Pharmaceutical Schedule

Community Pharmaceuticals Alimentary Tract and Metabolism Antacids and Antiflatulents Antacids and Reflux Barrier Agents Alginic acid Sodium alginate 225 mg and magnesium alginate 87.5 mg per sachet Gaviscon Infant 30 8.06 8.06 8.06 0.00000 Sodium alginate Oral liq 500 mg with sodium bicarbonate 267 mg and calcium carbonate 160 mg per 10 ml Acidex 500 1.50 7.50 1.50 0.01200 Tab 500 mg with sodium bicarbonate 267 mg and calcium carbonate 160 mg - peppermint flavour Gaviscon Extra Strength 60 1.80 17.99 1.80 0.26983 Phosphate Binding Agents Aluminium hydroxide Tab 600 mg Alu-Tab 100 12.56 12.56 12.56 0.00000 Calcium carbonate Oral liq 1,250 mg per 5 ml (500 mg elemental per 5 ml)

Only when prescribed for patients unable to swallow calcium carbonate tablets or where calcium carbonate tablets are inappropriate and the prescription is endorsed accordingly.

Roxane 500 39.00 39.00 39.00 0.00000 Calcium carbonate PAI 473 47.30 47.30 47.30 0.00000 Antidiarrhoeals Agents Which Reduce Motility Loperamide hydrochloride Cap 2 mg Diamide Relief 400 12.00 12.00 12.00 0.00000 Tab 2 mg Nodia 400 10.75 10.75 10.75 0.00000 Rectal and Colonic Anti-inflammatories Budesonide Cap modified-release 3 mg <range>Budesonide - Cap 3 mg Controlled Release</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)

any relevant practitioner

Patient has a diagnosis of microscopic colitis
        (collagenous or lymphocytic colitis) by colonoscopy with biopsies

any relevant practitioner

Patient has a gut Graft versus Host disease following
        allogenic bone marrow transplantation*

any relevant practitioner 6

Indication marked with * is an unapproved indication.

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)

any relevant practitioner 6

Indication marked with * is an unapproved indication.

The treatment remains appropriate and the patient is
        benefiting from treatment

any relevant practitioner 6

The treatment remains appropriate and the patient is
        benefiting from treatment

any relevant practitioner 6 Budesonide Te Arai 90 33.38 33.38 33.38 0.00000 Hydrocortisone acetate Rectal foam 10%, CFC-Free (14 applications) Colifoam 15 57.09 57.09 57.09 0.00000 Sodium cromoglicate Cap 100 mg Nalcrom 20 44.50 44.50 44.50 0.00000 Ralicrom 100 113.35 113.35 113.35 0.00000 Somex 100 365.00 365.00 365.00 0.00000 Allergoval 100 125.70 125.70 125.70 0.00000 Sulfasalazine Tab 500 mg Salazopyrin 100 19.49 19.49 19.49 0.00000 Tab EC 500 mg Salazopyrin EN 100 20.54 20.54 20.54 0.00000 Olsalazine Cap 250 mg Dipentum 100 53.00 53.00 53.00 0.00000 Tab 500 mg Dipentum 100 93.37 93.37 93.37 0.00000 Atnahs Olsalazine 60 56.02 56.02 56.02 0.00000 Mesalazine Tab long-acting 500 mg Pentasa 100 56.10 56.10 56.10 0.00000 Enema 1 g per 100 ml Pentasa 7 41.30 41.30 41.30 0.00000 Tab 400 mg Asacol 100 49.50 49.50 49.50 0.00000 100 49.50 49.50 49.50 0.00000 Octasa 90 71.00 71.00 71.00 0.00000 Suppos 500 mg Asacol 20 22.80 22.80 22.80 0.00000 20 22.80 22.80 22.80 0.00000 Suppos 1 g Pentasa 28 50.96 50.96 50.96 0.00000 Modified release granules, 1 g Pentasa 100 118.10 118.10 118.10 0.00000 Tab 800 mg Asacol 90 85.50 85.50 85.50 0.00000 90 85.50 85.50 85.50 0.00000 Asacol S29 90 85.50 85.50 85.50 0.00000 Tab 1,600 mg Asacol 60 85.50 85.50 85.50 0.00000 Hydrocortisone acetate with pramoxine hydrochloride Topical aerosol foam, 1% with pramoxine hydrochloride 1% Proctofoam 10 26.55 26.55 26.55 0.00000 Local preparations for Anal and Rectal Disorders Antihaemorrhoidal Preparations Fluocortolone caproate with fluocortolone pivalate and cinchocaine Suppos 630 mcg, with fluocortolone pivalate 610 mcg, and cinchocaine hydrochloride 1 mg Ultraproct 12 8.61 8.61 8.61 0.00000 Oint 950 mcg, with fluocortolone pivalate 920 mcg, and cinchocaine hydrochloride 5 mg per g Ultraproct 30 13.05 13.05 13.05 0.00000 Hydrocortisone with cinchocaine Oint 5 mg with cinchocaine hydrochloride 5 mg per g Proctosedyl 30 15.00 15.00 15.00 0.00000 Suppos 5 mg with cinchocaine hydrochloride 5 mg per g Proctosedyl 12 9.90 9.90 9.90 0.00000 Prednisolone hexanoate with cinchocaine hydrochloride Suppos 1.3 mg with cinchocaine hydrochloride 1 mg per g Scheriproct 12 8.61 8.61 8.61 0.00000 Management of Anal Fissures Glyceryl trinitrate <range>Glyceryl trinitrate Oint 0.2%</range>

the patient has a chronic anal fissure that has persisted for longer than three weeks

any relevant practitioner Oint 0.2% Rectogesic 30 22.00 22.00 22.00 0.00000 Antispasmodics and Other Agents Altering Gut Motility Antispasmodics and Other Agents Altering Gut Motility Hyoscine butylbromide Tab 10 mg Hyoscine Butylbromide (Adiramedica) 20 2.25 2.25 2.25 0.00000 Inj 20 mg, 1 ml Spazmol 5 1 1.91 1.91 1.91 0.00000 Mebeverine hydrochloride Tab 135 mg Colofac 90 8.50 8.50 8.50 0.00000 Glycopyrronium bromide Inj 200 mcg per ml, 1 ml ampoule Robinul 5 1 19.00 19.00 19.00 0.00000 Glycopyrronium-AFT 10 11.99 11.99 11.99 0.00000 Antiulcerants Antisecretory and Cytoprotective Misoprostol Tab 200 mcg Cytotec 120 47.73 47.73 47.73 0.00000 Helicobacter Pylori Eradication Clarithromycin Tab 500 mg

Subsidised only if prescribed for helicobacter pylori eradication and prescription is endorsed accordingly.

Note: the prescription is considered endorsed if clarithromycin is prescribed in conjunction with a proton pump inhibitor and either amoxicillin or metronidazole.

Klacid 14 14.58 14.58 14.58 0.00000 H2 Antagonists Famotidine Tab 20 mg Famotidine Hovid 100 4.86 4.86 4.86 0.00000 Tab 40 mg Famotidine Hovid MY 100 10.27 10.27 10.27 0.00000 Inj 10 mg per ml, 4 ml

Subsidy by endorsement – Subsidised for patients receiving treatment as part of palliative care.

Mylan 10 1 Proton Pump Inhibitors Lansoprazole Cap 30 mg Lanzol Relief 100 5.43 5.43 5.43 0.00000 Cap 15 mg Lanzol Relief 100 4.04 4.04 4.04 0.00000 30 1.21 1.21 1.21 0.00000 Pantoprazole Tab EC 40 mg Panzop Relief 90 2.70 2.70 2.70 0.00000 Tab EC 20 mg Panzop Relief 90 1.81 1.81 1.81 0.00000 Omeprazole

For omeprazole suspension refer Standard Formulae

Cap 20 mg Omeprazole actavis 20 90 2.02 2.02 2.02 0.00000 Omeprazole Teva 90 2.02 2.02 2.02 0.00000 Inj 40 mg ampoule with diluent Dr Reddy's Omeprazole 5 1 37.38 37.38 37.38 0.00000 Ocicure 5 1 37.38 37.38 37.38 0.00000 Cap 10 mg Omeprazole actavis 10 90 2.06 2.06 2.06 0.00000 Omeprazole Teva 90 2.06 2.06 2.06 0.00000 Cap 40 mg Omeprazole actavis 40 90 3.18 3.18 3.18 0.00000 Omeprazole Teva 90 3.18 3.18 3.18 0.00000 Powder

Only in extemporaneously compounded omeprazole suspension.

Midwest 5 52.00 52.00 52.00 0.00000 Site Protective Agents Sucralfate Tab 1 g Carafate 120 35.50 48.28 35.50 0.10650 Colloidal bismuth subcitrate Tab 120 mg Gastrodenol 50 14.51 14.51 14.51 0.00000 Bile and Liver Therapy Bile and Liver Therapy Rifaximin <range>Rifaximin</range>

The patient has hepatic encephalopathy despite an adequate trial of maximum tolerated doses of lactulose

gastroenterologist hepatologist Practitioner 6

The treatment remains appropriate and the patient is benefiting from treatment

gastroenterologist hepatologist Practitioner Tab 550 mg Xifaxan 56 625.00 625.00 625.00 0.00000 Diabetes Hyperglycaemic Agents Glucagon hydrochloride Inj 1 mg syringe kit Glucagen Hypokit 1 32.00 32.00 32.00 0.00000 Diazoxide <range>Diazoxide</range>

used for the treatment of confirmed hypoglycaemia caused by hyperinsulinism

any relevant practitioner 12

The treatment remains appropriate and the patient is benefiting from treatment

any relevant practitioner Cap 100 mg Proglicem 100 280.00 280.00 280.00 0.00000 Cap 25 mg Proglicem 100 110.00 110.00 110.00 0.00000 Oral liq 50 mg per ml e5 Pharma 30 620.00 620.00 620.00 0.00000 Insulin - Short-acting Preparations Insulin neutral Inj human 100 u per ml, 3 ml Actrapid Penfill 5 1 42.66 42.66 42.66 0.00000 Humulin R 5 1 42.66 42.66 42.66 0.00000 Inj human 100 u per ml, 10 ml vial Actrapid 1 25.26 25.26 25.26 0.00000 Humulin R 1 25.26 25.26 25.26 0.00000 Insulin - Intermediate-acting Preparations Insulin isophane Inj human 100 u per ml, 3 ml Protaphane Penfill 5 1 29.86 29.86 29.86 0.00000 Humulin NPH 5 1 29.86 29.86 29.86 0.00000 Inj human 100 u per ml, 10 ml vial Humulin NPH 1 17.68 17.68 17.68 0.00000 Protaphane 1 17.68 17.68 17.68 0.00000 Insulin lispro with insulin lispro protamine Inj lispro 25% with insulin lispro protamine 75% 100 u per ml, 3 ml Humalog Mix 25 5 1 42.66 42.66 42.66 0.00000 Inj lispro 50% with insulin lispro protamine 50% 100 u per ml, 3 ml Humalog Mix 50 5 1 42.66 42.66 42.66 0.00000 Insulin aspart with insulin aspart protamine Inj 100 iu per ml, 3 ml prefilled pen NovoMix 30 FlexPen 5 1 52.15 52.15 52.15 0.00000 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 80.00 80.00 0.00000 Insulin isophane with insulin neutral Inj human with neutral insulin 100 u per ml, 3 ml Humulin 30/70 5 1 42.66 42.66 42.66 0.00000 Inj human with neutral insulin 100 u per ml, 10 ml vial Humulin 30/70 1 25.26 25.26 25.26 0.00000 Insulin - Long-acting Preparations Insulin glargine Inj 100 u per ml, 3 ml Lantus 5 1 94.50 94.50 94.50 0.00000 Inj 100 u per ml, 10 ml Lantus 1 1 63.00 63.00 63.00 0.00000 Inj 100 u per ml, 3 ml disposable pen Lantus SoloStar 5 1 94.50 94.50 94.50 0.00000 Insulin - Rapid Acting Preparations Insulin lispro Inj 100 u per ml, 3 ml Humalog 5 1 59.52 59.52 59.52 0.00000 Inj 100 u per ml, 10 ml vial Humalog 1 34.92 34.92 34.92 0.00000 Insulin aspart Inj 100 u per ml, 3 ml NovoRapid Penfill 5 1 51.19 51.19 51.19 0.00000 Inj 100 u per ml, 10 ml NovoRapid 1 1 30.03 30.03 30.03 0.00000 Inj 100 u per ml, 3 ml syringe NovoRapid FlexPen 5 1 51.19 51.19 51.19 0.00000 Insulin glulisine Inj 100 u per ml, 10 ml Apidra 1 1 27.03 27.03 27.03 0.00000 Inj 100 u per ml, 3 ml disposable pen Apidra SoloStar 5 1 46.07 46.07 46.07 0.00000 Inj 100 u per ml, 3 ml Apidra 5 1 46.07 46.07 46.07 0.00000 Alpha Glucosidase Inhibitors Acarbose Tab 50 mg Accarb 90 11.20 11.20 11.20 0.00000 Tab 100 mg Accarb 90 17.38 17.38 17.38 0.00000 Oral Hypoglycaemic Agents Glibenclamide Tab 5 mg Daonil 100 7.50 7.50 7.50 0.00000 Gliclazide Tab 80 mg Glizide 500 20.10 20.10 20.10 0.00000 Glipizide Tab 5 mg Minidiab 100 6.86 6.86 6.86 0.00000 Metformin hydrochloride Tab immediate-release 500 mg Metformin Viatris 1000 14.74 14.74 14.74 0.00000 Tab immediate-release 850 mg Metformin Viatris 500 11.28 11.28 11.28 0.00000 Pioglitazone Tab 15 mg Vexazone 90 6.15 6.15 6.15 0.00000 Tab 30 mg Vexazone 90 7.25 7.25 7.25 0.00000 Tab 45 mg Vexazone 90 12.00 12.00 12.00 0.00000 Vildagliptin Tab 50 mg Galvus 60 35.00 35.00 35.00 0.00000 Vildagliptin with metformin hydrochloride Tab 50 mg with 850 mg metformin hydrochloride Galvumet 60 35.00 35.00 35.00 0.00000 Tab 50 mg with 1,000 mg metformin hydrochloride Galvumet 60 35.00 35.00 35.00 0.00000 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>

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)*

any relevant practitioner

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

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.
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.
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.

Inj 1.5mg per 0.5 ml prefilled pen Trulicity 4 1 115.23 115.23 115.23 0.00000 Liraglutide

<range>Liraglutide</range>

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)*

any relevant practitioner

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

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.
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.
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.

Inj 6 mg per ml, 3 ml prefilled pen Victoza 3 1 383.72 383.72 383.72 0.00000 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

any relevant practitioner

Patient has previously received 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

any relevant practitioner

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

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.
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.
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.

Empagliflozin Tab 10 mg Jardiance 30 58.56 58.56 58.56 0.00000 Tab 25 mg Jardiance 30 58.56 58.56 58.56 0.00000 Empagliflozin with metformin hydrochloride Tab 5 mg with 500 mg metformin hydrochloride Jardiamet 60 58.56 58.56 58.56 0.00000 Tab 5 mg with 1,000 mg metformin hydrochloride Jardiamet 60 58.56 58.56 58.56 0.00000 Tab 12.5 mg with 500 mg metformin hydrochloride Jardiamet 60 58.56 58.56 58.56 0.00000 Tab 12.5 mg with 1,000 mg metformin hydrochloride Jardiamet 60 58.56 58.56 58.56 0.00000 Diabetes Management Ketone Testing Blood Ketone Diagnostic Test Strip

Patient has any of the following:

type 1 diabetes; or
permanent neonatal diabetes; or
undergone a pancreatectomy; or
cystic fibrosis-related diabetes; or
metabolic disease or epilepsy under the care of a paediatrician, neurologist or metabolic specialist.

The prescription must be endorsed accordingly.

Test strips KetoSens 10 15.50 15.50 15.50 0.00000 Dual Blood Glucose and Blood Ketone Testing Dual blood glucose and blood ketone diagnostic test meter

A dual blood glucose and blood ketone diagnostic test meter is subsidised for a patient who has:

type 1 diabetes; or
permanent neonatal diabetes; or
undergone a pancreatectomy; or
cystic fibrosis-related diabetes; or
metabolic disease or epilepsy under the care of a paediatrician, neurologist or metabolic specialist.

The prescription must be endorsed accordingly.

Only 1 meter per patient will be subsidised (no repeat prescriptions).

For the avoidance of doubt patients who have previously received a funded meter, other than CareSens, are eligible for a funded CareSens meter.

Meter with 50 lancets, a lancing device and 10 blood glucose diagnostic test strips CareSens Dual 1 20.00 20.00 20.00 0.00000 Blood Glucose Testing Blood glucose diagnostic test strip

The number of test strips available on a prescription is restricted to 50 unless:

Prescribed for a patient on insulin or a sulphonylurea and endorsed accordingly. Pharmacists may annotate the prescription as endorsed where there exists a record of prior dispensing of insulin or sulphonylurea; or
Prescribed on the same prescription as insulin or a sulphonylurea in which case the prescription is deemed to be endorsed; or
Prescribed for a pregnant woman with diabetes and endorsed accordingly; or
Prescribed for a patient on home TPN at risk of hypoglycaemia or hyperglycaemia and endorsed accordingly; or
Prescribed for a patient with a genetic or an acquired disorder of glucose homeostasis excluding type 1 or type 2 diabetes and metabolic syndrome and endorsed accordingly.

Test strips CareSens N 50 10.56 10.56 10.56 0.00000 CareSens PRO 50 10.56 10.56 10.56 0.00000 Blood glucose diagnostic test meter

A diagnostic blood glucose test meter is subsidised for a patient who:

is receiving insulin or sulphonylurea therapy; or
is pregnant with diabetes; or
is on home TPN at risk of hypoglycaemia or hyperglycaemia; or
has a genetic or an acquired disorder of glucose homeostasis, excluding type 1 or type 2 diabetes and metabolic syndrome.

The prescription must be endorsed accordingly.

Only one CareSens meter per patient will be subsidised (no repeat prescriptions).

Patients already using the CareSens N POP meter and CareSens N meter are not eligible for a new meter, unless they have:

type 1 diabetes; or
permanent neonatal diabetes; or
undergone a pancreatectomy; or
cystic fibrosis-related diabetes.

For the avoidance of doubt patients who have previously received a funded meter, other than CareSens, are eligible for a funded CareSens meter.

Meter with 50 lancets, a lancing device and 10 diagnostic test strips

Note: Only 1 meter available per PSO

CareSens N 1 10.00 10.00 10.00 0.00000 CareSens N POP 1 10.00 10.00 10.00 0.00000 CareSens N Premier 1 20.00 20.00 20.00 0.00000 Blood glucose test strips (visually impaired)

The number of test strips available on a prescription is restricted to 50 unless:

Prescribed for a patient on insulin or a sulphonylurea and endorsed accordingly. Pharmacists may annotate the prescription as endorsed where there exists a record of prior dispensing of insulin or sulphonylurea; or
Prescribed on the same prescription as insulin or a sulphonylurea in which case the prescription is deemed to be endorsed; or
Prescribed for a pregnant woman with diabetes and endorsed accordingly; or
Prescribed for a patient on home TPN at risk of hypoglycaemia or hyperglycaemia and endorsed accordingly; or
Prescribed for a patient with a genetic or an acquired disorder of glucose homeostasis excluding type 1 or type 2 diabetes and metabolic syndrome and endorsed accordingly.

Blood glucose test strips SensoCard 50 33.69 33.69 33.69 0.00000 Insulin Syringes and Needles

Subsidy is available for disposable insulin syringes, needles, and pen needles if prescribed on the same form as the one used for the supply of insulin or liraglutide or when prescribed for a patient and the prescription is endorsed accordingly. Pharmacists may annotate the prescription as endorsed where there exists a record of prior dispensing of insulin or liraglutide.

Insulin pen needles

Maximum of 200 dev per three months

29 g x 12.7 mm B-D Micro-Fine 100 10.95 10.95 10.95 0.00000 31 g x 8 mm B-D Micro-Fine 100 10.95 10.95 10.95 0.00000 31 g x 5 mm B-D Micro-Fine 100 12.26 12.26 12.26 0.00000 31 g x 6 mm Berpu 100 9.50 9.50 9.50 0.00000 32 g x 4 mm B-D Micro-Fine 100 10.95 10.95 10.95 0.00000 Insulin syringes, disposable with attached needle

Maximum of 200 dev per three months

Syringe 0.3 ml with 29 g x 12.7 mm needle B-D Ultra Fine 100 13.56 13.56 13.56 0.00000 10 1.36 1.99 1.36 0.06300 Syringe 0.5 ml with 29 g x 12.7 mm needle B-D Ultra Fine 100 13.56 13.56 13.56 0.00000 10 1.36 1.99 1.36 0.06300 Syringe 1 ml with 29 g x 12.7 mm needle B-D Ultra Fine 100 13.56 13.56 13.56 0.00000 10 1.36 1.99 1.36 0.06300 Syringe 0.3 ml with 31 g x 8 mm needle B-D Ultra Fine II 100 13.56 13.56 13.56 0.00000 10 1.30 1.99 1.30 0.06900 Syringe 0.5 ml with 31 g x 8 mm needle B-D Ultra Fine II 100 13.56 13.56 13.56 0.00000 10 1.36 1.99 1.36 0.06300 Syringe 1 ml with 31 g x 8 mm needle B-D Ultra Fine II 100 13.56 13.56 13.56 0.00000 10 1.36 1.99 1.36 0.06300 Insulin Pumps Insulin pump with algorithm

Maximum of 1 insulin pump per patient each four year period.

<range>Insulin pump with algorithm </range>

The patient has type 1 diabetes The patient has permanent neonatal
                        diabetes or specific monogenic diabetes subtypes with insulin deficiency,
                        considered by the treating endocrinologist as likely to benefit The patient has Type 3c diabetes
                        considered by the treating endocrinologist as likely to benefit (Type 3c
                        diabetes includes insulin deficiency due to pancreatectomy, insulin
                        deficiency secondary to cystic fibrosis or pancreatitis) The patient has atypical inherited forms
                        of diabetes Patient has been evaluated by a diabetes
                    multidisciplinary team for their suitability for insulin pump therapy In the opinion of the treating relevant
                    practitioner the patient would benefit from an Automated Insulin Delivery (AID)
                    system

any relevant practitioner 6 6

the patient is continuing to derive benefit
                    according to the treatment plan agreed at induction

any relevant practitioner 6 6 Min basal rate 0.1 U/h Tandem t:slim X2 with Basal-IQ 1 7653.00 7653.00 7653.00 0.00000 Tandem t:slim X2 with Control-IQ+ 1 7653.00 7653.00 7653.00 0.00000 Min basal rate 0.02 U/h mylife YpsoPump with CamAPS FX 1 8970.00 8970.00 8970.00 0.00000 Insulin Pump Consumables <range>Insulin Pump Consumables</range>

The patient has type 1 diabetes The patient has permanent neonatal
                        diabetes or specific monogenic diabetes subtypes with insulin deficiency,
                        considered by the treating endocrinologist as likely to benefit The patient has Type 3c diabetes
                        considered by the treating endocrinologist as likely to benefit (Type 3c
                        diabetes includes insulin deficiency due to pancreatectomy, insulin
                        deficiency secondary to cystic fibrosis or pancreatitis) The patient has atypical inherited forms
                        of diabetes Patient has been evaluated by a diabetes
                    multidisciplinary team for their suitability for insulin pump therapy In the opinion of the treating relevant
                    practitioner the patient would benefit from an Automated Insulin Delivery (AID)
                    system

any relevant practitioner Insulin pump infusion set (steel cannula)

Maximum of 19 infusion sets will be funded per year.

Maximum of 5 set per three months

6 mm steel needle; 60 cm tubing x 10 MiniMed Sure-T MMT-864A 1 219.00 219.00 219.00 0.00000 6 mm steel needle; 80 cm tubing x 10 MiniMed Sure-T MMT-866A 1 219.00 219.00 219.00 0.00000 8 mm steel needle; 60 cm tubing x 10 MiniMed Sure-T MMT-874A 1 219.00 219.00 219.00 0.00000 8 mm steel needle; 80 cm tubing x 10 MiniMed Sure-T MMT-876A 1 219.00 219.00 219.00 0.00000 Insulin pump reservoir

Maximum of 360 reservoirs will be funded per year.

Maximum of 90 cart per three months

10 x 1.6 ml glass reservoir for YpsoPump mylife YpsoPump Reservoir 10 50.00 50.00 50.00 0.00000 10 x luer lock conversion cartridges 1.8 ml for paradigm pumps ADR Cartridge 1.8 10 50.00 50.00 50.00 0.00000 Cartridge for 7 series pump; 3.0 ml x 10 MiniMed 3.0 Reservoir MMT-332A 10 98.00 98.00 98.00 0.00000 Cartridge for 7 series pump; 3.0 ml x 5 MiniMed 3.0 Ext Reservoir MDT-MMT-342G 5 102.00 102.00 102.00 0.00000 Insulin pump infusion set (teflon cannula, straight insertion with insertion device)

Maximum of 19 infusion sets will be funded per year.

Maximum of 5 sets per three months

6 mm teflon cannula; straight insertion; insertion device; 60 cm line x 10 with 10 needles AutoSoft 90 1 182.00 182.00 182.00 0.00000 6 mm teflon cannula; straight insertion; insertion device; 110 cm line x 10 with 10 needles AutoSoft 90 1 182.00 182.00 182.00 0.00000 9 mm teflon cannula; straight insertion; insertion device; 60 cm line x 10 with 10 needles AutoSoft 90 1 182.00 182.00 182.00 0.00000 9 mm teflon cannula; straight insertion; insertion device; 110 cm line x 10 with 10 needles AutoSoft 90 1 182.00 182.00 182.00 0.00000 Insulin pump infusion set (teflon cannula, angle insertion with insertion device)

Maximum of 19 infusion sets will be funded per year.

Maximum of 5 sets per three months

13 mm teflon cannula; angle insertion; insertion device; 60 cm line x 10 with 10 needles AutoSoft 30 1 182.00 182.00 182.00 0.00000 13 mm teflon cannula; angle insertion; insertion device; 110 cm line x 10 with 10 needles AutoSoft 30 1 182.00 182.00 182.00 0.00000 6 mm teflon cannula; angle insertion; insertion device; 60 cm line x 4 with 4 needles Med Adv Ext Infusion Set MDT-MMT-431AK 1 210.00 210.00 210.00 0.00000 6 mm teflon cannula; angle insertion; insertion device; 80 cm line x 4 with 4 needles Med Adv Ext Infusion Set MDT-MMT-432AK 1 210.00 210.00 210.00 0.00000 9 mm teflon cannula; angle insertion; insertion device; 60 cm line x 4 with 4 needles Med Adv Ext Infusion Set MDT-MMT-441AK 1 210.00 210.00 210.00 0.00000 9 mm teflon cannula; angle insertion; insertion device; 80 cm line x 4 with 4 needles Med Adv Ext Infusion Set MDT-MMT-442AK 1 210.00 210.00 210.00 0.00000 Insulin pump infusion set (steel cannula, straight insertion)

Maximum of 19 infusion sets will be funded per year.

Maximum of 5 sets per three months

6 mm steel cannula; straight insertion; 60 cm line x 10 with 10 needles TruSteel 1 182.00 182.00 182.00 0.00000 8 mm steel cannula; straight insertion; 60 cm line x 10 with 10 needles TruSteel 1 182.00 182.00 182.00 0.00000 6 mm steel cannula; straight insertion; 80 cm line x 10 with 10 needles TruSteel 1 182.00 182.00 182.00 0.00000 8 mm steel cannula; straight insertion; 80 cm line x 10 with 10 needles TruSteel 1 182.00 182.00 182.00 0.00000 5.5 mm steel cannula; straight insertion; 45 cm line x 10 with 10 needles mylife Orbit micro 1 136.00 136.00 136.00 0.00000 5.5 mm steel needle; straight insertion; 60 cm line x 10 with 10 needles mylife Orbit micro 1 136.00 136.00 136.00 0.00000 5.5 mm steel needle; straight insertion; 80 cm line x 10 with 10 needles mylife Orbit micro 1 136.00 136.00 136.00 0.00000 8.5 mm steel needle; straight insertion; 60 cm line x 10 with 10 needles mylife Orbit micro 1 136.00 136.00 136.00 0.00000 8.5 mm steel needle; straight insertion; 80 cm line x 10 with 10 needles mylife Orbit micro 1 136.00 136.00 136.00 0.00000 Insulin pump cartridge

Maximum of 190 cartridges will be funded per year.

Maximum of 50 cart per three months

Cartridge 300 u, t:lock x 10 Tandem Cartridge 10 86.00 86.00 86.00 0.00000 Insulin pump infusion set (teflon cannula)

Maximum of 19 infusion sets will be funded per year.

Maximum of 5 set per three months

6 mm teflon needle, 60 cm tubing x 10 MiniMed Quick-Set MMT-399A 1 219.00 219.00 219.00 0.00000 6 mm teflon needle, 110 cm tubing x 10 MiniMed Quick-Set MMT-398A 1 219.00 219.00 219.00 0.00000 9 mm teflon needle, 60 cm tubing x 10 MiniMed Quick-Set MMT-397A 1 219.00 219.00 219.00 0.00000 9 mm teflon needle, 110 cm tubing x 10 MiniMed Quick-Set MMT-396A 1 219.00 219.00 219.00 0.00000 13 mm teflon needle, 60 cm tubing x 10 MiniMed Silhouette MMT-381A 1 219.00 219.00 219.00 0.00000 17 mm teflon needle, 60 cm tubing x 10 MiniMed Silhouette MMT-378A 1 219.00 219.00 219.00 0.00000 17 mm teflon needle, 110 cm tubing x 10 MiniMed Silhouette MMT-377A 1 219.00 219.00 219.00 0.00000 Insulin pump infusion set (teflon cannula, flexible insertion with insertion device)

Maximum of 19 infusion sets will be funded per year.

Maximum of 5 set per three months

6 mm teflon cannula; flexible insertion; insertion device; 46 cm line x 10 with 10 needles mylife Inset soft 1 157.00 157.00 157.00 0.00000 6 mm teflon cannula; flexible insertion; insertion device; 60 cm line with integrated inserter x 10 with 10 needles mylife Inset soft 1 157.00 157.00 157.00 0.00000 6 mm teflon cannula; flexible insertion; insertion device; 80 cm line x 10 with 10 needles mylife Inset soft 1 157.00 157.00 157.00 0.00000 9 mm teflon cannula; flexible insertion; insertion device; 60 cm line x 10 with 10 needles mylife Inset soft 1 157.00 157.00 157.00 0.00000 9 mm teflon cannula; flexible insertion; insertion device; 80 cm line x 10 with 10 needles mylife Inset soft 1 157.00 157.00 157.00 0.00000 Insulin pump infusion set (teflon cannula, variable insertion)

Maximum of 19 infusion sets will be funded per year.

Maximum of 5 set per three months

13 mm teflon cannula; variable insertion; 60 cm line x 10 with 10 needles VariSoft 1 182.00 182.00 182.00 0.00000 Continuous Glucose Monitor Continuous glucose monitor (standalone) <range>Continuous glucose monitor (standalone)</range>

The patient has type 1 diabetes The patient has permanent neonatal diabetes or
          specific monogenic diabetes subtypes with insulin deficiency, considered by the treating
          endocrinologist or relevant secondary health care professional as practicable, as likely
          to benefit The patient has Type 3c diabetes considered by the
          treating endocrinologist or relevant secondary health care professional as practicable, as
          likely to benefit (Type 3c diabetes includes insulin deficiency due to pancreatectomy,
          insulin deficiency secondary to cystic fibrosis or pancreatitis) The patient has atypical inherited forms of
          diabetes

any relevant practitioner Sensor (Dexcom ONE+)

Maximum of 40 dev will be funded per year.

Maximum of 9 dev per three months

Dexcom ONE+ 1 81.00 81.00 81.00 0.00000 Sensor (Freestyle Libre 2 Plus)

Maximum of 28 dev will be funded per year.

Maximum of 6 dev per three months

Freestyle Libre 2 Plus 1 99.46 99.46 99.46 0.00000 Continuous glucose monitor (interoperable) <range>Continuous glucose monitor (interoperable)</range>

The patient has type 1 diabetes The patient has permanent neonatal
                        diabetes or specific monogenic diabetes subtypes with insulin deficiency,
                        considered by the treating endocrinologist or relevant secondary health care
                        professional as practicable, as likely to benefit The patient has Type 3c diabetes
                        considered by the treating endocrinologist or relevant secondary health care
                        professional as practicable, as likely to benefit (Type 3c diabetes includes
                        insulin deficiency due to pancreatectomy, insulin deficiency secondary to
                        cystic fibrosis or pancreatitis) The patient has atypical inherited forms
                        of diabetes In the opinion of the treating relevant
                    practitioner the patient would benefit from an Automated Insulin Delivery (AID)
                    system

any relevant practitioner Sensor (9) and transmitter (Dexcom G6)

Maximum of 5 dev will be funded per year.

Maximum of 1 dev per three months

Dexcom G6 1 990.00 990.00 990.00 0.00000 Sensor (Dexcom G7)

Maximum of 40 dev will be funded per year.

Maximum of 9 dev per three months

Dexcom G7 1 110.00 110.00 110.00 0.00000 Sensor (Freestyle Libre 3 Plus)

Maximum of 28 dev will be funded per year.

Maximum of 6 dev per three months

Freestyle Libre 3 Plus 1 99.46 99.46 99.46 0.00000 Digestives Including Enzymes Digestives Including Enzymes Ursodeoxycholic acid <range>Ursodeoxycholic Acid</range>

Patient has been diagnosed with Alagille
                    syndrome Patient has progressive familial intrahepatic
                    cholestasis

any relevant 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

any relevant practitioner 3

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)

any relevant practitioner 6

The patient diagnosed with cholestasis of
                pregnancy

any relevant practitioner 6

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

any relevant practitioner 6

Paediatric patient has developed abnormal
                    liver function as indicated on testing which is likely to be induced by Total
                    Parenteral Nutrition (TPN) Liver function has not improved with modifying
                    the TPN composition

any relevant practitioner 6

The patient continues to benefit from
                treatment

any relevant practitioner 6

The treatment remains appropriate and the patient
                is benefiting from treatment

any relevant practitioner 2

The paediatric patient continues to require TPN
                and who is benefiting from treatment, defined as a sustained improvement in
                bilirubin levels

any relevant practitioner 6

the individual has leukaemia/lymphoma and requires
                prophylaxis for medications/therapies with a high risk of sinusoidal obstruction
                syndrome

any relevant practitioner Cap 250 mg Ursosan 100 33.95 33.95 33.95 0.00000 Pancreatic enzyme 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 94.38 94.38 0.00000 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 34.93 34.93 0.00000 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 34.93 34.93 0.00000 Laxatives Bulk-forming Agents Ispaghula (psyllium) husk Powder for oral soln Konsyl-D 500 22.10 22.10 22.10 0.00000 Faecal Softeners Docusate sodium Tab 50 mg Coloxyl 100 3.20 3.20 3.20 0.00000 Tab 120 mg Coloxyl 100 4.98 4.98 4.98 0.00000 Poloxamer

Not funded for use in the ear.

