patient is benefitting from treatment Durvalumab is to be used at a maximum dose of no greater than 10 mg/kg every 2 weeks Durvalumab is to be used at a flat dose of 1500 mg every 4 weeks Treatment with durvalumab to cease upon signs of disease progression Total continuous treatment duration must not exceed 12 months medical practitioner 4 Atezolizumab <range>Atezolizumab</range> Patient has locally advanced or metastatic non-small cell lung cancer Patient has not received prior funded treatment with an immune checkpoint inhibitor for NSCLC For patients with non-squamous histology there is documentation confirming that the disease does not express activating mutations of EGFR, ROS-1 or ALK tyrosine kinase unless not possible to ascertain Patient has an ECOG 0-2 Patient has documented disease progression following treatment with at least two cycles of platinum-based chemotherapy Atezolizumab is to be used as monotherapy at a dose of 1200 mg every three weeks (or equivalent) for a maximum of 16 weeks Baseline measurement of overall tumour burden is documented clinically and radiologically medical oncologist 4 Patient’s disease has had a complete response to treatment Patient’s disease has had a partial response to treatment Patient has stable disease Response to treatment in target lesions has been determined by comparable radiologic assessment following the most recent treatment period No evidence of disease progression The treatment remains clinically appropriate and patient is benefitting from treatment Atezolizumab to be used at a maximum dose of 1200 mg every three weeks (or equivalent) Treatment with atezolizumab to cease after a total duration of 24 months from commencement (or equivalent of 35 cycles dosed every 3 weeks) medical oncologist 4 Patient is currently on treatment with atezolizumab and met all remaining criteria prior to commencing treatment Patient has locally advanced or metastatic, unresectable hepatocellular carcinoma Patient has preserved liver function (Child-Pugh A) Transarterial chemoembolisation (TACE) is unsuitable Patient has not received prior systemic therapy for the treatment of hepatocellular carcinoma Patient received funded lenvatinib before 1 March 2025 Patient has experienced treatment-limiting toxicity from treatment with lenvatinib No disease progression since initiation of lenvatinib Patient has an ECOG performance status of 0-2 To be given in combination with bevacizumab medical practitioner 6 no evidence of disease progression medical practitioner 6 Ipilimumab <range>Ipilimumab</range> The patient is currently on treatment with ipilimumab and met all remaining criteria prior to commencing treatment The patient has metastatic renal cell carcinoma The patient is treatment naive The patient has ECOG performance status 0-2 The disease is predominantly of clear cell histology The patient has sarcomatoid histology Haemoglobin levels less than the lower limit of normal Corrected serum calcium level greater than 10 mg/dL (2.5 mmol/L) Neutrophils greater than the upper limit of normal Platelets greater than the upper limit of normal Interval of less than 1 year from original diagnosis to the start of systemic therapy Karnofsky performance score of less than or equal to 70 Ipilimumab is to be used at a maximum dose of 1 mg/kg for up to four cycles in combination with nivolumab medical practitioner 4 Other Immunosuppressants Antithymocyte globulin (rabbit) Inj 25 mg vial Any 0 Picibanil Inj 100 mcg vial Any 0 Everolimus <range>Everolimus</range> Patient has tuberous sclerosis Patient has progressively enlarging sub-ependymal giant cell astrocytomas (SEGAs) that require treatment neurologist oncologist 3 Documented evidence of SEGA reduction or stabilisation by MRI within the last 3 months The treatment remains appropriate and the patient is benefiting from treatment Everolimus to be discontinued at progression of SEGAs neurologist oncologist 12 The patient has metastatic renal cell carcinoma The disease is of predominant clear-cell histology The patient has documented disease progression following one previous line of treatment The patient has an ECOG performance status of 0-2 Everolimus is to be used in combination with lenvatinib Patient has received funded treatment with nivolumab for the second line treatment of metastatic renal cell carcinoma Patient has experienced treatment limiting toxicity from treatment with nivolumab Everolimus is to be used in combination with lenvatinib There is no evidence of disease progression medical practitioner 4 there is no evidence of disease progression medical practitioner 4 Mycophenolate mofetil Inj 500 mg vial CellCept 4 133.33 Cap 250 mg CellCept 100 35.90 Tab 500 mg CellCept 50 35.90 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 4439.17 Sirolimus <range>Sirolimus</range> For rescue therapy for an organ transplant recipient medical practitioner

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

 Patient has severe non-malignant lymphovascular malformation* Malformations are not adequately controlled by sclerotherapy and surgery Malformations are widespread/extensive and sclerotherapy and surgery are not considered clinically appropriate Sirolimus is to be used to reduce malformation prior to consideration of surgery Patient is being treated by a specialist lymphovascular malformation multi-disciplinary team Patient has measurable disease as defined by RECIST version 1.1 (see Note) medical practitioner 6 Patient’s disease has had either a complete response or a partial response to treatment, or patient has stable disease according to RECIST version 1.1 (see Note) Patient’s disease has stabilised or responded clinically and disease response to treatment has been clearly documents in patient notes No evidence of progressive disease The treatment remains clinically appropriate and the patient is benefitting from the treatment medical practitioner 12

Baseline assessment and disease responses to be assessed according to the Response Evaluation Criteria in Solid Tumours (RECIST) version 1.1 (Eisenhauer et al. Eur J Cancer 2009;45:228-47)

Indications marked with * are unapproved indications

 Patient has tuberous sclerosis complex* Evidence of renal angiomyolipoma(s) measuring 3 cm or greater and that have shown interval growth nephrologist urologist 6 Documented evidence of renal angiomyolipoma reduction or stability by magnetic resonance imaging (MRI) or ultrasound Demonstrated stabilisation or improvement in renal function The patient has not experienced angiomyolipoma haemorrhage or significant adverse effects to sirolimus treatment The treatment remains appropriate and the patient is benefitting from treatment medical practitioner 12

Indications marked with * are unapproved indications

 Patient has epilepsy with a background of documented tuberous sclerosis complex* Vigabatrin has been trialled and has not adequately controlled seizures Seizures are not adequately controlled by, or the patient has experienced unacceptable side effects from, optimal treatment with at least two of the following: sodium valproate, topiramate, levetiracetam, carbamazepine, lamotrigine, phenytoin sodium, and lacosamide (see Note) Vigabatrin is contraindicated Seizures are not adequately controlled by, or the patient has experienced unacceptable side effects from, optimal treatment with at least three of the following: sodium valproate, topiramate, levetiracetam, carbamazepine, lamotrigine, phenytoin sodium, and lacosamide (see Note) Seizures have a significant impact on quality of life Patient has been assessed and surgery is considered inappropriate for this patient, or the patient has been assessed and would benefit from mTOR inhibitor treatment prior to surgery neurologist 6

Those of childbearing potential are not required to trial phenytoin sodium, sodium valproate, and topiramate. Those who can father children are not required to trial sodium valproate.

 demonstrated significant and sustained improvement in seizure rate (e.g. 50% reduction in seizure frequency) or severity and/or patient quality of life compared with baseline prior to starting sirolimus treatment neurologist 12

Indications marked with * are unapproved indications

 Azathioprine Inj 50 mg vial Any 0 Tab 50 mg Azamun 100 10.34 Tab 25 mg Azamun 60 10.15 Inj 100 mg vial Any 0 Bacillus calmette-guerin (BCG) <range>Bacillus calmette-guerin (BCG)</range> For use in bladder cancer medical practitioner JAK inhibitors Upadacitinib <range>Upadacitinib</range> The individual has had an initial Special Authority approval for adalimumab and/or etanercept for rheumatoid arthritis The individual has experienced intolerable side effects with adalimumab and/or etanercept The individual 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 Rituximab is not clinically appropriate The individual is seronegative for both anti-cyclic citrullinated peptide (CCP) antibodies and rheumatoid factor The individual has been started on rituximab for rheumatoid arthritis in a Health NZ Hospital The individual has experienced intolerable side effects with rituximab At four months following the initial course of rituximab the individual has received insufficient benefit such that they do not meet the renewal criteria for rheumatoid arthritis medical practitioner 6 Following 6 months' initial treatment, the individual has experienced at least a 50% decrease in active joint count from baseline On subsequent reapplications, the individual has experienced at least a continuing 30% improvement in active joint count from baseline medical practitioner 6 Individual is currently on treatment with upadacitinib for atopic dermatitis and met all remaining criteria prior to commencing treatment Individual has moderate to severe atopic dermatitis, severity as defined by an Eczema Area and Severity Index (EASI) score of greater than or equal to 16 or a Dermatology Life Quality Index (DLQI) score of greater than or equal to 10 Individual has received insufficient benefit from topical therapy (including topical corticosteroids or topical calcineurin inhibitors) for a 28-day trial within the last 6 months, unless contraindicated to all Individual has trialled and received insufficient benefit from at least one systemic therapy for a minimum of three months (eg ciclosporin, azathioprine, methotrexate or mycophenolate mofetil), unless contraindicated to all An EASI assessment or DLQI assessment has been completed for at least the most recent prior treatment course, preferably while still on treatment but no longer than 1 month following cessation of each prior treatment course The most recent EASI or DQLI assessment is no more than 1 month old at the time of application medical practitioner 6 Individual has received a 75% or greater reduction in EASI score (EASI 75) as compared to baseline EASI prior to commencing upadacitinib Individual has received a DLQI improvement of 4 or more as compared to baseline DLQI prior to commencing upadacitinib medical practitioner 12 Individual is currently on treatment with upadacitinib for Crohn’s disease and met all remaining criteria prior to commencing treatment Individual has active Crohn’s disease Individual has had an initial approval for prior biologic therapy and has experienced intolerable side effects or insufficient benefit to meet renewal criteria Individual meets the initiation criteria for prior biologic therapies for Crohn’s disease Other biologic therapies for Crohn’s disease are contraindicated medical practitioner 6 CDAI score has reduced by 100 points from the CDAI score when the individual was initiated on biologic therapy HBI score has reduced by 3 points from when individual was initiated on biologic therapy CDAI score is 150 or less HBI score is 4 or less The individual has experienced an adequate response to treatment, but CDAI score cannot be assessed medical practitioner 2 Individual is currently on treatment with upadacitinib for Crohn’s disease and met all remaining criteria prior to commencing treatment Child has active Crohn’s disease Child has had an initial approval for prior biologic therapy for Crohn’s disease and has experienced intolerable side effects or insufficient benefit to meet renewal criteria Child meets the initiation criteria for prior biologic therapies for Crohn’s disease Other biologic therapies for Crohn’s disease are contraindicated medical practitioner 6 PCDAI score has reduced by 10 points from when the child was initiated on treatment PCDAI score is 15 or less The child has experienced an adequate response to treatment, but PCDAI score cannot be assessed medical practitioner 2

Indications marked with * are unapproved indications.

 Individual is currently on treatment with upadacitinib for ulcerative colitis and met all remaining criteria prior to commencing treatment Individual has active ulcerative colitis Individual has had an initial approval for prior biologic therapy for ulcerative colitis and has experienced intolerable side effects or insufficient benefit to meet renewal criteria Individual meets the initiation criteria for prior biologic therapies for ulcerative colitis Other biologic therapies for ulcerative colitis are contraindicated medical practitioner 6 The SCCAI score has reduced by 2 points or more from the SCCAI score when the individual was initiated on treatment PUCAI score has reduced by 10 points or more from the PUCAI score when the individual was initiated on treatment medical practitioner 2 Respiratory System and Allergies Antiallergy Preparations Allergic Emergencies Icatibant <range>Icatibant</range> Supply for anticipated emergency treatment of laryngeal/oro-pharyngeal or severe abdominal attacks of acute hereditary angioedema (HAE) for patients with confirmed diagnosis of C1-esterase inhibitor deficiency The patient has undergone product training and has agreed upon an action plan for self-administration clinical immunologist relevant specialist 12 The treatment remains appropriate and the patient is benefiting from treatment medical practitioner 12 Adrenaline <range>Adrenaline</range> Patient has experienced a previous anaphylactic reaction which has resulted in presentation to a hospital or emergency department Patient has been assessed to be at significant risk of anaphylaxis by a relevant practitioner medical practitioner Allergy Desensitisation Bee venom <range>Bee venom</range> RAST or skin test positive Patient has had severe generalised reaction to the sensitising agent medical practitioner Paper wasp venom <range>Paper wasp venom</range> RAST or skin test positive Patient has had severe generalised reaction to the sensitising agent medical practitioner Yellow jacket wasp venom <range>Yellow jacket wasp venom</range> RAST or skin test positive Patient has had severe generalised reaction to the sensitising agent medical practitioner Allergy Prophylactics Sodium cromoglicate Nasal spray 4% Any 0 Budesonide Nasal spray 50 mcg per dose SteroClear 200 2.59 Nasal spray 100 mcg per dose SteroClear 200 2.89 Ipratropium bromide Aqueous nasal spray 0.03% Univent 15 5.23 Fluticasone propionate Metered dose nasal spray 50 mcg per dose Flixonase Hayfever & Allergy 120 2.57 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 Fexaclear 30 3.49 Tab 180 mg Fexaclear 30 4.10 Tab 60 mg Any 0 Promethazine hydrochloride Inj 25 mg per ml, 2 ml ampoule Hospira 5 21.09 Tab 10 mg Allersoothe 100 2.19 Tab 25 mg Allersoothe 100 2.69 Oral liq 1 mg per ml Allersoothe 100 3.39 Cetirizine hydrochloride Oral liq 1 mg per ml Histaclear 200 3.99 Tab 10 mg Zista 100 1.71 Loratadine Oral liq 1 mg per ml Haylor Syrup 100 1.43 Tab 10 mg Lorafix 100 6.02 Loratadine Noumed 100 1.59 Anticholinergic Agents Anticholinergic Agents Ipratropium bromide Aerosol inhaler 20 mcg per dose Any 0 Nebuliser soln 250 mcg per ml, 1 ml ampoule Any 0 Nebuliser soln 250 mcg per ml, 2 ml ampoule Univent 20 11.73 Accord 20 11.73 Ipratropium Viatris 10 8.11 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 11.04 Nebuliser soln, 2.5 mg with ipratropium bromide 0.5 mg per vial, 3.0 ml vial Cipla 30 16.56 Long-Acting Muscarinic Agents Glycopyrronium

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

Powder for inhalation 50 mcg per dose Seebri Breezhaler 30 61.00 Umeclidinium

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

Powder for inhalation 62.5 mcg per dose Incruse Ellipta 30 61.50 Tiotropium bromide

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

Powder for inhalation 18 mcg per dose Spiriva 30 50.37 Soln for inhalation 2.5 mcg per dose Spiriva Respimat 60 50.37 Long-Acting Muscarinic Antagonists with Long-Acting Beta-Adrenoceptor Agonists

Note: Combination long acting muscarinic antagonist and long acting beta-2 agonist must not be used if the patient is also receiving treatment with a combination inhaled corticosteroid and long acting beta-2 agonist.

<range>Long-Acting Muscarinic Antagonists with Long-Acting Beta-Adrenoceptor Agonists</range> Patient has been stabilised on a long acting muscarinic antagonist The prescriber considers that the patient would receive additional benefit from switching to a combination product medical practitioner Inhaled Corticosteroid with Long-Acting Muscarinic Antagonist and Beta Agonist Fluticasone furoate with umeclidinium and vilanterol <range>Fluticasone furoate with umeclidinium and vilanterol</range> Patient has a diagnosis of COPD confirmed by spirometry or spirometry has been attempted and technically acceptable results are not possible Patient is currently receiving an inhaled corticosteroid with long acting beta-2 agonist (ICS/LABA) or a long acting muscarinic antagonist with long acting beta-2 agonist (LAMA/LABA) Clinical criteria: Patient has a COPD Assessment Test (CAT) score greater than 10 Patient has had 2 or more exacerbations in the previous 12 months Patient has had one exacerbation requiring hospitalisation in the previous 12 months Patient has had an eosinophil count greater than or equal to 0.3 x 10ˆ9 cells/L in the previous 12 months Patient is currently receiving multiple inhaler triple therapy (inhaled corticosteroid with long acting muscarinic antagonist and long acting beta-2 agonist – ICS/LAMA/LABA) and met at least one of the clinical criteria above prior to commencing multiple inhaler triple therapy medical practitioner Budesonide with glycopyrronium and eformoterol <range>Budesonide with glycopyrronium and eformoterol</range> Patient has a diagnosis of COPD confirmed by spirometry or spirometry has been attempted and technically acceptable results are not possible Patient is currently receiving an inhaled corticosteroid with long acting beta-2 agonist (ICS/LABA) or a long acting muscarinic antagonist with long acting beta-2 agonist (LAMA/LABA) Clinical criteria: Patient has a COPD Assessment Test (CAT) score greater than 10 Patient has had 2 or more exacerbations in the previous 12 months Patient has had one exacerbation requiring hospitalisation in the previous 12 months Patient has had an eosinophil count greater than or equal to 0.3 x 10ˆ9 cells/L in the previous 12 months Patient is currently receiving multiple inhaler triple therapy (inhaled corticosteroid with long-acting muscarinic antagonist and long-acting beta-2 agonist – ICS/LAMA/LABA) and met at least one of the clinical criteria above prior to commencing multiple inhaler therapy medical practitioner Antifibrotics Antifibrotics Pirfenidone <range>Pirfenidone</range> Patient has been diagnosed with idiopathic pulmonary fibrosis by a multidisciplinary team including a radiologist Forced vital capacity is between 50% and 90% predicted Pirfenidone is to be discontinued at disease progression (See Notes) Pirfenidone is not to be used in combination with subsidised nintedanib The patient has not previously received treatment with nintedanib Patient has previously received nintedanib, but discontinued nintedanib within 12 weeks due to intolerance Patient has previously received nintedanib, but the patient’s disease has not progressed (disease progression defined as 10% or more decline in predicted FVC within any 12 month period since starting treatment with nintedanib) respiratory specialist 12 Treatment remains clinically appropriate and patient is benefitting from and tolerating treatment Pirfenidone is not to be used in combination with subsidised nintedanib Pirfenidone is to be discontinued at disease progression (See Note) respiratory specialist 12

disease progression is defined as a decline in percent predicted FVC of 10% or more within any 12 month period.