Oral drops 10% Coloxyl 30 4.17 4.17 4.17 0.00000 Docusate sodium with sennosides Tab 50 mg with sennosides 8 mg Solax 100 1.50 1.50 1.50 0.00000 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

any relevant practitioner Inj 12 mg per 0.6 ml vial Relistor 1 1 36.00 36.00 36.00 0.00000 7 1 246.00 246.00 246.00 0.00000 Osmotic Laxatives Glycerol Suppos 2.8/4.0 g Lax-suppositories Glycerol 20 12.39 12.39 12.39 0.00000 Sodium citrate with sodium lauryl sulphoacetate Enema 90 mg with sodium lauryl sulphoacetate 9 mg per ml, 5 ml Micolette 50 36.89 36.89 36.89 0.00000 Lactulose Oral liq 10 g per 15 ml Laevolac 500 6.16 6.16 6.16 0.00000 Sodium acid phosphate Enema 16% with sodium phosphate 8% Fleet Phosphate Enema 1 3.70 3.70 3.70 0.00000 Macrogol 3350 with potassium chloride, sodium bicarbonate and sodium chloride 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 12.19 12.19 0.00000 Molaxole 30 10.15 10.15 10.15 0.00000 30 10.15 10.15 10.15 0.00000 Stimulant Laxatives Senna Tab, standardised Senokot 100 2.17 9.38 2.17 0.07210 20 0.43 2.06 0.43 0.08150 Bisacodyl Tab 5 mg Bisacodyl Viatris 200 10.00 10.00 10.00 0.00000 Bisacodyl-AFT 200 6.28 6.28 6.28 0.00000 Suppos 10 mg Lax-Suppositories 10 4.14 4.14 4.14 0.00000 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 or hospital admission

any relevant practitioner 6

the treatment remains appropriate and the patient is benefiting from treatment

any relevant practitioner 12 Oral soln 7.5 mg per ml Dulcolax SP Drop 30 7.40 7.40 7.40 0.00000 Metabolic Disorder Agents Metabolic Disorder Agents 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 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 Inj 1 mg per ml, 5 ml vial Naglazyme 1 1 2234.00 2234.00 2234.00 0.00000 Sodium phenylbutyrate <range>Sodium phenylbutyrate</range>

the patient has a diagnosis 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 Grans 483 mg per g Pheburane 174 2016.00 2016.00 2016.00 0.00000 Sodium benzoate <range>Sodium benzoate</range>

the patient has a diagnosis of a urea cycle disorder

metabolic physician 12

the treatment remains appropriate and the patient is benefiting from treatment

metabolic physician 12 Soln 100 mg per ml Amzoate 100 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 Inj 50 mg vial Myozyme 1 1 1142.60 1142.60 1142.60 0.00000 Idursulfase <range>Idursulfase</range>

The patient has been diagnosed with Hunter Syndrome (mucopolysaccharidosis 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 Inj 2 mg per ml, 3 ml vial Elaprase 1 1 4608.30 4608.30 4608.30 0.00000 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 Inj 100 U per ml, 5 ml vial Aldurazyme 1 1 1335.16 1335.16 1335.16 0.00000 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 Powder for oral soln Cystadane 180 575.00 575.00 575.00 0.00000 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 any relevant practitioner 12 10 Tab soluble 100 mg Kuvan 30 1452.70 1452.70 1452.70 0.00000 Coenzyme Q10 <range>Coenzyme Q10</range>

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 Cap 120 mg Solgar 30 Cap 160 mg Go Healthy 60 Levocarnitine <range>Levocarnitine</range>

patient has a suspected inborn error of metabolism that may respond to carnitine supplementation

metabolic physician 6

The patient has a confirmed diagnosis of an inborn error of metabolism that responds to carnitine supplementation The treatment remains appropriate and the patient is benefiting from treatment

metabolic physician 24 Tab 500 mg Solgar 30 Cap 250 mg Solgar 30 Cap 500 mg Balance 60 Metabolics 300 Oral liq 500 mg per 10 ml Balance 300 Oral liq 1 g per 10 ml Lacuna 118 Riboflavin <range>Riboflavin</range>

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 Cap 100 mg Solgar 100 Tab 100 mg Country Life 100 Puritan's Pride Vitamin B-2 100 mg 100 Arginine <range>Arginine</range>

patient has a suspected inborn error of metabolism that may respond to arginine supplementation

metabolic physician 6

The patient has a confirmed diagnosis of an inborn error of metabolism that responds to arginine supplementation The treatment remains appropriate and the patient is benefiting from treatment

metabolic physician 24 Tab 1,000 mg Clinicians 90 Cap 500 mg Solgar 50 Powder Biomed 400 Taurine <range>Taurine</range>

patient has a suspected specific mitochondrial disorder that may respond taurine supplementation

metabolic physician 6

The patient has 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 Cap 1,000 mg Life Extension 90 Powder Life Extension 300 Cap 500 mg Solgar 50 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 trailled 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

any relevant practitioner Cap 250 mg Trientine Waymade 100 2022.00 2022.00 2022.00 0.00000 Nitisinone <range>Nitisinone</range>

patient requires nitisinone for the management of
        inherited metabolic disorders

any relevant practitioner Cap 2 mg Nitisinone LogixX Pharma 60 676.00 676.00 676.00 0.00000 Cap 5 mg Nitisinone LogixX Pharma 60 1302.00 1302.00 1302.00 0.00000 Cap 10 mg Nitisinone LogixX Pharma 60 1704.00 1704.00 1704.00 0.00000 Gaucher's Disease 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 Radiological (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 Inj 200 unit vial Elelyso 1 1 1072.00 1072.00 1072.00 0.00000 Mouth and Throat Agents Used in Mouth Ulceration Benzydamine hydrochloride Soln 0.15%

Additional subsidy by endorsement for a patient who has oral mucositis as a result of treatment for cancer, and the prescription is endorsed accordingly.

Difflam 500 9.00 22.60 22.60 0.02720 Carmellose sodium with gelatin and pectin Paste Orabase 15 4.55 7.90 4.55 0.22333 5 1.52 3.60 1.52 0.41600 Stomahesive 56.7 17.20 17.20 17.20 0.00000 Powder Stomahesive 28 8.48 10.95 8.48 0.08821 Triamcinolone acetonide Paste 0.1% Kenalog in Orabase 5 5.49 5.49 5.49 0.00000 Oropharyngeal Anti-infectives Amphotericin B Lozenges 10 mg Fungilin 20 5.86 5.86 5.86 0.00000 Miconazole Oral gel 20 mg per g Decozol 40 5.19 5.19 5.19 0.00000 Nystatin Oral liq 100,000 u per ml Nilstat 24 2.22 2.22 2.22 0.00000 Vitamins Vitamin B Hydroxocobalamin Inj 1 mg per ml, 1 ml ampoule Hydroxocobalamin Panpharma 3 1 3.95 3.95 3.95 0.00000 Pyridoxine hydrochloride Tab 25 mg Vitamin B6 25 90 3.43 3.43 3.43 0.00000 Tab 50 mg Pyridoxine multichem 500 23.45 23.45 23.45 0.00000 Thiamine hydrochloride Tab 50 mg Thiamine multichem 100 4.65 4.65 4.65 0.00000 Vitamin B complex Tab, strong, BPC Bplex 500 11.25 11.25 11.25 0.00000 Vitamin C Ascorbic acid Tab 100 mg Cvite 500 16.00 16.00 16.00 0.00000 Vitamin D Alfacalcidol Cap 0.25 mcg One-Alpha 100 26.32 26.32 26.32 0.00000 Cap 1 mcg One-Alpha 100 87.98 87.98 87.98 0.00000 Oral drops 2 mcg per ml One-Alpha 20 60.68 60.68 60.68 0.00000 Colecalciferol Cap 1.25 mg (50,000 iu)

Maximum of 12 cap per three months

Vit.D3 12 3.65 3.65 3.65 0.00000 Oral liq 188 mcg per ml (7,500 iu per ml) Clinicians 5 9.00 9.00 9.00 0.00000 Calcitriol Cap 0.25 mcg Calcitriol-AFT 100 7.89 7.89 7.89 0.00000 Calcitriol XL 100 7.89 7.89 7.89 0.00000 Cap 0.5 mcg Calcitriol-AFT 100 13.68 13.68 13.68 0.00000 Calcitriol XL 100 13.68 13.68 13.68 0.00000 Multivitamin Preparations Vitamins Tab (BPC cap strength) Mvite 1000 24.00 24.00 24.00 0.00000 Cap (fat soluble vitamins A, D, E, K) <range>Vitabdeck</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

any relevant practitioner Vitabdeck 60 23.40 23.40 23.40 0.00000 Multivitamins <range>Multivitamins<instance>Paediatric Seravit</instance></range>

The patient has inborn errors of metabolism

any relevant practitioner

Patient has had a previous approval for multivitamins

any relevant practitioner Powder Paediatric Seravit 200 74.88 74.88 74.88 0.00000 Multivitamin renal <range>Multivitamin renal<instance>Clinicians Renal Vit</instance></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/1.73 m² body surface area (BSA)

any relevant practitioner Cap Clinicians Renal Vit 30 7.28 7.28 7.28 0.00000 Minerals Calcium Calcium carbonate Tab 1.25 g (500 mg elemental) Calci-Tab 500 250 7.28 7.28 7.28 0.00000 Tab eff 1.25 g (500 mg elemental)

Subsidy by endorsement – Only when prescribed for paediatric patients (<5 years) where calcium carbonate oral liquid is considered unsuitable.

Calcium 500 mg Hexal 100 260.00 260.00 260.00 0.00000 Calcium gluconate Inj 10%, 10 ml ampoule Max Health - Hameln 10 1 32.00 32.00 32.00 0.00000 Iodine Potassium iodate Tab 253 mcg (150 mcg elemental iodine) NeuroTabs 90 5.99 5.99 5.99 0.00000 Iron Iron polymaltose Inj 50 mg per ml, 2 ml ampoule Ferrosig 5 1 41.75 41.75 41.75 0.00000 Ferrous sulfate Oral liq 30 mg (6 mg elemental) per 1 ml Ferro-Liquid 250 10.25 10.25 10.25 0.00000 Ferrous fumarate Tab 200 mg (65.7 mg elemental) Ferro-tab 100 3.49 3.49 3.49 0.00000 Ferrous fumarate with folic acid Tab 310 mg (100 mg elemental) with folic acid 350 mcg Ferro-F-Tabs 100 5.98 5.98 5.98 0.00000 Iron (as ferric carboxymaltose) <range>Ferric carboxymaltose</range>

Patient has been diagnosed with anaemia Serum ferritin level is 20 mcg/L or
                        less Serum ferritin is between 20 and 50
                            mcg/L C-Reactive Protein (CRP) is at least 5
                            mg/L Patient has chronic inflammatory disease
                        with symptoms of anaemia despite normal iron levels Oral iron treatment has proven
                        ineffective Oral iron treatment has resulted in
                        dose-limiting intolerance Rapid correction of anaemia is
                        required

any relevant practitioner 3

Patient continues to have anaemia with a serum
                    ferritin level of 20 mcg/L, or less or between 20 and 50 mcg/L with CRP of at
                    least 5 mg/L, or has chronic inflammatory disease with symptoms of anaemia
                    despite normal iron levels A trial (or re-trial) with oral iron is
                    clinically inappropriate

any relevant practitioner 3

Patient has been diagnosed with
                    iron-deficiency anaemia Patient has been compliant with oral iron
                        treatment and treatment has proven ineffective Treatment with oral iron has resulted in
                        dose-limiting intolerance Patient has symptomatic heart failure,
                        chronic kidney disease stage 3 or more or active inflammatory bowel disease
                        and a trial of oral iron is unlikely to be effective Rapid correction of anaemia is
                        required

internal medicine physician obstetrician gynaecologist anaesthetist medical practitioner 3

Patient continues to have iron-deficiency
                    anaemia A re-trial with oral iron is clinically
                    inappropriate

internal medicine physician obstetrician gynaecologist anaesthetist medical practitioner 3 Inj 50 mg per ml, 10 ml vial Ferinject 1 1 150.00 150.00 150.00 0.00000 Magnesium Magnesium hydroxide Suspension 8% Phillips Milk of Magnesia 355 33.60 33.60 33.60 0.00000 Magnesium sulphate Inj 2 mmol per ml, 5 ml ampoule Martindale 10 1 37.53 37.53 37.53 0.00000 Inj 2 mmol per ml, 10 ml ampoule Inresa 10 1 75.06 75.06 75.06 0.00000 Zinc Zinc sulphate Cap 137.4 mg (50 mg elemental) Zincaps 100 11.00 11.00 11.00 0.00000 Zincaps S29 100 11.00 11.00 11.00 0.00000 Cap 220 mg (50 mg elemental) Rugby 100 29.14 29.14 29.14 0.00000 Blood and Blood Forming Organs Antianaemics Hypoplastic and Haemolytic <range>Hypoplastic and Haemolytic</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

any relevant 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

any specialist 2

Indication marked with * is an unapproved indication

The patient's transfusion requirement
                    continues to be reduced with erythropoietin 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

any specialist 12

Indication marked with * is an unapproved indication

Epoetin alfa Inj 3,000 iu in 0.3 ml, syringe Binocrit 6 1 150.00 150.00 150.00 0.00000 Inj 4,000 iu in 0.4 ml, syringe Binocrit 6 1 96.50 96.50 96.50 0.00000 Inj 10,000 iu in 1 ml, syringe Binocrit 6 1 197.50 197.50 197.50 0.00000 Inj 1,000 iu in 0.5 ml, syringe Binocrit 6 1 250.00 250.00 250.00 0.00000 Inj 5,000 iu in 0.5 ml, syringe Binocrit 6 1 125.00 125.00 125.00 0.00000 Inj 6,000 iu in 0.6 ml, syringe Binocrit 6 1 145.00 145.00 145.00 0.00000 Inj 8,000 iu in 0.8 ml, syringe Binocrit 6 1 175.00 175.00 175.00 0.00000 Inj 40,000 iu in 1 ml, syringe Binocrit 1 1 250.00 250.00 250.00 0.00000 Inj 2,000 iu in 1 ml, syringe Binocrit 6 1 100.00 100.00 100.00 0.00000 Megaloblastic Folic acid Tab 5 mg Folic Acid Viatris 100 5.82 5.82 5.82 0.00000 Oral liq 50 mcg per ml Biomed 25 31.77 31.77 31.77 0.00000 Tab 0.8 mg Folic Acid multichem 1000 26.60 26.60 26.60 0.00000 Antifibrinolytics, Haemostatics and Local Sclerosants Antifibrinolytics, Haemostatics and Local Sclerosants Sodium tetradecyl sulphate Inj 3% 2 ml Fibro-vein 5 1 28.50 140.00 28.50 22.30000 Tranexamic acid Tab 500 mg Mercury Pharma 60 9.93 9.93 9.93 0.00000 Inj 100 mg per ml, 10 ml ampoule

Subsidised only for use within a Primary Response in Medical Emergencies (PRIME) service or for the treatment of post-partum haemorrhage (PPH) and the PSO is endorsed accordingly.

Tranexamic-AFT 5 1 7.99 7.99 7.99 0.00000 Octocog alfa [Recombinant factor VIII] (Advate)

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.

Inj 500 iu vial Advate 1 1 420.00 420.00 420.00 0.00000 Inj 1,000 iu vial Advate 1 1 840.00 840.00 840.00 0.00000 Inj 2,000 iu vial Advate 1 1 1680.00 1680.00 1680.00 0.00000 Inj 3,000 iu vial Advate 1 1 2520.00 2520.00 2520.00 0.00000 Eptacog alfa [Recombinant factor VIIa]

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.

Inj 1 mg syringe NovoSeven RT 1 1 1178.30 1178.30 1178.30 0.00000 Inj 2 mg syringe NovoSeven RT 1 1 2356.60 2356.60 2356.60 0.00000 Inj 5 mg syringe NovoSeven RT 1 1 5891.50 5891.50 5891.50 0.00000 Inj 8 mg syringe NovoSeven RT 1 1 9426.40 9426.40 9426.40 0.00000 Moroctocog alfa [Recombinant factor VIII]

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.

Inj 250 iu prefilled syringe Xyntha 1 1 287.50 287.50 287.50 0.00000 Inj 500 iu prefilled syringe Xyntha 1 1 575.00 575.00 575.00 0.00000 Inj 1,000 iu prefilled syringe Xyntha 1 1 1150.00 1150.00 1150.00 0.00000 Inj 2,000 iu prefilled syringe Xyntha 1 1 2300.00 2300.00 2300.00 0.00000 Inj 3,000 iu prefilled syringe Xyntha 1 1 3450.00 3450.00 3450.00 0.00000 Octocog alfa [Recombinant factor VIII] (Kogenate FS)

Inj 250 iu vial Kogenate FS 1 1 237.50 237.50 237.50 0.00000 Inj 500 iu vial Kogenate FS 1 1 475.00 475.00 475.00 0.00000 Inj 1,000 iu vial Kogenate FS 1 1 950.00 950.00 950.00 0.00000 Inj 2,000 iu vial Kogenate FS 1 1 1900.00 1900.00 1900.00 0.00000 Inj 3,000 iu vial Kogenate FS 1 1 2850.00 2850.00 2850.00 0.00000 Factor eight inhibitor bypassing fraction

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.

Inj 500 U FEIBA NF 1 1 1315.00 1315.00 1315.00 0.00000 Inj 1,000 U FEIBA NF 1 1 2630.00 2630.00 2630.00 0.00000 Inj 2,500 U FEIBA NF 1 1 6575.00 6575.00 6575.00 0.00000 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

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

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 (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.

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

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 Tab 25 mg Revolade 28 1550.00 1550.00 1550.00 0.00000 Tab 50 mg Revolade 28 3100.00 3100.00 3100.00 0.00000 Nonacog gamma, [Recombinant Factor IX]

For patients with haemophilia. Access to funded treatment is managed by the Haemophilia Treaters Group in conjunction with the National Haemophilia Management Group.

Inj 1,000 iu vial RIXUBIS 1 1 870.00 870.00 870.00 0.00000 Inj 2,000 iu vial RIXUBIS 1 1 1740.00 1740.00 1740.00 0.00000 Inj 3,000 iu vial RIXUBIS 1 1 2610.00 2610.00 2610.00 0.00000 Eftrenonacog alfa [Recombinant factor IX]

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.

Inj 250 iu vial Alprolix 1 1 612.50 612.50 612.50 0.00000 1 1 612.50 612.50 612.50 0.00000 Inj 500 iu vial Alprolix 1 1 1225.00 1225.00 1225.00 0.00000 1 1 1225.00 1225.00 1225.00 0.00000 Inj 1,000 iu vial Alprolix 1 1 2450.00 2450.00 2450.00 0.00000 1 1 2450.00 2450.00 2450.00 0.00000 Inj 2,000 iu vial Alprolix 1 1 4900.00 4900.00 4900.00 0.00000 1 1 4900.00 4900.00 4900.00 0.00000 Inj 3,000 iu vial Alprolix 1 1 7350.00 7350.00 7350.00 0.00000 1 1 7350.00 7350.00 7350.00 0.00000 Inj 4,000 iu vial Alprolix 1 1 9800.00 9800.00 9800.00 0.00000 1 1 9800.00 9800.00 9800.00 0.00000 Rurioctocog alfa pegol [Recombinant factor VIII]

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.

Inj 1,000 iu vial Adynovate 1 1 1200.00 1200.00 1200.00 0.00000 Inj 2,000 iu vial Adynovate 1 1 2400.00 2400.00 2400.00 0.00000 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 Inj 30 mg in 1 ml vial Hemlibra 1 1 3570.00 3570.00 3570.00 0.00000 Inj 60 mg in 0.4 ml vial Hemlibra 1 1 7138.00 7138.00 7138.00 0.00000 Inj 105 mg in 0.7 ml vial Hemlibra 1 1 12492.00 12492.00 12492.00 0.00000 Inj 150 mg in 1 ml vial Hemlibra 1 1 17846.00 17846.00 17846.00 0.00000 Vitamin K Phytomenadione Inj 10 mg per ml, 1 ml Konakion MM 5 1 9.21 9.21 9.21 0.00000 Inj 2 mg per 0.2 ml Konakion MM Paediatric 5 1 8.00 8.00 8.00 0.00000 Antithrombotic Agents Antiplatelet Agents Aspirin Tab 100 mg Ethics Aspirin EC 990 12.65 12.65 12.65 0.00000 Dipyridamole

Note: No new patients to be initiated on dipyridamole.

Cap modified-release 200 mg Dipyridamole - Strides 60 55.13 55.13 55.13 0.00000 Clopidogrel Tab 75 mg Arrow - Clopid 84 5.07 5.07 5.07 0.00000 Ticagrelor <range>Ticagrelor</range>

Patient has recently (within the last 60 days)
                    been diagnosed with an ST-elevation or a non-ST-elevation acute coronary
                    syndrome Fibrinolytic therapy has not been given in the
                    last 24 hours and is not planned

any relevant practitioner 12

Patient has recently (within the last 60 days)
                    been diagnosed with an ST-elevation or a non-ST-elevation acute coronary
                    syndrome Fibrinolytic therapy has not been given in the
                    last 24 hours and is not planned

any relevant practitioner 12

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

any relevant practitioner 12

Patient is continuing to benefit from
                    treatment Treatment continues to be clinically
                    appropriate

any relevant practitioner 12

Patient has undergone percutaneous coronary
                    intervention Patient has had a stent deployed in the
                    previous 4 weeks Patient is clopidogrel-allergic**

any relevant practitioner 6

Patient has undergone percutaneous coronary
                    intervention Patient has had a stent deployed in the
                    previous 4 weeks Patient is clopidogrel-allergic**

any relevant practitioner 6

patient has experienced cardiac stent thrombosis
                whilst on clopidogrel

any relevant practitioner

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

any relevant practitioner 1

patient has been diagnosed with a minor stroke
                (NIHSS score 3 or less) or high-risk transient ischemic attack (ABCD2 score 4 or
                more) or Crescendo TIA

any relevant 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.

Tab 90 mg Ticagrelor Sandoz 56 20.35 20.35 20.35 0.00000 Ticagrelor Sandoz S29 56 20.35 20.35 20.35 0.00000 Ticagrelor Mylan 56 23.85 23.85 23.85 0.00000 Heparin and Antagonist Preparations Heparin sodium Inj 1,000 iu per ml, 5 ml ampoule Pfizer 50 1 164.40 164.40 164.40 0.00000 Inj 5,000 iu per ml, 1 ml Hospira 5 1 70.33 70.33 70.33 0.00000 Inj 5,000 iu per ml, 5 ml ampoule Pfizer 50 1 406.15 406.15 406.15 0.00000 Inj 25,000 iu per ml, 0.2 ml Hospira 5 1 25.78 25.78 25.78 0.00000 Inj 10 iu per ml, 5 ml ampoule (flushing solution) Wockhardt 10 1 19.38 19.38 19.38 0.00000 Enoxaparin sodium <range>Enoxaparin sodium</range>

Low molecular weight heparin treatment is required during a patients pregnancy For the treatment of venous thromboembolism where the patient has a malignancy For the prevention of thrombus formation in the extra-corporeal circulation during haemodialysis

any relevant practitioner 1

For the short-term treatment of venous thromboembolism prior to establishing a therapeutic level of oral anti-coagulant treatment For the prophylaxis and treatment of venous thromboembolism in high risk surgery To enable cessation/re-establishment of existing oral anticoagulant treatment pre/post surgery For the prophylaxis and treatment of venous thromboembolism in Acute Coronary Syndrome surgical intervention To be used in association with cardioversion of atrial fibrillation

any relevant practitioner 1

Patient is receiving an anticoagulation treatment that has drug/drug interactions with ritonavir that increases risk of bleeding Patient meets the Access Criteria for COVID-19 antivirals published on the Pharmac website* Other antiviral treatments for COVID-19 have been considered and are not clinically suitable options

any relevant practitioner 2

Low molecular weight heparin treatment is required during a patient's pregnancy For the treatment of venous thromboembolism where the patient has a malignancy For the prevention of thrombus formation in the extra-corporeal circulation during haemodialysis

any relevant practitioner 1

Low molecular weight heparin treatment or prophylaxis is required for a second or subsequent event (surgery, ACS, cardioversion, or prior to oral
                anti-coagulation)

any relevant practitioner 1

Subsidy by Endorsement - enoxaparin 100 mg syringe available on PSO for use within a Primary Response in Medical Emergencies (PRIME) service and the PSO is endorsed accordingly.

Inj 20 mg in 0.2 ml syringe Clexane 10 1 21.90 21.90 21.90 0.00000 Inj 40 mg in 0.4 ml syringe Clexane 10 1 29.74 29.74 29.74 0.00000 Inj 60 mg in 0.6 ml syringe Clexane 10 1 42.47 42.47 42.47 0.00000 Inj 80 mg in 0.8 ml syringe Clexane 10 1 56.62 56.62 56.62 0.00000 Inj 100 mg in 1 ml syringe Clexane 10 1 70.91 70.91 70.91 0.00000 Inj 120 mg in 0.8 ml syringe Clexane Forte 10 1 88.11 88.11 88.11 0.00000 Inj 150 mg in 1 ml syringe Clexane Forte 10 1 100.70 100.70 100.70 0.00000 Heparinised saline Inj 10 iu per ml, 5 ml Pfizer 50 1 96.91 96.91 96.91 0.00000 Oral Anticoagulants Warfarin sodium

Note: Marevan and Coumadin are not interchangeable.

Tab 1 mg Coumadin 50 3.46 3.46 3.46 0.00000 Marevan 100 7.50 7.50 7.50 0.00000 Tab 2 mg Coumadin 50 4.31 4.31 4.31 0.00000 Tab 3 mg Marevan 100 12.00 12.00 12.00 0.00000 Tab 5 mg Coumadin 50 5.93 5.93 5.93 0.00000 Marevan 100 13.50 13.50 13.50 0.00000 Rivaroxaban Tab 10 mg Xarelto 30 15.60 15.60 15.60 0.00000 Tab 15 mg Xarelto 28 14.56 14.56 14.56 0.00000 Tab 20 mg Xarelto 28 14.56 14.56 14.56 0.00000 Dabigatran Cap 75 mg Pradaxa 60 27.99 27.99 27.99 0.00000 Cap 110 mg Pradaxa 60 27.99 27.99 27.99 0.00000 Cap 150 mg Pradaxa 60 27.99 27.99 27.99 0.00000 Blood Colony-stimulating Factors Blood Colony-stimulating Factors Filgrastim <range>Filgrastim</range>

Prevention of neutropenia in patients undergoing high
          risk chemotherapy for cancer (febrile neutropenia risk greater than or equal to 20%*) Peripheral blood stem cell mobilisation in patients
          undergoing haematological transplantation Peripheral blood stem cell mobilisation or bone marrow
          donation from healthy donors for transplantation Treatment of severe chronic neutropenia (ANC < 0.5 × 10^{9} /L) Treatment of drug-induced prolonged neutropenia (ANC
          < 0.5 × 10^{9} /L)

any relevant practitioner

*Febrile neutropenia risk greater than or equal to 20% after taking into account other risk factors as defined by the European Organisation for Research and Treatment of Cancer (EORTC) guidelines.

Inj 300 mcg per 0.5 ml prefilled syringe Nivestim 10 1 86.60 86.60 86.60 0.00000 Inj 480 mcg per 0.5 ml prefilled syringe Nivestim 10 1 133.72 133.72 133.72 0.00000 Pegfilgrastim <range>Pegfilgrastim</range>

Used for prevention of neutropenia in patients
                undergoing high risk chemotherapy for cancer (febrile neutropenia risk greater than
                or equal to 5%*)

any relevant 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.

Inj 6 mg per 0.6 ml syringe Ziextenzo 1 1 69.50 69.50 69.50 0.00000 1 1 69.50 69.50 69.50 0.00000 Fluids and Electrolytes Intravenous Administration Glucose [Dextrose] Inj 50%, 10 ml ampoule Biomed 5 1 34.75 34.75 34.75 0.00000 Inj 50%, 90 ml bottle Biomed 1 1 17.50 17.50 17.50 0.00000 Inj 5%, 100 ml bag

Subsidised only for use within a Primary Response in Medical Emergencies (PRIME) service and the PSO is endorsed accordingly.

Fresenius Kabi 50 1 97.00 97.00 97.00 0.00000 Inj 10%, 500 ml bag

Subsidised only for use within a Primary Response in Medical Emergencies (PRIME) service and the PSO is endorsed accordingly.

Baxter Glucose 10% 18 1 126.00 126.00 126.00 0.00000 Potassium chloride Inj 75 mg per ml, 10 ml Juno 50 1 65.00 65.00 65.00 0.00000 Pfizer 50 1 65.00 65.00 65.00 0.00000 LumaCina 50 65.00 65.00 65.00 0.00000 Sodium bicarbonate Inj 8.4%, 100 ml Biomed 1 1 25.31 25.31 25.31 0.00000 Inj 8.4%, 50 ml Biomed 1 1 24.70 24.70 24.70 0.00000 Sodium chloride

Not funded for use as a nasal drop. Not funded for nebuliser use except when used in conjunction with an antibiotic intended for nebuliser use.

Inj 0.9%, 5 ml ampoule Fresenius Kabi 20 1 4.12 4.12 4.12 0.00000 Inj 0.9%, 10 ml ampoule Fresenius Kabi 50 1 7.50 7.50 7.50 0.00000 Inj 0.9%, 20 ml ampoule Fresenius Kabi 20 1 5.20 5.20 5.20 0.00000 Inj 23.4% (4 mmol/ml), 20 ml ampoule

For Sodium chloride oral liquid formulation refer Standard Formulae

Biomed 5 1 40.15 40.15 40.15 0.00000 Inj 0.9%, 500 ml bag

Only if prescribed on a prescription for renal dialysis, maternity or post-natal care in the home of the patient, or on a PSO for emergency use. (500 ml and 1,000 ml packs)

Baxter 1 1 1.53 1.53 1.53 0.00000 Inj 0.9%, 1,000 ml bag

Only if prescribed on a prescription for renal dialysis, maternity or post-natal care in the home of the patient, or on a PSO for emergency use. (500 ml and 1,000 ml packs)

Baxter 1 1 1.58 1.58 1.58 0.00000 Water

On a prescription or Practitioner’s Supply Order only when on the same form as an injection listed in the Pharmaceutical Schedule requiring a solvent or diluent; or
On a bulk supply order; or
When used in the extemporaneous compounding of eye drops; or
When used for the dilution of sodium chloride soln 7% for cystic fibrosis patients only.

Inj 10 ml ampoule Multichem 50 1 7.60 7.60 7.60 0.00000 Fresenius Kabi 50 1 7.60 7.60 7.60 0.00000 Inj 20 ml ampoule Fresenius Kabi 20 1 5.00 5.00 5.00 0.00000 Total parenteral nutrition (TPN) Infusion TPN 1 Oral Administration Calcium polystyrene sulphonate Powder Calcium Resonium 300 169.85 169.85 169.85 0.00000 Roma 300 169.85 169.85 169.85 0.00000 Compound electrolytes with glucose [Dextrose] Soln with electrolytes Hydralyte - Lemonade 1 6.53 6.53 6.53 0.00000 Soln with electrolytes (2 x 500 ml) Pedialyte 1 8.45 8.45 8.45 0.00000 Compound electrolytes Powder for oral soln Electral 50 9.50 9.50 9.50 0.00000 Phosphorus Tab eff 500 mg (16 mmol) Phosphate Phebra 100 82.50 82.50 82.50 0.00000 Potassium chloride Tab eff 548 mg (14 m eq) with chloride 285 mg (8 m eq) Chlorvescent 60 5.26 17.10 5.26 0.19733 Tab long-acting 600 mg (8 mmol) Span-K 200 16.15 16.15 16.15 0.00000 200 16.15 16.15 16.15 0.00000 Sodium bicarbonate Cap 840 mg Sodibic 100 8.52 8.52 8.52 0.00000 100 8.52 8.52 8.52 0.00000 Sodium polystyrene sulphonate Powder Resonium-A 454 84.65 84.65 84.65 0.00000 Cardiovascular System Alpha-Adrenoceptor Blockers Alpha Adrenoceptor Blockers Phenoxybenzamine hydrochloride Cap 10 mg BNM 30 65.00 65.00 65.00 0.00000 Prazosin Tab 1 mg Minipress 100 9.98 9.98 9.98 0.00000 Arrotex-Prazosin S29 100 5.53 5.53 5.53 0.00000 Tab 2 mg Minipress 100 13.29 13.29 13.29 0.00000 Arrotex-Prazosin S29 100 7.00 7.00 7.00 0.00000 Tab 5 mg Minipress 100 22.00 22.00 22.00 0.00000 Arrotex-Prazosin S29 100 11.70 11.70 11.70 0.00000 Cap 1 mg Prazosin Mylan 100 15.40 15.40 15.40 0.00000 Cap 2 mg Prazosin Mylan 100 15.58 15.58 15.58 0.00000 Cap 5 mg Prazosin Mylan 100 23.32 23.32 23.32 0.00000 Doxazosin Tab 2 mg Doxazosin Clinect 500 17.35 17.35 17.35 0.00000 Tab 4 mg Doxazosin Clinect 500 20.94 20.94 20.94 0.00000 Agents Affecting the Renin-Angiotensin System ACE Inhibitors Enalapril maleate Tab 5 mg Acetec 90 4.25 4.25 4.25 0.00000 Ipca-Enalapril 90 1.40 1.40 1.40 0.00000 Tab 10 mg Acetec 90 5.50 5.50 5.50 0.00000 Ipca-Enalapril 90 1.58 1.58 1.58 0.00000 Tab 20 mg Acetec 90 6.50 6.50 6.50 0.00000 Ipca-Enalapril 90 2.00 2.00 2.00 0.00000 Quinapril Tab 5 mg Arrow-Quinapril 5 90 10.24 10.24 10.24 0.00000 Tab 10 mg Arrow-Quinapril 10 90 12.51 12.51 12.51 0.00000 Tab 20 mg Arrow-Quinapril 20 90 14.83 14.83 14.83 0.00000 Lisinopril Tab 5 mg Teva Lisinopril 90 12.00 12.00 12.00 0.00000 Tab 10 mg Teva Lisinopril 90 12.00 12.00 12.00 0.00000 Tab 20 mg Teva Lisinopril 90 16.00 16.00 16.00 0.00000 Perindopril Tab 4 mg Coversyl 30 2.44 2.44 2.44 0.00000 Tab 2 mg Coversyl 30 1.79 1.79 1.79 0.00000 Tab 8 mg Coversyl 30 3.94 3.94 3.94 0.00000 Captopril Oral liq 5 mg per ml

Oral liquid restricted to children under 12 years of age.