 Nintedanib <range>Nintedanib</range> Patient has been diagnosed with idiopathic pulmonary fibrosis by a multidisciplinary team including a radiologist Forced vital capacity is between 50% and 90% predicted Nintedanib is to be discontinued at disease progression (See Note) Nintedanib is not to be used in combination with subsidised pirfenidone The patient has not previously received treatment with pirfenidone Patient has previously received pirfenidone, but discontinued pirfenidone within 12 weeks due to intolerance Patient has previously received pirfenidone, but the patient’s disease has not progressed (disease progression defined as 10% or more decline in predicted FVC within any 12 month period since starting treatment with pirfenidone) respiratory specialist 12 Treatment remains clinically appropriate and patient is benefitting from and tolerating treatment Nintedanib is not to be used in combination with subsidised pirfenidone Nintedanib is to be discontinued at disease progression (See Note) respiratory specialist 12

disease progression is defined as a decline in percent predicted FVC of 10% or more within any 12 month period.

 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 Powder for inhalation, 200 mcg per dose (equivalent to 250 mcg metered dose), breath activated Bricanyl Turbuhaler 120 22.20 Salbutamol Aerosol inhaler, 100 mcg per dose Ventolin 200 7.45 SalAir 200 4.18 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 8.96 UK Cipla 20 1 8.96 Nebuliser soln 2 mg per ml, 2.5 ml ampoule Asthalin 20 9.43 UK Cipla 20 9.43 Oral liq 400 mcg per ml Ventolin 150 50.00 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 14.01 Aerosol inhaler 100 mcg per dose Beclazone 100 200 12.50 Qvar 200 17.52 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 7.19 Aerosol inhaler 125 mcg per dose Flixotide 120 13.60 Aerosol inhaler 250 mcg per dose Flixotide 120 24.62 Powder for inhalation 50 mcg per dose Flixotide Accuhaler 60 8.61 Powder for inhalation 100 mcg per dose Flixotide Accuhaler 60 7.81 Powder for inhalation 250 mcg per dose Flixotide Accuhaler 60 11.93 Leukotriene Receptor Antagonists Leukotriene Receptor Antagonists Montelukast Tab 5 mg Montelukast Viatris 28 3.10 Tab 4 mg Montelukast Viatris 28 3.10 Tab 10 mg Montelukast Viatris 28 2.45 Long-Acting Beta-Adrenoceptor Agonists Long-Acting Beta-Adrenoceptor Agonists Eformoterol fumarate Powder for inhalation 12 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 Eformoterol fumarate dihydrate Powder for inhalation 4.5 mcg per dose, breath activated (equivalent to eformoterol fumarate 6 mcg metered dose) Any 0 1 Salmeterol Powder for inhalation 50 mcg per dose Serevent Accuhaler 60 26.25 Aerosol inhaler 25 mcg per dose Serevent 120 26.25 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 Symbicort Turbuhaler 120 33.74 Powder for inhalation 400 mcg with eformoterol fumarate 12 mcg Symbicort Turbuhaler 60 33.74 Powder for inhalation 160 mcg with 4.5 mcg eformoterol fumarate per dose (equivalent to 200 mcg budesonide with 6 mcg eformoterol fumarate metered dose) DuoResp Spiromax 120 41.50 Powder for inhalation 320 mcg with 9 mcg eformoterol fumarate per dose (equivalent to 400 mcg budesonide with 12 mcg eformoterol fumarate metered dose) DuoResp Spiromax 120 82.50 Fluticasone furoate with vilanterol Powder for inhalation 100 mcg with vilanterol 25 mcg Breo Ellipta 30 44.08 Fluticasone with salmeterol Aerosol inhaler 50 mcg with salmeterol 25 mcg Seretide 120 25.79 Aerosol inhaler 125 mcg with salmeterol 25 mcg Seretide 120 32.60 Powder for inhalation 100 mcg with salmeterol 50 mcg Seretide Accuhaler 60 33.74 Powder for inhalation 250 mcg with salmeterol 50 mcg Seretide Accuhaler 60 44.08 Methylxanthines Methylxanthines Theophylline Oral liq 80 mg per 15 ml Nuelin 500 18.49 Tab long-acting 250 mg Nuelin-SR 100 25.65 Caffeine citrate Oral liq 20 mg per ml (caffeine 10 mg per ml) Biomed 25 16.91 Inj 20 mg per ml (caffeine 10 mg per ml), 2.5 ml ampoule Biomed 5 69.70 Aminophylline Inj 25 mg per ml, 10 ml ampoule DBL Aminophylline 5 180.00 Mucolytics and Expectorants Mucolytics and Expectorants Ivacaftor <range>Ivacaftor</range> Patient has been diagnosed with cystic fibrosis Patient has two cystic fibrosis-causing mutations in the cystic fibrosis transmembrane regulator (CFTR) gene (one from each parental allele) Patients must have a sweat chloride value of at least 60 mmol/L Patient must have at least one mutation on the list of CFTR mutations that produce CFTR protein and are known to be responsive to ivacaftor** Treatment with ivacaftor must be given concomitantly with standard therapy for this condition The dose of ivacaftor will not exceed one tablet or one sachet twice daily medical practitioner

** Mutations listed in Table 3 of the Food and Drug Administration (FDA) Ivacaftor prescribing information https://www.accessdata.fda.gov/drugsatfda_docs/label/2023/203188s038lbl.pdf

Elexacaftor with tezacaftor, ivacaftor and ivacaftor <range>Elexacaftor with tezacaftor, ivacaftor and ivacaftor</range> Patient has been diagnosed with cystic fibrosis Patient has two cystic fibrosis-causing mutations in the cystic fibrosis transmembrane regulator (CFTR) gene (one from each parental allele) Patient has a sweat chloride value of at least 60 mmol/L Patient has a heterozygous or homozygous F508del mutation Patient has a mutation responsive to elexacaftor/tezacaftor/ivacaftor (see note) The treatment must be the sole funded CFTR modulator therapy for this condition Treatment with elexacaftor/tezacaftor/ivacaftor must be given concomitantly with standard therapy for this condition medical practitioner

Eligible mutations are listed in the Food and Drug Administration (FDA) Trikafta prescribing information https://www.accessdata.fda.gov/drugsatfda_docs/label/2025/212273s015lbl.pdf

 Vanzacaftor with tezacaftor and deutivacaftor <range>Vanzacaftor with tezacaftor and deutivacaftor</range> Patient has been diagnosed with cystic fibrosis Patient has two cystic fibrosis-causing mutations in the cystic fibrosis transmembrane regulator (CFTR) gene (one from each parental allele) Patient has a sweat chloride value of at least 60 mmol/L Patient has a heterozygous or homozygous F508del mutation Patient has a mutation responsive to vanzacaftor/tezacaftor/deutivacaftor (see note) The treatment must be the sole funded CFTR modulator therapy for this condition Treatment with vanzacaftor/tezacaftor/deutivacaftor must be given concomitantly with standard therapy for this condition medical practitioner

Eligible mutations are listed in the in the Food and Drug Administration (FDA) Alyftrek prescribing information https://www.accessdata.fda.gov/drugsatfda_docs/label/2025/218730s002lbl.pdf

 Sodium chloride Nebuliser soln 7%, 90 ml bottle Biomed 90 25.73 Dornase alfa <range>Dornase alfa</range> Patient has a confirmed diagnosis of cystic fibrosis Patient has previously undergone a trial with, or is currently being treated with, hypertonic saline Patient has required one or more hospital inpatient respiratory admissions in the previous 12 month period Patient has had 3 exacerbations due to CF, requiring oral or intravenous (IV) antibiotics in in the previous 12 month period Patient has had 1 exacerbation due to CF, requiring oral or IV antibiotics in the previous 12 month period and a Brasfield score of <22/25 Patient has a diagnosis of allergic bronchopulmonary aspergillosis (ABPA) respiratory physician paediatrician 12 The treatment remains appropriate and the patient continues to benefit from treatment respiratory physician paediatrician Patient is an in-patient The mucus production cannot be cleared by first line chest techniques medical practitioner 4 Patient is an in-patient Patient diagnoses with pleural emphyema medical practitioner 3 Pulmonary Surfactants Pulmonary Surfactants Beractant Soln 200 mg per 8 ml vial Any 0 1 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% Any 0 Chloramphenicol Ear drops 0.5% Any 0 Eye drops 0.5%, single dose Any 0 Eye drops 0.5% Chlorafast 10 1.84 Eye oint 1% Devatis 5 1.55 Ciprofloxacin Eye drops 0.3% Ciprofloxacin Teva 5 10.85 Sodium fusidate [Fusidic acid] Eye drops 1% Fucithalmic 5 5.29 5 5.29 5 5.29 Tobramycin Eye oint 0.3% Tobrex 3.5 10.45 Eye drops 0.3% Tobrex 5 11.48 Antifungals Natamycin Eye drops 5% Any 0 Antivirals Aciclovir Eye oint 3% ViruPOS 4.5 15.89 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 3.5 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 7.5 5.16 Anti-Inflammatory Preparations Corticosteroids Prednisolone acetate Eye drops 0.12% Any 0 Eye drops 1% Prednisolone- AFT 10 6.92 Pred Forte 5 7.00 Fluorometholone Eye drops 0.1% FML 5 3.09 Prednisolone sodium phosphate Eye drops 0.5%, single dose (preservative free) Minims Prednisolone 20 43.26 Dexamethasone Eye drops 0.1% Maxidex 5 4.50 Eye oint 0.1% Maxidex 3.5 5.86 Ocular implant 700 mcg <range>Dexamethasone</range> Patients have diabetic macular oedema with pseudophakic lens Patient has reduced visual acuity of between 6/9 – 6/48 with functional awareness of reduction in vision Patient’s disease has progressed despite 3 injections with bevacizumab Patient is unsuitable or contraindicated to treatment with anti-VEGF agents Dexamethasone implants are to be administered not more frequently than once every 4 months into each eye, and up to a maximum of 3 implants per eye per year ophthalmologist 12 Patient’s vision is stable or has improved (prescriber determined) Dexamethasone implants are to be administered not more frequently than once every 4 months into each eye, and up to a maximum of 3 implants per eye per year ophthalmologist 12 Patients have diabetic macular oedema Patient has reduced visual acuity of between 6/9 – 6/48 with functional awareness of reduction in vision Patient is of child bearing potential and has not yet completed a family Dexamethasone implants are to be administered not more frequently than once every 4 months into each eye, and up to a maximum of 3 implants per eye per year ophthalmologist 12 Patient’s vision is stable or has improved (prescriber determined) Patient is of child bearing potential and has not yet completed a family Dexamethasone implants are to be administered not more frequently than once every 4 months into each eye, and up to a maximum of 3 implants per eye per year ophthalmologist 12 Non-Steroidal Anti-Inflammatory Drugs Ketorolac trometamol Eye drops 0.5% Any 0 Diclofenac sodium Eye drops 0.1%, single dose Diclofenac Devatis 30 5.54 10 1.85 Eye drops 0.1% Any 0 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% Olopatadine Teva 5 3.39 Sodium cromoglicate Eye drops 2% Allerfix 10 2.91 Decongestants Naphazoline hydrochloride Eye drops 0.1% Albalon 15 5.65 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 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 bag e.g. Balanced Salt Solution 0 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 per ml with chondroitin sulphate 40 mg per ml, 0.75 ml syringe Viscoat 1 67.00 Sodium hyaluronate [Hyaluronic acid] Inj 23 mg per ml, 0.6 ml syringe Healon 5 1 60.00 Inj 10 mg per ml, 0.85 ml syringe Healon 1 28.50 Inj 18 mg per ml, 0.85 ml syringe Healon GV Pro 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 Inj 0.1% plus hydroxypropyl methylcellulose Any 0 Glaucoma Preparations Beta Blockers Betaxolol Eye drops 0.25% Any 0 Eye drops 0.5% Any 0 Timolol Eye drops 0.25% Arrow-Timolol 5 2.42 Eye drops 0.5% Arrow-Timolol 5 2.50 Eye drops 0.5%, gel forming

For continuation only

Any 0 Carbonic Anhydrase Inhibitors Brinzolamide Eye drops 1% Azopt 5 5.11 Dorzolamide

For continuation only

Eye drops 2% Any 0 Acetazolamide Inj 500 mg Any 0 Tab 250 mg Medsurge 100 13.96 Dorzolamide with timolol Eye drops 2% with timolol 0.5% Dortimopt 5 3.58 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 4% Isopto Carpine 15 7.99 Pilocarpine nitrate Eye drops 2%, single dose Any 0 Carbachol Inj 150 mcg vial Any 0 Prostaglandin Analogues Bimatoprost Eye drops 0.03% Lumigan 3 5.15 Travoprost Eye drops 0.004% Travatan 2.5 6.80 Latanoprost with timolol Eye drops 0.005% with timolol 0.5% Arrow - Lattim 2.5 4.95 Latanoprost Eye drops 0.005% Teva 2.5 2.08 Sympathomimetics Apraclonidine Eye drops 0.5% Iopidine 5 19.77 Brimonidine tartrate with timolol maleate Eye drops 0.2% with timolol 0.5% Combigan 5 7.13 Brimonidine tartrate Eye drops 0.2% Arrow-Brimonidine 5 5.16 Mydriatics and Cycloplegics Anticholinergic Agents Cyclopentolate hydrochloride Eye drops 0.5%, single dose Any 0 Eye drops 1% Cyclogyl 15 25.16 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 18.27 Tropicamide Eye drops 0.5%, single dose Any 0 Eye drops 1%, single dose Any 0 Eye drops 0.5% Mydriacyl 15 20.52 Eye drops 1% Mydriacyl 15 24.82 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 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 3.5 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 Polyethylene glycol 400 and propylene glycol Eye drops 0.4% with propylene glycol 0.3% preservative free, single dose Systane Unit Dose 30 10.78 Eye drops 0.4% with propylene glycol 0.3%, 10 ml bottle