DP-Captopril 100 86.00 86.00 86.00 0.00000 Ramipril Cap 1.25 mg Tryzan 90 17.25 17.25 17.25 0.00000 Cap 2.5 mg Tryzan 90 16.50 16.50 16.50 0.00000 Cap 5 mg Tryzan 90 16.88 16.88 16.88 0.00000 Cap 10 mg Tryzan 90 17.63 17.63 17.63 0.00000 Tab 1.25 mg Ramipril Viatris 30 5.75 5.75 5.75 0.00000 Tab 5 mg Ramipril Mylan Generics 28 5.25 5.25 5.25 0.00000 Tab 10 mg Ramipril Mylan Generics 28 5.48 5.48 5.48 0.00000 Angiotensin II Antagonists Losartan potassium Tab 50 mg Losartan Actavis 84 2.86 2.86 2.86 0.00000 Tab 12.5 mg Losartan Actavis 84 2.00 2.00 2.00 0.00000 Tab 100 mg Losartan Actavis 84 4.57 4.57 4.57 0.00000 Tab 25 mg Losartan Actavis 84 2.29 2.29 2.29 0.00000 Candesartan cilexetil Tab 4 mg Candestar 90 2.68 2.68 2.68 0.00000 Candesartan Viatris Sante 90 2.68 2.68 2.68 0.00000 Candesartan Viatris 90 2.68 2.68 2.68 0.00000 Tab 8 mg Candestar 90 2.67 2.67 2.67 0.00000 Candesartan Viatris 90 2.67 2.67 2.67 0.00000 Tab 16 mg Candestar 90 4.22 4.22 4.22 0.00000 Candesartan Viatris 90 4.22 4.22 4.22 0.00000 Tab 32 mg Candestar 90 5.24 5.24 5.24 0.00000 Candesartan Viatris 90 5.24 5.24 5.24 0.00000 Angiotensin II Antagonists with Diuretics Losartan potassium with hydrochlorothiazide Tab 50 mg with hydrochlorothiazide 12.5 mg Arrow-Losartan & Hydrochlorothiazide 30 4.31 4.31 4.31 0.00000 Losartan & Hydrochlorothiazide (Ipca) 90 7.25 7.25 7.25 0.00000 Candesartan cilexetil with hydrochlorothiazide Tab 16 mg with hydrochlorothiazide 12.5 mg APO-Candesartan HCTZ 16/12.5 30 4.10 4.10 4.10 0.00000 Tab 32 mg with hydrochlorothiazide 12.5 mg APO-Candesartan HCTZ 32/12.5 30 5.25 5.25 5.25 0.00000 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

any relevant practitioner Tab 24.3 mg with valsartan 25.7 mg Entresto 24/26 56 190.00 190.00 190.00 0.00000 Tab 48.6 mg with valsartan 51.4 mg Entresto 49/51 56 190.00 190.00 190.00 0.00000 Tab 97.2 mg with valsartan 102.8 mg Entresto 97/103 56 190.00 190.00 190.00 0.00000 Antiarrhythmics

For lignocaine hydrochloride refer to NERVOUS SYSTEM, Anaesthetics, Local

Antiarrhythmics Amiodarone hydrochloride Tab 100 mg Aratac 30 4.95 4.95 4.95 0.00000 Tab 200 mg Aratac 30 5.86 5.86 5.86 0.00000 Inj 50 mg per ml, 3 ml ampoule Max Health 10 1 17.96 17.96 17.96 0.00000 Atropine sulphate Inj 600 mcg per ml, 1 ml ampoule Martindale 10 1 16.10 16.10 16.10 0.00000 Hikma 10 1 16.10 16.10 16.10 0.00000 Digoxin Tab 62.5 mcg Lanoxin PG 240 8.58 8.58 8.58 0.00000 Tab 250 mcg Lanoxin 240 18.75 18.75 18.75 0.00000 Oral liq 50 mcg per ml Lanoxin 60 16.60 16.60 16.60 0.00000 Lanoxin S29 60 16.60 16.60 16.60 0.00000 Disopyramide phosphate Cap 100 mg Rythmodan - Cheplafarm 84 55.90 55.90 55.90 0.00000 Rythmodan Neon 84 55.90 55.90 55.90 0.00000 Flecainide acetate Tab 50 mg Flecainide BNM 60 19.95 19.95 19.95 0.00000 Inj 10 mg per ml, 15 ml ampoule Tambocor 5 1 108.16 108.16 108.16 0.00000 Almarytm 5 1 102.79 102.79 102.79 0.00000 Tambocor German 5 1 108.16 108.16 108.16 0.00000 Cap long-acting 100 mg Flecainide Controlled Release Teva 90 35.78 35.78 35.78 0.00000 Cap long-acting 200 mg Flecainide Controlled Release Teva 90 54.28 54.28 54.28 0.00000 Mexiletine hydrochloride Cap 150 mg Teva 100 162.00 162.00 162.00 0.00000 Cap 250 mg Teva 100 202.00 202.00 202.00 0.00000 Propafenone hydrochloride Tab 150 mg Rytmonorm 50 40.90 40.90 40.90 0.00000 Antihypotensives Antihypotensives Midodrine <range>Midodrine</range>

Patient has disabling orthostatic hypotension not due to drugs

any relevant practitioner 2

the treatment remains appropriate and the patient is benefiting from treatment

any relevant practitioner 2 Tab 2.5 mg Midodrine Medsurge 100 36.68 36.68 36.68 0.00000 Tab 5 mg Midodrine Medsurge 100 58.88 58.88 58.88 0.00000 Beta-Adrenoceptor Blockers Beta Adrenoceptor Blockers Atenolol Tab 50 mg Viatris 500 11.00 11.00 11.00 0.00000 Tab 100 mg Atenolol Viatris 500 18.50 18.50 18.50 0.00000 Oral liq 25 mg per 5 ml

Restricted to children under 12 years of age.

Atenolol AFT 300 49.85 49.85 49.85 0.00000 Labetalol Tab 100 mg Trandate 100 14.50 14.50 14.50 0.00000 Biocon 100 49.54 49.54 49.54 0.00000 Tab 200 mg Trandate 100 27.00 27.00 27.00 0.00000 Presolol 100 42.07 42.07 42.07 0.00000 Inj 5 mg per ml, 20 ml ampoule Trandate 5 1 59.06 88.60 59.06 5.90800 Metoprolol succinate Tab long-acting 47.5 mg Myloc CR 90 3.65 3.65 3.65 0.00000 Tab long-acting 95 mg Myloc CR 90 5.24 5.24 5.24 0.00000 Tab long-acting 190 mg Myloc CR 90 9.76 9.76 9.76 0.00000 Tab long-acting 23.75 mg Myloc CR 90 4.20 4.20 4.20 0.00000 Metoprolol tartrate Tab 50 mg IPCA-Metoprolol 100 5.66 5.66 5.66 0.00000 Tab 100 mg IPCA-Metoprolol 60 7.55 7.55 7.55 0.00000 Tab long-acting 200 mg Slow-Lopresor 28 23.40 23.40 23.40 0.00000 Inj 1 mg per ml, 5 ml vial Metoprolol IV Mylan 5 1 26.50 26.50 26.50 0.00000 Metoprolol IV Viatris 5 1 26.50 26.50 26.50 0.00000 Nadolol Tab 40 mg Nadolol BNM 100 19.19 19.19 19.19 0.00000 100 19.19 19.19 19.19 0.00000 Tab 80 mg Nadolol BNM 100 30.39 30.39 30.39 0.00000 100 30.39 30.39 30.39 0.00000 Propranolol Tab 10 mg Drofate 100 7.04 7.04 7.04 0.00000 Tab 40 mg IPCA-Propranolol 100 8.75 8.75 8.75 0.00000 Cap long-acting 160 mg Cardinol LA 100 18.17 18.17 18.17 0.00000 Oral liq 4 mg per ml <range>Propranolol</range>

For the treatment of a child under 12 years with an haemangioma causing functional impairment (not for cosmetic reasons only) For the treatment of a child under 12 years with cardiac arrthymias or congenital cardiac  abnormalities

any relevant practitioner 2

For the treatment of a child under 12 years with an haemangioma causing functional impairment (not for cosmetic reasons only) For the treatment of a child under 12 years with cardiac arrthymias or congenital cardiac  abnormalities

any relevant practitioner 2 Roxane-Propranolol 500 Hikma-Propranolol 500 Sotalol Tab 80 mg Mylan 500 40.00 40.00 40.00 0.00000 Tab 160 mg Mylan 100 20.00 20.00 20.00 0.00000 Carvedilol Tab 6.25 mg Carvedilol Sandoz 60 1.97 1.97 1.97 0.00000 Tab 12.5 mg Carvedilol Sandoz 60 2.03 2.03 2.03 0.00000 Tab 25 mg Carvedilol Sandoz 60 2.46 2.46 2.46 0.00000 Bisoprolol fumarate Tab 2.5 mg Ipca-Bisoprolol 90 1.36 1.36 1.36 0.00000 Tab 5 mg Ipca-Bisoprolol 90 1.91 1.91 1.91 0.00000 Tab 10 mg Ipca-Bisoprolol 90 2.71 2.71 2.71 0.00000 Calcium Channel Blockers Dihydropyridine Calcium Channel Blockers Nifedipine Tab long-acting 10 mg

Subsidised for patients who were taking nifedipine tab long-acting 10 mg prior to 1 July 2023 and the prescription is endorsed accordingly. Pharmacists may annotate the prescription as endorsed where there exists a record of prior dispensing of nifedipine tab long-acting 10 mg.

Tensipine MR10 56 19.42 19.42 19.42 0.00000 Tab long-acting 20 mg Nyefax Retard 100 17.72 17.72 17.72 0.00000 Valni Retard 56 9.92 9.92 9.92 0.00000 Tab long-acting 30 mg Mylan (24 hr release) 100 34.10 34.10 34.10 0.00000 Mylan Italy (24 hr release) 14 4.78 4.78 4.78 0.00000 Tab long-acting 60 mg Mylan (24 hr release) 100 52.81 52.81 52.81 0.00000 Felodipine Tab long-acting 5 mg Felo 5 ER 90 6.57 6.57 6.57 0.00000 Tab long-acting 10 mg Felo 10 ER 90 6.95 6.95 6.95 0.00000 Tab long-acting 2.5 mg Plendil ER 30 2.18 2.18 2.18 0.00000 Amlodipine Tab 5 mg Vasorex 90 1.21 1.21 1.21 0.00000 Tab 10 mg Vasorex 90 1.31 1.31 1.31 0.00000 Tab 2.5 mg Vasorex 90 1.45 1.45 1.45 0.00000 Other Calcium Channel Blockers Perhexiline maleate Tab 100 mg Pexsig 100 62.90 62.90 62.90 0.00000 Verapamil hydrochloride Tab 40 mg Isoptin 100 7.01 7.01 7.01 0.00000 Tab 80 mg Isoptin 100 11.74 11.74 11.74 0.00000 Inj 2.5 mg per ml, 2 ml ampoule Isoptin 5 1 25.00 25.00 25.00 0.00000 Tab long-acting 120 mg Isoptin SR 100 36.02 36.02 36.02 0.00000 Isoptin Retard 100 36.02 36.02 36.02 0.00000 Tab long-acting 240 mg Isoptin SR 30 15.12 15.12 15.12 0.00000 Diltiazem hydrochloride Cap long-acting 120 mg Diltiazem CD Clinect 500 65.35 65.35 65.35 0.00000 Cap long-acting 180 mg Cardizem CD 30 7.00 7.00 7.00 0.00000 Cap long-acting 240 mg Cardizem CD 30 9.30 9.30 9.30 0.00000 Centrally-Acting Agents Centrally-Acting Agents Clonidine Patch 2.5 mg, 100 mcg per day Mylan 4 11.70 11.70 11.70 0.00000 Patch 5 mg, 200 mcg per day Mylan 4 12.80 12.80 12.80 0.00000 Patch 7.5 mg, 300 mcg per day Mylan 4 17.90 17.90 17.90 0.00000 Clonidine hydrochloride Tab 150 mcg Catapres 100 40.41 40.41 40.41 0.00000 Inj 150 mcg per ml, 1 ml ampoule Catapres 5 1 14.10 14.10 14.10 0.00000 Tab 25 mcg Clonidine Teva 112 29.74 29.74 29.74 0.00000 Methyldopa Tab 250 mg Methyldopa Viatris 100 15.10 15.10 15.10 0.00000 Diuretics Loop Diuretics Bumetanide Tab 1 mg Burinex 100 16.36 16.36 16.36 0.00000 Inj 500 mcg per ml, 4 ml vial Burinex 5 1 7.95 7.95 7.95 0.00000 Furosemide [Frusemide] Tab 40 mg IPCA-Frusemide 1000 12.80 12.80 12.80 0.00000 Tab 500 mg Urex Forte 50 25.00 25.00 25.00 0.00000 Oral liq 10 mg per ml Lasix 30 11.20 11.20 11.20 0.00000 Inj 10 mg per ml, 2 ml ampoule Furosemide-Baxter 5 1 2.40 2.40 2.40 0.00000 Furosemide-AFT 10 1 3.97 3.97 3.97 0.00000 Inj 10 mg per ml, 25 ml ampoule Lasix 6 60.65 60.65 60.65 0.00000 Potassium Sparing Diuretics Amiloride hydrochloride Tab 5 mg Wockhardt 28 171.41 171.41 171.41 0.00000 Padagis 100 81.07 81.07 81.07 0.00000 Oral liq 1 mg per ml Biomed 25 35.40 35.40 35.40 0.00000 Spironolactone Tab 25 mg Spiractin 100 4.20 4.20 4.20 0.00000 Tab 100 mg Spiractin 100 11.40 11.40 11.40 0.00000 Oral liq 5 mg per ml Biomed 25 35.70 35.70 35.70 0.00000 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

any relevant practitioner Tab 25 mg Inspra 30 15.84 15.84 15.84 0.00000 Tab 50 mg Inspra 30 25.00 25.00 25.00 0.00000 Potassium Sparing Combination Diuretics Amiloride hydrochloride with furosemide Tab 5 mg with furosemide 40 mg Frumil 28 8.63 8.63 8.63 0.00000 Amiloride hydrochloride with hydrochlorothiazide Tab 5 mg with hydrochlorothiazide 50 mg Moduretic 50 5.00 5.00 5.00 0.00000 Thiazide and Related Diuretics Bendroflumethiazide [Bendrofluazide] Tab 2.5 mg

May be supplied on a PSO for reasons other than emergency.

Arrow-Bendrofluazide 500 51.50 51.50 51.50 0.00000 Tab 5 mg Arrow-Bendrofluazide 500 61.00 61.00 61.00 0.00000 Chlorothiazide Oral liq 50 mg per ml Biomed 25 30.67 30.67 30.67 0.00000 Chlortalidone [Chlorthalidone] Tab 25 mg Hygroton 50 6.95 6.95 6.95 0.00000 Indapamide Tab 2.5 mg Dapa-Tabs 90 16.00 16.00 16.00 0.00000 Metolazone Tab 5 mg Zaroxolyn 50 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 Tab 15 mg Jinarc 28 873.50 873.50 873.50 0.00000 Tab 30 mg Jinarc 28 873.50 873.50 873.50 0.00000 Tab 45 mg + 15 mg Jinarc 56 1747.00 1747.00 1747.00 0.00000 Tab 60 mg + 30 mg Jinarc 56 1747.00 1747.00 1747.00 0.00000 Tab 90 mg + 30 mg Jinarc 56 1747.00 1747.00 1747.00 0.00000 Lipid-Modifying Agents Fibrates Bezafibrate Tab 200 mg Bezalip 90 22.65 22.65 22.65 0.00000 Tab long-acting 400 mg Bezalip Retard 30 21.54 21.54 21.54 0.00000 Other Lipid-Modifying Agents Acipimox Cap 250 mg Olbetam 30 38.19 38.19 38.19 0.00000 Resins Colestyramine Powder for oral suspension 4 g sachet Colestyramine - Mylan 50 61.50 61.50 61.50 0.00000 Quantalan sugar free 50 61.50 61.50 61.50 0.00000 HMG CoA Reductase Inhibitors (Statins) Atorvastatin Tab 10 mg Lorstat 500 5.16 5.16 5.16 0.00000 30 0.31 0.31 0.31 0.00000 Tab 20 mg Lorstat 500 8.12 8.12 8.12 0.00000 Tab 40 mg Lorstat 500 13.79 13.79 13.79 0.00000 Tab 80 mg Lorstat 500 25.39 25.39 25.39 0.00000 30 1.52 1.52 1.52 0.00000 Simvastatin Tab 10 mg Simvastatin Mylan 90 1.68 1.68 1.68 0.00000 Simvastatin Viatris 90 1.68 1.68 1.68 0.00000 Tab 20 mg Simvastatin Viatris 90 2.54 2.54 2.54 0.00000 Tab 40 mg Simvastatin Viatris 90 4.11 4.11 4.11 0.00000 Tab 80 mg Simvastatin Viatris 90 8.81 8.81 8.81 0.00000 Pravastatin Tab 20 mg Clinect 100 7.16 7.16 7.16 0.00000 Tab 40 mg Clinect 100 12.25 12.25 12.25 0.00000 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

any relevant 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

any relevant 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

any relevant 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

any relevant practitioner Tab 5 mg Rosuvastatin Viatris 30 1.29 1.29 1.29 0.00000 Rosuvastatin - Sandoz 30 4.21 4.21 4.21 0.00000 Tab 10 mg Rosuvastatin Viatris 30 1.69 1.69 1.69 0.00000 Rosuvastatin - Sandoz 30 4.21 4.21 4.21 0.00000 Tab 20 mg Rosuvastatin Viatris 30 2.71 2.71 2.71 0.00000 Rosuvastatin - Sandoz 30 4.21 4.21 4.21 0.00000 Tab 40 mg Rosuvastatin Viatris 30 4.55 4.55 4.55 0.00000 Rosuvastatin - Sandoz 30 4.55 4.55 4.55 0.00000 Selective Cholesterol Absorption Inhibitors Ezetimibe Tab 10 mg Ezetimibe Sandoz 30 1.76 1.76 1.76 0.00000 Ezetimibe with simvastatin Tab 10 mg with simvastatin 20 mg Zimybe 30 12.55 12.55 12.55 0.00000 Tab 10 mg with simvastatin 40 mg Vytorin 30 11.55 11.55 11.55 0.00000 Zimybe 30 11.55 11.55 11.55 0.00000 Tab 10 mg with simvastatin 80 mg Zimybe 30 14.27 14.27 14.27 0.00000 30 14.27 14.27 14.27 0.00000 Tab 10 mg with simvastatin 10 mg Zimybe 30 11.86 11.86 11.86 0.00000 Nitrates Nitrates Glyceryl trinitrate Patch 50 mg, 10 mg per day Nitroderm TTS 30 18.62 18.62 18.62 0.00000 Patch 25 mg, 5 mg per day Nitroderm TTS 30 15.73 15.73 15.73 0.00000 Oral pump spray, 400 mcg per dose Nitrolingual Pump Spray 250 7.48 7.48 7.48 0.00000 Isosorbide mononitrate Tab 20 mg Ismo 20 100 22.49 22.49 22.49 0.00000 Tab long-acting 40 mg Ismo 40 Retard 30 9.80 9.80 9.80 0.00000 Tab long-acting 60 mg Duride 90 13.50 13.50 13.50 0.00000 Sympathomimetics Sympathomimetics Adrenaline Inj 1 in 1,000, 1 ml ampoule

Note: adrenaline inj 1 in 1,000, 1 ml ampoule can be supplied on BSO to a Vaccinator (other than a Pharmacist) under the provisions in Part I of Section A
Note: Direct Provision by a pharmacist of Inj 1 in 1,000, 1 ml ampoule permitted under the provisions in Part I of Section A.

DBL Adrenaline 5 1 17.78 17.78 17.78 0.00000 Aspen Adrenaline 5 1 4.98 4.98 4.98 0.00000 Inj 1 in 10,000, 10 ml ampoule DBL Adrenaline 5 1 36.18 36.18 36.18 0.00000 Aspen Adrenaline 10 1 49.00 49.00 49.00 0.00000 Vasodilators Vasodilators Hydralazine hydrochloride Tab 25 mg <range>Hydralazine</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

any relevant practitioner Hydralazine 1 Onelink 56 AMDIPHARM 84 Camber 100 Inj 20 mg ampoule Apresoline 5 1 25.90 25.90 25.90 0.00000 5 1 25.90 25.90 25.90 0.00000 Hydrapres 5 25.90 25.90 25.90 0.00000 Inj 20 mg per ml, 1 ml vial Eugia 25 1 283.00 283.00 283.00 0.00000 Papaverine hydrochloride Inj 12 mg per ml, 10 ml ampoule Hospira 5 1 257.12 257.12 257.12 0.00000 Minoxidil Tab 10 mg Loniten 100 78.40 78.40 78.40 0.00000 Minoxidil Roma 60 47.04 47.04 47.04 0.00000 Pentoxifylline [Oxpentifylline] Tab 400 mg Trental 400 50 44.37 44.37 44.37 0.00000 Nicorandil Tab 10 mg Max Health 60 27.81 27.81 27.81 0.00000 Tab 20 mg Max Health 60 35.12 35.12 35.12 0.00000 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.

Tab 62.5 mg Bosentan Dr Reddy's 60 100.00 100.00 100.00 0.00000 Tab 125 mg Bosentan Dr Reddy's 60 100.00 100.00 100.00 0.00000 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

Tab 5 mg Ambrisentan Viatris 30 200.00 200.00 200.00 0.00000 Tab 10 mg Ambrisentan Viatris 30 200.00 200.00 200.00 0.00000 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 (avoidance of cold exposure, sufficient protection, smoking cessation support, avoidance of
          sympathomimetic drugs) Patient is being treated with calcium channel blockers and nitrates (or these are contraindicated/not tolerated)

any relevant 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 greater than 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

Patient has a documented history of traumatic or non-traumatic spinal cord injury Patient has erectile dysfunction secondary to spinal cord injury requiring pharmacological treatment

any relevant practitioner 6

The treatment remains appropriate and the patient is benefiting from treatment

any relevant practitioner 2

Indications marked with * are Unapproved Indications.

Tab 25 mg Vedafil 4 0.72 0.72 0.72 0.00000 Tab 50 mg Vedafil 4 1.45 1.45 1.45 0.00000 Tab 100 mg Vedafil 12 11.22 11.22 11.22 0.00000 Prostacyclin Analogues Iloprost <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 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 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 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

Nebuliser soln 10 mcg per ml, 2 ml Vebulis 30 166.53 166.53 166.53 0.00000 Vebulis S29 30 166.53 166.53 166.53 0.00000 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 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 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

Inj 500 mcg vial Veletri 1 1 36.61 36.61 36.61 0.00000 Inj 1.5 mg vial Veletri 1 1 73.21 73.21 73.21 0.00000 Dermatologicals Antiacne Preparations

For systemic antibacterials, refer to INFECTIONS, Antibacterials

Antiacne Preparations Isotretinoin <range>Isotretinoin</range>

Applicant is a vocationally registered dermatologist,
          paediatrician, vocationally registered general practitioner, or nurse practitioner working
          in a relevant scope of practice Applicant has an up to date knowledge of the safety
          issues around isotretinoin and is competent to prescribe isotretinoin Patient is of child bearing potential and the
            possibility of pregnancy has been excluded prior to commencement of treatment and
            patient has been counselled and understands the risk of teratogenicity if isotretinoin
            is used during pregnancy and that they must not become pregnant during treatment and for
            a period of one month after the completion of treatment Patient is not of child bearing potential Patient is a child and it is considered not
            appropriate to exclude pregnancy or start contraceptives or undertake pregnancy-related
            isotretinoin counselling

any relevant practitioner 1

Patient is of child bearing potential and the
          possibility of pregnancy has been excluded prior to commencement of treatment and patient
          has been counselled and understands the risk of teratogenicity if isotretinoin is used
          during pregnancy and that they must not become pregnant during treatment and for a period
          of one month after the completion of treatment Patient is not of child bearing potential Patient is a child and it is considered not
          appropriate to exclude pregnancy or start contraceptives or undertake pregnancy-related
          isotretinoin counselling

any relevant practitioner 1

The patient has neuroblastoma Patient is of child bearing potential and the
            possibility of pregnancy has been excluded prior to commencement of treatment and
            patient has been counselled and understands the risk of teratogenicity if isotretinoin
            is used during pregnancy and that they must not become pregnant during treatment and for
            a period of one month after the completion of treatment Patient is not of child bearing potential Patient is a child and it is considered not
            appropriate to exclude pregnancy or start contraceptives or undertake pregnancy-related
            isotretinoin counselling

any relevant practitioner 6

The patient has neuroblastoma Patient is of child bearing potential and the
            possibility of pregnancy has been excluded prior to commencement of treatment and
            patient has been counselled and understands the risk of teratogenicity if isotretinoin
            is used during pregnancy and that they must not become pregnant during treatment and for
            a period of one month after the completion of treatment Patient is not of child bearing potential Patient is a child and it is considered not
            appropriate to exclude pregnancy or start contraceptives or undertake pregnancy-related
            isotretinoin counselling

any relevant practitioner 12 Cap 10 mg Oratane 120 18.75 18.75 18.75 0.00000 Cap 20 mg Oratane 120 26.73 26.73 26.73 0.00000 Cap 5 mg Oratane 60 11.26 11.26 11.26 0.00000 Tretinoin Crm 0.5 mg per g

Maximum of 50 g per three months

ReTrieve 50 16.82 16.82 16.82 0.00000 Adapalene

Maximum of 30 g per three months

Gel 0.1% Differin 30 22.89 22.89 22.89 0.00000 Antibacterials Topical

For systemic antibacterials, refer to INFECTIONS, Antibacterials

Antibacterials Topical Sodium Fusidate [fusidic acid] Crm 2% Foban 5 1.69 1.69 1.69 0.00000 Oint 2% Foban 5 1.69 1.69 1.69 0.00000 Mupirocin Oint 2% Bactroban 15 6.60 13.00 6.60 0.42667 Sulfadiazine Silver Crm 1% Flamazine 50 10.80 10.80 10.80 0.00000 Hydrogen peroxide Crm 1% Crystaderm 15 4.89 4.89 4.89 0.00000 Antifungals Topical

For systemic antifungals, refer to INFECTIONS, Antifungals

Antifungals Topical Clotrimazole Soln 1% Canesten 20 4.36 11.58 4.36 0.36100 Crm 1% Clomazol 20 1.15 1.15 1.15 0.00000 Econazole nitrate Foaming soln 1%, 10 ml sachets Pevaryl 3 9.89 18.64 9.89 2.91667 Crm 1% Pevaryl 20 8.04 8.04 8.04 0.00000 Miconazole nitrate Lotn 2% Daktarin 30 4.36 10.03 4.36 0.18900 Tinct 2% Daktarin 30 4.36 12.10 4.36 0.25800 Crm 2% Multichem 15 0.90 0.90 0.90 0.00000 Amorolfine Nail soln 5% MycoNail 5 21.87 21.87 21.87 0.00000 Antipruritic Preparations Antipruritic Preparations Calamine Crm, aqueous, BP healthE Calamine Aqueous 100 3.45 3.45 3.45 0.00000 Crotamiton Crm 10% Itch-Soothe 20 3.49 3.49 3.49 0.00000 Menthol

Only in combination with a dermatological base or proprietary Topical Corticosteriod – Plain
With or without other dermatological galenicals.

Crystals MidWest 100 36.80 36.80 36.80 0.00000 25 12.60 12.60 12.60 0.00000 Corticosteroids Topical

For systemic corticosteroids, refer to CORTICOSTEROIDS AND RELATED AGENTS

Corticosteroids - Plain Methylprednisolone aceponate Crm 0.1% Advantan 15 4.95 4.95 4.95 0.00000 Oint 0.1% Advantan 15 4.95 4.95 4.95 0.00000 Betamethasone dipropionate Crm 0.05% Diprosone 15 2.96 2.96 2.96 0.00000 50 36.00 36.00 36.00 0.00000 Oint 0.05% Diprosone 15 2.96 2.96 2.96 0.00000 50 36.00 36.00 36.00 0.00000 Oint 0.05% in propylene glycol base Diprosone OV 30 4.33 4.33 4.33 0.00000 Clobetasol propionate Crm 0.05% Dermol 30 3.75 3.75 3.75 0.00000 Oint 0.05% Dermol 30 3.68 3.68 3.68 0.00000 Clobetasone butyrate Crm 0.05% Eumovate 30 5.38 10.00 5.38 0.15400 30 5.38 10.00 5.38 0.15400 Hydrocortisone and paraffin liquid and lanolin Lotn 1% with paraffin liquid 15.9% and lanolin 0.6% DP Lotn HC 250 12.83 12.83 12.83 0.00000 Hydrocortisone butyrate Oint 0.1% Locoid 100 10.28 10.28 10.28 0.00000 Lipocream 0.1% Locoid Lipocream 100 4.85 4.85 4.85 0.00000 Milky emul 0.1% Locoid Crelo 100 12.33 12.33 12.33 0.00000 Hydrocortisone Powder

Up to 5% in a dermatological base (not proprietary Topical Corticosteriod – Plain) with or without other dermatological galenicals

ABM 25 49.95 49.95 49.95 0.00000 Crm 1% Ethics 30 1.75 1.75 1.75 0.00000 Noumed 500 20.40 20.40 20.40 0.00000 Triamcinolone acetonide Crm 0.02% Aristocort 100 6.49 6.49 6.49 0.00000 Oint 0.02% Aristocort 100 6.54 6.54 6.54 0.00000 Betamethasone valerate Lotn 0.1% Betnovate 50 30.00 30.00 30.00 0.00000 Crm 0.1% Beta Cream 50 5.85 5.85 5.85 0.00000 Oint 0.1% Beta Ointment 50 7.90 7.90 7.90 0.00000 Mometasone furoate Lotn 0.1% Elocon 30 4.99 4.99 4.99 0.00000 Crm 0.1% Elocon Alcohol Free 15 2.25 2.25 2.25 0.00000 50 3.50 3.50 3.50 0.00000 Oint 0.1% Elocon 15 2.25 2.25 2.25 0.00000 50 3.50 3.50 3.50 0.00000 Corticosteroids - Combination Betamethasone valerate with sodium fusidate [fusidic acid] Crm 0.1% with sodium fusidate (fusidic acid) 2% Fucicort 15 3.49 10.45 3.49 0.46400 Hydrocortisone with miconazole Crm 1% with miconazole nitrate 2% Micreme H 15 2.85 2.85 2.85 0.00000 Hydrocortisone with natamycin and neomycin Oint 1% with natamycin 1% and neomycin sulphate 0.5% Pimafucort 15 4.34 4.34 4.34 0.00000 Triamcinolone acetonide with gramicidin, neomycin and nystatin Crm 1 mg with nystatin 100,000 u, neomycin sulphate 2.5 mg and gramicidin 250 mcg per g Viaderm KC 15 3.49 9.28 3.49 0.38600 Barrier Creams and Emollients Barrier Creams Dimethicone Crm 5% pump bottle healthE Dimethicone 5% 460 4.30 4.30 4.30 0.00000 Hydralock 460 4.14 4.14 4.14 0.00000 Crm 10% pump bottle healthE Dimethicone 10% 460 4.52 4.52 4.52 0.00000 Zinc and castor oil Oint Evara 500 4.25 4.25 4.25 0.00000 Emollients Urea Crm 10% healthE Urea Cream 100 1.37 1.37 1.37 0.00000 Wool fat with mineral oil Lotn hydrous 3% with mineral oil Alpha-Keri Lotion 1000 5.60 20.53 5.60 0.01493 BK Lotion 250 1.40 7.73 1.40 0.02532 1000 5.60 23.91 5.60 0.01831 DP Lotion 250 1.40 5.87 1.40 0.01788 1000 5.60 14.96 5.60 0.00936 Aqueous cream Crm Evara 500 1.65 1.65 1.65 0.00000 Cetomacrogol Crm BP Cetomacrogol-AFT 500 2.29 2.29 2.29 0.00000 Emulsifying ointment Oint BP Evara Emulsifying Ointment 500 3.13 3.13 3.13 0.00000 Paraffin Oint liquid paraffin 50% with white soft paraffin 50% White Soft Liquid Paraffin AFT 500 4.94 4.94 4.94 0.00000 EVARA Paraffin Ointment 50/50 500 4.45 4.45 4.45 0.00000 Oil in water emulsion Crm Fatty Emulsion Cream (Evara) 500 2.10 2.10 2.10 0.00000 Cetomacrogol with glycerol Crm 90% with glycerol 10% Evara 460 1.92 1.92 1.92 0.00000 920 3.25 3.25 3.25 0.00000 Other Dermatological Bases Paraffin White soft

Only in combination with a dermatological galenical or as a diluent for a proprietary Topical Corticosteroid – Plain.

EVARA White Soft Paraffin 450 4.74 4.74 4.74 0.00000 2500 19.00 19.00 19.00 0.00000 Minor Skin Infections Minor Skin Infections Povidone iodine Oint 10% Betadine 65 7.40 7.40 7.40 0.00000 Antiseptic soln 10% Riodine 500 6.99 6.99 6.99 0.00000 15 3.83 3.83 3.83 0.00000 Skin preparation, povidone iodine 10% with 30% alcohol Betadine Skin Prep 100 1.63 3.48 1.63 0.01850 Antiseptic Solution 10% Riodine 100 4.99 4.99 4.99 0.00000 Parasiticidal Preparations Parasiticidal Preparations Dimethicone Lotn 4% healthE Dimethicone 4% Lotion 200 4.60 4.60 4.60 0.00000 Permethrin Lotn 5% A-Scabies 30 4.28 4.28 4.28 0.00000 Ivermectin <range>Ivermectin</range>

The person has a severe scabies hyperinfestation
          (Crusted/ Norwegian scabies) The person has a confirmed diagnosis of scabies or
            is a close contact of a scabies case The person is unable to complete topical
              therapy Previous treatment with topical therapy has been
              tried and not cleared the infestation

any relevant practitioner 1

filariasis cutaneous larva migrans (creeping eruption) strongyloidiasis The individual has a travel or residence history that requires presumptive parasite treatment

any relevant practitioner 1

The person has a severe scabies hyperinfestation
          (Crusted/ Norwegian scabies) The person has a confirmed diagnosis of scabies or
            is a close contact of a scabies case The person is unable to complete topical
              therapy Previous treatment with topical therapy has been
              tried and not cleared the infestation

any relevant practitioner 1

filariasis cutaneous larva migrans (creeping eruption) strongyloidiasis

any relevant practitioner 1 Tab 3 mg

PSO for institutional use only. Must be endorsed with the name of the institution for which the PSO is required and a valid Special Authority for patient of that institution.
Ivermectin available on BSO provided the BSO includes a valid Special Authority for a patient of the institution.
For the purposes of subsidy of ivermectin, institution means age related residential care facilities, disability care facilities or prisons.

Stromectol 4 17.20 17.20 17.20 0.00000 4 17.20 17.20 17.20 0.00000 Psoriasis and Eczema Preparations Psoriasis and Eczema Preparations Tacrolimus Oint 0.1%

Note: a maximum of 30 g per prescription and no more than one prescription per 12 weeks.