Note: Only for use in compounding an eye drop formulation

Any 0 Sodium hyaluronate [Hyaluronic acid] Eye drops 1 mg per ml Hylo-Fresh 10 13.58 Hypromellose Eye drops 0.5% Methopt 15 19.50 Ophthalmic gel 0.3% Any 0 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 Amyl nitrite Liq 98% in 3 ml capsule Any 0 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 Inj 250 mg per ml. 50 ml vial Any 0 Inj 250 mg per ml, 100 ml vial Any 0 Soya oil Inj 20%, 500 ml bag Any 0 Inj 20%, 500 ml bottle Any 0 Ethanol Liq 96% Any 0 Pralidoxime chloride Inj 1 g vial Any 0 Flumazenil Inj 0.1 mg per ml, 5 ml ampoule Flumazenil-Baxter 5 44.00 Naloxone hydrochloride Inj 400 mcg per ml, 1 ml ampoule DBL Naloxone Hydrochloride 5 13.29 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 42.99 Inj 200 mg per ml, 10 ml vial Hikma Acetylcysteine 10 1 42.99 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 e.g. PCNZ, Optimus Healthcare, Chemet 0 Cap 200 mg e.g. PCNZ, Optimus Healthcare, Chemet 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 Inj 50 mg per ml, 10 ml ampoule Any 0 Deferasirox <range>Deferasirox</range> The patient has been diagnosed with chronic iron overload due to congenital inherited anaemia Deferasirox is to be given at a daily dose not exceeding 40 mg/kg/day 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* Treatment with deferiprone has resulted in severe persistent vomiting or diarrhoea Treatment with deferiprone has resulted in arthritis 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) haematologist 2 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 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. haematologist 2 Desferrioxamine mesilate Inj 500 mg vial DBL Desferrioxamine Mesylate for Inj BP 10 332.88 Charcoal Oral liq 200 mg per ml Carbasorb-X 250 59.85 Deferiprone <range>Deferiprone</range> Patient has been diagnosed with chronic iron overload due to congenital inherited anaemia or acquired red cell aplasia medical practitioner Antiseptics and Disinfectants Antiseptics and Disinfectants Povidone-iodine with ethanol Soln 10% with ethanol 30% Any 0 Soln 10% with ethanol 70% Any 0 Sodium hypochlorite Soln Any 0 Chlorhexidine Soln 5% healthE 500 15.50 Soln 4% Any 0 Soln 0.1% Any 0 Povidone-iodine Pad 10% Any 0 Soln 5% Any 0 Soln 7.5% Any 0 Swab set 10% Any 0 Soln 10% Riodine 100 4.99 Oint 10% Betadine 65 7.40 Vaginal tab 200 mg <range>Povidone-iodine - Vaginal tab 200 mg</range> Rectal administration pre-prostate biopsy medical practitioner Soln 10%, Riodine 500 6.99 15 3.83 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) 25 ml healthE 1 1.55 Soln 0.5% with ethanol 70% Any 0 Soln 2% with ethanol 70% Any 0 Iodine with ethanol Soln 1% with ethanol 70% Any 0 Isopropyl alcohol Soln 70%, 500 ml healthE 1 5.65 Contrast Media Iodinated X-ray Contrast Media Iodised oil Inj 38% w/w (480 mg per ml), 10 ml ampoule Lipiodol Ultra Fluid 1 410.00 Iodixanol Inj 270 mg per ml (iodine equivalent), 50 ml bottle Visipaque 10 275.00 Inj 270 mg per ml (iodine equivalent), 100 ml bottle Visipaque 10 505.00 Inj 320 mg per ml (iodine equivalent), 50 ml bottle Visipaque 10 280.00 Inj 320 mg per ml (iodine equivalent), 100 ml bottle Visipaque 10 510.00 Inj 320 mg per ml (iodine equivalent), 200 ml bottle Visipaque 10 1020.00 Iohexol Inj 240 mg per ml (iodine equivalent), 50 ml bottle Omnipaque 10 117.00 Inj 300 mg per ml (iodine equivalent), 20 ml bottle Omnipaque 10 110.00 Inj 300 mg per ml (iodine equivalent), 50 ml bottle Omnipaque 10 121.00 Inj 300 mg per ml (iodine equivalent), 100 ml bottle Omnipaque 10 200.00 Inj 350 mg per ml (iodine equivalent), 50 ml bottle Omnipaque 10 125.00 Inj 350 mg per ml (iodine equivalent), 100 ml bottle Omnipaque 10 210.00 Inj 350 mg per ml (iodine equivalent), 200 ml bottle Omnipaque 10 420.00 Inj 350 mg per ml, 500 ml bottle Omnipaque 6 655.00 Inj 300 mg per ml (iodine equivalent), 10 ml bottle Omnipaque 10 91.00 Diatrizoate meglumine with sodium amidotrizoate Inj 260 mg with sodium amidotrizoate 40 mg per ml, 250 ml bottle Urografin 1 120.00 Oral liq 660 mg per ml with sodium amidotrizoate 100 mg per ml, 100 ml bottle Gastrografin 100 30.00 100 30.00 Diatrizoate sodium Oral liq 370 mg per ml, 10 ml sachet Ioscan 50 156.12 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-Z-Gas II 50 90.25 Barium sulphate Oral liq 1 mg per ml (0.1% w/v, 0.1% w/w), 450 ml bottle Neulumex 1 15.95 12 191.40 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 250 189.15 Varibar - Pudding 230 159.05 Oral liq 400 mg per ml (40% w/v, 30% w/w), bottle Varibar - Thin Liquid 148 17.39 Grans for oral liq 960 mg per g (96% w/w), 176 g bottle Vanilla SilQ MD 24 530.00 Grans for oral liq 980 mg per g (98% w/w), 310 g bottle Vanilla SilQ HD 24 490.00 Oral liq 20.9 mg per ml (2.1% w/v, 2% w/w), 450 ml bottle Readi-CAT 2 12 97.50 Paramagnetic Contrast Media Gadoteric acid Inj 279.32 mg per ml (0.5 mmol per ml), 10 ml bottle Dotarem 1 14.30 Inj 279.32 mg per ml (0.5 mmol per ml), 20 ml bottle Dotarem 1 28.90 Inj 279.32 mg per ml (0.5 mmol per ml), 5 ml bottle Dotarem 1 9.10 Inj 279.32 mg per ml (0.5 mmol per ml), 10 ml prefilled syringe Dotarem 10 172.00 Inj 279.32 mg per ml (0.5 mmol per ml), 20 ml prefilled syringe Dotarem 10 344.00 Inj 279.32 mg per ml (0.5 mmol per ml), 15 ml prefilled syringe Dotarem 10 258.00 Inj 279.32 mg per ml (0.5 mmol per ml), 15 ml bottle Dotarem 1 25.35 Inj 279.30 mg per ml, 10 ml prefilled syringe e.g. Clariscan 0 Inj 279.30 mg per ml, 15 ml prefilled syringe e.g. Clariscan 0 Inj 279.30 mg per ml, 5 ml vial e.g. Clariscan 0 Inj 279.30 mg per ml, 10 ml vial e.g. Clariscan 0 Inj 279.30 mg per ml, 20 ml vial e.g. Clariscan 0 Gadoxetate disodium Inj 181.43 mg per ml (equivalent to 0.25 mmol per ml), 10 ml prefilled syringe Primovist 1 300.00 1 300.00 Meglumine iotroxate Inj 105 mg per ml, 100 ml bottle Biliscopin 100 169.15 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 604.72 mg per ml (equivalent to 1 mmol per ml), 7.5 ml prefilled syringe Gadovist 1.0 5 189.00 5 189.00 Inj 604.72 mg per ml (equivalent to 1 mmol per ml), 15 ml vial Gadovist 1.0 10 735.00 Inj 604.72 mg per ml (equivalent to 1 mmol per ml), 5 ml prefilled syringe Gadovist 1.0 5 126.00 5 126.00 Inj 604.72 mg per ml (equivalent to 1 mmol per ml), 65 ml bottle Gadovist 1.0 10 3120.00 Inj 604.72 mg per ml (equivalent to 1 mmol per ml), 10 ml prefilled syringe Gadovist 1.0 5 245.00 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 Inj 80 u vial Any 0 Inj 100 u 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 5 mg per ml, 10 ml ampoule Proveblue 5 259.57 Patent blue V Inj 2.5%, 2 ml ampoule Obex Medical 5 440.00 Inj 2.5%, 5 ml prefilled syringe InterPharma 5 435.00 Irrigation Solutions Irrigation Solutions Sodium chloride Irrigation soln 0.9%, 1,000 ml bottle Baxter Sodium Chloride 0.9% 10 19.50 Irrigation soln 0.9%, 30 ml ampoule InterPharma 20 13.25 Irrigation soln 0.9%, 250 ml bottle Fresenius Kabi 12 24.60 Irrigation soln 0.9%, 3,000 ml bag B Braun 4 80.00 Water Irrigation soln, 1,000 ml bottle Baxter Water for Irrigation 10 19.50 Irrigation soln, 250 ml bottle Fresenius Kabi 12 26.40 Irrigation soln, 3,000 ml bag B Braun 4 84.52 Chlorhexidine with cetrimide Irrigation soln 0.015% with cetrimide 0.15%, 100 ml bottle Any 0 Irrigation soln 0.015% with cetrimide 0.15%, 30 ml ampoule LumaCina 30 29.70 Irrigation soln 0.015% with cetrimide 0.15%, 500 ml bottle <range>Chlorhexidine with cetrimide</range> Patient has burns that are greater than 30% of total body surface area (BSA) For use in the perioperative preparation and cleansing of large burn areas requiring debridement/skin grafting The use of 30 ml ampoules is impractical due to the size of the area to be covered medical practitioner 3 The treatment remains appropriate for the patient and the patient is benefiting from the treatment medical practitioner 3 Glycine Irrigation soln 1.5%, 3,000 ml bag B Braun 4 96.28 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 Sodium hydroxide Soln 10% 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 Midwest 200 46.00 Collodion flexible Liq Any 0 Compound hydroxybenzoate Soln Midwest 100 36.00 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 49.95 Codeine phosphate Powder Any 0 Methadone hydrochloride Powder Any 0 Sodium bicarbonate Powder BP Midwest 500 13.50 Glucose [Dextrose] Powder Any 0 Glycerol Liq healthE Glycerol BP Liquid 500 3.23 Syrup Liq (pharmaceutical grade) Midwest 500 25.00 Methyl hydroxybenzoate Powder Midwest 25 11.00 Methylcellulose Powder Midwest 100 44.00 Suspension Ora-Plus 473 38.00 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 38.00 Glycerin with sodium saccharin Suspension Ora-Sweet SF 473 38.00 Methylcellulose with glycerin and sucrose Suspension Ora-Blend 473 38.00 Methylcellulose with glycerin and sodium saccharin Suspension Ora-Blend SF 473 38.00 Special Foods Food Modules Carbohydrate <range>Carbohydrate</range> Cystic fibrosis Chronic kidney disease Cancer in children Cancers affecting alimentary tract where there are malabsorption problems in patients over the age of 20 years Faltering growth in an infant/child Bronchopulmonary dysplasia Premature and post premature infant Inborn errors of metabolism medical practitioner 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 medical practitioner

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

 Fat <range>Fat</range> Patient has inborn errors of metabolism Faltering growth in an infant/child Bronchopulmonary dysplasia Fat malabsorption Lymphangiectasia Short bowel syndrome Infants with necrotising enterocolitis Biliary atresia For use in a ketogenic diet Chyle leak Ascites Patient has increased energy requirements, and for whom dietary measures have not been successful medical practitioner 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. medical practitioner

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

 Protein <range>Protein</range> Protein losing enteropathy High protein needs medical practitioner 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. medical practitioner

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

 Other Supplements Human 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 0.325 g protein, 0.37 g carbohydrate and 0.175 g fat per 1 g sachet Human Milk Fortifier 50 33.48 Carbohydrate and fat supplement <range>Carbohydrate and fat supplement</range> Infant or child aged four years or under Cystic fibrosis Cancer in children Faltering growth Bronchopulmonary dysplasia Premature and post premature infants medical practitioner Food/Fluid Thickeners

NOTE:

While pre-thickened drinks and supplements have not been included in Section H, Health NZ 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.