<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 any relevant practitioner Zematop 30 33.00 33.00 33.00 0.00000 Coal tar with allantoin, menthol, phenol and sulphur Soln 5% with sulphur 0.5%, menthol 0.75%, phenol 0.5% and allantoin crm 2.5% Egopsoryl TA 30 3.43 4.35 3.43 0.03067 75 6.59 8.00 6.59 0.01880 Pine tar with trolamine laurilsulfate and fluorescein Soln 2.3% with trolamine laurilsulfate and fluorescein sodium Pinetarsol 500 5.41 5.41 5.41 0.00000 Acitretin <range>Acitretin</range>

Applicant is a vocationally registered dermatologist,
          vocationally registered general practitioner, or nurse practitioner working in a relevant
          scope of practice Applicant has an up to date knowledge of the safety
          issues around acitretin and is competent to prescribe acitretin Patient is of child bearing potential and the
            possibility of pregnancy has been excluded prior to commencement of treatment and
            patient has been counselled and understands the risk of teratogenicity if acitretin
            is used during pregnancy and that they must not become pregnant during treatment and for
            a period of three years after the completion of treatment Patient is not of child bearing potential

any relevant practitioner 1

Patient is of child bearing potential and the
          possibility of pregnancy has been excluded prior to commencement of treatment and patient
          has been counselled and understands the risk of teratogenicity if acitretin is used
          during pregnancy and that they must not become pregnant during treatment and for a period
          of three years after the completion of treatment Patient is not of child bearing potential

any relevant practitioner 1 Cap 10 mg Novatretin 60 26.20 26.20 26.20 0.00000 Cap 25 mg Novatretin 60 57.37 57.37 57.37 0.00000 Calcipotriol Oint 50 mcg per g Daivonex 120 40.00 40.00 40.00 0.00000 Coal tar Soln BP

Up to 10% only in combination with a dermatological base or proprietary Topical Corticosteriod – Plain
With or without other dermatological galenicals.

Midwest 200 46.00 46.00 46.00 0.00000 Salicylic acid Powder

Only in combination with a dermatological base or proprietary Topical Corticosteroid – Plain or collodion flexible
With or without other dermatological galenicals.

Midwest 250 29.00 29.00 29.00 0.00000 Sulphur Precipitated

Only in combination with a dermatological base or proprietary Topical Corticosteroid – Plain
With or without other dermatological galenicals.

Midwest 100 6.35 6.35 6.35 0.00000 Coal tar with salicylic acid and sulphur Soln 12% with salicylic acid 2% and sulphur 4% oint Coco-Scalp 40 7.95 7.95 7.95 0.00000 Betamethasone dipropionate with calcipotriol Oint 500 mcg with calcipotriol 50 mcg per g Daivobet 30 14.31 14.31 14.31 0.00000 Gel 500 mcg with calcipotriol 50 mcg per g Daivobet 60 40.92 40.92 40.92 0.00000 Foam spray 500 mcg with calcipotriol 50 mcg per g Enstilar 60 59.95 59.95 59.95 0.00000 Pimecrolimus

Note: a maximum of 15 g per prescription and no more than one prescription per 12 weeks.

<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 any relevant practitioner Cream 1% Elidel 15 33.00 33.00 33.00 0.00000 Scalp Preparations Scalp Preparations Clobetasol propionate Scalp app 0.05% Dermol 30 6.90 6.90 6.90 0.00000 Hydrocortisone butyrate Scalp lotn 0.1% Locoid 100 6.57 6.57 6.57 0.00000 Ketoconazole Shampoo 2% Sebizole 100 4.09 4.09 4.09 0.00000 Betamethasone valerate Scalp app 0.1% Beta Scalp 100 12.95 12.95 12.95 0.00000 Sunscreens Sunscreens Sunscreens, proprietary

Only if prescribed for a patient with severe photosensitivity secondary to a defined clinical condition and the prescription is endorsed accordingly.

Lotn, Marine Blue Lotion SPF 50+ 200 6.50 6.50 6.50 0.00000 Wart Preparations Wart Preparations

For salicylic acid preparations refer to PSORIASIS AND ECZEMA PREPARATIONS

Podophyllotoxin Soln 0.5% Condyline 3.5 33.60 33.60 33.60 0.00000 Condyline S29 3.5 33.60 33.60 33.60 0.00000 Other Skin Preparations Antineoplastics Fluorouracil sodium Crm 5% Efudix 20 5.56 5.56 5.56 0.00000 Other Skin Preparations Imiquimod Crm 5%, 250 mg sachet Perrigo 24 21.72 21.72 21.72 0.00000 Padagis 24 21.72 21.72 21.72 0.00000 Aldara 12 34.50 34.50 34.50 0.00000 Genito-Urinary System Contraceptives - Non-hormonal Condoms Condoms 53 mm Moments 144 14.25 14.25 14.25 0.00000 10 1.15 1.15 1.15 0.00000 49 mm Moments 144 14.25 14.25 14.25 0.00000 60 mm Gold Knight XL 12 1.82 1.82 1.82 0.00000 144 21.89 21.89 21.89 0.00000 56 mm Moments 144 14.50 14.50 14.50 0.00000 10 1.15 1.15 1.15 0.00000 53 mm, 0.05 mm thickness Moments 144 14.25 14.25 14.25 0.00000 10 1.15 1.15 1.15 0.00000 53 mm, strawberry, red Moments 144 14.25 14.25 14.25 0.00000 10 1.15 1.15 1.15 0.00000 53 mm, chocolate, brown Moments 144 14.25 14.25 14.25 0.00000 10 1.15 1.15 1.15 0.00000 56 mm, 0.08 mm thickness Moments 144 14.25 14.25 14.25 0.00000 10 1.15 1.15 1.15 0.00000 56 mm, 0.08 mm thickness, red Moments 144 14.25 14.25 14.25 0.00000 10 1.15 1.15 1.15 0.00000 56 mm, 0.05 mm thickness Gold Knight 144 24.10 24.10 24.10 0.00000 12 2.00 2.00 2.00 0.00000 56 mm, chocolate Gold Knight 144 21.45 21.45 21.45 0.00000 12 1.79 1.79 1.79 0.00000 56 mm, strawberry Gold Knight 144 21.45 21.45 21.45 0.00000 12 1.79 1.79 1.79 0.00000 60 mm (bulk pack) Gold Knight XL 144 17.78 17.78 17.78 0.00000 56 mm, 0.05mm thickness (bulk pack) Gold Knight 144 20.17 20.17 20.17 0.00000 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 29.80 29.80 0.00000 IUD 33.6 mm length x 29.9 mm width TCu 380 Plus Normal 1 26.80 26.80 26.80 0.00000 IUD 35.5 mm length x 19.6 mm width Cu 375 Standard 1 33.00 33.00 33.00 0.00000 Contraceptives - Hormonal Combined Oral Contraceptives Ethinyloestradiol with norethisterone Tab 35 mcg with norethisterone 500 mcg and 7 inert tab Norimin 84 28 23.75 23.75 23.75 0.00000 112 28 29.32 29.32 29.32 0.00000 Tab 35 mcg with norethisterone 1 mg and 7 inert tab Brevinor 1/28 84 28 14.09 14.09 14.09 0.00000 Ethinyloestradiol with desogestrel Tab 20 mcg with desogestrel 150 mcg and 7 inert tab Mercilon 28 84 28 10.00 10.00 10.00 0.00000 Ethinyloestradiol with levonorgestrel Tab 30 mcg with levonorgestrel 150 mcg and 7 inert tablets Oralcon 30 ED 84 2.30 2.30 2.30 0.00000 Tab 20 mcg with levonorgestrel 100 mcg and 7 inert tablets Lo-Oralcon 20 ED 84 2.00 2.00 2.00 0.00000 Progestogen-only Contraceptives Levonorgestrel Tab 30 mcg Microlut 112 28 22.00 22.00 22.00 0.00000 Intra-uterine device 52 mg Mirena 1 269.50 269.50 269.50 0.00000 Intra-uterine device 13.5 mg Jaydess 1 215.60 215.60 215.60 0.00000 Subdermal implant (2 x 75 mg rods) Jadelle 2 106.92 106.92 106.92 0.00000 Medroxyprogesterone acetate Inj 150 mg per ml, 1 ml syringe Depo-Provera 1 1 10.56 10.56 10.56 0.00000 Norethisterone Tab 350 mcg Noriday 28 84 28 13.23 13.23 13.23 0.00000 Noriday 84 28 12.25 12.25 12.25 0.00000 Desogestrel Tab 75 mcg Cerazette 84 28 24.50 24.50 24.50 0.00000 Emergency Contraceptives Levonorgestrel Tab 1.5 mg

Note: Direct Provision by a pharmacist permitted under the provisions in Part I of Section A.

Levonorgestrel BNM 1 1.75 1.75 1.75 0.00000 Levonorgestrel -1 (Lupin) 1 1.31 1.31 1.31 0.00000 Antiandrogen Oral Contraceptives Antiandrogen Oral Contraceptives

Prescribers may code prescriptions “contraceptive” (code “O”) when used as indicated for contraception. The period of supply and prescription charge will be as per other contraceptives, as follows:

A maximum $5.00 prescription charge (patient co-payment) may apply.
prescription may be written for up to six months supply.

Prescriptions coded in any other way are subject to any non contraceptive prescription charges that apply, and the non-contraceptive period of supply. ie. Prescriptions may be written for up to three months supply.

Cyproterone acetate with ethinyloestradiol Tab 2 mg with ethinyloestradiol 35 mcg and 7 inert tabs Ginet 168 28 5.08 5.08 5.08 0.00000 Gynaecological Anti-infectives Gynaecological Anti-infectives Acetic acid with hydroxyquinoline and ricinoleic acid Jelly with glacial acetic acid 0.94%, hydroxyquinoline sulphate 0.025%, glycerol 5% and ricinoleic acid 0.75% with applicator Aci-Jel 100 8.43 24.87 8.43 0.16440 Clotrimazole Vaginal crm 1% with applicators Clomazol 35 4.20 4.20 4.20 0.00000 Vaginal crm 2% with applicators Clomazol 20 4.60 4.60 4.60 0.00000 Miconazole nitrate Vaginal crm 2% with applicator Micreme 40 6.89 6.89 6.89 0.00000 Nystatin Vaginal crm 100,000 u per 5 g with applicator(s) Nilstat 75 5.70 5.70 5.70 0.00000 Myometrial and Vaginal Hormone Preparations Myometrial and Vaginal Hormone Preparations Ergometrine maleate Inj 500 mcg per ml, 1 ml ampoule DBL Ergometrine 5 1 160.00 160.00 160.00 0.00000 Oxytocin with ergometrine maleate Inj 5 iu with ergometrine maleate 500 mcg per ml, 1 ml ampoule Syntometrine 5 1 41.47 41.47 41.47 0.00000 Oxytocin Inj 5 iu per ml, 1 ml ampoule Oxytocin BNM 5 1 5.98 5.98 5.98 0.00000 Inj 10 iu per ml, 1 ml ampoule Oxytocin BNM 5 1 7.18 7.18 7.18 0.00000 Oestriol Crm 1 mg per g with applicator Ovestin 15 6.95 6.95 6.95 0.00000 Pessaries 500 mcg Ovestin 15 7.55 7.55 7.55 0.00000 Pregnancy Tests - hCG Urine Pregnancy Tests - hCG Urine Pregnancy tests - HCG urine Cassette David One Step Cassette Pregnancy Test 40 16.00 16.00 16.00 0.00000 Beta-hCG low sensitivity urine test kit

Note: For use in abortion services only.

Midstream CheckTop 1 16.28 16.28 16.28 0.00000 Urinary Agents

For urinary tract Infections refer to INFECTIONS, Antibacterials

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

any relevant practitioner Tab 5 mg Ricit 100 4.79 4.79 4.79 0.00000 Alpha-1A Adrenoreceptor 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

any relevant practitioner Cap 400 mcg Tamsulosin-Rex 100 28.56 28.56 28.56 0.00000 Other Urinary Agents Oxybutynin Tab 5 mg Alchemy Oxybutynin 100 5.42 5.42 5.42 0.00000 Sodium citro-tartrate Grans eff 4 g sachets Ural 28 3.50 3.50 3.50 0.00000 Potassium citrate Oral liq 3 mmol per ml <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

any relevant practitioner 12

The treatment remains appropriate and the patient is benefitting from the treatment

any relevant practitioner 2 Biomed 200 37.49 37.49 37.49 0.00000 Solifenacin succinate Tab 5 mg Solifenacin succinate Max Health 30 1.95 1.95 1.95 0.00000 Tab 10 mg Solifenacin succinate Max Health 30 3.53 3.53 3.53 0.00000 Detection of Substances in Urine Detection of Substances in Urine Ortho-tolidine Compound diagnostic sticks Hemastix 50 7.50 8.25 7.50 0.01500 Tetrabromophenol Blue diagnostic strips Albustix 100 13.92 13.92 13.92 0.00000 Obstetric Preparations Antiprogesterones Mifepristone Tab 200 mg Mifegyne 3 180.00 180.00 180.00 0.00000 1 83.90 83.90 83.90 0.00000 Hormone Preparations - Systemic Excluding Contraceptive Hormones Calcium Homeostasis Calcium Homeostasis Calcitonin Inj 100 iu per ml, 1 ml ampoule Miacalcic 5 1 121.00 121.00 121.00 0.00000 Miacalcic S29 5 121.00 121.00 121.00 0.00000 Zoledronic acid Inj 4 mg per 5 ml, vial Zoledronic acid Viatris 1 1 15.65 15.65 15.65 0.00000 Zoledronic acid Injection Mylan 1 1 15.65 15.65 15.65 0.00000 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

any relevant 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

any relevant 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

any relevant practitioner 12 Tab 30 mg Cinacalet Devatis 28 25.24 25.24 25.24 0.00000 Tab 60 mg Cinacalet Devatis 28 50.47 50.47 50.47 0.00000 Corticosteroids and Related Agents for Systemic Use Corticosteroids and Related Agents for Systemic Use Dexamethasone Tab 4 mg Dexmethsone 30 3.18 3.18 3.18 0.00000 Oral liq 1 mg per ml Biomed 25 53.86 53.86 53.86 0.00000 Tab 0.5 mg Dexmethsone 30 1.80 1.80 1.80 0.00000 Dexamethasone phosphate

Dexamethasone phosphate injection will not be funded for oral use.

Inj 4 mg per ml, 1 ml ampoule Dexamethasone Medsurge 10 6.88 6.88 6.88 0.00000 Inj 4 mg per ml, 2 ml ampoule Dexamethasone Medsurge 10 10.98 10.98 10.98 0.00000 Fludrocortisone acetate Tab 100 mcg Florinef 100 8.05 8.05 8.05 0.00000 Hydrocortisone Tab 5 mg Douglas 100 8.10 8.10 8.10 0.00000 Tab 20 mg Douglas 100 20.32 20.32 20.32 0.00000 Inj 100 mg vial Solu-Cortef 1 1 3.96 3.96 3.96 0.00000 Methylprednisolone acetate Inj 40 mg per ml, 1 ml vial Depo-Medrol 5 1 47.06 47.06 47.06 0.00000 Methylprednisolone Tab 4 mg Medrol 100 112.00 112.00 112.00 0.00000 Tab 100 mg Medrol 20 223.10 223.10 223.10 0.00000 Methylprednisolone (as sodium succinate) Inj 40 mg vial Solu-Medrol-Act-O-Vial 1 1 22.30 22.30 22.30 0.00000 Inj 125 mg vial Solu-Medrol-Act-O-Vial 1 1 34.10 34.10 34.10 0.00000 Inj 500 mg vial Solu-Medrol-Act-O-Vial 1 1 43.01 43.01 43.01 0.00000 Inj 1 g vial Solu-Medrol 1 1 52.54 52.54 52.54 0.00000 Prednisolone Oral liq 5 mg per ml

Restricted to children under 12 years of age.

Redipred 30 6.00 6.00 6.00 0.00000 Prednisone Tab 1 mg Prednisone Clinect 500 18.58 18.58 18.58 0.00000 Tab 2.5 mg Prednisone Clinect 500 21.04 21.04 21.04 0.00000 Tab 5 mg Prednisone Clinect 500 19.30 19.30 19.30 0.00000 Tab 20 mg Prednisone Clinect 500 50.51 50.51 50.51 0.00000 Tetracosactrin Inj 250 mcg per ml, 1 ml ampoule Synacthen 1 1 86.25 86.25 86.25 0.00000 UK Synacthen 1 1 86.25 86.25 86.25 0.00000 Inj 1 mg per ml, 1 ml ampoule Synacthen Depot 1 1 690.00 690.00 690.00 0.00000 Synacthene Retard 1 1 690.00 690.00 690.00 0.00000 Triamcinolone acetonide Inj 10 mg per ml, 1 ml ampoule Kenacort-A 10 5 1 21.42 21.42 21.42 0.00000 Inj 40 mg per ml, 1 ml ampoule Kenacort-A 40 5 1 52.63 52.63 52.63 0.00000 Betamethasone sodium phosphate with betamethasone acetate Inj 3.9 mg with betamethasone acetate 3 mg per ml, 1 ml Celestone Chronodose 5 1 19.20 36.96 19.20 3.55200 Sex Hormones Non Contraceptive Androgen Agonists and Antagonists Cyproterone acetate Tab 50 mg Siterone 50 17.05 17.05 17.05 0.00000 Tab 100 mg Siterone 50 31.00 31.00 31.00 0.00000 Testosterone cipionate Inj 100 mg per ml, 10 ml vial Depo-Testosterone 1 1 97.75 97.75 97.75 0.00000 Testosterone undecanoate Cap 40 mg

Subsidy by endorsement – subsidised for patients who were taking testosterone undecanoate cap 40mg prior to 1 November 2021 and the prescription is endorsed accordingly. Pharmacists may annotate the prescription as endorsed where there exists a record of prior dispensing of testosterone undecanoate cap 40 mg in the preceding 12 months.

Steril-Gene 100 36.00 36.00 36.00 0.00000 Inj 250 mg per ml, 4 ml vial Reandron 1000 1 1 86.00 86.00 86.00 0.00000 Testosterone esters Inj 250 mg per ml, 1 ml Sustanon Ampoules 1 1 12.98 12.98 12.98 0.00000 Testosterone Gel (transdermal) 16.2 mg per g, 88 g Testogel 60 52.00 52.00 52.00 0.00000 Hormone Replacement Therapy - Systemic Oestrogens Oestradiol valerate Tab 1 mg Progynova 84 12.36 12.36 12.36 0.00000 Tab 2 mg Progynova 84 12.36 12.36 12.36 0.00000 Oestradiol Patch 25 mcg per day Estradot 8 16.23 16.23 16.23 0.00000 Estradiol TDP Mylan 8 8.89 8.89 8.89 0.00000 Patch 50 mcg per day Estradot 8 15.79 15.79 15.79 0.00000 Estradiol TDP Mylan 8 9.26 9.26 9.26 0.00000 Patch 100 mcg per day Estradot 8 16.18 16.18 16.18 0.00000 Estradiol TDP Mylan 8 10.59 10.59 10.59 0.00000 Tab 2 mg Estrofem 28 4.12 11.10 4.12 0.24929 Tab 1 mg Estrofem 28 4.12 11.10 4.12 0.24929 Patch 75 mcg per day Estradot 8 16.53 16.53 16.53 0.00000 Estradiol TDP Mylan 8 10.33 10.33 10.33 0.00000 Gel (transdermal) 0.06% (750 mcg/actuation) Estrogel 80 14.25 14.25 14.25 0.00000 Oestrogens Conjugated, equine tab 300 mcg Premarin 28 3.01 19.25 3.01 0.58000 Conjugated, equine tab 625 mcg Premarin 28 4.12 19.25 4.12 0.54036 Progestogens Medroxyprogesterone acetate Tab 2.5 mg Provera 30 7.54 7.54 7.54 0.00000 56 8.75 8.75 8.75 0.00000 Tab 5 mg Provera 100 23.15 23.15 23.15 0.00000 56 9.80 9.80 9.80 0.00000 Tab 10 mg Provera 30 11.10 11.10 11.10 0.00000 Progestogen and Oestrogen Combined Preparations Oestradiol with norethisterone Tab 2 mg with 1 mg norethisterone acetate (10), and 2 mg oestradiol tab (12) and 1 mg oestradiol tab (6) Trisequens 28 5.40 18.10 5.40 0.45357 Tab 2 mg with 1 mg norethisterone acetate Kliogest 28 5.40 18.10 5.40 0.45357 Tab 1 mg with 0.5 mg norethisterone acetate Kliovance 28 5.40 18.10 5.40 0.45357 Other Oestrogen Preparations Other Oestrogen Preparations Oestriol Tab 2 mg Ovestin 30 7.70 7.70 7.70 0.00000 Other Progestogen Preparations Other Progestogen Preparations Medroxyprogesterone acetate Tab 100 mg Provera HD 100 153.60 153.60 153.60 0.00000 Norethisterone Tab 5 mg Primolut N 30 5.49 5.49 5.49 0.00000 Progesterone Cap 100 mg Utrogestan 30 14.85 14.85 14.85 0.00000 30 14.85 14.85 14.85 0.00000 Thyroid and Antithyroid Agents Thyroid and Antithyroid Agents Carbimazole Tab 5 mg Neo-Mercazole 100 7.56 7.56 7.56 0.00000 Propylthiouracil <range>Propylthiouracil</range>

The patient has hyperthyroidism The patient is intolerant of carbimazole or carbimazole is contraindicated

any relevant practitioner 2

the treatment remains appropriate and the patient is benefitting from the treatment

any relevant practitioner 2 Tab 50 mg PTU 100 35.00 35.00 35.00 0.00000 Levothyroxine Tab 50 mcg Eltroxin 1000 64.28 64.28 64.28 0.00000 Mercury Pharma 28 1.71 1.71 1.71 0.00000 Synthroid 90 5.79 5.79 5.79 0.00000 Tab 100 mcg Eltroxin 1000 66.78 66.78 66.78 0.00000 Mercury Pharma 28 1.78 1.78 1.78 0.00000 Synthroid 90 6.01 6.01 6.01 0.00000 Tablet 50 mcg Eltroxin 200 12.86 12.86 12.86 0.00000 Tablet 100 mcg Eltroxin 200 13.36 13.36 13.36 0.00000 Tab 25 mcg Synthroid 90 5.55 5.55 5.55 0.00000 Trophic Hormones Growth Hormones Somatropin (Omnitrope) <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 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

paediatric endocrinologist endocrinologist 9

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

paediatric endocrinologist 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

paediatric endocrinologist endocrinologist 9

Height velocity is 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

paediatric endocrinologist 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 or under
                    (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

paediatric endocrinologist endocrinologist 9

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 considers is likely to be attributable to growth hormone treatment
                    has occurred

paediatric endocrinologist 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/1.73m² as measured by the Schwartz method (Height(cm)/plasma
                        creatinine (umol/l)) x 40 = corrected GFR (ml/min/1.73m²) 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.

paediatric endocrinologist endocrinologist renal physician 9

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

paediatric endocrinologist 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

paediatric endocrinologist endocrinologist 9

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 considers 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

paediatric endocrinologist 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®)

paediatric endocrinologist endocrinologist 9

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

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 Quality
                        of Life 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 been increased
                        within ±1SD of the mean of the normal range for age and sex 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 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®)

paediatric endocrinologist endocrinologist 12

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

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.

Inj 5 mg cartridge Omnitrope 1 1 80.21 80.21 80.21 0.00000 Omnitrope AU 1 1 80.21 80.21 80.21 0.00000 Inj 10 mg cartridge Omnitrope 1 1 80.21 80.21 80.21 0.00000 Inj 15 mg cartridge Omnitrope 1 1 139.50 139.50 139.50 0.00000 GnRH Analogues Leuprorelin

Additional subsidy by endorsement where the patient is a child or adolescent and is unable to tolerate administration of goserelin and the prescription is endorsed accordingly.

Inj 3.75 mg prefilled dual chamber syringe Lucrin Depot 1-month 1 1 66.48 221.60 221.60 155.12000 Inj 11.25 mg prefilled dual chamber syringe Lucrin Depot 3-month 1 1 177.50 591.68 591.68 414.18000 Goserelin Implant 3.6 mg, syringe Zoladex 1 1 66.48 66.48 66.48 0.00000 Implant 10.8 mg, syringe Zoladex 1 1 138.23 138.23 138.23 0.00000 Vasopressin Agonists Vasopressin Agonists Desmopressin acetate Inj 4 mcg per ml, 1 ml Minirin 10 1 67.18 67.18 67.18 0.00000 Tab 100 mcg Minirin 30 25.00 25.00 25.00 0.00000 Tab 200 mcg Minirin 30 54.45 54.45 54.45 0.00000 Nasal spray 10 mcg per dose, 6 ml Desmopressin-PH&T 60 34.95 34.95 34.95 0.00000 Desmopressin Wafer 120 mcg Minirin Melt 30 47.00 47.00 47.00 0.00000 Other Endocrine Agents Other Endocrine Agents Clomifene citrate Tab 50 mg Mylan Clomiphen 10 29.84 29.84 29.84 0.00000 Metyrapone Cap 250 mg Metopirone 50 558.00 558.00 558.00 0.00000 Cabergoline <range>Cabergoline</range>

Hyperprolactinemia Acromegaly* Inhibition of lactation

any relevant practitioner

The patient has previously held a valid Special
        Authority which has expired and the treatment remains appropriate and the patient is
        benefiting from treatment

any relevant practitioner

Indication marked with * is an unapproved indication.

Tab 0.5 mg Dostinex 2 4.43 4.43 4.43 0.00000 8 17.94 17.94 17.94 0.00000 Infections - Agents for Systemic Use Anthelmintics Anthelmintics Mebendazole Oral liq 100 mg per 5 ml Vermox 15 2.18 7.83 2.18 0.37667 Tab 100 mg Vermox 6 5.18 5.18 5.18 0.00000 Albendazole <range>Albendazole</range>

The individual has hydatids The individual has a travel or residence history that requires presumptive parasite treatment

relevant specialist 6

The treatment remains appropriate and the patient is benefitting from the treatment

infectious disease specialist clinical microbiologist 6 Tab 400 mg Eskazole 60 469.20 469.20 469.20 0.00000 Praziquantel Tab 600 mg Distoside 8 87.68 87.68 87.68 0.00000 Antibacterials

For topical antibacterials, refer to DERMATOLOGICALS

For anti-infective eye preparations, refer to SENSORY ORGANS

Cephalosporins and Cephamycins Cefuroxime axetil

Only if prescribed for prophylaxis of endocarditis and the prescription is endorsed accordingly.

Tab 250 mg Ascend-Cefuroxime 20 Cefaclor monohydrate Cap 250 mg Ranbaxy-Cefaclor 100 29.73 29.73 29.73 0.00000 Grans for oral liq 125 mg per 5 ml Ranbaxy-Cefaclor 100 5.83 5.83 5.83 0.00000 Ceftriaxone

Subsidised only if prescribed for a dialysis or cystic fibrosis patient, or the treatment of gonorrhoea, or the treatment of pelvic inflammatory disease, or the treatment of suspected meningococcal disease, and the prescription or PSO is endorsed accordingly.

Inj 500 mg vial Ceftriaxone-AFT 1 1 0.94 0.94 0.94 0.00000 Inj 1 g vial Ceftriaxone-AFT 5 1 3.49 3.49 3.49 0.00000 Cefalexin Cap 250 mg Cephalexin ABM 20 3.85 3.85 3.85 0.00000 Cefalexin Lupin 20 3.90 3.90 3.90 0.00000 Grans for oral liq 25 mg per ml Cefalexin Sandoz 100 5.41 5.41 5.41 0.00000 Flynn 100 7.88 7.88 7.88 0.00000 Grans for oral liq 50 mg per ml Cefalexin Sandoz 100 7.54 7.54 7.54 0.00000 Flynn 100 10.38 10.38 10.38 0.00000 Cap 500 mg Cephalexin ABM 20 5.85 5.85 5.85 0.00000 Cefalexin Sandoz 20 3.33 3.33 3.33 0.00000 Cefazolin

Only if prescribed for dialysis or cellulitis in accordance with a Health NZ Hospital approved protocol and the prescription is endorsed accordingly.

Inj 500 mg vial Cefazolin-AFT 5 1 3.39 3.39 3.39 0.00000 Inj 1 g vial Cefazolin-AFT 5 1 3.59 3.59 3.59 0.00000 Inj 2 g vial Cefazolin-AFT 5 1 7.09 7.09 7.09 0.00000 Macrolides 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

relevant specialist

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.

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 2

No further renewals will be subsidised. A maximum of 24 months of azithromycin treatment for non-cystic fibrosis bronchiectasis will be subsidised. Indications marked with * are unapproved indications

A maximum of 24 months of azithromycin treatment for non-cystic fibrosis bronchiectasis will be subsidised on Special Authority.

Tab 500 mg Zithromax 2 2.80 2.80 2.80 0.00000 Grans for oral liq 200 mg per 5 ml (40 mg per ml) Zithromax 15 16.97 16.97 16.97 0.00000 Tab 250 mg Apo-Azithromycin 30 8.19 8.19 8.19 0.00000 Roxithromycin Tab 150 mg Arrow-Roxithromycin 50 13.19 13.19 13.19 0.00000 Tab 300 mg Arrow-Roxithromycin 50 25.00 25.00 25.00 0.00000 Clarithromycin <range>Clarithromycin</range>

Atypical mycobacterial infection Mycobacterium tuberculosis infection where there is drug-resistance or intolerance to standard pharmaceutical agents

respiratory specialist infectious disease specialist paediatrician 2

For the eradication of helicobacter pylori in a patient unable to swallow tablets For use only in combination with omeprazole and amoxicillin as part of a triple therapy regimen

any relevant practitioner 3

Prophylaxis of infective endocarditis associated with surgical or dental procedures if amoxicillin is contra-indicated

any relevant practitioner 3

The treatment remains appropriate and the patient is benefiting from treatment

respiratory specialist infectious disease specialist paediatrician 2 Tab 250 mg Klacid 14 8.53 8.53 8.53 0.00000 Klaricid 12 7.31 7.31 7.31 0.00000 Grans for oral liq 250 mg per 5 ml Klacid 50 192.00 192.00 192.00 0.00000 Erythromycin ethyl succinate Tab 400 mg E-Mycin 100 35.82 35.82 35.82 0.00000 Grans for oral liq 200 mg per 5 ml E-Mycin 100 6.53 6.53 6.53 0.00000 Grans for oral liq 400 mg per 5 ml E-Mycin 100 9.41 9.41 9.41 0.00000 Erythromycin (as lactobionate) Inj 1 g vial Erythrocin IV 1 1 10.00 10.00 10.00 0.00000 Penicillins Amoxicillin with clavulanic acid Tab 500 mg with clavulanic acid 125 mg Curam Duo 500/125 10 1.59 1.59 1.59 0.00000 Grans for oral liq amoxicillin 25 mg with clavulanic acid 6.25 mg per ml Augmentin 100 8.50 8.50 8.50 0.00000 Grans for oral liq amoxicillin 50 mg with clavulanic acid 12.5 mg per ml Amoxiclav Devatis Forte 100 5.61 5.61 5.61 0.00000 Amoxicillin Cap 250 mg Miro-Amoxicillin 500 54.00 54.00 54.00 0.00000 Cap 500 mg Miro-Amoxicillin 500 41.00 41.00 41.00 0.00000 Amoxycillin Sandoz 20 1.14 1.14 1.14 0.00000 Grans for oral liq 125 mg per 5 ml Alphamox 125 100 2.22 2.22 2.22 0.00000 Grans for oral liq 250 mg per 5 ml Alphamox 250 100 2.81 2.81 2.81 0.00000 Inj 1 g vial Ibiamox 10 1 21.64 21.64 21.64 0.00000 Inj 500 mg vial Ibiamox 10 1 17.43 17.43 17.43 0.00000 Inj 250 mg vial Ibiamox 10 1 15.97 15.97 15.97 0.00000 Benzathine benzylpenicillin Inj 900 mg (1.2 million units) in 2.3 ml syringe Bicillin LA 10 1 432.37 432.37 432.37 0.00000 Inj 900 mg (1.2 million units) vial Benzetacil 1 1 43.24 43.24 43.24 0.00000 Benzylpenicillin sodium [Penicillin G] Inj 600 mg (1 million units) vial Sandoz 10 1 16.50 16.50 16.50 0.00000 Flucloxacillin Cap 250 mg Staphlex 250 22.58 22.58 22.58 0.00000 Cap 500 mg Staphlex 500 72.71 72.71 72.71 0.00000 Grans for oral liq 25 mg per ml AFT 100 4.89 4.89 4.89 0.00000 Grans for oral liq 50 mg per ml AFT 100 5.89 5.89 5.89 0.00000 Inj 250 mg vial Flucloxin 10 1 42.60 42.60 42.60 0.00000 Inj 500 mg vial Flucloxin 10 1 45.63 45.63 45.63 0.00000 Inj 1 g vial Flucil 5 1 6.00 6.00 6.00 0.00000 Phenoxymethylpenicillin (Penicillin V) Cap 250 mg Cilicaine VK 50 7.68 7.68 7.68 0.00000 Cap 500 mg Cilicaine VK 50 13.72 13.72 13.72 0.00000 Grans for oral liq 125 mg per 5 ml AFT 100 5.75 5.75 5.75 0.00000 Grans for oral liq 250 mg per 5 ml AFT 100 5.89 5.89 5.89 0.00000 Tetracyclines Minocycline hydrochloride Tab 50 mg <range>Minocycline hydrochloride Tab 50 mg</range>

The patient has rosacea

any relevant practitioner Mino-tabs 60 5.79 12.05 12.05 0.10433 Cap 100 mg Minomycin 100 19.32 52.04 19.32 0.32720 Doxycycline Tab 100 mg Doxine 500 64.43 64.43 64.43 0.00000 Tetracycline <range>Tetracycline</range>

For the eradication of helicobacter pylori following
          unsuccessful treatment with appropriate first-line therapy For use only in combination with bismuth as part of a
          quadruple therapy regimen

any relevant practitioner 3

For the eradication of helicobacter pylori following
          unsuccessful treatment with, or noncompletion of second line therapy For use only in combination with bismuth as part of a
          quadruple therapy regimen

any relevant practitioner 3 Tab 250 mg Accord 28 68.44 68.44 68.44 0.00000 Other Antibiotics

For topical antibiotics, refer to DERMATOLOGICALS

Clindamycin Cap hydrochloride 150 mg Dalacin C 24 4.94 4.94 4.94 0.00000 Inj 150 mg per ml, 4 ml ampoule Dalacin C 10 1 48.78 48.78 48.78 0.00000 Colistin sulphomethate

Only if prescribed for dialysis or cystic fibrosis patient and the prescription is endorsed accordingly.

Inj 2 million iu, 10 ml vial Colomycin 10 1 216.67 216.67 216.67 0.00000 Trimethoprim with sulphamethoxazole [Co-trimoxazole] Oral liq 8 mg sulphamethoxazole 40 mg per ml Deprim 100 4.95 4.95 4.95 0.00000 Tab trimethoprim 80 mg and sulphamethoxazole 400 mg Trisul 500 115.74 115.74 115.74 0.00000 Sodium Fusidate [fusidic acid] Tab 250 mg Fucidin 36 135.70 135.70 135.70 0.00000 Gentamicin sulphate Inj 10 mg per ml, 1 ml ampoule

Only if prescribed for a dialysis or cystic fibrosis patient or complicated urinary tract infection and the prescription is endorsed accordingly.

DBL Gentamicin 5 1 102.60 102.60 102.60 0.00000 Inj 40 mg per ml, 2 ml ampoule

Only if prescribed for a dialysis or cystic fibrosis patient or complicated urinary tract infection and the prescription is endorsed accordingly.

Pfizer 10 1 18.38 18.38 18.38 0.00000 Inj 40 mg per ml, 2 ml vial

Only if prescribed for a dialysis or cystic fibrosis patient or complicated urinary tract infection and the prescription is endorsed accordingly.