Food/Fluid Thickeners Carob bean gum with maize starch and maltodextrin Powder Aptamil Feed Thickener 380 24.00 Guar gum Powder e.g. Guarcol 0 Maize starch Powder Nutilis 300 8.29 Maltodextrin with xanthan gum Powder e.g. Instant Thick 0 Maltodextrin with xanthan gum and ascorbic acid Powder e.g. Easy Thick 0 Metabolic Products <range>Metabolic Products</range> For the dietary management of inherited metabolic disease Patient has adrenoleukodystrophy medical practitioner Specialised Formulas Diabetic Products <range>Diabetic Products</range> For patients with type I or type II diabetes suffering weight loss and malnutrition that requires nutritional support For patients with pancreatic insufficiency For patients who have, or are expected to, eat little or nothing for 5 days For patients who have a poor absorptive capacity and/or high nutrient losses and/or increased nutritional needs from causes such as catabolism For use pre- and post-surgery For patients being tube-fed For tube-feeding as a transition from intravenous nutrition medical practitioner Elemental and Semi-Elemental Products <range>Elemental and Semi-Elemental Products</range> Malabsorption Short bowel syndrome Enterocutaneous fistulas Eosinophilic enteritis (including oesophagitis) Inflammatory bowel disease Acute pancreatitis where standard feeds are not tolerated Patients with multiple food allergies requiring enteral feeding medical practitioner Fat Modified Products Fat-modified feed <range>Fat-modified feed</range> Patient has metabolic disorders of fat metabolism Patient has a chyle leak 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 medical practitioner

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

Hepatic Products <range>Hepatic Products</range> For children (up to 18 years) who require a liver transplant medical practitioner High Calorie Products <range>High Calorie Products</range> Patient is fluid volume or rate restricted Patient requires low electrolyte Cystic fibrosis Any condition causing malabsorption Faltering growth in an infant/child Increased nutritional requirements Patient has substantially increased metabolic requirements medical practitioner High Protein Products High protein enteral feed 1.28 kcal/ml <range>High protein enteral feed</range> The patient has a high protein requirement Patient has liver disease Patient is obese (BMI > 30) and is undergoing surgery Patient is fluid restricted Patient's needs cannot be more appropriately met using high calorie product medical practitioner High protein enteral feed 1.25 kcal/ml <range>High protein enteral feed</range> The patient has a high protein requirement Patient has liver disease Patient is obese (BMI > 30) and is undergoing surgery Patient is fluid restricted Patient's needs cannot be more appropriately met using high calorie product medical practitioner High protein enteral feed 1.26 kcal/ml <range>High protein enteral feed</range> The patient has a high protein requirement Patient has liver disease Patient is obese (BMI > 30) and is undergoing surgery Patient is fluid restricted Patient's needs cannot be more appropriately met using high calorie product medical practitioner Infant Formulas Extensively hydrolysed formula <range>Extensively hydrolysed formula</range> Cows' milk formula is inappropriate due to severe intolerance or allergy to its protein content Soy milk formula has been reasonably trialled without resolution of symptoms Soy milk formula is considered clinically inappropriate or contraindicated Severe malabsorption Short bowel syndrome Intractable diarrhoea Biliary atresia Cholestatic liver diseases causing malsorption Cystic fibrosis Proven fat malabsorption Severe intestinal motility disorders causing significant malabsorption Intestinal failure For step down from Amino Acid Formula medical practitioner

A reasonable trial is defined as a 2-4 week trial, or signs of an immediate IgE mediated allergic reaction.

 An assessment as to whether the infant can be transitioned to a cows' milk protein or soy infant formula has been undertaken The outcome of the assessment is that the infant continues to require an extensively hydrolysed infant formula medical practitioner 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 14.8 g protein, 53.7 g carbohydrate and 26.7 g fat per 100 g and tuna fish oil (DHA), can Locasol 400 46.18 Preterm formula <range>Preterm formula</range> For infants born before 33 weeks' gestation or weighing less than 1.5 kg at birth medical practitioner 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 Paediatric oral/enteral feed 1 kcal/ml <range>Paediatric oral/enteral feed 1 kcal/ml</range> The patient is fluid restricted or volume intolerant The patient has increased nutritional requirements due to faltering growth Patient is under 18 months old and weighs less than 8kg medical practitioner

‘Volume intolerant’ patients are those who are unable to tolerate an adequate volume of infant formula to achieve expected growth rate. These patients should have first trialled appropriate clinical alternative treatments, such as concentrating, fortifying and adjusting the frequency of feeding.

 Enteral liquid peptide formula <range>Enteral liquid peptide formula</range> Patient has impaired gastrointestinal function and either cannot tolerate polymeric feeds, or polymeric feeds are unsuitable Severe malabsorption Short bowel syndrome Intractable diarrhoea Biliary atresia Cholestatic liver diseases causing malabsorption Cystic fibrosis Proven fat malabsorption Severe intestinal motility disorders causing significant malabsorption Intestinal failure The patient is currently receiving funded amino acid formula The patient is to be trialled on, or transitioned to, an enteral liquid peptide formula A semi-elemental or partially hydrolysed powdered feed has been reasonably trialled and considered unsuitable For step down from intravenous nutrition medical practitioner

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

 An assessment as to whether the patient can be transitioned to a cows milk protein or soy infant formula or extensively hydrolysed formula has been undertaken The outcome of the assessment is that the patient continues to require an enteral liquid peptide formula medical practitioner Amino acid formula <range>Amino acid formula</range> Extensively hydrolysed formula has been reasonably trialled for 2-4 weeks and is inappropriate due to documented severe intolerance or allergy or malabsorption History of anaphylaxis to cows' milk protein formula or dairy products Eosinophilic oesophagitis Ultra-short gut Severe Immune deficiency medical practitioner An assessment as to whether the infant can be transitioned to a cows' milk protein, soy, or extensively hydrolysed infant formula has been undertaken The outcome of the assessment is that the infant continues to require an amino acid infant formula Amino acid formula is required for a nutritional deficit medical practitioner Patient has a valid initiation or renewal approval for extensively hydrolysed formula (RS1502) Patient is unable to source funded Aptamil powder at this time The approval only applies to funded dispensings of Neocate Gold and Neocate Syneo medical practitioner 3

This criteria is short term funding to cover an out-of-stock situation on some extensively hydrolysed formula powder funded under Hospital Restriction RS1502. There is no continuation criteria under this criterion.

 Ketogenic Diet Products High fat formula <range>High fat formula</range> For patients with intractable epilepsy, pyruvate dehydrogenase deficiency or glucose transported type-1 deficiency and other conditions requiring a ketogenic diet medical practitioner Paediatric Products <range>Paediatric Products</range> Child is aged one to ten years The child is being fed via a tube or a tube is to be inserted for the purposes of feeding Any condition causing malabsorption Faltering growth in an infant/child Increased nutritional requirements The child is being transitioned from TPN or tube feeding to oral feeding The child has eaten, or is expected to eat, little or nothing for 3 days medical practitioner Renal Products Low electrolyte oral feed <range>Low electrolyte oral feed</range> For children (up to 18 years) with acute or chronic kidney disease medical practitioner 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, 220 ml bottle Nepro HP (strawberry) 1 3.31 Nepro HP (vanilla) 1 3.31 Low electrolyte oral feed 2 kcal/ml <range>Low electrolyte oral feed</range> For patients with acute or chronic kidney disease medical practitioner Surgical Products Preoperative carbohydrate feed 0.5 kcal/ml <range>Preoperative carbohydrate feed 0.5 kcal/ml</range> Maximum of 400 ml as part of an Enhanced Recovery After Surgery (ERAS) protocol 2 to 3 hours before major abdominal surgery medical practitioner High arginine oral feed 1.4 kcal/ml <range>High arginine oral feed 1.4 kcal/ml</range> Three packs per day for 5 to 7 days prior to major gastrointestinal, head or neck surgery medical practitioner Standard Feeds <range>Standard Feeds</range> For patients with malnutrition, defined as any of the following: BMI < 18.5 Greater than 10% weight loss in the last 3-6 months BMI < 20 with greater than 5% weight loss in the last 3-6 months For patients who have, or are expected to, eat little or nothing for 5 days For patients who have a poor absorptive capacity and/or high nutrient losses and/or increased nutritional needs from causes such as catabolism For use pre- and post-surgery For patients being tube-fed For tube-feeding as a transition from intravenous nutrition For any other condition that meets the community Special Authority criteria medical practitioner Vaccines Bacterial and Viral Vaccines Bacterial and Viral Vaccines Diphtheria, tetanus, pertussis and polio vaccine <range>Diphtheria, tetanus, pertussis and polio vaccine</range> A single dose for children up to the age of 7 who have completed primary immunisation 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 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 Five doses will be funded for children requiring solid organ transplantation medical practitioner

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 <range>Diphtheria, tetanus, pertussis, polio, hepatitis B and haemophilus influenzae type B vaccine</range> Up to four doses for children under the age of 10 years for primary immunisation An additional four doses (as appropriate) for (re-)immunisation of children under the age of 18 years post haematopoietic stem cell transplantation An additional four doses (as appropriate) for (re-)immunisation of children under the age of 10 years who are post chemotherapy; pre or post splenectomy; undergoing renal dialysis and other severely immunosuppressive regimens Up to five doses for children under the age of 10 years receiving solid organ transplantation medical practitioner

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 <range>Bacillus calmette-guerin vaccine</range> For infants at increased risk of tuberculosis defined as: Living in a house or family with a person with current or past history of TB 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 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 medical practitioner

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

 Diphtheria, tetanus and pertussis vaccine <range>Diphtheria, tetanus and pertussis vaccine</range> A single dose for pregnant women in the second or third trimester of each pregnancy; or A single dose for parents or primary caregivers of infants admitted to a Neonatal Intensive Care Unit or Specialist Care Baby Unit for more than 3 days, who had not been exposed to maternal vaccination at least 14 days prior to birth; or A course of up to four doses is funded for children from age 7 up the age of 18 years inclusive to complete full primary immunisation 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 A single dose for vaccination of patients aged from 65 years old A single dose for vaccination of patients aged from 45 years old who have not had 4 previous tetanus doses For vaccination of previously unimmunised or partially immunised patients For revaccination following immunosuppression For boosting of patients with tetanus-prone wounds medical practitioner