Cidomycin P/Free 5 1 36.70 36.70 36.70 0.00000 Tobramycin Inj 40 mg per ml, 2 ml vial

Only if prescribed for dialysis or cystic fibrosis patient and the prescription is endorsed accordingly.

Tobramycin (Viatris) 5 1 15.50 15.50 15.50 0.00000 Solution for inhalation 60 mg per ml, 5 ml

Only if prescribed for a cystic fibrosis patient and the prescription is endorsed accordingly.

Tobramycin BNM 56 395.00 395.00 395.00 0.00000 Trimethoprim Tab 300 mg TMP 50 27.83 27.83 27.83 0.00000 Vancomycin

Only if prescribed for a dialysis or cystic fibrosis patient or for prophylaxis of endocarditis or for treatment of Clostridium difficile following metronidazole failure and the prescription is endorsed accordingly.

Inj 500 mg vial Vancomycin Viatris 1 1 3.38 3.38 3.38 0.00000 Ciprofloxacin

Recommended for patients with any of the following:

microbiologically confirmed and clinically significant pseudomonas infection; or
prostatitis; or
pyelonephritis; or
gonorrhoea.

Tab 250 mg Ipca-Ciprofloxacin 28 1.95 1.95 1.95 0.00000 Tab 500 mg Ipca-Ciprofloxacin 28 3.10 3.10 3.10 0.00000 Tab 750 mg Ipca-Ciprofloxacin 28 4.80 4.80 4.80 0.00000 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

respiratory specialist infectious disease specialist 1

Indications marked with * are unapproved indications.

The treatment remains appropriate and the patient is benefiting from treatment

respiratory specialist infectious disease specialist 1

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

sexual health specialist Practitioner 1

The patient requires prophylaxis following a penetrating eye injury and treatment is for 5 days only

ophthalmologist 1

Indications marked with * are unapproved indications.

Tab 400 mg Avelox 5 42.00 42.00 42.00 0.00000 Sulfadiazine sodium <range>Sulfadiazine</range>

For the treatment of toxoplasmosis in patients with HIV for a period of 3 months For pregnant patients for the term of the pregnancy For infants with congenital toxoplasmosis until 12 months of age

any relevant practitioner Tab 500 mg Sulfadiazin-Heyl 100 150.70 150.70 150.70 0.00000 Paromomycin <range>Paromomycin</range>

Patient has confirmed cryptosporidium infection For the eradication of Entamoeba histolytica carriage

infectious disease specialist clinical microbiologist gastroenterologist 1

Patient has confirmed cryptosporidium infection For the eradication of Entamoeba histolytica carriage

infectious disease specialist clinical microbiologist gastroenterologist 1 Cap 250 mg Humatin 16 126.00 126.00 126.00 0.00000 Antifungals

For topical antifungals refer to DERMATOLOGICALS

For topical antifungals refer to GENITO URINARY

Antifungals Ketoconazole Tab 200 mg Strides Shasun 100 Taro 100 Burel 30 Teva-Ketoconazole 100 Nystatin Tab 500,000 u Nilstat 50 14.16 17.09 14.16 0.05860 Cap 500,000 u Nilstat 50 12.81 15.47 12.81 0.05320 Fluconazole Cap 50 mg Mylan 28 4.10 4.10 4.10 0.00000 Cap 150 mg Mylan 1 0.45 0.45 0.45 0.00000 Flucazole 1 0.45 0.45 0.45 0.00000 Cap 200 mg Mylan 28 8.90 8.90 8.90 0.00000 Powder for oral suspension 10 mg per ml <range>Fluconazole oral liquid</range>

Patient requires prophylaxis for, or treatment of systemic candidiasis Patient is unable to swallow capsules

any relevant practitioner 6

Patient is immunocompromised Patient is at moderate to high risk of invasive fungal infection Patient is unable to swallow capsules

any relevant practitioner 6

Patient requires prophylaxis for, or treatment of systemic candidiasis Patient is unable to swallow capsules

any relevant practitioner 6

Patient remains immunocompromised Patient remains at moderate to high risk of invasive fungal infection Patient is unable to swallow capsules

any relevant practitioner 6 Diflucan 35 129.02 129.02 129.02 0.00000 Itraconazole Cap 100 mg Itrazole 15 6.83 6.83 6.83 0.00000 Itraconazole Cresent 15 6.83 6.83 6.83 0.00000 Oral liq 10 mg per ml <range>Itraconazole</range>

The patient has a congenital immune deficiency

infectious disease specialist clinical microbiologist clinical immunologist any relevant practitioner 6

The treatment remains appropriate and the patient is benefitting from the treatment

any relevant practitioner 6 Itraconazole Kent 150 141.80 141.80 141.80 0.00000 Terbinafine Tab 250 mg Deolate 84 8.97 8.97 8.97 0.00000 Voriconazole <range>Voriconazole</range>

Patient is immunocompromised Applicant is part of a multidisciplinary team
          including an infectious disease specialist Patient has proven or probable invasive aspergillus
            infection Patient has possible invasive aspergillus
            infection Patient has fluconazole resistant candidiasis Patient has mould strain such as Fusarium spp. and
            Scedosporium spp

haematologist infectious disease specialist clinical microbiologist 3

Patient is immunocompromised Applicant is part of a multidisciplinary team
          including an infectious disease specialist Patient continues to require treatment for proven or
            probable invasive aspergillus infection Patient continues to require treatment for possible
            invasive aspergillus infection Patient has fluconazole resistant candidiasis Patient has mould strain such as Fusarium spp. and
            Scedosporium spp

haematologist infectious disease specialist clinical microbiologist 3

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 Tab 50 mg Vttack 56 71.00 71.00 71.00 0.00000 Tab 200 mg Vttack 56 263.00 263.00 263.00 0.00000 Powder for oral suspension 40 mg per ml Vfend 70 1523.22 1523.22 1523.22 0.00000 Posaconazole <range>Posaconazole </range>

Patient has acute myeloid leukaemia and is to be
          treated with high dose remission induction, re-induction or consolidation
          chemotherapy Patient has received a stem cell transplant and has
          graft versus host disease and is on significant immunosuppressive therapy*

haematologist infectious disease specialist 6

Patient has acute myeloid leukaemia and is to be
          treated with high dose remission induction, re-induction or consolidation therapy Patient has received a stem cell transplant and has
          graft versus host disease and is on significant immunosuppression* and requires on going
          posaconazole treatment

haematologist infectious disease specialist 6

* Graft versus host disease (GVHD) on significant immunosuppression is defined as acute GVHD, grade II to IV, or extensive chronic GVHD, or if they were being treated with intensive immunosuppressive therapy consisting of either high-dose corticosteroids (1 mg or greater per kilogram of body weight per day for patients with acute GVHD or 0.8 mg or greater per kilogram every other day for patients with chronic GVHD), antithymocyte globulin, or a combination of two or more immunosuppressive agents or types of treatment.

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 Oral liq 40 mg per ml Devatis 105 308.26 308.26 308.26 0.00000 Tab modified-release 100 mg Posaconazole Juno 24 123.60 123.60 123.60 0.00000 Antimalarials Antimalarials Primaquine <range>Primaquine</range>

The patient has vivax or ovale malaria Primaquine is to be given for a maximum of 21 days

infectious disease specialist clinical microbiologist 1

The patient has relapsed vivax or ovale malaria Primaquine is to be given for a maximum of 21 days

infectious disease specialist clinical microbiologist 1 Tab 15 mg Sanofi Primaquine 100 400.00 400.00 400.00 0.00000 Bayshore 100 395.00 395.00 395.00 0.00000 Antitrichomonal Agents Antitrichomonal Agents Metronidazole Tab 200 mg Metronidamed 250 25.86 25.86 25.86 0.00000 Tab 400 mg Metronidamed 21 4.29 4.29 4.29 0.00000 Oral liq benzoate 200 mg per 5 ml Flagyl-S 100 25.00 25.00 25.00 0.00000 Suppos 500 mg Flagyl 10 24.48 24.48 24.48 0.00000 Ornidazole Tab 500 mg Arrow-Ornidazole 10 36.52 36.52 36.52 0.00000 Antituberculotics and Antileprotics Antituberculotics and Antileprotics

Note: There is no co-payment charge for all pharmaceuticals listed in the Antituberculotics and Antileprotics group regardless of immigration status.

Clofazimine

Prescriptions must be written by, or on the recommendation of, an infectious disease physician, clinical microbiologist or dermatologist.

Cap 50 mg Lamprene 100 442.00 442.00 442.00 0.00000 Dapsone

Prescriptions must be written by, or on the recommendation of, an infectious disease physician, clinical microbiologist or dermatologist

Tab 100 mg Dapsone 100 329.50 329.50 329.50 0.00000 Tab 25 mg Dapsone 100 268.50 268.50 268.50 0.00000 Isoniazid

Prescriptions must be written by, or on the recommendation of, an internal medicine physician, paediatrician, clinical microbiologist, dermatologist or public health physician

Tab 100 mg Isoniazid Teva 100 94.50 94.50 94.50 0.00000 Noumed Isoniazid 100 327.41 327.41 327.41 0.00000 Isoniazid with rifampicin

Prescriptions must be written by, or on the recommendation of, an internal medicine physician, paediatrician, clinical microbiologist, dermatologist or public health physician

Tab 100 mg with rifampicin 150 mg Rifinah 100 89.82 89.82 89.82 0.00000 Tab 150 mg with rifampicin 300 mg Rifinah 100 179.13 179.13 179.13 0.00000 Cap 100 mg with rifampicin 150 mg Rifamazid 100 199.00 199.00 199.00 0.00000 Pyrazinamide

Prescriptions must be written by, or on the recommendation of, an infectious disease physician, clinical microbiologist or respiratory physician

Tab 500 mg AFT-Pyrazinamide 100 64.95 64.95 64.95 0.00000 Rifampicin

For confirmed recurrent Staphylococcus aureus infection in combination with other effective anti-staphylococcal antimicrobial based on susceptibilities and the prescription is endorsed accordingly; can be waived by endorsement - Retail pharmacy - Specialist. Specialist must be an internal medicine physician, clinical microbiologist, dermatologist, paediatrician, or public health physician.

Cap 150 mg Rifadin 100 58.54 58.54 58.54 0.00000 Cap 300 mg Rifadin 100 122.06 122.06 122.06 0.00000 Rifadin Sanofi 100 122.06 122.06 122.06 0.00000 Oral liq 100 mg per 5 ml Rifadin 60 12.60 12.60 12.60 0.00000 Rifabutin

Prescriptions must be written by, or on the recommendation of, an infectious disease physician, respiratory physician or gastroenterologist

Cap 150 mg Mycobutin 30 353.71 353.71 353.71 0.00000 Ethambutol hydrochloride

Prescriptions must be written by, or on the recommendation of, an infectious disease physician, clinical microbiologist or respiratory physician

Tab 400 mg Myambutol 56 49.34 49.34 49.34 0.00000 Tab 100 mg EMB Fatol 100 85.73 85.73 85.73 0.00000 Cycloserine

Prescriptions must be written by, or on the recommendation of, an infectious disease physician, clinical microbiologist or respiratory physician.

Cap 250 mg Cyclorin 60 344.00 344.00 344.00 0.00000 Para-amino salicylic acid

Prescriptions must be written by, or on the recommendation of, an infectious disease specialist, clinical microbiologist or respiratory physician

Grans for oral liq 4 g sachet Paser 30 280.00 280.00 280.00 0.00000 Protionamide

Prescriptions must be written by, or on the recommendation of, an infectious disease specialist, clinical microbiologist or respiratory physician

Tab 250 mg Peteha 100 305.00 305.00 305.00 0.00000 100 305.00 305.00 305.00 0.00000 Linezolid <range>Linezolid</range>

The person has multi-drug resistant tuberculosis (MDR-TB) Ministry of Health’s Tuberculosis Clinical Network has reviewed the individual case and recommends linezolid as part of the treatment regimen

any relevant practitioner 18 Tab 600 mg Zyvox 10 194.60 194.60 194.60 0.00000 Oral liq 20 mg per ml Zyvox 150 1879.00 1879.00 1879.00 0.00000 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

any relevant practitioner 6 Tab 100mg Sirturo 24 3084.51 3084.51 3084.51 0.00000 Antivirals

For eye preparations refer to Eye Preparations, Anti-Infective Preparations

Hepatitis B Treatment Lamivudine <range>Lamivudine</range>

Used for the treatment or prevention of hepatitis B

relevant specialist medical practitioner 1

Used for the treatment or prevention of hepatitis B

any relevant practitioner 2 Oral liq 5 mg per ml Zeffix 240 270.00 270.00 270.00 0.00000 Tab 100 mg Zetlam 28 12.06 12.06 12.06 0.00000 Tenofovir disoproxil

Tenofovir disoproxil prescribed under endorsement for the treatment of HIV is included in the count of up to 4 subsidised antiretrovirals for the purposes of Special Authority SA2139.

Tab 245 mg (300 mg as a fumarate) Ricovir 30 13.80 13.80 13.80 0.00000 Tab 245 mg (300 mg as a maleate) Tenofovir Disoproxil Viatris 30 13.80 13.80 13.80 0.00000 Entecavir Tab 0.5 mg Entecavir (Rex) 30 12.04 12.04 12.04 0.00000 Herpesvirus Treatments Valaciclovir Tab 500 mg Vaclovir 30 9.64 9.64 9.64 0.00000 Tab 1,000 mg Vaclovir 30 17.78 17.78 17.78 0.00000 Valaciclovir Mylan 21 12.45 12.45 12.45 0.00000 Valaciclovir Viatris 21 12.45 12.45 12.45 0.00000 Aciclovir Tab dispersible 200 mg Lovir 25 2.05 2.05 2.05 0.00000 Tab dispersible 400 mg Lovir 56 7.55 7.55 7.55 0.00000 Tab dispersible 800 mg Lovir 35 7.43 7.43 7.43 0.00000 Valganciclovir <range>Valganciclovir</range>

the patient has undergone a solid organ transplant and
        requires valganciclovir for CMV prophylaxis

relevant specialist 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

relevant specialist 3

Patient has undergone a solid organ transplant and
          received valganciclovir under Special Authority more than 2 years ago (27 months) Patient has received anti-thymocyte globulin and
          requires valganciclovir for CMV prophylaxis

relevant specialist 3

The patient has received a further course of
        anti-thymocyte globulin and requires valganciclovir for CMV prophylaxis

relevant specialist 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

relevant specialist 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

relevant specialist 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

relevant specialist 3

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

relevant specialist 3

for the purpose of this Special Authority "immunocompromised" includes transplant recipients, patients with immunosuppressive diseases (e.g. HIV) or those receiving immunosuppressive treatment for other conditions.

Tab 450 mg Valganciclovir Viatris 60 140.89 140.89 140.89 0.00000 Letermovir <range>Letermovir</range>

Patient has undergone an allogeneic
                    haematopoietic stem cell transplant The patient has confirmed presence of
                    cytomegalovirus-specific antibodies Treatment to commence within 28 days of an
                    allogeneic haematopoietic stem cell transplant Maximum treatment duration of 100 days
                    post-transplant

any relevant practitioner 4

Patient has undergone an allogeneic
                    haematopoietic stem cell transplant The patient has confirmed presence of
                    cytomegalovirus-specific antibodies Treatment to commence within 28 days of an
                    allogeneic haematopoietic stem cell transplant Maximum treatment duration of 100 days
                    post-transplant

any relevant practitioner 4

Patient has severe immunosuppression requiring
                    prophylaxis of CMV Patient is contraindicated to all other
                        funded CMV active oral antiviral agents Patient’s CMV is resistant to all other
                        funded CMV active oral antiviral agents

infectious disease specialist clinical microbiologist any relevant practitioner 6

Patient has severe immunosuppression requiring
                    prophylaxis of CMV Patient is contraindicated to all other
                        funded CMV active oral antiviral agents Patient’s CMV is resistant to all other
                        funded CMV active oral antiviral agents

infectious disease specialist clinical microbiologist any relevant practitioner 6

Indications marked with * are unapproved indications.

Tab 240 mg Prevymis 28 6664.00 6664.00 6664.00 0.00000 Hepatitis C Treatment Ledipasvir with sofosbuvir <range>Ledipasvir with sofosbuvir</range>

The patient is likely to benefit from  treatment

medical practitioner

By application to the Hepatitis C Treatment Panel (HepCTP).

Applications will be considered by HepCTP and approved subject to confirmation of eligibility.

Application details may be obtained from Pharmac's website http://www.pharmac.govt.nz/harvoni or:

The Coordinator, Hepatitis C Treatment Panel

Pharmac, PO Box 10-254, WELLINGTON Tel: (04) 460 4990,

Email: hepcpanel@pharmac.govt.nz

Tab 90 mg with sofosbuvir 400 mg Harvoni 28 24363.46 24363.46 24363.46 0.00000 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://pharmac.govt.nz/maviret

Tab 100 mg with pibrentasvir 40 mg Maviret 84 24750.00 24750.00 24750.00 0.00000 HIV Prophylaxis and Treatment Emtricitabine with tenofovir disoproxil <range>Emtricitabine with tenofovir disoproxil</range>

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

any relevant 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

any relevant 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/

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 appropriate Patient has had condomless anal
                        intercourse with a person from a high HIV prevalence country or risk group
                        whose HIV status is unknown

any relevant practitioner 4

Tenofovir disoproxil prescribed under endorsement for HIV is included in the count of up to 4 subsidised antiretrovirals.

Subsidies apply for a combination of up to four antiretroviral medications. The combination of a protease inhibitor and low-dose ritonavir given as a booster (either as part of a combination product or separately) will be counted as one protease inhibitor for the purpose of accessing funding to antiretrovirals.

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/).

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 appropriate Patient has had condomless anal
                        intercourse with a person from a high HIV prevalence country or risk group
                        whose HIV status is unknown

any relevant practitioner 4

Funding for emtricitabine with tenofovir disoproxil for use as PrEP or PEP, should be applied using Special Authority SA2520.

Endorsement for treatment of conditions approved via Special Authority SA2139 (antiretrovirals for confirmed HIV, prevention of maternal transmission, post-exposure prophylaxis following exposure to HIV (when co-prescribed with other antiretrovirals) and percutaneous exposure): Prescription is deemed to be endorsed if emtricitabine with tenofovir disoproxil is co-prescribed with another antiretroviral subsidised under Special Authority SA2139 and the prescription is annotated accordingly by the Pharmacist or endorsed by the prescriber.

Note:

Emtricitabine with tenofovir disoproxil prescribed under endorsement, for treatment of conditions approved via Special Authority SA2139 (antiretrovirals for confirmed HIV, prevention of maternal transmission, post-exposure prophylaxis following exposure to HIV and percutaneous exposure), is included in the count of up to 4 subsidised antiretrovirals, and counts as two antiretroviral medications, for the purposes of Special Authority SA2139

There is an approval process to become a named specialist to prescribe antiretroviral therapy in New Zealand. Further information is available on the Pharmac website.

Tab 200 mg with tenofovir disoproxil 245 mg (300 mg as a fumarate) Tenofovir Disoproxil Emtricitabine Mylan 30 13.45 13.45 13.45 0.00000 Tab 200 mg with tenofovir disoproxil 245 mg (300 mg as a maleate) Tenofovir Disoproxil Emtricitabine Viatr 30 13.45 13.45 13.45 0.00000 COVID-19 Treatments Nirmatrelvir with ritonavir

Subsidised for patients meeting access criteria for oral COVID-19 antiviral treatments (as on Pharmac’s website) and where the prescription is endorsed accordingly. Pharmacists may annotate the prescription as endorsed when supplying by Direct Provision under the provisions in Part I of Section A of the Pharmaceutical Schedule.

Tab 150 mg with ritonavir 100 mg Paxlovid 30 1274.00 1274.00 1274.00 0.00000 Remdesivir

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

Inj 100 mg vial Veklury 1 615.23 615.23 615.23 0.00000 Antiretrovirals <range>Antiretrovirals</range>

The patient has confirmed HIV infection

named specialist

Tenofovir disoproxil prescribed under endorsement for HIV is included in the count of up to 4 subsidised antiretrovirals.

The treatment remains appropriate and the patient is
        benefiting from treatment

named specialist

Prevention of maternal foetal transmission Treatment of the newborn for up to eight weeks

named specialist 1

Tenofovir disoproxil prescribed under endorsement for HIV is included in the count of up to 4 subsidised antiretrovirals.

Some antiretrovirals are unapproved or contraindicated for this indication. Practitioners prescribing these medications should exercise their own skill, judgement, expertise and discretion, and make their own prescribing decisions with respect to the use of a Pharmaceutical for an indication for which it is not approved or contraindicated.

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

any relevant practitioner 4

Tenofovir disoproxil prescribed under endorsement for HIV is included in the count of up to 4 subsidised antiretrovirals.

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/).

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

any relevant practitioner 4

The patient has percutaneous exposure to blood known to
        be HIV positive

named specialist 6

Tenofovir disoproxil prescribed under endorsement for HIV is included in the count of up to 4 subsidised antiretrovirals.

The patient has percutaneous exposure to blood known to
        be HIV positive

named specialist 6 Non-nucleosides Reverse Transcriptase Inhibitors Nevirapine Tab 200 mg Nevirapine Viatris 60 198.25 198.25 198.25 0.00000 Oral suspension 10 mg per ml Viramune Suspension 240 203.55 203.55 203.55 0.00000 Efavirenz

Note: No new patients to be initiated on efavirenz.

Tab 600 mg Efavirenz Milpharm 30 65.38 65.38 65.38 0.00000 Etravirine Tab 200 mg Intelence 60 770.00 770.00 770.00 0.00000 Nucleosides Reverse Transcriptase Inhibitors Zidovudine with lamivudine

Note: zidovudine [AZT] with lamivudine (combination tablets) counts as two anti-retroviral medications for the purposes of the anti-retroviral Special Authority.

Tab 300 mg with lamivudine 150 mg Lamivudine/Zidovudine Viatris 60 92.40 92.40 92.40 0.00000 60 92.40 92.40 92.40 0.00000 Zidovudine Cap 100 mg Retrovir 100 152.25 152.25 152.25 0.00000 Oral liq 10 mg per ml Retrovir 200 30.45 30.45 30.45 0.00000 Lamivudine Tab 150 mg Lamivudine Viatris 60 98.00 98.00 98.00 0.00000 Oral liq 10 mg per ml 3TC 240 102.50 102.50 102.50 0.00000 Abacavir sulphate Tab 300 mg Ziagen 60 180.00 180.00 180.00 0.00000 Abacavir sulphate with lamivudine

Note: abacavir with lamivudine (combination tablets) counts as two anti-retroviral medications for the purposes of the anti-retroviral Special Authority.

Tab 600 mg with lamivudine 300 mg Abacavir/Lamivudine Viatris 30 35.00 35.00 35.00 0.00000 Emtricitabine Cap 200 mg Emtriva 30 307.20 307.20 307.20 0.00000 Efavirenz with emtricitabine and tenofovir disoproxil

Note: Efavirenz with emtricitabine and tenofovir disoproxil counts as three anti-retroviral medications for the purposes of the anti-retroviral Special Authority

Tab 600 mg with emtricitabine 200 mg and tenofovir disoproxil 245 mg (300 mg as a fumarate) TEEVIR 30 106.88 106.88 106.88 0.00000 Tab 600 mg with emtricitabine 200 mg and tenofovir disoproxil 245 mg (300 mg as a maleate) Viatris 30 106.88 106.88 106.88 0.00000 Protease Inhibitors Ritonavir Tab 100 mg Norvir 30 43.31 43.31 43.31 0.00000 Lopinavir with ritonavir Tab 200 mg with ritonavir 50 mg Lopinavir/Ritonavir Mylan 120 875.00 875.00 875.00 0.00000 Atazanavir sulphate Cap 150 mg Atazanavir Viatris 60 102.50 102.50 102.50 0.00000 Cap 200 mg Atazanavir Viatris 60 152.30 152.30 152.30 0.00000 Darunavir Tab 400 mg Darunavir Viatris 60 150.00 150.00 150.00 0.00000 Tab 600 mg Darunavir Viatris 60 225.00 225.00 225.00 0.00000 Strand Transfer Inhibitors Raltegravir potassium Tab 400 mg Isentress 60 1090.00 1090.00 1090.00 0.00000 Tab 600 mg Isentress HD 60 1090.00 1090.00 1090.00 0.00000 Dolutegravir Tab 50 mg Tivicay 30 1090.00 1090.00 1090.00 0.00000 Dolutegravir with lamivudine Tab 50 mg with lamivudine 300 mg Dovato 30 1090.00 1090.00 1090.00 0.00000 Immune Modulators Immune Modulators Pegylated interferon alfa-2a

Note: Pharmac will consider funding ribavirin for the small group of patients who have a clinical need for ribavirin and meet Special Authority criteria. Please contact the Hepatitis C Coordinator at Pharmac on 0800-023-588 option 4.

<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 Maximum of 48 weeks therapy

any specialist 18

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 Maximum of 48 weeks therapy

gastroenterologist infectious disease specialist general physician 18

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 Maximum of 48 weeks therapy

gastroenterologist infectious disease specialist general physician 18

Patient has chronic hepatitis C, genotype 2 or 3 infection Maximum of 6 months therapy

any specialist 12

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 (Metavir Stage F2 or greater 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 Maximum of 48 weeks therapy

gastroenterologist infectious disease specialist general physician 18

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

any relevant 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

any relevant practitioner 12

Indications marked with * are unapproved indications.

patient has received an allogeneic bone marrow transplant* and has evidence of disease relapse

any relevant practitioner 3

patient is responding and ongoing treatment remains appropriate

any relevant practitioner 3

Indications marked with * are unapproved indications.

Inj 135 mcg prefilled syringe Pegasys (S29) 1 1 887.35 887.35 887.35 0.00000 Inj 180 mcg prefilled syringe Pegasys 4 1 1074.79 1074.79 1074.79 0.00000 Pegasys S29 4 1355.71 1355.71 1355.71 0.00000 Urinary Tract Infections Urinary Tract Infections Methenamine (hexamine) hippurate Tab 1 g Hiprex 100 19.95 19.95 19.95 0.00000 100 19.95 19.95 19.95 0.00000 Nitrofurantoin Tab 50 mg Nifuran 100 22.20 22.20 22.20 0.00000 Nitrofurantoin Clinect 100 22.20 22.20 22.20 0.00000 Tab 100 mg Nifuran 100 37.50 37.50 37.50 0.00000 Cap modified-release 100 mg Macrobid 100 81.20 81.20 81.20 0.00000 Norfloxacin Tab 400 mg

Only if prescribed for a patient with an uncomplicated urinary tract infection that is unresponsive to a first line agent or with proven resistance to first line agents and the prescription is endorsed accordingly.

Arrow-Norfloxacin 100 245.00 245.00 245.00 0.00000 Fosfomycin <range>Fosfomycin</range>

Patient has an acute, symptomatic, bacteriologically-proven uncomplicated urinary tract infection (UTI)/cystitis with Escherichia Coli Microbiological testing confirms the pathogen is resistant to all of: trimethoprim, nitrofurantoin, amoxicillin, cefaclor, cefalexin, amoxicillin with clavulanic acid, and norfloxacin The patient has a contraindication or intolerance to all of: trimethoprim, nitrofurantoin, amoxicillin, cefaclor, cefalexin, amoxicillin with clavulanic acid, and norfloxacin that the pathogen is susceptible to

any relevant practitioner 2

Patient has an acute, symptomatic, bacteriologically-proven uncomplicated urinary tract infection (UTI)/cystitis with Escherichia Coli Microbiological testing confirms the pathogen is resistant to all of: trimethoprim, nitrofurantoin, amoxicillin, cefaclor, cefalexin, amoxicillin with clavulanic acid, and norfloxacin The patient has a contraindication or intolerance to all of: trimethoprim, nitrofurantoin, amoxicillin, cefaclor, cefalexin, amoxicillin with clavulanic acid, and norfloxacin that the pathogen is susceptible to

any relevant practitioner 2 Powder for oral solution, 3 g sachet UroFos 1 18.70 18.70 18.70 0.00000 Musculoskeletal System Anticholinesterases Anticholinesterases Neostigmine metilsulfate Inj 2.5 mg per ml, 1 ml ampoule Max Health 10 1 48.25 48.25 48.25 0.00000 Pyridostigmine bromide Tab 60 mg Mestinon 100 50.28 50.28 50.28 0.00000 Non-Steroidal Anti-Inflammatory Drugs Non-Steroidal Anti-Inflammatory Drugs Diclofenac sodium Tab EC 25 mg Diclofenac Sandoz 50 2.19 2.19 2.19 0.00000 Tab EC 50 mg Diclofenac Sandoz 50 2.19 2.19 2.19 0.00000 Tab long-acting 75 mg Voltaren SR 100 10.00 10.00 10.00 0.00000 Inj 25 mg per ml, 3 ml ampoule Voltaren 5 1 13.20 13.20 13.20 0.00000 Suppos 12.5 mg Voltaren 10 2.04 2.04 2.04 0.00000 Suppos 25 mg Voltaren 10 2.44 2.44 2.44 0.00000 Suppos 50 mg Voltaren 10 4.22 4.22 4.22 0.00000 Suppos 100 mg Voltaren 10 7.00 7.00 7.00 0.00000 Tab 50 mg dispersible Voltaren D 20 1.50 1.50 1.50 0.00000 Ketoprofen Cap long-acting 200 mg Oruvail SR 28 12.07 12.07 12.07 0.00000 Mefenamic acid Cap 250 mg Ponstan 20 0.50 7.50 3.67 0.35000 50 1.25 10.82 1.25 0.19140 20 0.50 7.50 0.50 0.35000 Tenoxicam Tab 20 mg Tilcotil 100 23.50 23.50 23.50 0.00000 Inj 20 mg vial AFT 1 1 9.95 9.95 9.95 0.00000 Naproxen Tab long-acting 750 mg Naprosyn SR 750 28 10.40 10.40 10.40 0.00000 Tab long-acting 1 g Naprosyn SR 1000 28 11.50 11.50 11.50 0.00000 Tab 250 mg Noflam 250 500 39.23 39.23 39.23 0.00000 90 7.06 7.06 7.06 0.00000 Inza 50 3.92 3.92 3.92 0.00000 Tab 500 mg Noflam 500 250 34.45 34.45 34.45 0.00000 Inza 50 6.89 6.89 6.89 0.00000 Ibuprofen Tab 200 mg Relieve 1000 21.40 21.40 21.40 0.00000 Tab long-acting 800 mg Ibuprofen SR BNM 30 3.65 3.65 3.65 0.00000 Oral liq 20 mg per ml Ethics 200 2.85 2.85 2.85 0.00000 NSAIDs Other Celecoxib Cap 100 mg Celebrex 60 3.60 3.60 3.60 0.00000 Cap 200 mg Celecoxib Pfizer 30 3.20 3.20 3.20 0.00000 Celebrex 30 3.20 3.20 3.20 0.00000 Celostea 30 2.55 2.55 2.55 0.00000 Topical Products for Joint and Muscular Pain Topical Products for Joint and Muscular Pain Capsaicin Crm 0.025% <range>Capsaicin</range>

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

any relevant practitioner Zostrix 45 9.75 9.75 9.75 0.00000 Zo-Rub Osteo 45 9.75 9.75 9.75 0.00000 Antirheumatoid Agents Antirheumatoid Agents Hydroxychloroquine sulphate Tab 200 mg Ipca-Hydroxychloroquine 100 7.80 7.80 7.80 0.00000 Penicillamine Tab 125 mg D-Penamine 100 67.23 67.23 67.23 0.00000 Tab 250 mg D-Penamine 100 110.12 110.12 110.12 0.00000 Leflunomide Tab 20 mg Arava 30 6.00 6.00 6.00 0.00000 Tab 10 mg Arava 30 6.00 6.00 6.00 0.00000 Drugs Affecting Bone Metabolism Alendronate for Osteoporosis Alendronate sodium Tab 70 mg Fosamax 4 3.10 3.10 3.10 0.00000 Alendronate sodium with colecalciferol Tab 70 mg with colecalciferol 5,600 iu Fosamax Plus 4 1.99 1.99 1.99 0.00000 Other Treatments Zoledronic acid Inj 0.05 mg per ml, 100 ml, bag Zoledronic Acid Viatris 1 19.45 19.45 19.45 0.00000 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)

any relevant practitioner 18

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
Antiresorptive agents and their adequate doses for the purposes of this Special Authority are defined as: alendronate sodium tab 70 mg or tab 70 mg with 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.
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.
A maximum of 18 months of treatment (18 cartridges) will be subsidised.

Inj 250 mcg per ml, 2.4 ml Forteo 1 490.00 490.00 490.00 0.00000 Teriparatide - Teva 1 1 200.27 200.27 200.27 0.00000 Risedronate sodium Tab 35 mg Risedronate Sandoz 4 3.00 3.00 3.00 0.00000 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

any relevant practitioner

Patient has hypercalcaemia of malignancy Patient has severe renal impairment

any relevant practitioner Inj 60 mg per 1 ml prefilled syringe Prolia 1 1 187.50 187.50 187.50 0.00000 Inj 120 mg per 1.7 ml vial Xgeva 1 375.00 375.00 375.00 0.00000 Pamidronate disodium Inj 3 mg per ml, 10 ml vial Pamisol 1 1 32.49 32.49 32.49 0.00000 Inj 6 mg per ml, 10 ml vial Pamisol 1 1 88.11 88.11 88.11 0.00000 Inj 9 mg per ml, 10 ml vial Pamisol 1 1 94.34 94.34 94.34 0.00000 Hyperuricaemia and Antigout Hyperuricaemia and Antigout Allopurinol Tab 100 mg Ipca-Allopurinol 1000 17.99 17.99 17.99 0.00000 Tab 300 mg Ipca-Allopurinol 500 22.50 22.50 22.50 0.00000 Colchicine Tab 500 mcg Colgout 100 6.30 6.30 6.30 0.00000 Probenecid Tab 500 mg Probenecid-AFT 100 66.95 66.95 66.95 0.00000 Benzbromarone <range>Benzbromarone</range>

The treatment remains appropriate and the
                    patient is benefitting from the treatment There is no evidence of liver toxicity and
                    patient is continuing to receive regular (at least every three months) liver
                    function tests

any relevant practitioner 2 Tab 50 mg Narcaricin mite 100 32.00 32.00 32.00 0.00000 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 The patient has previously had an initial
                        Special Authority approval for benzbromarone for treatment of gout.

any relevant 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 the patient
                is benefitting from treatment

haematologist oncologist 6 Tab 80 mg Febuxostat (Teva) 28 4.73 4.73 4.73 0.00000 Tab 120 mg Febuxostat (Teva) 28 11.78 11.78 11.78 0.00000 Muscle Relaxants Muscle Relaxants Dantrolene Cap 25 mg Dantrium S29 100 145.77 145.77 145.77 0.00000 Cap 50 mg Dantrium 100 77.00 77.00 77.00 0.00000 Orphenadrine citrate Tab 100 mg Norflex 100 23.25 23.25 23.25 0.00000 Baclofen Tab 10 mg Pacifen 100 3.70 3.70 3.70 0.00000 Inj 0.05 mg per ml, 1 ml ampoule

Subsidised only for use in a programmable pump in patients where oral antispastic agents have been ineffective or have caused intolerable side effects and the prescription is endorsed accordingly.

Lioresal Intrathecal 1 1 11.55 11.55 11.55 0.00000 Inj 2 mg per ml, 5 ml ampoule

Subsidised only for use in a programmable pump in patients where oral antispastic agents have been ineffective or have caused intolerable side effects and the prescription is endorsed accordingly.

Sintetica Baclofen Intrathecal 10 1 490.91 490.91 490.91 0.00000 Nervous System Agents for Parkinsonism and Related Disorders Dopamine Agonists and Related Agents Apomorphine hydrochloride Inj 10 mg per ml, 2 ml ampoule Movapo 5 1 59.50 59.50 59.50 0.00000 Inj 10 mg per ml, 5 ml ampoule Movapo 5 1 121.84 121.84 121.84 0.00000 Amantadine hydrochloride Cap 100 mg Symmetrel 100 63.73 63.73 63.73 0.00000 60 38.24 38.24 38.24 0.00000 Tolcapone Tab 100 mg Tasmar 100 152.38 152.38 152.38 0.00000 Levodopa with benserazide Cap 200 mg with benserazide 50 mg Madopar 250 100 26.25 26.25 26.25 0.00000 Cap 100 mg with benserazide 25 mg Madopar 125 100 15.80 15.80 15.80 0.00000 Cap long-acting 100 mg with benserazide 25 mg Madopar HBS 100 22.85 22.85 22.85 0.00000 Cap 50 mg with benserazide 12.5 mg Madopar 62.5 100 13.75 13.75 13.75 0.00000 Tab dispersible 50 mg with benserazide 12.5 mg Madopar Rapid 100 13.25 13.25 13.25 0.00000 Levodopa with carbidopa Tab 100 mg with carbidopa 25 mg Sinemet 100 26.49 26.49 26.49 0.00000 Tab 250 mg with carbidopa 25 mg Sinemet 100 39.49 39.49 39.49 0.00000 Tab long-acting 200 mg with carbidopa 50 mg Sinemet CR 100 44.99 44.99 44.99 0.00000 Entacapone Tab 200 mg Entacapone Viatris 100 13.73 13.73 13.73 0.00000 Ropinirole hydrochloride Tab 0.25 mg Ropin 84 8.83 8.83 8.83 0.00000 Tab 1 mg Ropin 84 10.09 10.09 10.09 0.00000 Tab 2 mg Ropin 84 12.29 12.29 12.29 0.00000 Tab 5 mg Ropin 84 25.94 25.94 25.94 0.00000 Pramipexole hydrochloride Tab 0.25 mg Ramipex 100 5.23 5.23 5.23 0.00000 Tab 1 mg Ramipex 100 17.73 17.73 17.73 0.00000 Rasagiline Tab 1 mg Azilect 30 53.50 53.50 53.50 0.00000 Levodopa with carbidopa and entacapone Tab 50 mg with carbidopa 12.5 mg and entacapone 200 mg Stalevo 100 27.01 27.01 27.01 0.00000 Tab 100 mg with carbidopa 25 mg and entacapone 200 mg Stalevo 100 34.18 34.18 34.18 0.00000 Tab 150 mg with carbidopa 37.5 mg and entacapone 200 mg Stalevo 100 44.96 44.96 44.96 0.00000 Tab 200 mg with carbidopa 50 mg and entacapone 200 mg Stalevo 100 51.23 51.23 51.23 0.00000 Anticholinergics Benzatropine mesylate Tab 2 mg Benztrop 60 10.99 10.99 10.99 0.00000 Inj 1 mg per ml, 2 ml Phebra 5 1 95.00 95.00 95.00 0.00000 Procyclidine hydrochloride Tab 5 mg Kemadrin 100 15.00 15.00 15.00 0.00000 Agents for Essential Tremor, Chorea and Related Disorders Tetrabenazine Tab 25 mg Motetis 112 126.02 126.02 126.02 0.00000 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

any relevant practitioner 18 Tab 50 mg Rilutek 56 117.00 117.00 117.00 0.00000 Anaesthetics Local Lidocaine [Lignocaine] hydrochloride Inj 1%, 20 ml ampoule Xylocaine 5 1 12.00 20.00 12.00 1.60000 Inj 1%, 5 ml ampoule Xylocaine 50 1 17.50 35.00 17.50 0.35000 Lidocaine-Baxter 25 1 15.00 15.00 15.00 0.00000 Inj 2%, 5 ml ampoule Lidocaine-Baxter 25 1 27.50 27.50 27.50 0.00000 Oral (gel) soln 2% Xylocaine Viscous 200 30.80 30.80 30.80 0.00000 Inj 1%, 20 ml vial Lidocaine-Baxter 5 1 19.50 19.50 19.50 0.00000 Inj 2%, 20 ml vial Lidocaine-Baxter 5 1 14.00 14.00 14.00 0.00000 Inj 10%, 5 ml ampoule

Subsidised only for people receiving palliative care services where other analgesic agents haven't been effective.

Xylocard 500 10 1 Lidocaine [Lignocaine] Gel 2%, tube

Subsidised only if prescribed for urethral or cervical administration and the prescription is endorsed accordingly.

Xylocaine 2% Jelly 30 14.50 14.50 14.50 0.00000 Gel 2%, 11 ml urethral syringe

Subsidised only if prescribed for urethral, cervical or rectal administration and the prescription is endorsed accordingly.

Instillagel Lido 10 65.45 65.45 65.45 0.00000 Topical Local Anaesthetics <range>Topical local anaesthetics<instance>EMLA</instance><instance>LMX4</instance></range>

the patient is a child with a chronic medical condition requiring frequent injections or venepuncture

any relevant practitioner 2

The treatment remains appropriate and the patient is benefiting from treatment

any relevant practitioner 2 Lidocaine [Lignocaine] with prilocaine Crm 2.5% with prilocaine 2.5% EMLA 30 45.00 45.00 45.00 0.00000 Crm 2.5% with prilocaine 2.5% (5 g tubes) EMLA 5 45.00 45.00 45.00 0.00000 Lidocaine [Lignocaine] Crm 4% LMX4 30 30.00 30.00 30.00 0.00000 5 7.60 7.60 7.60 0.00000 General Anaesthetics Ketamine

Subsidised only for use within a Primary Response in Medical Emergencies (PRIME) service or to treat intractable pain in palliative care* and the prescription or PSO is endorsed accordingly.

Note: Indication marked with * is an unapproved indication.

Inj 100 mg per ml, 2 ml vial Ketalar 5 1 91.98 91.98 91.98 0.00000 Analgesics

For Anti-inflammatory NSAIDS refer to MUSCULOSKELETAL

Non-opioid Analgesics Aspirin Tab dispersible 300 mg Ethics Aspirin 100 5.65 5.65 5.65 0.00000 Nefopam hydrochloride Tab 30 mg Acupan 90 23.40 23.40 23.40 0.00000 Paracetamol Oral liq 120 mg per 5 ml

Maximum of 200 ml per dispensing for non-endorsed patients. If quantities prescribed exceed 200 ml (for non-endorsed patients), then dispense in repeat dispensing not exceeding 200 ml per dispensing.
Subsidy by endorsement for higher quantities is available for patients with long term conditions who require regular daily dosing for one month or greater and the prescription is endorsed or annotated accordingly. Pharmacists may annotate the prescription as endorsed where dispensing history supports a long-term condition.
Note: 200 ml presentations of paracetamol oral liquid may be supplied on BSO to a Vaccinator (other than a Pharmacist) under the provisions in Part I of Section A
Note: Direct Provision by a pharmacist of up to 200 ml permitted under the provisions in Part I of Section A in conjunction with immunisation of a child under 2 years of age with meningococcal B multicomponent vaccine.

Paracetamol (Ethics) 200 3.98 3.98 3.98 0.00000 Oral liq 250 mg per 5 ml

Maximum of 200 ml per dispensing for non-endorsed patients. If quantities prescribed exceed 200 ml (for non-endorsed patients), then dispense in repeat dispensing not exceeding 200 ml per dispensing.
Subsidy by endorsement for higher quantities is available for patients with long term conditions who require regular daily dosing for one month or greater and the prescription is endorsed or annotated accordingly. Pharmacists may annotate the prescription as endorsed where dispensing history supports a long-term condition.
Note: 200 ml presentations of paracetamol oral liquid may be supplied on BSO to a Vaccinator (other than a Pharmacist) under the provisions in Part I of Section A
Note: Direct Provision by a pharmacist of up to 200 ml permitted under the provisions in Part I of Section A in conjunction with immunisation of a child under 2 years of age with meningococcal B multicomponent vaccine.

Pamol 200 3.18 3.18 3.18 0.00000 Suppos 125 mg Gacet 10 4.29 4.29 4.29 0.00000 Suppos 250 mg Gacet 10 5.39 5.39 5.39 0.00000 Suppos 500 mg Gacet 50 16.55 16.55 16.55 0.00000 Tab 500 mg - blister pack

Subsidy by endorsement for higher quantities is available for patients with long term conditions who require regular daily dosing for one month or greater, and the prescription is annotated accordingly. Pharmacists may annotate the prescription as endorsed where dispensing history supports a long-term condition.
Maximum of 100 tab per dispensing for non-endorsed patients. If quantities prescribed for more than 100 tabs (for non-endorsed patients), then dispense in repeat dispensings not exceeding 100 tab per dispensing.

Pacimol 1000 19.75 19.75 19.75 0.00000 Tab 500 mg - bottle pack

Subsidy by endorsement for higher quantities is available for patients with long term conditions who require regular daily dosing for one month or greater, and the prescription is annotated accordingly. Pharmacists may annotate the prescription as endorsed where dispensing history supports a long-term condition.
Maximum of 100 tab per dispensing for non-endorsed patients. If quantities prescribed for more than 100 tabs (for non-endorsed patients), then dispense in repeat dispensings not exceeding 100 tab per dispensing.

Noumed Paracetamol 1000 17.92 17.92 17.92 0.00000 Capsaicin

Subsidised only if prescribed for post-herpetic neuralgia or diabetic peripheral neuropathy and the prescription is endorsed accordingly.

Crm 0.075% Zostrix HP 45 11.95 11.95 11.95 0.00000 Zo-Rub HP 45 11.95 11.95 11.95 0.00000 Methoxyflurane

Subsidised only for use within a Primary Response in Medical Emergencies (PRIME) service and the PSO is endorsed accordingly.

Soln for inhalation 999.9 mg per g, 3 ml bottle with inhaler device and activated carbon chamber Penthrox 1 54.00 54.00 54.00 0.00000 Soln for inhalation 999.9 mg per g, 3 ml bottle Penthrox 10 1 276.00 276.00 276.00 0.00000 Opioid Analgesics Codeine phosphate Tab 15 mg Noumed 100 5.82 5.82 5.82 0.00000 Tab 30 mg Noumed 100 6.88 6.88 6.88 0.00000 Tab 60 mg Noumed 100 13.89 13.89 13.89 0.00000 Methadone hydrochloride Tab 5 mg Methadone BNM 10 1.38 1.38 1.38 0.00000 Inj 10 mg per ml, 1 ml AFT 10 1 72.99 72.99 72.99 0.00000 Oral liq 2 mg per ml Biodone 200 7.80 7.80 7.80 0.00000 Oral liq 5 mg per ml Biodone Forte 200 7.80 7.80 7.80 0.00000 Oral liq 10 mg per ml Biodone Extra Forte 200 9.65 9.65 9.65 0.00000 Morphine hydrochloride Oral liq 1 mg per ml RA-Morph 200 19.00 19.00 19.00 0.00000 Oral liq 2 mg per ml RA-Morph 200 23.55 23.55 23.55 0.00000 Oral liq 5 mg per ml RA-Morph 200 28.20 28.20 28.20 0.00000 Oral liq 10 mg per ml RA-Morph 200 40.25 40.25 40.25 0.00000 Morphine sulphate Inj 5 mg per ml, 1 ml ampoule Medsurge 5 1 5.96 5.96 5.96 0.00000 Inj 10 mg per ml, 1 ml ampoule Medsurge 5 1 4.99 4.99 4.99 0.00000 Inj 15 mg per ml, 1 ml ampoule Medsurge 5 1 6.93 6.93 6.93 0.00000 Inj 30 mg per ml, 1 ml ampoule Medsurge 5 1 7.28 7.28 7.28 0.00000 Cap long-acting 100 mg m-Eslon 10 14.50 14.50 14.50 0.00000 Tab immediate-release 10 mg Sevredol 10 2.80 2.80 2.80 0.00000 Tab immediate-release 20 mg Sevredol 10 5.52 5.52 5.52 0.00000 Cap long-acting 10 mg m-Eslon 10 4.10 4.10 4.10 0.00000 Cap long-acting 30 mg m-Eslon 10 6.05 6.05 6.05 0.00000 Cap long-acting 60 mg m-Eslon 10 12.10 12.10 12.10 0.00000 Oral liq 2 mg per ml Wockhardt 100 16.31 16.31 16.31 0.00000 Oramorph 100 29.80 29.80 29.80 0.00000 Oramorph CDC S29 100 29.80 29.80 29.80 0.00000 Paracetamol with codeine Tab paracetamol 500 mg with codeine phosphate 8 mg Paracetamol + Codeine (Relieve) 1000 31.95 31.95 31.95 0.00000 Pethidine hydrochloride Tab 50 mg Noumed Pethidine 10 8.68 8.68 8.68 0.00000 Inj 50 mg per ml, 1 ml ampoule DBL Pethidine Hydrochloride 5 1 29.88 29.88 29.88 0.00000 Inj 50 mg per ml, 2 ml ampoule DBL Pethidine Hydrochloride 5 1 30.72 30.72 30.72 0.00000 Dihydrocodeine tartrate Tab long-acting 60 mg DHC Continus 60 9.20 9.20 9.20 0.00000 Fentanyl Inj 50 mcg per ml, 2 ml ampoule Boucher and Muir 10 1 4.25 4.25 4.25 0.00000 Inj 50 mcg per ml, 10 ml ampoule Boucher and Muir 10 1 9.41 9.41 9.41 0.00000 Patch 25 mcg per hour Fentanyl Sandoz 5 6.91 6.91 6.91 0.00000 Patch 50 mcg per hour Fentanyl Sandoz 5 9.28 9.28 9.28 0.00000 Patch 75 mcg per hour Fentanyl Sandoz 5 15.50 15.50 15.50 0.00000 Patch 100 mcg per hour Fentanyl Sandoz 5 16.37 16.37 16.37 0.00000 Patch 12 mcg per hour Fentanyl Sandoz 5 6.02 6.02 6.02 0.00000 Oxycodone hydrochloride Tab controlled-release 10 mg Oxycodone Sandoz 20 2.49 2.49 2.49 0.00000 Tab controlled-release 20 mg Oxycodone Sandoz 20 3.41 3.41 3.41 0.00000 Tab controlled-release 40 mg Oxycodone Sandoz 20 6.67 6.67 6.67 0.00000 Tab controlled-release 80 mg Oxycodone Sandoz 20 12.99 12.99 12.99 0.00000 Tab controlled-release 5 mg Oxycodone Sandoz 20 2.49 2.49 2.49 0.00000 Inj 10 mg per ml, 1 ml ampoule Hameln 5 1 4.37 4.37 4.37 0.00000 Inj 10 mg per ml, 2 ml ampoule Hameln 5 1 8.62 8.62 8.62 0.00000 Inj 50 mg per ml, 1 ml ampoule Hameln 5 1 14.90 14.90 14.90 0.00000 Oral liq 1 mg per ml Oxycodone Lucis 250 37.08 37.08 37.08 0.00000 Rosemont 250 37.08 37.08 37.08 0.00000 Tab immediate-release 5 mg Oxycodone Amneal 100 13.77 13.77 13.77 0.00000 Tab immediate-release 10 mg Oxycodone Amneal 100 18.77 18.77 18.77 0.00000 Tab immediate-release 20 mg Oxycodone Amneal 100 26.77 26.77 26.77 0.00000 Tramadol hydrochloride Cap 50 mg Arrow-Tramadol 100 3.33 3.33 3.33 0.00000 Tab sustained-release 100 mg Tramal SR 100 20 1.95 1.95 1.95 0.00000 20 1.95 1.95 1.95 0.00000 Tab sustained-release 150 mg Tramal SR 150 20 2.95 2.95 2.95 0.00000 20 2.95 2.95 2.95 0.00000 Tab sustained-release 200 mg Tramal SR 200 20 3.80 3.80 3.80 0.00000 20 3.80 3.80 3.80 0.00000 Antidepressants Cyclic and Related Agents Amitriptyline Tab 10 mg Arrow-Amitriptyline 100 2.99 2.99 2.99 0.00000 Tab 25 mg Arrow-Amitriptyline 100 1.99 1.99 1.99 0.00000 Tab 50 mg Arrow-Amitriptyline 100 3.14 3.14 3.14 0.00000 Clomipramine hydrochloride Tab 25 mg APO Clomipramine 50 16.99 16.99 16.99 0.00000 Dosulepin [Dothiepin] hydrochloride

Subsidy by endorsement – Subsidised for patients who were taking dosulepin [dothiepin] hydrochloride prior to 1 June 2019 and the prescription is endorsed accordingly. Pharmacists may annotate the prescription as endorsed where there exists a record of prior dispensing of dosulepin [dothiepin] hydrochloride.

Tab 75 mg Dosulepin Viatris 30 3.85 3.85 3.85 0.00000 Cap 25 mg Dosulepin Viatris 50 7.83 7.83 7.83 0.00000 Imipramine hydrochloride Tab 10 mg Tofranil 50 5.48 5.48 5.48 0.00000 100 10.96 10.96 10.96 0.00000 Tab 25 mg Tofranil 50 8.80 8.80 8.80 0.00000 Imipramine Crescent 28 4.93 4.93 4.93 0.00000 Nortriptyline hydrochloride Tab 10 mg Allegron 50 2.24 2.24 2.24 0.00000 Tab 25 mg Allegron 50 2.95 2.95 2.95 0.00000 Monoamine-Oxidase Inhibitors (MAOIs) - Non Selective Tranylcypromine sulphate Tab 10 mg Parnate 50 22.94 22.94 22.94 0.00000 Monoamine-Oxidase Type A Inhibitors Moclobemide Tab 150 mg Aurorix 60 23.60 23.60 23.60 0.00000 Tab 300 mg Aurorix 60 38.50 38.50 38.50 0.00000 Selective Serotonin Reuptake Inhibitors Citalopram hydrobromide Tab 20 mg Celapram 84 3.55 3.55 3.55 0.00000 Fluoxetine hydrochloride Cap 20 mg Arrow-Fluoxetine 90 3.50 3.50 3.50 0.00000 Tab dispersible 20 mg, scored

Subsidised by endorsement

When prescribed for a patient who cannot swallow whole tablets or capsules and the prescription is endorsed accordingly; or
When prescribed in a daily dose that is not a multiple of 20 mg in which case the prescription is deemed to be endorsed. Note: Tablets should be combined with capsules to facilitate incremental 10 mg doses.

Fluox 28 2.37 2.37 2.37 0.00000 Escitalopram Tab 10 mg Escitalopram (Ethics) 28 1.07 1.07 1.07 0.00000 Ipca-Escitalopram 28 0.79 0.79 0.79 0.00000 Tab 20 mg Ipca-Escitalopram 28 1.49 1.49 1.49 0.00000 Sertraline Tab 50 mg Setrona 30 1.24 1.24 1.24 0.00000 Tab 100 mg Setrona 30 2.00 2.00 2.00 0.00000 Paroxetine Tab 20 mg Loxamine 90 4.98 4.98 4.98 0.00000 Other Antidepressants Venlafaxine Cap 75 mg Enlafax XR 84 10.32 10.32 10.32 0.00000 84 10.32 10.32 10.32 0.00000 Cap 150 mg Enlafax XR 84 13.95 13.95 13.95 0.00000 Cap 37.5 mg Enlafax XR 84 8.29 8.29 8.29 0.00000 84 8.29 8.29 8.29 0.00000 Mirtazapine Tab 30 mg Noumed 30 2.34 2.34 2.34 0.00000 Tab 45 mg Noumed 30 3.10 3.10 3.10 0.00000 Antiepilepsy Drugs Agents for Control of Status Epilepticus Diazepam Rectal tubes 5 mg Stesolid 5 54.58 54.58 54.58 0.00000 Inj 5 mg per ml, 2 ml ampoule

PSO must be endorsed “not for anaesthetic procedures”.

Hospira 5 1 27.92 27.92 27.92 0.00000 Phenytoin sodium Inj 50 mg per ml, 5 ml ampoule Hospira 5 1 154.01 154.01 154.01 0.00000 Control of Epilepsy Lamotrigine Tab dispersible 5 mg Lamictal 30 50.00 50.00 50.00 0.00000 Tab dispersible 25 mg Logem 56 4.20 4.20 4.20 0.00000 Tab dispersible 50 mg Logem 56 5.11 5.11 5.11 0.00000 Tab dispersible 100 mg Logem 56 6.75 6.75 6.75 0.00000 Tab dispersible 2 mg Lamictal 30 55.00 55.00 55.00 0.00000 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.

any relevant 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.

any relevant practitioner Tab 500 mg Sabril 100 119.30 119.30 119.30 0.00000 Gabapentin

Note: Not subsidised in combination with subsidised pregabalin

Cap 300 mg Nupentin 100 8.45 8.45 8.45 0.00000 Cap 400 mg Nupentin 100 10.26 10.26 10.26 0.00000 Cap 100 mg Nupentin 100 6.45 6.45 6.45 0.00000 Topiramate Tab 25 mg Topamax 60 26.04 26.04 26.04 0.00000 Arrow-Topiramate 60 11.07 11.07 11.07 0.00000 Topiramate Actavis 60 11.07 11.07 11.07 0.00000 Tab 50 mg Topamax 60 44.26 44.26 44.26 0.00000 Arrow-Topiramate 60 18.81 18.81 18.81 0.00000 Topiramate Actavis 60 18.81 18.81 18.81 0.00000 Tab 100 mg Topamax 60 75.25 75.25 75.25 0.00000 Arrow-Topiramate 60 31.99 31.99 31.99 0.00000 Topiramate Actavis 60 31.99 31.99 31.99 0.00000 Tab 200 mg Topamax 60 129.85 129.85 129.85 0.00000 Arrow-Topiramate 60 55.19 55.19 55.19 0.00000 Topiramate Actavis 60 55.19 55.19 55.19 0.00000 Sprinkle cap 15 mg Topamax 60 20.84 20.84 20.84 0.00000 Sprinkle cap 25 mg Topamax 60 26.04 26.04 26.04 0.00000 Carbamazepine Oral liq 20 mg per ml Tegretol 250 26.37 26.37 26.37 0.00000 Tab 200 mg Tegretol 100 14.53 14.53 14.53 0.00000 Tab long-acting 200 mg Tegretol CR 100 16.98 16.98 16.98 0.00000 200 33.96 33.96 33.96 0.00000 Tab 400 mg Tegretol 100 34.58 34.58 34.58 0.00000 Tab long-acting 400 mg Tegretol CR 100 39.17 39.17 39.17 0.00000 Clobazam Tab 10 mg Frisium 50 9.12 9.12 9.12 0.00000 Clonazepam Oral drops 2.5 mg per ml Rivotril 10 7.38 7.38 7.38 0.00000 Ethosuximide Cap 250 mg Zarontin 100 140.88 140.88 140.88 0.00000 Oral liq 250 mg per 5 ml Zarontin 200 56.35 56.35 56.35 0.00000 Phenytoin sodium Tab 50 mg Dilantin Infatab 200 75.00 75.00 75.00 0.00000 Cap 30 mg Dilantin 200 74.00 74.00 74.00 0.00000 Cap 100 mg Dilantin 200 37.00 37.00 37.00 0.00000 Oral liq 30 mg per 5 ml Dilantin Paediatric 500 22.03 22.03 22.03 0.00000 Primidone Tab 250 mg Primidone Clinect 100 37.35 37.35 37.35 0.00000 Sodium valproate Tab 100 mg Epilim Crushable 100 13.65 13.65 13.65 0.00000 Tab 200 mg EC Epilim 100 27.44 27.44 27.44 0.00000 Tab 500 mg EC Epilim 100 52.24 52.24 52.24 0.00000 Oral liq 200 mg per 5 ml Epilim S/F Liquid 300 20.48 20.48 20.48 0.00000 Epilim Syrup 300 20.48 20.48 20.48 0.00000 Inj 100 mg per ml, 4 ml Epilim IV 1 1 41.50 41.50 41.50 0.00000 Phenobarbitone

For phenobarbitone oral liquid refer Standard Formulae

Tab 15 mg Noumed Phenobarbitone 500 248.50 248.50 248.50 0.00000 Tab 30 mg Noumed Phenobarbitone 500 398.50 398.50 398.50 0.00000 Levetiracetam Tab 250 mg Everet 60 5.84 5.84 5.84 0.00000 Tab 500 mg Everet 60 10.51 10.51 10.51 0.00000 Tab 750 mg Everet 60 16.71 16.71 16.71 0.00000 Tab 1,000 mg Everet 60 21.82 21.82 21.82 0.00000 Oral liq 100 mg per ml Levetiracetam-AFT 300 44.78 44.78 44.78 0.00000 Inj 100 mg per ml, 5 ml vial Levetiracetam-AFT 10 1 38.95 38.95 38.95 0.00000 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)

any relevant 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.

The 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

any relevant practitioner 24 Tab 50 mg Vimpat 14 25.04 25.04 25.04 0.00000 Tab 100 mg Vimpat 14 50.06 50.06 50.06 0.00000 56 200.24 200.24 200.24 0.00000 Tab 150 mg Vimpat 14 75.10 75.10 75.10 0.00000 56 300.40 300.40 300.40 0.00000 Tab 200 mg Vimpat 56 400.55 400.55 400.55 0.00000 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 Practitioner 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.

the patient continues to benefit from treatment as measured by reduced seizure frequency from baseline

any relevant practitioner Cap 250 mg Diacomit 60 509.29 509.29 509.29 0.00000 Powder for oral liq 250 mg sachet Diacomit 60 509.29 509.29 509.29 0.00000 Pregabalin

Note: Not subsidised in combination with subsidised gabapentin

Cap 25 mg Pregabalin Pfizer 56 2.25 2.25 2.25 0.00000 Lyrica 56 2.25 2.25 2.25 0.00000 Cap 75 mg Pregabalin Pfizer 56 2.65 2.65 2.65 0.00000 Lyrica 56 2.65 2.65 2.65 0.00000 Cap 150 mg Pregabalin Pfizer 56 4.01 4.01 4.01 0.00000 Lyrica 56 4.01 4.01 4.01 0.00000 Cap 300 mg Pregabalin Pfizer 56 7.38 7.38 7.38 0.00000 Lyrica 56 7.38 7.38 7.38 0.00000 Antimigraine Preparations

For Anti-inflammatory NSAIDS refer to MUSCULOSKELETAL

Acute Migraine Treatment Sumatriptan Tab 50 mg Sumagran 90 14.41 14.41 14.41 0.00000 Tab 100 mg Sumagran 90 22.68 22.68 22.68 0.00000 Inj 12 mg per ml, 0.5 ml prefilled pen Clustran 2 2 29.80 29.80 29.80 0.00000 Rizatriptan Tab orodispersible 10 mg Rizamelt 30 4.84 4.84 4.84 0.00000 Prophylaxis of Migraine

For Beta Adrenoceptor Blockers refer to CARDIOVASCULAR SYSTEM

Pizotifen Tab 500 mcg Sandomigran 100 23.21 23.21 23.21 0.00000 Antinausea and Vertigo Agents

For Antispasmodics refer to ALIMENTARY TRACT

Antinausea and Vertigo Agents Betahistine dihydrochloride Tab 16 mg Serc 100 3.70 3.70 3.70 0.00000 Domperidone Tab 10 mg Domperidone Viatris 100 3.80 3.80 3.80 0.00000 Hyoscine hydrobromide Patch 1 mg per 72 hours <range>Hyoscine (Scopolamine)</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

any relevant practitioner 1

The treatment remains appropriate and the patient
                is benefiting from treatment

any relevant practitioner 1 Scopolamine Transdermal System Viatris 10 88.50 88.50 88.50 0.00000 Inj 400 mcg per ml, 1 ml ampoule Martindale 10 1 93.00 93.00 93.00 0.00000 Metoclopramide hydrochloride Tab 10 mg Metoclopramide Actavis 10 100 1.57 1.57 1.57 0.00000 Inj 5 mg per ml, 2 ml ampoule Medsurge 10 5.48 5.48 5.48 0.00000 Ondansetron Tab 4 mg Periset 50 1.95 1.95 1.95 0.00000 Tab 8 mg Periset 50 3.50 3.50 3.50 0.00000 Tab disp 4 mg Periset ODT 10 0.56 0.56 0.56 0.00000 Tab disp 8 mg Periset ODT 10 0.90 0.90 0.90 0.00000 Aprepitant <range>Aprepitant</range>

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

any relevant practitioner 12

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

any relevant practitioner 12 Cap 2 x 80 mg and 1 x 125 mg Emend Tri-Pack 3 21.90 21.90 21.90 0.00000 Cyclizine hydrochloride Tab 50 mg Nausicalm 10 0.66 0.66 0.66 0.00000 Cyclizine lactate Inj 50 mg per ml, 1 ml ampoule Hameln 10 1 16.36 16.36 16.36 0.00000 Prochlorperazine Tab 3 mg buccal Prochlorperazine maleate (Brown & Burk) 50 5.97 30.00 5.97 0.48060 Tab 5 mg Nausafix 250 25.00 25.00 25.00 0.00000 Inj 12.5 mg per ml, 1 ml Stemetil 10 1 25.81 25.81 25.81 0.00000 Droperidol

Subsidised only for use within a Primary Response in Medical Emergencies (PRIME) service and the PSO is endorsed accordingly.

Inj 2.5 mg per ml, 1 ml ampoule Droperidol Medsurge 10 1 28.68 28.68 28.68 0.00000 Antipsychotics General Risperidone Tab 1 mg Risperidone (Teva) 60 2.44 2.44 2.44 0.00000 Tab 2 mg Risperidone (Teva) 60 2.72 2.72 2.72 0.00000 Tab 3 mg Risperidone (Teva) 60 4.50 4.50 4.50 0.00000 Tab 4 mg Risperdal 60 6.25 6.25 6.25 0.00000 Risperidone (Teva) 60 6.25 6.25 6.25 0.00000 Oral liq 1 mg per ml Risperon 30 10.29 10.29 10.29 0.00000 100 34.30 34.30 34.30 0.00000 Tab 0.5 mg Risperidone (Teva) 60 2.17 2.17 2.17 0.00000 Clozapine Tab 25 mg Clozaril 50 6.69 6.69 6.69 0.00000 100 13.37 13.37 13.37 0.00000 50 6.69 6.69 6.69 0.00000 Clopine 100 13.37 13.37 13.37 0.00000 50 6.69 6.69 6.69 0.00000 Tab 100 mg Clozaril 50 17.33 17.33 17.33 0.00000 100 34.65 34.65 34.65 0.00000 50 17.33 17.33 17.33 0.00000 Clopine 100 34.65 34.65 34.65 0.00000 50 17.33 17.33 17.33 0.00000 Tab 50 mg Clopine 100 17.33 17.33 17.33 0.00000 50 8.67 8.67 8.67 0.00000 Tab 200 mg Clopine 100 69.30 69.30 69.30 0.00000 50 34.65 34.65 34.65 0.00000 Suspension 50 mg per ml Versacloz 100 173.30 173.30 173.30 0.00000 Olanzapine Tab 5 mg Zypine 30 1.93 1.93 1.93 0.00000 Tab 10 mg Zypine 28 1.80 1.80 1.80 0.00000 30 1.93 1.93 1.93 0.00000 Tab 2.5 mg Zypine 30 1.40 1.40 1.40 0.00000 Tab orodispersible 5 mg Zypine ODT 28 2.42 2.42 2.42 0.00000 Olanzapine ODT Viatris 100 8.64 8.64 8.64 0.00000 APO-Olanzapine 28 3.93 3.93 3.93 0.00000 Tab orodispersible 10 mg Zypine ODT 28 2.89 2.89 2.89 0.00000 Olanzapina Mylan Pharma 28 2.89 2.89 2.89 0.00000 Olanzapina Mylan 28 2.89 2.89 2.89 0.00000 Olanzapine ODT Viatris 100 10.32 10.32 10.32 0.00000 APO-Olanzapine 28 4.49 4.49 4.49 0.00000 Quetiapine Tab 25 mg Quetapel 90 2.36 2.36 2.36 0.00000 Quetiapine Viatris 30 0.79 0.79 0.79 0.00000 500 13.11 13.11 13.11 0.00000 Tab 100 mg Quetapel 90 6.40 6.40 6.40 0.00000 Tab 200 mg Quetapel 90 10.97 10.97 10.97 0.00000 Tab 300 mg Quetapel 90 15.83 15.83 15.83 0.00000 Chlorpromazine hydrochloride Tab 25 mg Largactil 100 15.62 15.62 15.62 0.00000 Tab 100 mg Largactil 100 36.73 36.73 36.73 0.00000 Inj 25 mg per ml, 2 ml Largactil 10 1 30.79 30.79 30.79 0.00000 Haloperidol Tab 500 mcg Serenace 100 6.23 6.23 6.23 0.00000 Tab 1.5 mg Serenace 100 9.43 9.43 9.43 0.00000 Tab 5 mg Serenace 100 29.72 29.72 29.72 0.00000 50 14.86 14.86 14.86 0.00000 Oral liq 2 mg per ml Serenace 100 23.84 23.84 23.84 0.00000 Inj 5 mg per ml, 1 ml ampoule Serenace 10 1 12.93 12.93 12.93 0.00000 Levomepromazine hydrochloride Inj 25 mg per ml, 1 ml ampoule Wockhardt 10 1 23.26 23.26 23.26 0.00000 Levomepromazine Tab 25 mg as a maleate Nozinan 100 16.10 16.10 16.10 0.00000 Tab 100 mg as a maleate Nozinan 100 41.75 41.75 41.75 0.00000 Tab 100 mg (135 mg as a maleate) Nozinan (Swiss) 100 41.75 41.75 41.75 0.00000 Tab 25 mg (33.8 mg as a maleate) Nozinan (Swiss) 100 16.10 16.10 16.10 0.00000 Pericyazine Tab 2.5 mg Neulactil 100 13.61 13.61 13.61 0.00000 Tab 10 mg Neulactil 100 48.45 48.45 48.45 0.00000 Lithium carbonate Tab long-acting 400 mg Priadel 100 82.80 82.80 82.80 0.00000 Cap 250 mg Douglas 100 35.78 35.78 35.78 0.00000 Ziprasidone Cap 20 mg Zusdone 60 17.90 17.90 17.90 0.00000 Cap 40 mg Zusdone 60 27.41 27.41 27.41 0.00000 Cap 60 mg Zusdone 60 38.39 38.39 38.39 0.00000 Cap 80 mg Zusdone 60 46.55 46.55 46.55 0.00000 Aripiprazole Tab 10 mg Aripiprazole Sandoz 30 10.50 10.50 10.50 0.00000 Tab 15 mg Aripiprazole Sandoz 30 10.50 10.50 10.50 0.00000 Tab 20 mg Aripiprazole Sandoz 30 10.50 10.50 10.50 0.00000 Tab 30 mg Aripiprazole Sandoz 30 10.50 10.50 10.50 0.00000 Tab 5 mg Aripiprazole Sandoz 30 10.50 10.50 10.50 0.00000 Amisulpride Tab 100 mg Sulprix 30 5.84 5.84 5.84 0.00000 Tab 200 mg Sulprix 60 14.47 14.47 14.47 0.00000 Tab 400 mg Sulprix 60 35.06 35.06 35.06 0.00000 Zuclopenthixol hydrochloride Tab 10 mg Clopixol 100 31.45 31.45 31.45 0.00000 Depot Injections 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 Has not been able to adhere with treatment using oral atypical antipsychotic agents 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

any relevant 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

any relevant practitioner 12 Inj 25 mg vial Risperdal Consta 1 1 135.98 135.98 135.98 0.00000 Inj 37.5 mg vial Risperdal Consta 1 1 178.71 178.71 178.71 0.00000 Inj 50 mg vial Risperdal Consta 1 1 217.56 217.56 217.56 0.00000 Olanzapine <range>Olanzapine depot injection</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

any relevant 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

any relevant practitioner 12 Inj 210 mg vial Zyprexa Relprevv 1 1 252.00 252.00 252.00 0.00000 Inj 300 mg vial Zyprexa Relprevv 1 1 414.00 414.00 414.00 0.00000 Inj 405 mg vial Zyprexa Relprevv 1 1 504.00 504.00 504.00 0.00000 Flupenthixol decanoate Inj 20 mg per ml, 1 ml Fluanxol 5 1 13.14 13.14 13.14 0.00000 Inj 20 mg per ml, 2 ml Fluanxol 5 1 20.90 20.90 20.90 0.00000 Inj 100 mg per ml, 1 ml Fluanxol 5 1 40.87 40.87 40.87 0.00000 Haloperidol decanoate Inj 50 mg per ml, 1 ml Haldol 5 1 28.39 28.39 28.39 0.00000 Inj 100 mg per ml, 1 ml Haldol Concentrate 5 1 55.90 55.90 55.90 0.00000 Haldol Decanoas 5 1 55.90 55.90 55.90 0.00000 Zuclopenthixol decanoate Inj 200 mg per ml, 1 ml Clopixol 5 1 19.80 19.80 19.80 0.00000 Aripiprazole <range>Aripiprazole</range>

The patient has had an initial Special Authority
            approval for risperidone depot injection, 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 started on olanzapine depot injection but has been unable to due to supply issues
          with olanzapine depot injection

any relevant 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 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.