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

 Haemophilus influenzae type B vaccine <range>Haemophilus influenzae type B vaccine</range> For primary vaccination in children An additional dose (as appropriate) is funded for (re-)immunisation for patients post haematopoietic stem cell transplantation, or chemotherapy; functional asplenic; pre or post splenectomy; pre- or post solid organ transplant, pre- or post cochlear implants, renal dialysis and other severely immunosuppressive regimens For use in testing for primary immunodeficiency diseases, on the recommendation of an internal medicine physician or paediatrician medical practitioner 1 Meningococcal (A, C, Y and W-135) conjugate vaccine Inj 10 mcg of each meningococcal polysaccharide conjugated to a total of approximately 55 mcg of tetanus toxoid carrier per 0.5 ml vial <range>Meningococcal (A, C, Y and W-135) conjugate vaccine</range> Up to three doses and a booster every five years for patients pre- and post splenectomy and for patients with HIV, complement deficiency (acquired or inherited), functional or anatomic asplenia or pre or post solid organ transplant One dose for close contacts of meningococcal cases of any group One dose for person who has previously had meningococcal disease of any group A maximum of two doses for bone marrow transplant patients A maximum of two doses for person pre and post-immunosuppression* Person is aged between 13 and 25 years, inclusive One dose for individuals who are entering within the next three months, or in their first year of living in boarding school hostels, tertiary education halls of residence, military barracks, or prisons One dose for individuals who turn 13 years of age while living in boarding school hostels medical practitioner

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.

 Inj 5 mcg of each meningococcal polysaccharide conjugated to a total of approximately 44 mcg of tetanus toxoid carrier in 0.5 ml vial <range>Meningococcal (A, C, Y and W-135) conjugate vaccine</range> A maximum of three doses (dependant on age at first dose) 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 A maximum of three doses (dependant on age at first dose) for close contacts of meningococcal cases of any group A maximum of three doses (dependant on age at first dose) for child who has previously had meningococcal disease of any group A maximum of three doses (dependant on age at first dose) for bone marrow transplant patients A maximum of three doses (dependant on age at first dose) for child pre- and post-immunosuppression* medical practitioner

infants from 6 weeks to less than 6 months of age require a 2+1 schedule, infants from 6 months to less than 12 months of age require a 1+1 schedule. Refer to the Immunisation Handbook for recommended booster schedules with meningococcal ACWY vaccine.

*Immunosuppression due to steroid or other immunosuppressive therapy must be for a period of greater than 28 days.

 Pneumococcal (PCV13) conjugate vaccine <range>Pneumococcal (PCV13) conjugate vaccine</range> A primary course of three doses for previously unvaccinated children up to the age of 59 months inclusive medical practitioner 3 Two doses are funded for high risk individuals (over the age of 12 months and under 18 years) who have previously received two doses of the primary course of PCV10 medical practitioner 2 Up to an additional four doses (as appropriate) are funded for the (re)immunisation of high-risk children aged under 5 years on immunosuppressive therapy or radiation therapy, vaccinate when there is expected to be a sufficient immune response primary immune deficiencies HIV infection renal failure, or nephrotic syndrome are immune-suppressed following organ transplantation (including haematopoietic stem cell transplant) cochlear implants or intracranial shunts cerebrospinal fluid leaks receiving corticosteroid therapy for more than two weeks, and who are on an equivalent daily dosage of prednisone of 2 mg/kg per day or greater, or children who weigh more than 10 kg on a total daily dosage of 20 mg or greater chronic pulmonary disease (including asthma treated with high-dose corticosteroid therapy) pre term infants, born before 28 weeks gestation cardiac disease, with cyanosis or failure diabetes Down syndrome who are pre-or post-splenectomy, or with functional asplenia medical practitioner 4 Up to an additional four doses (as appropriate) are funded for the (re-)immunisation of individuals 5 years and over with HIV, pre or post haematopoietic stem cell transplantation, or chemotherapy; pre- or post splenectomy; functional asplenia, pre- or post- solid organ transplant, renal dialysis, complement deficiency (acquired or inherited), cochlear implants, intracranial shunts, cerebrospinal fluid leaks or primary immunodeficiency medical practitioner 4 For use in testing for primary immunodeficiency diseases, on the recommendation of an internal medicine physician or paediatrician medical practitioner

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

 Pneumococcal (PPV23) polysaccharide vaccine <range>Pneumococcal (PPV23) polysaccharide vaccine</range> For patients with HIV, for patients post haematopoietic stem cell transplant, or chemotherapy; pre- or post-splenectomy; or with functional asplenia, pre- or post-solid organ transplant, renal dialysis, complement deficiency (acquired or inherited), cochlear implants, or primary immunodeficiency medical practitioner 3 Patient is a child under 18 years for (re-)immunisation On immunosuppressive therapy or radiation therapy, vaccinate when there is expected to be a sufficient immune response With primary immune deficiencies With HIV infection With renal failure, or nephrotic syndrome Who are immune-suppressed following organ transplantation (including haematopoietic stem cell transplant) With cochlear implants or intracranial shunts With cerebrospinal fluid leaks Receiving corticosteroid therapy for more than two weeks, and who are on an equivalent daily dosage of prednisone of 2 mg/kg per day or greater, or children who weigh more than 10 kg on a total daily dosage of 20 mg or greater With chronic pulmonary disease (including asthma treated with high-dose corticosteroid therapy) Pre term infants, born before 28 weeks gestation With cardiac disease, with cyanosis or failure With diabetes With Down syndrome Who are pre-or post-splenectomy, or with functional asplenia medical practitioner 2 For use in testing for primary immunodeficiency diseases, on the recommendation of an internal medicine physician or paediatrician medical practitioner Salmonella typhi vaccine <range>Salmonella typhi vaccine</range> For use during typhoid fever outbreaks medical practitioner Meningococcal B multicomponent vaccine <range>Meningococcal B multicomponent vaccine</range> A primary course of up to three doses (dependent on age at first dose) for previously unvaccinated children up to the age of 59 months inclusive medical practitioner 3 Person is aged at least 5 years Up to two doses and a booster every five years for patients pre- and post-splenectomy Up to two doses and a booster every five years for patients with functional or anatomic asplenia, HIV, complement deficiency (acquired or inherited) Up to two doses and a booster every five years pre- or post-solid organ transplant Up to two doses for close contacts of meningococcal cases of any group Up to two doses for person who has previously had meningococcal disease of any group Up to two doses for bone marrow transplant patients Up to two doses for person pre- and post-immunosuppression* medical practitioner Person is aged between 13 and 25 years (inclusive) Two doses for individuals who are entering within the next three months, or in their first year of living in boarding school hostels, tertiary education halls of residence, military barracks, Youth Justice residences, or prisons Two doses for individuals who turn 13 years of age while living in boarding school hostels medical practitioner 2

*Immunosuppression due to corticosteroid or other immunosuppressive therapy must be for a period of greater than 28 days.

 Viral Vaccines Viral Vaccines Hepatitis A vaccine <range>Hepatitis A vaccine</range> Two vaccinations for use in transplant patients Two vaccinations for use in children with chronic liver disease One dose of vaccine for close contacts of known hepatitis A cases medical practitioner Hepatitis B recombinant vaccine Inj 20 mcg per 1 ml prefilled syringe <range>Hepatitis B recombinant vaccine</range> For household or sexual contacts of known acute hepatitis B patients or hepatitis B carriers For children born to mothers who are hepatitis B surface antigen (HBsAg) positive 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 require a primary course of vaccination For HIV positive patients For hepatitis C positive patients For patients following non-consensual sexual intercourse For patients prior to planned immunosuppression for greater than 28 days For patients following immunosuppression For solid organ transplant patients For post-haematopoietic stem cell transplant (HSCT) patients Following needle stick injury For chronic kidney disease (CKD) stage 4 or 5 patients For liver or kidney transplant patients medical practitioner Inj 10 mcg per 0.5 ml prefilled syringe <range>Hepatitis B recombinant vaccine</range> For household or sexual contacts of known acute hepatitis B patients or hepatitis B carriers For children born to mothers who are hepatitis B surface antigen (HBsAg) positive 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 require a primary course of vaccination For HIV positive patients For hepatitis C positive patients For patients following non-consensual sexual intercourse For patients prior to planned immunosuppression for greater than 28 days For patients following immunosuppression For solid organ transplant patients For post-haematopoietic stem cell transplant (HSCT) patients Following needle stick injury medical practitioner Influenza vaccine Inj 60 mcg in 0.5 ml syringe (quadrivalent vaccine) <range>Influenza vaccine Inj 60 mcg in 0.5 ml syringe (quadrivalent vaccine)</range> The patient is 65 years of age or over medical practitioner Ischaemic heart disease Congestive heart failure Rheumatic heart disease Congenital heart disease Cerebro-vascular disease medical practitioner

hypertension and/or dyslipidaemia without evidence of end-organ disease is excluded from funding.

 Asthma, if on a regular preventative therapy Other chronic respiratory disease with impaired lung function medical practitioner

asthma not requiring regular preventative therapy is excluded from funding.

 Diabetes chronic renal disease Any cancer, excluding basal and squamous skin cancers if not invasive Autoimmune disease Immune suppression or immune deficiency HIV Transplant recipient Neuromuscular and CNS diseases/ disorders Haemoglobinopathies Is a child on long term aspirin Has a cochlear implant Errors of metabolism at risk of major metabolic decompensation Pre and post splenectomy Down syndrome Is pregnant Is a child 4 years of age or under (inclusive) who has been hospitalised for respiratory illness or has a history of significant respiratory illness Patients in a long-stay inpatient mental health care unit or who are compulsorily detained long-term in a forensic unit within a Public Hospital medical practitioner schizophrenia major depressive disorder bipolar disorder schizoaffective disorder person is currently accessing secondary or tertiary mental health and addiction services medical practitioner Measles, mumps and rubella vaccine <range>Measles, mumps and rubella vaccine</range> For primary vaccination in children For revaccination following immunosuppression For any individual susceptible to measles, mumps or rubella medical practitioner 3 For primary vaccination in children For revaccination following immunosuppression For any individual susceptible to measles, mumps or rubella medical practitioner 2

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

 Poliomyelitis vaccine <range>Poliomyelitis vaccine</range> For partially vaccinated or previously unvaccinated individuals For revaccination following immunosuppression medical practitioner 3

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 [Chickenpox vaccine] Inj 2000 PFU prefilled syringe plus vial <range>Varicella vaccine [Chickenpox vaccine]</range> Any infant born on or after 1 April 2016 For previously unvaccinated children turning 11 years old on or after 1 July 2017, who have not previously had a varicella infection (chickenpox) medical practitioner 1 for non-immune patients: With chronic liver disease who may in future be candidates for transplantation With deteriorating renal function before transplantation Prior to solid organ transplant Prior to any elective immunosuppression* For post exposure prophylaxis who are immune competent inpatients For patients at least 2 years after bone marrow transplantation, on advice of their specialist For patients at least 6 months after completion of chemotherapy, on advice of their specialist For HIV positive patients non immune to varicella with mild or moderate immunosuppression on advice of HIV specialist For patients with inborn errors of metabolism at risk of major metabolic decompensation, with no clinical history of varicella 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 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 medical practitioner 2

* immunosuppression due to steroid or other immunosuppressive therapy must be for a treatment period of greater than 28 days

 Human papillomavirus (6, 11, 16, 18, 31, 33, 45, 52 and 58) vaccine [HPV] <range>Human papillomavirus (6, 11, 16, 18, 31, 33, 45, 52 and 58) vaccine [HPV]</range> Children aged 14 years and under medical practitioner 2 Up to 3 doses for people aged 15 to 26 years inclusive People aged 9 to 26 years inclusive Up to 3 doses for confirmed HIV infection Up to 3 doses people with a transplant (including stem cell) Up to 4 doses for Post chemotherapy medical practitioner Maximum of two doses for children aged 14 years and under Maximum of three doses for people aged 15 years and over The person has recurrent respiratory papillomatosis The person has not previously had an HPV vaccine medical practitioner Rotavirus oral vaccine <range>Rotavirus oral vaccine</range> First dose to be administered in infants aged under 14 weeks of age No vaccination being administered to children aged 24 weeks or over medical practitioner 2 Varicella zoster vaccine [Shingles vaccine] <range>Varicella zoster vaccine [shingles vaccine]</range> Pre- and post-haematopoietic stem cell transplant or cellular therapy Pre- or post-solid organ transplant Haematological malignancies People living with poorly controlled HIV infection Planned or receiving disease modifying anti-rheumatic drugs (DMARDs – targeted synthetic, biologic, or conventional synthetic) for polymyalgia rheumatica, systemic lupus erythematosus or rheumatoid arthritis End stage kidney disease (CKD 4 or 5); Primary immunodeficiency medical practitioner 2 COVID-19 vaccine Inj 3 mcg bretovameran per 0.3 ml, 0.48 ml vial; infant vaccine, yellow cap <range>COVID-19 vaccine</range> Up to three doses for previously unvaccinated children aged 6 months – 4 years at high risk of severe illness or highly immunocompromised medical practitioner One additional dose with the most current variant-matched vaccine every 6 months for highly immunocompromised children aged 6 months to 4 years One additional dose with the most current variant-matched vaccine every 12 months for children aged 6 months to 4 years old at high risk of severe illness medical practitioner Inj 10 mcg bretovameran per 0.3 ml, 0.48 ml vial; paediatric vaccine, light blue cap <range>COVID-19 vaccine</range> One dose for previously unvaccinated children aged 5-11 years old Up to three doses for immunocompromised children aged 5-11 years old medical practitioner One additional dose with the most current variant-matched vaccine every 6 months for highly immunocompromised children aged 5 to 11 years old One additional dose with the most current variant-matched vaccine up to every 12 months for children aged 5 to 11 years old at high-risk of severe illness medical practitioner Inj 30 mcg bretovameran per 0.3 ml, 0.48 ml vial; adult vaccine, light grey cap <range>COVID-19 vaccine</range> One dose for previously unvaccinated people aged 12-15 years and over 30 years old Two doses for previously unvaccinated people aged 16-29 years old Up to three doses for previously unvaccinated immunocompromised people from 12 years old Up to four doses for people at risk of severe illness aged from 12-29 years medical practitioner One additional dose with the most current variant-matched vaccine every 6 months, additional dose to be given at least 6 months after last dose Previously vaccinated people aged 30 years and over Previously vaccinated immunocompromised people from 12 years Previously vaccinated people at high-risk of severe illness from 12 years medical practitioner Inj 3 mcg SARS-CoV-2 spike protein (mRNA) LP.8.1 per 0.3 ml, 0.48 ml multi-dose vial; infant vaccine, yellow cap <range>COVID-19 vaccine</range> Up to three doses for previously unvaccinated children aged 6 months – 4 years at high risk of severe illness or highly immunocompromised medical practitioner One additional dose with the most current variant-matched vaccine every 6 months for highly immunocompromised children aged 6 months to 4 years One additional dose with the most current variant-matched vaccine every 12 months for children aged 6 months to 4 years old at high risk of severe illness medical practitioner Inj 10 mcg SARS-CoV-2 spike protein (mRNA) LP.8.1 per 0.3 ml, 0.48 ml single-dose vial; paediatric vaccine, light blue cap <range>COVID-19 vaccine</range> One dose for previously unvaccinated children aged 5-11 years old Up to three doses for immunocompromised children aged 5-11 years old medical practitioner One additional dose with the most current variant-matched vaccine every 6 months for highly immunocompromised children aged 5 to 11 years old One additional dose with the most current variant-matched vaccine up to every 12 months for children aged 5 to 11 years old at high-risk of severe illness medical practitioner Inj 30 mcg SARS-CoV-2 spike protein (mRNA) LP.8.1 per 0.3 ml, pre-filled syringe; adult dose <range>COVID-19 vaccine</range> One dose for previously unvaccinated people aged 12-15 years and over 30 years old Two doses for previously unvaccinated people aged 16-29 years old Up to three doses for previously unvaccinated immunocompromised people from 12 years old Up to four doses for people at risk of severe illness aged from 12-29 years medical practitioner One additional dose with the most current variant-matched vaccine every 6 months, additional dose to be given at least 6 months after last dose Previously vaccinated people aged 30 years and over Previously vaccinated immunocompromised people from 12 years Previously vaccinated people at high-risk of severe illness from 12 years medical practitioner Diagnostic Agents Diagnostic Agents Tuberculin PPD [Mantoux] test Inj 5 TU per 0.1 ml, 1 ml vial Tubersol 1 0.00 Part III - OPTIONAL PHARMACEUTICALS Optional Pharmaceuticals

NOTE:

In addition to the products expressly listed here in Part III: Optional Pharmaceuticals, a range of hospital medical devices are listed in an addendum to Part III which is available at schedule.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.

Optional Pharmaceuticals Pregnancy test - hCG urine Cassette David One Step Cassette Pregnancy Test 40 16.00 Blood ketone diagnostic test strip Test strips KetoSens 10 15.50 Dual blood glucose and blood ketone diagnostic test meter Meter with 50 lancets, a lancing device, and 10 blood glucose diagnostic test strips CareSens Dual 1 20.00 Beta-hCG low sensitivity urine test kit

Note: For use in abortion services only.

Midstream CheckTop 1 16.28 Blood glucose diagnostic test strip Blood glucose test strips CareSens N 50 10.56 Test strips CareSens PRO 50 10.56 Blood glucose diagnostic test meter 1 meter with 50 lancets, a lancing device, and 10 diagnostic test strips Caresens N 1 10.00 Caresens N POP 1 10.00 CareSens N Premier 1 20.00 Spacer device 800 ml Volumatic 1 6.50 220 ml (single patient) e-chamber Turbo 1 3.65 510 ml (single patient) e-chamber La Grande 1 5.95 Mask for spacer device Small e-chamber Mask 1 2.70 Peak flow meter Low Range Mini-Wright AFS Low Range 1 9.54 Normal Range Mini-Wright Standard 1 9.54 Sodium nitroprusside Test strip Ketostix 50 22.00