Inj 300 mg vial Abilify Maintena 1 1 273.56 273.56 273.56 0.00000 1 273.56 273.56 273.56 0.00000 Inj 400 mg vial Abilify Maintena 1 1 341.96 341.96 341.96 0.00000 1 341.96 341.96 341.96 0.00000 Paliperidone <range>Paliperidone depot injection</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 Has been unable to adhere to treatment using oral atypical antipsychotic agents 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

any relevant 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

any relevant practitioner 12 Inj 25 mg syringe Invega Sustenna 1 1 194.25 194.25 194.25 0.00000 Inj 50 mg syringe Invega Sustenna 1 1 271.95 271.95 271.95 0.00000 Inj 75 mg syringe Invega Sustenna 1 1 357.42 357.42 357.42 0.00000 Inj 100 mg syringe Invega Sustenna 1 1 435.12 435.12 435.12 0.00000 Inj 150 mg syringe Invega Sustenna 1 1 435.12 435.12 435.12 0.00000 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

any relevant 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

any relevant practitioner 12 Inj 175 mg syringe Invega Trinza 1 1 815.85 815.85 815.85 0.00000 Inj 263 mg syringe Invega Trinza 1 1 1072.26 1072.26 1072.26 0.00000 Inj 350 mg syringe Invega Trinza 1 1 1305.36 1305.36 1305.36 0.00000 Inj 525 mg syringe Invega Trinza 1 1 1305.36 1305.36 1305.36 0.00000 Anxiolytics Anxiolytics Clonazepam Tab 500 mcg Paxam 100 5.64 5.64 5.64 0.00000 Tab 2 mg Paxam 100 10.78 10.78 10.78 0.00000 Diazepam Tab 2 mg Arrow-Diazepam 500 95.00 95.00 95.00 0.00000 Tab 5 mg Arrow-Diazepam 500 115.00 115.00 115.00 0.00000 Lorazepam Tab 2.5 mg Ativan 100 13.13 13.13 13.13 0.00000 Tab 1 mg Ativan 250 10.20 10.20 10.20 0.00000 Buspirone hydrochloride Tab 5 mg Buspirone Viatris 100 13.95 13.95 13.95 0.00000 Tab 10 mg Buspirone Viatris 100 12.50 12.50 12.50 0.00000 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 of 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 12

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

Interferon beta-1-alpha

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

Inj 6 million iu prefilled syringe Avonex 4 1 1170.00 1170.00 1170.00 0.00000 Interferon beta-1-beta

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

Inj 8 million iu per 1 ml Betaferon 15 1 1322.89 1322.89 1322.89 0.00000 Glatiramer acetate

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

Inj 40 mg prefilled syringe Copaxone 12 1 1500.00 1500.00 1500.00 0.00000 Fingolimod

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

Cap 0.5 mg Gilenya 28 2200.00 2200.00 2200.00 0.00000 Natalizumab

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

Inj 20 mg per ml, 15 ml vial Tysabri 1 1 1750.00 1750.00 1750.00 0.00000 Dimethyl fumarate

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

Cap 120 mg Tecfidera 14 520.00 520.00 520.00 0.00000 Cap 240 mg Tecfidera 56 2000.00 2000.00 2000.00 0.00000 Teriflunomide

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

Tab 14 mg Teriflunomide Sandoz 28 263.96 263.96 263.96 0.00000 Multiple Sclerosis Treatments - Other Ocrelizumab

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

<range>Ocrelizumab</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 of 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 12

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 12 Inj 30 mg per ml, 10 ml vial Ocrevus 1 1 8450.00 8450.00 8450.00 0.00000 Inj 40 mg per ml, 23 ml vial Ocrevus SC 1 1 16900.00 16900.00 16900.00 0.00000 Sedatives and Hypnotics Sedatives and Hypnotics Phenobarbitone sodium <range>Phenobarbitone</range>

For the treatment of terminal agitation that is unresponsive to other agents The applicant is part of a multidisciplinary team working in palliative care

any relevant practitioner Inj 200 mg per ml, 1 ml ampoule Max Health 10 1 113.37 113.37 113.37 0.00000 Temazepam Tab 10 mg Normison 25 1.40 1.40 1.40 0.00000 Zopiclone Tab 7.5 mg Zopiclone Actavis 500 21.85 21.85 21.85 0.00000 Midazolam Inj 1 mg per ml, 5 ml ampoule Midazolam-Baxter 10 1 7.80 7.80 7.80 0.00000 Inj 5 mg per ml, 3 ml ampoule Midazolam-Baxter 5 1 4.75 4.75 4.75 0.00000 Inj 1 mg per ml, 5 ml plastic ampoule

On a PSO for status epilepticus use only. PSO must be endorsed for status epilepticus use only.

Midazolam-Pfizer 10 1 46.65 46.65 46.65 0.00000 Inj 5 mg per ml, 3 ml plastic ampoule

On a PSO for status epilepticus use only. PSO must be endorsed for status epilepticus use only.

Midazolam-Pfizer 5 1 35.10 35.10 35.10 0.00000 Inj 5 mg per ml, 1 ml plastic ampoule

On a PSO for status epilepticus use only. PSO must be endorsed for status epilepticus use only.

Midazolam-Pfizer 10 1 22.50 22.50 22.50 0.00000 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 and were unsuccessful, 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 any relevant practitioner 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 any relevant practitioner 12

Indications marked with * are unapproved indications.

Tab modified-release 2 mg

Restricted to patients aged 18 years or under.

Vigisom 30 5.80 5.80 5.80 0.00000 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

any relevant 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

any relevant practitioner 12 Inj 12 mg per 5 ml vial Spinraza 1 120000.00 120000.00 120000.00 0.00000 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

any relevant 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

any relevant practitioner 12 Powder for oral soln 750 mcg per ml, 60 mg per bottle Evrysdi 80 14100.00 14100.00 14100.00 0.00000 Stimulants/ADHD Treatments Stimulants/ADHD Treatments 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 Applicant is a health practitioner authorised to
            prescribe treatment consistent with the approval notice gazetted for lisdexamfetamine
            (see note) 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

any relevant 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).

Cap 30 mg Vyvanse 30 60.00 60.00 60.00 0.00000 Cap 50 mg Vyvanse 30 60.00 60.00 60.00 0.00000 Cap 70 mg Vyvanse 30 60.00 60.00 60.00 0.00000 Dexamfetamine sulfate <range>Dexamfetamine sulfate</range>

ADHD (Attention Deficit and Hyperactivity Disorder) in
          patients aged 5 years or over Diagnosed according to DSM-IV or ICD 10 criteria Applicant is a health practitioner authorised to
          prescribe treatment consistent with the approval notice gazetted for dexamfetamine (see
          note)

any relevant practitioner

ADHD (Attention Deficit and Hyperactivity Disorder) in
          patients under 5 years of age Diagnosed according to DSM-IV or ICD 10 criteria Applicant is a health practitioner authorised to
          prescribe treatment consistent with the approval notice gazetted for dexamfetamine (see
          note)

any relevant practitioner

The patient suffers from narcolepsy

neurologist respiratory specialist Tab 5 mg Dexamfetamine Aspen 100 29.80 29.80 29.80 0.00000 Noumed Dexamfetamine 100 29.80 29.80 29.80 0.00000 Methylphenidate hydrochloride <range>Methylphenidate hydrochloride<instance>Rubifen</instance><instance>Rubifen SR</instance><instance>Ritalin</instance><instance>Methylphenidate ER - Teva</instance><instance>Methylphenidate Sandoz XR</instance></range>

ADHD (Attention Deficit and Hyperactivity Disorder) in
          patients aged 5 years or over Diagnosed according to DSM-IV or ICD 10 criteria Applicant is a health practitioner authorised to
          prescribe treatment consistent with the approval notice gazetted for methylphenidate (see
          note)

any relevant practitioner

ADHD (Attention Deficit and Hyperactivity Disorder) in
          patients under 5 years of age Diagnosed according to DSM-IV or ICD 10 criteria Applicant is a health practitioner authorised to
          prescribe treatment consistent with the approval notice gazetted for methylphenidate (see
          note)

any relevant practitioner

The patient suffers from narcolepsy

neurologist respiratory specialist

*narcolepsy is not a registered indication for Methylphenidate ER – Teva or Methylphenidate Sandoz XR.

Tab immediate-release 10 mg Ritalin 30 4.00 4.00 4.00 0.00000 Rubifen 30 3.00 3.00 3.00 0.00000 Tab sustained-release 20 mg Rubifen SR 30 10.95 10.95 10.95 0.00000 Tab immediate-release 5 mg Rubifen 30 3.20 3.20 3.20 0.00000 Tab immediate-release 20 mg Rubifen 30 7.85 7.85 7.85 0.00000 Tab extended-release 18 mg Methylphenidate ER - Teva 30 15.25 15.25 15.25 0.00000 Tab extended-release 36 mg Methylphenidate ER - Teva 30 21.25 21.25 21.25 0.00000 Tab extended-release 27 mg Methylphenidate ER - Teva 30 16.25 16.25 16.25 0.00000 Tab extended-release 54 mg Methylphenidate ER - Teva 30 24.25 24.25 24.25 0.00000 Tab modified-release 18 mg Methylphenidate Sandoz XR 30 15.25 15.25 15.25 0.00000 Tab modified-release 27 mg Methylphenidate Sandoz XR 30 16.25 16.25 16.25 0.00000 Tab modified-release 36 mg Methylphenidate Sandoz XR 30 21.25 21.25 21.25 0.00000 Tab modified-release 54 mg Methylphenidate Sandoz XR 30 24.25 24.25 24.25 0.00000 Methylphenidate hydrochloride extended-release <range>Methylphenidate hydrochloride Extended Release<instance>Concerta</instance><instance>Ritalin LA</instance></range>

ADHD (Attention Deficit and Hyperactivity
            Disorder) Diagnosed according to DSM-IV or ICD 10
            criteria Applicant is a health practitioner authorised to
            prescribe treatment consistent with the approval notice gazetted for methylphenidate
            (see note) 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 difficulties with
              adherence There is significant concern regarding the risk
              of diversion or abuse of immediate-release methylphenidate hydrochloride Patient meets the Special Authority criteria for SA2590
            methylphenidate hydrochloride Patient is unable to access other methylphenidate
            hydrochloride presentations under Special Authority criteria SA2590 due to an out of
            stock (see note)

any relevant practitioner

Criterion 2 is to permit short-term funding to cover an out-of-stock on tab extended-release Methylphenidate ER – Teva and tab sustained-release 20 mg Rubifen SR subsidised under SA2590 (https://schedule.pharmac.govt.nz/latest/SA2590.pdf).

the patient suffers from narcolepsy

neurologist respiratory specialist

*narcolepsy is not a registered indication for Concerta or Ritalin LA.

Tab extended-release 18 mg Concerta 30 58.96 58.96 58.96 0.00000 Tab extended-release 36 mg Concerta 30 71.93 71.93 71.93 0.00000 Tab extended-release 27 mg Concerta 30 65.44 65.44 65.44 0.00000 Tab extended-release 54 mg Concerta 30 86.24 86.24 86.24 0.00000 Cap modified-release 20 mg Ritalin LA 30 27.72 27.72 27.72 0.00000 Cap modified-release 30 mg Ritalin LA 30 34.39 34.39 34.39 0.00000 Cap modified-release 40 mg Ritalin LA 30 38.67 38.67 38.67 0.00000 Cap modified-release 10 mg Ritalin LA 30 19.41 19.41 19.41 0.00000 Atomoxetine Cap 10 mg APO-Atomoxetine 28 43.02 43.02 43.02 0.00000 Cap 18 mg APO-Atomoxetine 28 45.57 45.57 45.57 0.00000 Cap 25 mg APO-Atomoxetine 28 44.30 44.30 44.30 0.00000 Cap 40 mg APO-Atomoxetine 28 46.21 46.21 46.21 0.00000 Cap 60 mg APO-Atomoxetine 28 51.31 51.31 51.31 0.00000 Cap 80 mg APO-Atomoxetine 28 65.20 65.20 65.20 0.00000 Cap 100 mg APO-Atomoxetine 28 65.71 65.71 65.71 0.00000 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 subsidised
                            formulation of methylphenidate or dexamfetamine has been trialled and
                            discontinued because of intolerable side effects Methylphenidate and dexamfetamine are
                            contraindicated Patient meets the Special Authority
                        criteria for methylphenidate hydrochloride or methylphenidate hydrochloride
                        extended-release 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 or methylphenidate hydrochloride extended release.

Tab 100 mg Modafinil Max Health 30 14.27 14.27 14.27 0.00000 Treatments for Dementia Treatments for Dementia Donepezil hydrochloride Tab 5 mg Ipca-Donepezil 84 3.70 3.70 3.70 0.00000 Tab 10 mg Ipca-Donepezil 84 5.50 5.50 5.50 0.00000 Rivastigmine <range>Rivastigmine patches</range>

The patient has been diagnosed with
                    dementia The patient is contraindicated to or has
                    experienced intolerable side effects from donepezil tablets

any relevant practitioner 6

The treatment remains appropriate The patient has demonstrated a significant and
                    sustained benefit from treatment

any relevant practitioner 12 Patch 4.6 mg per 24 hour Rivastigmine Patch BNM 5 30 49.40 49.40 49.40 0.00000 Patch 9.5 mg per 24 hour Rivastigmine Patch BNM 10 30 49.40 49.40 49.40 0.00000 Treatments for Substance Dependence Treatments for Substance Dependence Disulfiram Tab 200 mg Antabuse 100 236.40 236.40 236.40 0.00000 Nicotine

Nicotine will not be funded in amounts less than 4 weeks of treatment.

Note: Direct Provision by a pharmacist permitted under the provisions in Part I of Section A.

Patch 21 mg Habitrol 28 24.72 24.72 24.72 0.00000 Patch 14 mg Habitrol 28 21.57 21.57 21.57 0.00000 Patch 7 mg Habitrol 28 19.62 19.62 19.62 0.00000 Gum 2 mg (Fruit) Habitrol 204 23.02 23.02 23.02 0.00000 Gum 4 mg (Fruit) Habitrol 204 25.98 25.98 25.98 0.00000 Gum 2 mg (Mint) Habitrol 204 23.02 23.02 23.02 0.00000 Gum 4 mg (Mint) Habitrol 204 25.98 25.98 25.98 0.00000 Lozenge 1 mg Habitrol 216 22.53 22.53 22.53 0.00000 Lozenge 2 mg Habitrol 216 24.68 24.68 24.68 0.00000 Patch 21 mg for direct distribution only Habitrol 7 13.19 13.19 13.19 0.00000 Patch 14 mg for direct distribution only Habitrol 7 12.49 12.49 12.49 0.00000 Gum 2 mg (Fruit) for direct distribution only Habitrol 96 17.57 17.57 17.57 0.00000 Gum 4 mg (Fruit) for direct distribution only Habitrol 96 23.87 23.87 23.87 0.00000 Gum 2 mg (Mint) for direct distribution only Habitrol 96 17.57 17.57 17.57 0.00000 Gum 4 mg (Mint) for direct distribution only Habitrol 96 23.87 23.87 23.87 0.00000 Lozenge 1 mg for direct distribution only Habitrol 36 12.89 12.89 12.89 0.00000 Lozenge 2 mg for direct distribution only Habitrol 36 13.25 13.25 13.25 0.00000 Naltrexone hydrochloride <range>Naltrexone</range>

Patient is currently enrolled in a recognised comprehensive treatment programme for alcohol dependence Applicant works in or with a community Alcohol and Drug Service contracted to Health NZ or accredited against the New Zealand Alcohol and Other Drug Sector Standard or the National Mental Health Sector Standard

any relevant practitioner 6

Compliance with the medication (prescriber determined) Patient is still unstable and requires further treatment Patient achieved significant improvement but requires further treatment Patient is well controlled but requires maintenance therapy

any relevant practitioner 6 Tab 50 mg Naltraccord 30 83.33 83.33 83.33 0.00000 Bupropion hydrochloride Tab modified-release 150 mg Zyban 30 15.00 15.00 15.00 0.00000 Varenicline tartrate

A maximum of 12 weeks' varenicline will be subsidised on each Special Authority approval, including the starter pack

Varenicline will not be funded in amounts less than 4 weeks of treatment.

The 6-month time period in which a patient can receive a funded 12-week course of varenicline tartrate starts from the date the Special Authority is approved.

<range>Varenicline tartrate</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 (see note)

any relevant practitioner 5

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 It has been 6 months since the patient’s previous Special Authority was approved 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 (see note)

any relevant practitioner 5 6 1

a maximum of 12 weeks' varenicline will be subsidised on each Special Authority approval.

This includes the 4-week 'starter' pack.

Tab 1 mg Champix 56 17.62 17.62 17.62 0.00000 Pharmacor Varenicline 56 10.99 10.99 10.99 0.00000 Tab 0.5 mg x 11 and 1 mg x 42 Champix 53 16.67 16.67 16.67 0.00000 Pharmacor Varenicline 53 15.99 15.99 15.99 0.00000 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 Applicant works in an opioid treatment service approved
          by the Ministry of Health.

medical practitioner 6

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 Applicant works in an opioid treatment service approved
          by the Ministry of Health

medical practitioner 12

Patient is opioid dependent Patient has previously trialled but failed
          detoxification with buprenorphine with naloxone with relapse back to opioid use and
          another attempt is planned Patient is currently engaged with an opioid treatment
          service approved by the Ministry of Health Applicant works in an opioid treatment service
          approved by the Ministry of Health

medical practitioner 6

Patient is or has been receiving maintenance therapy
          with buprenorphine with naloxone (and is not receiving methadone) Patient is currently enrolled in an opioid substitution
          program in a service approved by the Ministry of Health Applicant works in an opioid treatment service approved
          by the Ministry of Health or is a medical practitioner authorised by the service to manage
          treatment in this patient

medical practitioner 12

Patient received but failed detoxification with
          buprenorphine with naloxone Maintenance therapy with buprenorphine with naloxone is
          planned (and patient will not be receiving methadone) Patient is currently enrolled in an opioid substitution
          program in a service approved by the Ministry of Health Applicant works in an opioid treatment service approved
          by the Ministry of Health

medical practitioner 12 Tab sublingual 2 mg with naloxone 0.5 mg Buprenorphine Naloxone BNM 28 11.76 11.76 11.76 0.00000 Tab sublingual 8 mg with naloxone 2 mg Buprenorphine Naloxone BNM 28 26.86 26.86 26.86 0.00000 Oncology Agents and Immunosuppressants Chemotherapeutic Agents Alkylating Agents Busulfan Tab 2 mg Myleran 100 89.25 89.25 89.25 0.00000 Chlorambucil Tab 2 mg Leukeran FC 25 29.06 29.06 29.06 0.00000 Cyclophosphamide Tab 50 mg Cyclonex 50 145.00 145.00 145.00 0.00000 Inj 1 g vial Cytoxan 6 127.80 127.80 127.80 0.00000 Endoxan 1 47.46 47.46 47.46 0.00000 Inj 2 g vial Endoxan 1 95.06 95.06 95.06 0.00000 Cyclophosphamide Seacross 1 95.06 95.06 95.06 0.00000 Inj 1 mg for ECP Baxter 1 0.05 0.05 0.05 0.00000 Melphalan Tab 2 mg Alkeran 25 40.70 40.70 40.70 0.00000 Inj 50 mg Alkeran 1 67.80 67.80 67.80 0.00000 Melpha 1 48.25 48.25 48.25 0.00000 Thiotepa Inj 15 mg vial THIO-TEPA 1 Bedford 1 Tepadina 1 398.00 398.00 398.00 0.00000 Max Health 1 Inj 100 mg vial Tepadina 1 1800.00 1800.00 1800.00 0.00000 Max Health 1 Thiotepa-Reach 1 1800.00 1800.00 1800.00 0.00000 Ifosfamide Inj 1 g Holoxan 1 96.00 96.00 96.00 0.00000 Inj 2 g Holoxan 1 180.00 180.00 180.00 0.00000 Inj 1 mg for ECP Baxter 1 0.10 0.10 0.10 0.00000 Carboplatin Inj 10 mg per ml, 45 ml vial DBL Carboplatin 1 32.59 32.59 32.59 0.00000 Carbaccord 1 48.50 48.50 48.50 0.00000 Carboplatin Accord 1 25.73 25.73 25.73 0.00000 Inj 1 mg for ECP Baxter 1 0.06 0.06 0.06 0.00000 Cisplatin Inj 1 mg per ml, 50 ml vial Cisplatin Ebewe 1 15.00 15.00 15.00 0.00000 Cisplatin Accord 1 9.45 9.45 9.45 0.00000 Inj 1 mg per ml, 100 ml vial DBL Cisplatin 1 29.66 29.66 29.66 0.00000 Cisplatin Ebewe 1 21.00 21.00 21.00 0.00000 Cisplatin Accord 1 18.90 18.90 18.90 0.00000 Inj 1 mg for ECP Baxter 1 0.19 0.19 0.19 0.00000 Oxaliplatin Inj 100 mg vial Oxaliplatin Ebewe 1 110.00 110.00 110.00 0.00000 Oxaliplatin Actavis 100 1 25.01 25.01 25.01 0.00000 Inj 1 mg for ECP Baxter 1 0.35 0.35 0.35 0.00000 Inj 5 mg per ml, 20 ml vial Oxaliplatin Accord 1 46.32 46.32 46.32 0.00000 Alchemy Oxaliplatin 1 33.35 33.35 33.35 0.00000 Carmustine Inj 100 mg vial BiCNU 1 710.00 710.00 710.00 0.00000 Inj 100 mg for ECP Baxter 100 710.00 710.00 710.00 0.00000 Lomustine Cap 40 mg Medac 20 880.00 880.00 880.00 0.00000 Bendamustine hydrochloride <range>Bendamustine hydrochloride</range>

The patient has chronic lymphocytic leukaemia requiring treatment Patient has ECOG performance status of 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

relevant specialist any relevant practitioner 12

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 The 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

relevant specialist any relevant 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

relevant specialist any relevant practitioner 9

'indolent, low-grade lymphomas' includes follicular, mantle cell, marginal zone and lymphoplasmacytic/ Waldenstrom'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 any relevant practitioner 6

Indications marked with * are unapproved indications.

Inj 25 mg vial Ribomustin 1 77.00 77.00 77.00 0.00000 Bendamustine Sandoz 1 50.05 50.05 50.05 0.00000 Inj 100 mg vial Ribomustin 1 308.00 308.00 308.00 0.00000 Bendamustine Sandoz 1 200.20 200.20 200.20 0.00000 Inj 1 mg for ECP Baxter 1 2.11 2.11 2.11 0.00000 Antimetabolites Calcium folinate Tab 15 mg DBL Leucovorin Calcium 10 135.33 135.33 135.33 0.00000 Inj 3 mg per ml, 1 ml Hospira 5 17.10 17.10 17.10 0.00000 Inj 50 mg Leucovorin Pharmacia 10 72.80 72.80 72.80 0.00000 Inj 300 mg Leucovorin DBL 1 21.55 21.55 21.55 0.00000 Inj 1 mg for ECP Baxter 1 0.14 0.14 0.14 0.00000 Inj 100 mg Leucovorin Pharmacia 10 94.90 94.90 94.90 0.00000 Inj 10 mg per ml, 5 ml vial Eurofolic 5 112.20 112.20 112.20 0.00000 Inj 10 mg per ml, 10 ml vial Eurofolic 5 163.35 163.35 163.35 0.00000 Inj 10 mg per ml, 100 ml vial Eurofolic 1 139.48 139.48 139.48 0.00000 Cytarabine Inj 20 mg per ml, 5 ml vial Pfizer 5 472.00 472.00 472.00 0.00000 5 472.00 472.00 472.00 0.00000 Inj 100 mg per ml, 20 ml vial Pfizer 1 48.80 48.80 48.80 0.00000 Cytarabine DBL 1 48.80 48.80 48.80 0.00000 Inj 1 mg for ECP Baxter 10 0.29 0.29 0.29 0.00000 Inj 100 mg intrathecal syringe for ECP Baxter 100 94.40 94.40 94.40 0.00000 Fluorouracil Inj 50 mg per ml, 20 ml vial Fluorouracil Accord 1 10.51 10.51 10.51 0.00000 Inj 50 mg per ml, 50 ml vial Fluorouracil Accord 1 14.72 14.72 14.72 0.00000 Inj 1 mg for ECP Baxter 100 0.41 0.41 0.41 0.00000 Inj 50 mg per ml, 100 ml vial Fluorouracil Accord 1 19.36 19.36 19.36 0.00000 Mercaptopurine Tab 50 mg Puri-nethol 25 19.50 19.50 19.50 0.00000 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

Patient still requires a total dose of less than one full 50 mg tablet per day

paediatric haematologist paediatric oncologist 12 Allmercap 100 428.00 428.00 428.00 0.00000 Xaluprine 100 428.00 428.00 428.00 0.00000 Methotrexate Tab 2.5 mg Trexate 90 7.80 7.80 7.80 0.00000 Tab 10 mg Trexate 90 26.40 26.40 26.40 0.00000 Inj 2.5 mg per ml, 2 ml Methotrexate DBL 5 95.29 95.29 95.29 0.00000 Inj 25 mg per ml, 2 ml vial Methotrexate DBL Onco-Vial 5 30.00 30.00 30.00 0.00000 Inj 25 mg per ml, 20 ml vial DBL Methotrexate Onco-Vial 1 45.00 45.00 45.00 0.00000 Inj 100 mg per ml, 50 ml vial Methotrexate Ebewe 1 67.99 67.99 67.99 0.00000 Inj 100 mg per ml, 10 ml Methotrexate Ebewe 1 25.00 25.00 25.00 0.00000 Inj 1 mg for ECP Baxter 1 0.06 0.06 0.06 0.00000 Inj 5 mg intrathecal syringe for ECP Baxter 5 19.06 19.06 19.06 0.00000 Inj 7.5 mg prefilled syringe Methotrexate Sandoz 1 1 29.17 29.17 29.17 0.00000 Inj 10 mg prefilled syringe Methotrexate Sandoz 1 1 19.09 19.09 19.09 0.00000 Inj 15 mg prefilled syringe Methotrexate Sandoz 1 1 24.53 24.53 24.53 0.00000 Inj 20 mg prefilled syringe Methotrexate Sandoz 1 1 16.64 16.64 16.64 0.00000 Inj 25 mg prefilled syringe Methotrexate Sandoz 1 1 20.72 20.72 20.72 0.00000 Inj 30 mg prefilled syringe Methotrexate Sandoz 1 1 55.00 55.00 55.00 0.00000 Thioguanine Tab 40 mg Lanvis 25 126.31 126.31 126.31 0.00000 Capecitabine Tab 150 mg Capecitabine Viatris 60 10.92 10.92 10.92 0.00000 Tab 500 mg Capecitabine Viatris 120 50.96 50.96 50.96 0.00000 Fludarabine phosphate Inj 50 mg vial Fludarabine Ebewe 5 744.95 744.95 744.95 0.00000 Inj 50 mg for ECP Baxter 50 148.99 148.99 148.99 0.00000 Tab 10 mg Fludara Oral 20 412.00 412.00 412.00 0.00000 Irinotecan hydrochloride Inj 20 mg per ml, 5 ml vial Irinotecan-Rex 1 100.00 100.00 100.00 0.00000 Irinotecan Actavis 100 1 71.44 71.44 71.44 0.00000 Accord 1 52.57 52.57 52.57 0.00000 Inj 1 mg for ECP Baxter 1 0.54 0.54 0.54 0.00000 Inj 20 mg per ml, 25 ml vial Accord 1 262.85 262.85 262.85 0.00000 Cladribine Inj 1 mg per ml, 10 ml Leustatin 1 749.96 749.96 749.96 0.00000 Inj 10 mg for ECP Baxter 10 749.96 749.96 749.96 0.00000 Gemcitabine hydrochloride Inj 1 g Gemcitabine Ebewe 1 15.89 15.89 15.89 0.00000 Inj 1 mg for ECP Baxter 1 0.02 0.02 0.02 0.00000 Inj 43.3 mg per ml (equivalent to 38 mg per ml gemcitabine), 26.3 ml vial DBL Gemcitabine 1 18.94 18.94 18.94 0.00000 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 Classification (WHO) The individual has an estimated life expectancy of at
          least 3 months

any relevant practitioner 12

there is no evidence of disease progression

any relevant practitioner 12 Inj 100 mg vial Azacitidine Dr Reddy's 1 50.00 50.00 50.00 0.00000 Inj 1 mg for ECP Baxter 1 0.54 0.54 0.54 0.00000 Pemetrexed Inj 100 mg vial Juno Pemetrexed 1 60.89 60.89 60.89 0.00000 Pemetrexed-AFT 1 8.99 8.99 8.99 0.00000 Inj 500 mg vial Juno Pemetrexed 1 217.77 217.77 217.77 0.00000 Pemetrexed-AFT 1 29.99 29.99 29.99 0.00000 Inj 1 mg for ECP Baxter 1 0.11 0.11 0.11 0.00000 Other Cytotoxic Agents Hydroxyurea [hydroxycarbamide] Cap 500 mg Devatis 100 20.72 20.72 20.72 0.00000 Procarbazine hydrochloride Cap 50 mg Natulan 50 980.00 980.00 980.00 0.00000 Tretinoin Cap 10 mg Vesanoid 100 479.50 479.50 479.50 0.00000 Vinblastine sulphate Inj 1 mg per ml, 10 ml vial Hospira 5 270.37 270.37 270.37 0.00000 Inj 1 mg for ECP Baxter 1 6.00 6.00 6.00 0.00000 Vincristine sulphate Inj 1 mg per ml, 1 ml vial DBL Vincristine Sulfate 5 74.52 74.52 74.52 0.00000 Inj 1 mg per ml, 2 ml vial DBL Vincristine Sulfate 5 102.73 102.73 102.73 0.00000 Inj 1 mg for ECP Baxter 1 12.60 12.60 12.60 0.00000 Etoposide Cap 50 mg Vepesid 20 340.73 340.73 340.73 0.00000 Cap 100 mg Vepesid 10 340.73 340.73 340.73 0.00000 Inj 20 mg per ml, 5 ml vial Rex Medical 1 7.90 7.90 7.90 0.00000 Inj 1 mg for ECP Baxter 1 0.09 0.09 0.09 0.00000 Bleomycin sulphate Inj 15,000 iu, vial DBL Bleomycin Sulfate 1 185.16 185.16 185.16 0.00000 Inj 1,000 iu for ECP Baxter 1000 14.32 14.32 14.32 0.00000 Doxorubicin hydrochloride Inj 1 mg for ECP Baxter 1 0.84 0.84 0.84 0.00000 Inj 2 mg per ml, 5 ml vial Doxorubicin Ebewe 1 10.00 10.00 10.00 0.00000 Inj 2 mg per ml, 100 ml vial Doxorubicin Ebewe 1 164.50 164.50 164.50 0.00000 Adriamycin 1 164.50 164.50 164.50 0.00000 Arrow-Doxorubicin 1 65.00 65.00 65.00 0.00000 Inj 2 mg per ml, 25 ml vial Doxorubicin Ebewe 1 75.55 75.55 75.55 0.00000 Arrow-Doxorubicin 1 17.00 17.00 17.00 0.00000 Epirubicin hydrochloride Inj 2 mg per ml, 25 ml vial Epirubicin Ebewe 1 284.36 284.36 284.36 0.00000 Inj 1 mg for ECP Baxter 1 1.42 1.42 1.42 0.00000 Inj 2 mg per ml, 100 ml vial Epirubicin Ebewe 1 284.36 284.36 284.36 0.00000 Paclitaxel Inj 6 mg per ml, 16.7 ml vial Paclitaxel Ebewe 1 24.00 24.00 24.00 0.00000 Paclitaxel Actavis 1 91.67 91.67 91.67 0.00000 Anzatax 1 19.59 19.59 19.59 0.00000 Inj 30 mg Paclitaxel Ebewe 5 47.30 47.30 47.30 0.00000 Inj 1 mg for ECP Baxter 1 0.17 0.17 0.17 0.00000 Inj 150 mg Paclitaxel Ebewe 1 26.69 26.69 26.69 0.00000 Anzatax 1 137.50 137.50 137.50 0.00000 Paclitaxel Actavis 1 137.50 137.50 137.50 0.00000 Inj 6 mg per ml, 50 ml vial Paclitaxel Ebewe 1 44.00 44.00 44.00 0.00000 Anzatax 1 37.89 37.89 37.89 0.00000 Paclitaxel Actavis 1 275.00 275.00 275.00 0.00000 Vinorelbine Inj 10 mg per ml, 5 ml vial Vinorelbine Ebewe 1 155.00 155.00 155.00 0.00000 Navelbine S29 1 168.00 168.00 168.00 0.00000 Inj 1 mg for ECP Baxter 1 3.51 3.51 3.51 0.00000 Cap 80 mg Vinorelbine Te Arai 1 80.00 80.00 80.00 0.00000 Cap 30 mg Vinorelbine Te Arai 1 42.80 42.80 42.80 0.00000 Cap 20 mg Vinorelbine Te Arai 1 32.10 32.10 32.10 0.00000 Mesna Inj 100 mg per ml, 4 ml ampoule Uromitexan 15 177.45 177.45 177.45 0.00000 Inj 100 mg per ml, 10 ml ampoule Uromitexan 15 407.40 407.40 407.40 0.00000 Tab 400 mg Uromitexan 50 314.00 314.00 314.00 0.00000 Tab 600 mg Uromitexan 50 448.50 448.50 448.50 0.00000 Inj 1 mg for ECP Baxter 100 2.96 2.96 2.96 0.00000 Mitozantrone Inj 2 mg per ml, 10 ml vial Mitozantrone Ebewe 1 170.63 170.63 170.63 0.00000 Inj 1 mg for ECP Baxter 1 9.64 9.64 9.64 0.00000 Dacarbazine Inj 200 mg vial DBL Dacarbazine 1 72.11 72.11 72.11 0.00000 Inj 200 mg for ECP Baxter 200 72.11 72.11 72.11 0.00000 Daunorubicin Inj 20 mg for ECP Baxter 20 171.93 171.93 171.93 0.00000 Inj 20 mg vial Cerubidine 1 171.93 171.93 171.93 0.00000 Inj 18.7 mg vial Pfizer 1 160.75 160.75 160.75 0.00000 Inj 18.7 mg for ECP Baxter 18.7 160.75 160.75 160.75 0.00000 Docetaxel Inj 20 mg Docetaxel Sandoz 1 48.75 48.75 48.75 0.00000 Inj 80 mg Docetaxel Sandoz 1 195.00 195.00 195.00 0.00000 Inj 1 mg for ECP Baxter 1 0.35 0.35 0.35 0.00000 Inj 20 mg per ml, 4 ml vial Docetaxel Accord 1 26.95 26.95 26.95 0.00000 Inj 10 mg per ml, 8 ml vial DBL Docetaxel 1 24.91 24.91 24.91 0.00000 Anagrelide hydrochloride Cap 0.5 mg Agrylin 100 1175.87 1175.87 1175.87 0.00000 Arsenic trioxide Inj 1 mg per ml, 10 ml vial Phenasen 10 4817.00 4817.00 4817.00 0.00000 Inj 10 mg for ECP Baxter 10 481.70 481.70 481.70 0.00000 Thalidomide <range>Thalidomide</range>

The patient has plasma cell dyscrasia, not including Waldenström macroglobulinaemia, requiring treatment

any relevant practitioner 12

The patient has obtained a response from treatment during the initial approval period

any relevant 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.

Cap 50 mg Thalomid 28 378.00 378.00 378.00 0.00000 Cap 100 mg Thalomid 28 756.00 756.00 756.00 0.00000 Dactinomycin [Actinomycin D] Inj 0.5 mg vial Cosmegen 1 255.00 255.00 255.00 0.00000 Inj 0.5 mg for ECP Baxter 0.5 255.00 255.00 255.00 0.00000 Etoposide phosphate Inj 100 mg (of etoposide base) Etopophos 1 40.00 40.00 40.00 0.00000 Inj 1 mg (of etoposide base) for ECP Baxter 1 0.47 0.47 0.47 0.00000 Idarubicin hydrochloride Inj 5 mg vial Zavedos 1 109.74 109.74 109.74 0.00000 Inj 10 mg vial Zavedos 1 233.64 233.64 233.64 0.00000 Inj 1 mg for ECP Baxter 1 25.77 25.77 25.77 0.00000 Mitomycin C Inj 1 mg for ECP Baxter 1 119.67 119.67 119.67 0.00000 Inj 5 mg vial Accord 1 517.65 517.65 517.65 0.00000 Mitomycin (Sagent) 1 526.00 526.00 526.00 0.00000 Mitomycin (Fresenius Kabi) 1 517.65 517.65 517.65 0.00000 Inj 20 mg vial Teva 1 1129.94 1129.94 1129.94 0.00000 Pentostatin [Deoxycoformycin] Inj 10 mg Nipent 1 1 Temozolomide <range>Temozolomide</range>

the patient has a glioma

relevant specialist 12

treatment remains appropriate and patient is
                benefitting from treatment

relevant specialist 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

relevant specialist 9

No evidence of disease progression The treatment remains appropriate and the
                    patient is benefitting from treatment

relevant specialist 6

the patient has relapsed/refractory Ewing’s
                sarcoma

relevant specialist 9

No evidence of disease progression The treatment remains appropriate and the
                    patient is benefitting from treatment

relevant specialist 6

the patient has neuroblastoma

any relevant practitioner 12

there is no evidence of disease progression

any relevant practitioner 12

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

Cap 5 mg Temaccord 5 9.13 9.13 9.13 0.00000 Temozolomide-Taro 5 9.13 9.13 9.13 0.00000 Cap 20 mg Temaccord 5 16.38 16.38 16.38 0.00000 Apo-Temozolomide 5 18.30 18.30 18.30 0.00000 Cap 100 mg Temaccord 5 35.98 35.98 35.98 0.00000 Apo-Temozolomide 5 40.20 40.20 40.20 0.00000 Cap 250 mg Temaccord 5 86.34 86.34 86.34 0.00000 Cap 140 mg Temaccord 5 50.12 50.12 50.12 0.00000 Amsacrine Inj 75 mg AmsaLyo 5 6218.00 6218.00 6218.00 0.00000 Inj 50 mg per ml, 1.5 ml ampoule Amsidine 6 4736.00 4736.00 4736.00 0.00000 Bortezomib <range>Bortezomib</range>

The patient has plasma cell dyscrasia, not including
        Waldenström macroglobulinaemia, requiring treatment

any relevant practitioner

The patient has Waldenström
          Macroglobulinaemia/Lymphoplasmacytic Lymphoma requiring treatment The patient has not received prior bortezomib
          treatment

any relevant practitioner 12

there is no evidence of clinical disease progression
        during bortezomib use

any relevant practitioner 12 Inj 3.5 mg vial DBL Bortezomib 1 74.93 74.93 74.93 0.00000 Bortezomib Eugia 1 23.99 23.99 23.99 0.00000 Inj 1 mg for ECP Baxter 1 22.26 22.26 22.26 0.00000 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

relevant specialist medical practitioner 15

the patient has lymphoma requiring L-asparaginase
        containing protocols (e.g. SMILE)

relevant specialist medical practitioner 12

The patient has relapsed acute lymphoblastic
          leukaemia Pegaspargase to be used with a contemporary intensive
          multi-agent chemotherapy treatment protocol

relevant specialist medical practitioner 12 Inj 750 iu per ml, 5 ml vial Oncaspar LYO 1 3973.25 3973.25 3973.25 0.00000 Venetoclax <range>Venetoclax</range>

Individual is currently on treatment with
                    venetoclax and obinutuzumab and met all of the following criteria prior to
                    commencing treatment Individual has previously untreated
                        chronic lymphocytic leukaemia Venetoclax is to be administered with
                        obinutuzumab Venetoclax is to be used to a maximum dose
                        of 400 mg and for a total of 12 (28 day) cycles*

any relevant practitioner 15

*maximum number of cycles refers to 12 cycles of full dose venetoclax, in addition to the initial 5-week dose ramp-up period.

Individual is currently on treatment with
                    venetoclax and/or ibrutinib and met all of the following criteria prior to
                    commencing treatment Individual has previously untreated
                        chronic lymphocytic leukaemia Venetoclax is to be administered in
                        combination with ibrutinib Venetoclax is to be used to a maximum dose
                        of 400 mg and for a total of 12 (28 day) cycles*

any relevant practitioner 15

*maximum number of cycles refers to 12 cycles of full dose venetoclax, in addition to the initial 5-week dose ramp-up period.

Individual has chronic lymphocytic leukaemia
                    requiring treatment Individual has received at least one prior
                    therapy for chronic lymphocytic leukaemia 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

any relevant practitioner 8

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

any relevant practitioner 6

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

Individual has previously untreated chronic
                    lymphocytic leukaemia There is documentation confirming that
                    individual has 17p deletion by FISH testing or TP53 mutation by sequencing Individual has an ECOG performance status of
                    0-2

any relevant practitioner 6

the treatment remains clinically appropriate and
                the patient is benefitting from and tolerating treatment

any relevant 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

any relevant practitioner 6

there is no evidence of disease progression

any relevant practitioner 6

‘Acute myeloid leukaemia’ includes myeloid sarcoma*
Indications marked with * are Unapproved indications

Tab 10 mg Venclexta 2 13.68 13.68 13.68 0.00000 Tab 50 mg Venclexta 7 239.44 239.44 239.44 0.00000 7 239.44 239.44 239.44 0.00000 Tab 100 mg Venclexta 120 8209.41 8209.41 8209.41 0.00000 Tab 14 x 10 mg, 7 x 50 mg, 21 x 100 mg Venclexta 42 1771.86 1771.86 1771.86 0.00000 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 medical practitioner 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 medical practitioner 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.

Tab 100 mg Lynparza 56 3701.00 3701.00 3701.00 0.00000 Tab 150 mg Lynparza 56 3701.00 3701.00 3701.00 0.00000 Ibrutinib <range>Ibrutinib</range>

Individual is currently on treatment with
                    ibrutinib and/or venetoclax and met all of the following criteria prior to
                    commencing treatment Individual has previously untreated
                        CLL Ibrutinib is to be administered at a
                        maximum dose of 420 mg daily for 3 (28 day) cycles as monotherapy, followed
                        by a maximum of 12 (28 day) cycles in combination with venetoclax

any relevant practitioner 15

Individual has chronic lymphocytic leukaemia
                    (CLL) requiring therapy Ibrutinib is to be used as monotherapy Individual has experienced intolerable side
                    effects, or their disease has relapsed or is refractory following at least one
                    prior line of therapy Individual has not received ibrutinib monotherapy previously

any relevant practitioner 6

there is no evidence of disease progression

any relevant practitioner 12

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

Tab 140 mg Imbruvica 30 3217.00 3217.00 3217.00 0.00000 Tab 420 mg Imbruvica 30 9652.00 9652.00 9652.00 0.00000 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

any relevant 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

any relevant 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

Cap 100 mg Zejula 56 8929.84 8929.84 8929.84 0.00000 Tab 100 mg Zejula 84 13393.50 13393.50 13393.50 0.00000 56 8929.84 8929.84 8929.84 0.00000 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 Cap 5 mg Lenalidomide Viatris 21 76.92 76.92 76.92 0.00000 Cap 10 mg Lenalidomide Viatris 21 50.30 50.30 50.30 0.00000 Cap 15 mg Lenalidomide Viatris 21 62.13 62.13 62.13 0.00000 21 62.13 62.13 62.13 0.00000 Cap 25 mg Lenalidomide Viatris 21 65.09 65.09 65.09 0.00000 21 65.09 65.09 65.09 0.00000 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

there is no evidence of disease
                progression

any relevant practitioner 12 Cap 1 mg Pomolide 14 47.45 47.45 47.45 0.00000 21 71.18 71.18 71.18 0.00000 Cap 2 mg Pomolide 14 94.90 94.90 94.90 0.00000 21 142.35 142.35 142.35 0.00000 Cap 3 mg Pomolide 14 142.35 142.35 142.35 0.00000 21 213.53 213.53 213.53 0.00000 Cap 4 mg Pomolide 14 189.81 189.81 189.81 0.00000 21 284.71 284.71 284.71 0.00000 Protein-tyrosine Kinase Inhibitors Imatinib mesilate Cap 100 mg Imatinib-Rex 60 44.93 44.93 44.93 0.00000 Cap 400 mg Imatinib-Rex 30 69.76 69.76 69.76 0.00000 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 Practitioner 6

Lack of treatment failure while on
                    dasatinib* Dasatinib treatment remains appropriate and
                    the patient is benefiting from treatment

haematologist Practitioner 6

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

Tab 20 mg Dasatinib-Teva 60 132.88 132.88 132.88 0.00000 Tab 50 mg Dasatinib-Teva 60 304.13 304.13 304.13 0.00000 Tab 70 mg Dasatinib-Teva 60 415.75 415.75 415.75 0.00000 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 gefitinib due to intolerance The cancer did not progress while on
                            osimertinib or gefitinib

any relevant practitioner 4

radiological assessment (preferably including CT
                scan) indicates NSCLC has not progressed

any relevant practitioner 6 Tab 100 mg Alchemy 30 280.84 280.84 280.84 0.00000 Tab 150 mg Alchemy 30 484.24 484.24 484.24 0.00000 Sunitinib <range>Sunitinib</range>

The patient has metastatic renal cell
                    carcinoma The patient has not previously received funded
                    sunitinib

any relevant 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

relevant specialist medical practitioner 3

there is no evidence of disease progression

any relevant practitioner 4

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

relevant specialist medical practitioner 6

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.

The patient has unresectable or metastatic
                    malignant gastrointestinal stromal (GIST) The patient is clinically benifiting from
                    treatment and continued treatment remains appropriate Sunitinib is to be discontinued at
                    progression The regular Special Authority renewal
                    requirements cannot be met due to COVID-19 constraints on the health sector

any relevant practitioner 6 Cap 12.5 mg Sunitinib Rex 28 103.11 103.11 103.11 0.00000 Cap 25 mg Sunitinib Rex 28 203.15 203.15 203.15 0.00000 Cap 50 mg Sunitinib Rex 28 343.19 343.19 343.19 0.00000 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 Pazopanib to be used for a maximum of 3 months 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

relevant specialist any relevant practitioner 4

there is no evidence of disease progression

relevant specialist any relevant practitioner 3 Tab 200 mg Pazopanib Teva 30 172.88 172.88 172.88 0.00000 Pazopanib ADVZ 30 172.88 172.88 172.88 0.00000 Tab 400 mg Pazopanib Teva 30 464.00 464.00 464.00 0.00000 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

any relevant practitioner 4

Radiological assessment (preferably including CT
                scan) indicates NSCLC has not progressed

any relevant practitioner 6 Tab 250 mg Iressa 30 918.00 918.00 918.00 0.00000 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 Cap 150 mg Tasigna 120 4680.00 4680.00 4680.00 0.00000 Cap 200 mg Tasigna 120 6532.00 6532.00 6532.00 0.00000 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 Tab 5 mg Jakavi 56 2500.00 2500.00 2500.00 0.00000 Tab 15 mg Jakavi 56 5000.00 5000.00 5000.00 0.00000 Tab 20 mg Jakavi 56 5000.00 5000.00 5000.00 0.00000 Tab 10mg Jakavi 56 5000.00 5000.00 5000.00 0.00000 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 oncologist medical practitioner 6

No evidence of progressive disease according to RECIST criteria The patient is benefitting from and tolerating treatment

medical oncologist medical practitioner 6 Cap 150 mg Alecensa 224 7935.00 7935.00 7935.00 0.00000 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

any relevant practitioner 6

Treatment must be used in combination with an endocrine
                    partner There is no evidence of progressive disease since initiation of
                    palbociclib

any relevant practitioner 12 Tab 75 mg Palbociclib Pfizer 21 1200.00 1200.00 1200.00 0.00000 Tab 100 mg Palbociclib Pfizer 21 1200.00 1200.00 1200.00 0.00000 Tab 125 mg Palbociclib Pfizer 21 1200.00 1200.00 1200.00 0.00000 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

any relevant practitioner 9 Cap 25 mg Rydapt 56 10981.00 10981.00 10981.00 0.00000 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

any relevant practitioner 6

Treatment must be used in combination with an endocrine
                    partner There is no evidence of progressive disease since initiation of
                    ribociclib

any relevant practitioner 12 Tab 200 mg Kisqali 21 1883.00 1883.00 1883.00 0.00000 42 3767.00 3767.00 3767.00 0.00000 63 5650.00 5650.00 5650.00 0.00000 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

any relevant practitioner 6

there is no evidence of disease progression

any relevant 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

any relevant practitioner 6

there is no evidence of disease progression

any relevant 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

any relevant practitioner 4

there is no evidence of disease progression

any relevant practitioner 4 Cap 4 mg Lenvima 30 3407.40 3407.40 3407.40 0.00000 Cap 10 mg Lenvima 30 3407.40 3407.40 3407.40 0.00000 Osimertinib <range>Osimertinib</range>

Patient is currently on treatment with
                    osimertinib and met all remaining criteria prior to commencing treatment Patient has locally advanced or metastatic,
                        incurable, non-squamous non-small cell lung cancer (NSCLC) Patient is treatment naïve Patient has received prior chemotherapy 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

any relevant 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

any relevant practitioner 6

Patient is currently on treatment with
                    osimertinib and met all remaining criteria prior to commencing treatment 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

any relevant practitioner 4

response to treatment in target lesions has been
                determined by comparable radiologic assessment following the most recent treatment
                period

any relevant practitioner 6 Tab 40 mg Tagrisso 30 9310.00 9310.00 9310.00 0.00000 Tab 80 mg Tagrisso 30 9310.00 9310.00 9310.00 0.00000 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

any relevant practitioner 4

there is no evidence of disease progression.

any relevant practitioner 4 Tab 1 mg Inlyta 28 536.40 536.40 536.40 0.00000 Tab 5 mg Inlyta 28 2682.00 2682.00 2682.00 0.00000 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 an initial Special Authority
                            approval for 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

any relevant practitioner 6

Response to treatment has been determined by comparable
                    radiological assessment following the most recent treatment period No evidence of disease progression

any relevant practitioner 6 Cap 200 mg Xalkori 60 7250.00 7250.00 7250.00 0.00000 Cap 250 mg Xalkori 60 7250.00 7250.00 7250.00 0.00000 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

Stage IIIB, IIIC, IIID or IV melanoma defined as per American Joint Committee on Cancer (AJCC) 8th Edition
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 initial application 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 renewal 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 Cap 50 mg Tafinlar 120 6320.86 6320.86 6320.86 0.00000 Cap 75 mg Tafinlar 120 9481.29 9481.29 9481.29 0.00000 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

Stage IIIB, IIIC, IIID or IV melanoma defined as per American Joint Committee on Cancer (AJCC) 8th Edition
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 initial application 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 renewal 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 Tab 0.5 mg Mekinist 30 2370.32 2370.32 2370.32 0.00000 Tab 2 mg Mekinist 30 9481.29 9481.29 9481.29 0.00000 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

any relevant practitioner 6

Response to treatment has been determined by comparable
                    radiological assessment following the most recent treatment period No evidence of disease progression

any relevant practitioner 6 Cap 200 mg Rozlytrek 90 9610.00 9610.00 9610.00 0.00000 Endocrine Therapy

For GnRH ANALOGUES – refer to HORMONE PREPARATIONS, Trophic Hormones

Endocrine Therapy Flutamide Tab 250 mg Flutamin 100 119.50 119.50 119.50 0.00000 Prostacur 90 107.55 107.55 107.55 0.00000 Tamoxifen citrate Tab 10 mg Tamoxifen Sandoz 60 15.00 15.00 15.00 0.00000 Tab 20 mg Tamoxifen Sandoz 60 5.32 5.32 5.32 0.00000 Octreotide Inj 500 mcg per ml, 1 ml ampoule Octreotide GH 5 1 113.10 113.10 113.10 0.00000 Max Health 5 1 113.10 113.10 113.10 0.00000 Sun Pharma 5 1 113.10 113.10 113.10 0.00000 Inj 50 mcg per ml, 1 ml vial Omega 5 1 27.58 27.58 27.58 0.00000 Inj 100 mcg per ml, 1 ml vial Omega 5 48.50 48.50 48.50 0.00000 Inj 500 mcg per ml, 1 ml vial Omega 5 1 113.10 113.10 113.10 0.00000 Inj 100 mcg per ml, 1 ml ampoule Octreotide GH 5 1 32.71 32.71 32.71 0.00000 Max Health 5 1 32.71 32.71 32.71 0.00000 Sun Pharma 5 1 32.71 32.71 32.71 0.00000 Inj 50 mcg per ml, 1 ml ampoule Octreotide GH 5 1 27.58 27.58 27.58 0.00000 Max Health 5 1 27.58 27.58 27.58 0.00000 Bicalutamide Tab 50 mg Binarex 28 4.18 4.18 4.18 0.00000 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 medical practitioner 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 medical practitioner 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 Special Authority renewal requirements cannot be met due to COVID-19 constraints on the health sector

any relevant practitioner 6 Tab 250 mg Zytiga 120 4276.19 4276.19 4276.19 0.00000 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 medical practitioner 6

Treatment remains appropriate and patient is benefitting from treatment Treatment to be given at a dose of 500 mg monthly There is no evidence of disease progression

medical oncologist medical practitioner 6 Inj 50 mg per ml, 5 ml prefilled syringe Fulvestrant EVER Pharma 2 1 181.00 181.00 181.00 0.00000 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

any relevant practitioner 2

Indications marked with * are unapproved indications.

The treatment remains appropriate and the patient
                is benefiting from treatment

any relevant practitioner 3

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

any relevant practitioner 3

IGF1 levels have decreased since starting
                treatment

any relevant practitioner 2

In patients with acromegaly, treatment should be discontinued if IGF1 levels have not 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

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

any relevant practitioner 12

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

any relevant practitioner 2

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

The treatment remains appropriate and the patient
                is benefiting from treatment

any relevant practitioner 2 Octreotide long-acting Inj depot 10 mg prefilled syringe Sandostatin LAR 1 438.40 438.40 438.40 0.00000 Inj depot 20 mg prefilled syringe Sandostatin LAR 1 583.70 583.70 583.70 0.00000 Inj depot 30 mg prefilled syringe Sandostatin LAR 1 670.80 670.80 670.80 0.00000 Lanreotide Inj 60 mg per 0.5 ml, 0.5 ml syringe Mytolac 1 1 382.77 382.77 382.77 0.00000 Mytolac S29 1 382.77 382.77 382.77 0.00000 Somatuline Autogel 1 1543.79 1543.79 1543.79 0.00000 Inj 120 mg per 0.5 ml, 0.5 ml syringe Mytolac 1 1 646.70 646.70 646.70 0.00000 Somatuline Autogel 1 2570.44 2570.44 2570.44 0.00000 Inj 90 mg per 0.5 ml, 0.5 ml syringe Mytolac 1 562.92 562.92 562.92 0.00000 Somatuline Autogel 1 2054.40 2054.40 2054.40 0.00000 Aromatase Inhibitors Anastrozole Tab 1 mg Anatrole 30 4.39 4.39 4.39 0.00000 Letrozole Tab 2.5 mg Letrole 30 4.67 4.67 4.67 0.00000 Accord 28 4.36 4.36 4.36 0.00000 Exemestane Tab 25 mg Pfizer Exemestane 30 9.86 9.86 9.86 0.00000 Immunosuppressants Cytotoxic Immunosuppressants Mycophenolate mofetil Cap 250 mg Cellcept 100 35.90 35.90 35.90 0.00000 Tab 500 mg Cellcept 50 35.90 35.90 35.90 0.00000 Powder for oral liq 1 g per 5 ml

Mycophenolate powder for oral liquid is subsidised only for patients unable to swallow tablets and capsules, and when the prescription is endorsed accordingly.

Cellcept 165 187.25 187.25 187.25 0.00000 Azathioprine Tab 50 mg Azamun 100 10.34 10.34 10.34 0.00000 Tab 25 mg Azamun 60 10.15 10.15 10.15 0.00000 Fusion Proteins Etanercept <range>Etanercept</range>

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 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

any relevant practitioner

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 NSAIDs (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 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

any relevant 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

any relevant practitioner 2

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

any relevant 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

any relevant 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

any relevant 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

any relevant 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 a 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

any relevant 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

any relevant practitioner 2

Patient has received insufficient benefit from
                    3 months of conventional therapy including a minimum of 3 pharmaceuticals (e.g.
                    prednisone, ciclosporine, 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

any relevant practitioner

Indications marked with * are unapproved indications.

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

any relevant 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

any relevant 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 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 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 before the application

any relevant 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 has 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 pre-treatment baseline Maximum dose 50 mg every 7 days

any relevant practitioner 2

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
                    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 3 months

any relevant 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 dose 50 mg every 7 days

any relevant practitioner 2 Inj 25 mg Enbrel 4 1 690.00 690.00 690.00 0.00000 Inj 50 mg autoinjector Enbrel 4 1 1050.00 1050.00 1050.00 0.00000 Inj 50 mg prefilled syringe Enbrel 4 1 1050.00 1050.00 1050.00 0.00000 Inj 25 mg autoinjector Enbrel 4 1 690.00 690.00 690.00 0.00000 Immune Modulators Antithymocyte globulin (equine) Inj 50 mg per ml, 5 ml ATGAM 5 4439.17 4439.17 4439.17 0.00000 Bacillus Calmette-Guerin (BCG) vaccine

Subsidised only for bladder cancer.

Inj 2-8 x 100 million CFU OncoTICE 1 149.37 149.37 149.37 0.00000 Inj 40 mg per ml, vial SII-Onco-BCG 3 182.45 182.45 182.45 0.00000 Monoclonal Antibodies Rituximab (Mabthera) <range>Rituximab<instance>Mabthera</instance></range>

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 3 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 ciclosporin,
                        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

any relevant practitioner 4

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

any relevant 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

any relevant 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

any relevant practitioner 12 Inj 100 mg per 10 ml vial Mabthera 2 1075.50 1075.50 1075.50 0.00000 Inj 500 mg per 50 ml vial Mabthera 1 2688.30 2688.30 2688.30 0.00000 Inj 1 mg for ECP Baxter (Mabthera) 1 5.64 5.64 5.64 0.00000 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 Amgevitat 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 Practitioner 6

the patient demonstrates at least a continuing 30% improvement in active
            joint count and continued improvement in physician's global assessment from
            baseline

named specialist 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 Practitioner 6

the patient demonstrates at least a continuing 30% improvement in active
            joint count and continued improvement in physician's global assessment from
            baseline

named specialist 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 Adalimumab to be administered at doses no greater
               than 40 mg every 14 days

named specialist 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

named specialist 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 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 Inj 20 mg per 0.2 ml prefilled syringe Humira 2 1 595.50 595.50 595.50 0.00000 Inj 40 mg per 0.4 ml prefilled syringe Humira 2 1 595.50 595.50 595.50 0.00000 Inj 40 mg per 0.4 ml prefilled pen HumiraPen 2 1 595.50 595.50 595.50 0.00000 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

respiratory specialist clinical immunologist 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 a Urticaria Control Test (UCT) of
                        8 or less 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 7

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

clinical immunologist respiratory specialist 2

Patient has previously adequately responded* 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.

Inj 150 mg vial Xolair 1 1 450.00 450.00 450.00 0.00000 Inj 150 mg prefilled syringe Xolair 1 1 450.00 450.00 450.00 0.00000 Xolair AU 1 450.00 450.00 450.00 0.00000 Siltuximab

Note: Siltuximab is to be administered at doses no greater than 11 mg/kg every 3 weeks.

<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 Inj 100 mg vial Sylvant 1 1 770.57 770.57 770.57 0.00000 Inj 400 mg vial Sylvant 1 1 3082.33 3082.33 3082.33 0.00000 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 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) 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

any relevant 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

any relevant practitioner 12 Inj 30 mg per ml, 14 ml vial Perjeta 1 3927.00 3927.00 3927.00 0.00000 Inj 420 mg for ECP Baxter 420 3927.00 3927.00 3927.00 0.00000 Obinutuzumab <range>Obinutuzumab</range>

Individual is currently on treatment with
                    obinutuzumab and venetoclax and met all of the following criteria prior to
                    commencing treatment Individual has previously untreated
                        chronic lymphocytic leukaemia Obinutuzumab is to be administered at a
                        maximum cumulative dose of 8,000 mg and in combination with venetoclax for a
                        maximum of 6 (28-day) cycles of treatment

any relevant practitioner 15

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

any relevant practitioner 12

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.

* Neutrophil 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*

any relevant 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

any relevant practitioner 24 Inj 25 mg per ml, 40 ml vial Gazyva 1 5910.00 5910.00 5910.00 0.00000 Inj 1 mg for ECP Baxter 1 6.21 6.21 6.21 0.00000 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

relevant specialist any relevant practitioner 6

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

relevant specialist any relevant practitioner 6

there is no evidence of disease progression

relevant specialist any relevant 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.

Inj 5 mg per ml, 20 ml vial Erbitux 1 364.00 364.00 364.00 0.00000 Inj 5 mg per ml, 100 ml vial Erbitux 1 1820.00 1820.00 1820.00 0.00000 Inj 1 mg for ECP Baxter 1 3.82 3.82 3.82 0.00000 Aflibercept <range>Aflibercept</range>

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

any relevant 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

any relevant 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 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

any relevant 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

any relevant practitioner 12 Inj 40 mg per ml, 0.1 ml vial Eylea 1 1 1250.00 1250.00 1250.00 0.00000 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

any relevant 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

any relevant 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

any relevant 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

any relevant 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

any relevant 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

any relevant practitioner 6 Inj 150 mg per ml, 1 ml prefilled syringe Cosentyx 1 1 799.50 799.50 799.50 0.00000 2 1599.00 1599.00 1599.00 0.00000 Infliximab <range>Infliximab</range>

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 has experienced an
                    inadequate response to, or 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. Up to 10 mg/kg every 8 weeks (or
                    equivalent) may be used for patients treated with this dose prior to 1 February
                    2019

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. Up to 10 mg/kg every 8 weeks (or
                    equivalent) may be used for patients treated with this dose prior to 1 February
                    2019

any relevant practitioner 2

patient has steroid-refractory acute graft vs.
                host disease of the gut

any relevant practitioner

patient has life-threatening pulmonary sarcoidosis
                diagnosed by a multidisciplinary team that is refractory to other treatments

any relevant practitioner

Patient has acute, fulminant ulcerative
                    colitis Treatment with intravenous or high dose oral
                    corticosteroids has not been successful

gastroenterologist 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 Following initial induction doses, maximum
                    dose 5mg/kg every 6-8 weeks

any relevant 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

any relevant practitioner 2

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

any relevant 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

any relevant 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 confirmed Crohn's disease Patient has one or more complex externally
                        draining enterocutaneous fistula(e) Patient has one or more rectovaginal
                        fistula(e) Patent has complex peri-anal fistula

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 (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. Up to 10 mg/kg every 8 weeks (or
                    equivalent) may be used for patients treated with this dose prior to 1 February
                    2019

gastroenterologist Practitioner 2

Patient has been diagnosed with
                    neurosarcoiosis by a multidisciplinary team Patient has CNS involvement Patient has steroid-refractory disease IV cyclophosphamide has been tried Treatment with IV cyclophosphamide is
                        clinically inappropriate

neurologist Practitioner 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 Practitioner 18

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

any relevant 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

any relevant practitioner 2

Patient was being treated with infliximab
                    prior to 1 February 2019 Rheumatoid arthritis Ankylosing spondylitis Psoriatic arthritis Severe ocular inflammation Chronic ocular inflammation Crohn’s disease (adults) Crohn’s disease (children) Fistulising Crohn’s disease Severe fulminant ulcerative colitis Severe ulcerative colitis Plaque psoriasis Neurosarcoidosis Severe Behcet’s disease

any relevant practitioner 6

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

any relevant 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

any relevant practitioner 2

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

any relevant 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

any relevant practitioner 2

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

any relevant practitioner

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. Up to 10 mg/kg every 8 weeks (or
                    equivalent) may be used for patients treated with this dose prior to 1 February
                    2019

any relevant 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

any relevant 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,
                    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

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 tried but has experienced an
                    inadequate response to, or has experienced 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 10 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. Up to 10 mg/kg every 8 weeks (or
                    equivalent) may be used for patients treated with this dose prior to 1 February
                    2019

any relevant practitioner 2

Patient has received insufficient benefit from
                    3 months of conventional therapy including a minimum of 3 pharmaceuticals (e.g.
                    prednisone, ciclosporine, 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

any relevant practitioner

Note: 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’s disease has not responded adequately
                    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

any relevant 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

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 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

any relevant 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

any relevant 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.

Inj 100 mg Remicade 1 428.00 428.00 428.00 0.00000 Inj 1 mg for ECP Baxter 1 4.40 4.40 4.40 0.00000 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

any relevant practitioner

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

any relevant practitioner 4

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.

Inj 20 mg per ml, 4 ml vial Actemra 1 220.00 220.00 220.00 0.00000 Inj 20 mg per ml, 10 ml vial Actemra 1 550.00 550.00 550.00 0.00000 Inj 20 mg per ml, 20 ml vial Actemra 1 1100.00 1100.00 1100.00 0.00000 Inj 1 mg for ECP Baxter 1 2.85 2.85 2.85 0.00000 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)

relevant specialist medical practitioner 12

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

relevant specialist any relevant 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

relevant specialist medical practitioner 6

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

Inj 100 mg vial Kadcyla 1 2320.00 2320.00 2320.00 0.00000 Inj 160 mg vial Kadcyla 1 3712.00 3712.00 3712.00 0.00000 Inj 1 mg for ECP Baxter 1 24.52 24.52 24.52 0.00000 Rituximab (Riximyo) <range>Rituximab<instance>Riximyo</instance></range>

patient is to undergo an ABO-incompatible solid organ transplant*

any relevant practitioner

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

any relevant 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

any relevant practitioner 8

Indications marked with * are unapproved indications.

patient has been diagnosed with antibody-mediated organ transplant
        rejection*

any relevant practitioner

Indications marked with * are unapproved indications.

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 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

any relevant practitioner 12 10

'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 It is planned that the patient receives full dose fludarabine and
              cyclophosphamide (orally or dose equivalent intravenous administration) or
              bendamustine Rituximab to be administered in combination with fludarabine and
          cyclophosphamide, bendamustine or venetoclax for a maximum of 6 treatment cycles

any relevant practitioner 12 10

Cumulative dose up to 1,500 mg/m² body surface area up to 2,000 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

any relevant practitioner

Indications marked with * are unapproved indications.

The patient has B-cell post-transplant lymphoproliferative disorder* To be used for a maximum of 8 treatment cycles

any relevant practitioner 12

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

any relevant practitioner 9

Indications marked with * are unapproved indications.

Cumulative dose up to 1,500 mg/m² body surface area up to 2,000 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

any relevant practitioner 2

Indications marked with * are unapproved indications.

Cumulative dose up to 1,500 mg/m² body surface area up to 2,000 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

any relevant practitioner 2

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

any relevant 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

any relevant 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

any relevant 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

nephrologist Practitioner 8

Indications marked with * are unapproved indications.

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

any relevant practitioner 12

'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

any relevant practitioner 12

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

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 Practitioner 4

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 Practitioner 4

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 Practitioner 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 Practitioner 8

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

any relevant 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

any relevant practitioner 12

patient has autoimmune pure red cell aplasia* associated with a
        demonstrable B-cell lymphoproliferative disorder

haematologist Practitioner 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 Practitioner 6

Indications marked with * are unapproved indications.

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 Practitioner 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 Practitioner 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 any relevant practitioner

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 any relevant practitioner

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 Practitioner 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 Practitioner 8

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 1000mg infusions every 6 months

any relevant 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

any relevant 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 any relevant practitioner

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

any relevant 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

any relevant 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)

any relevant 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 375
          mg/m² of body surface area per week for a total of 4 weeks Subsequent retreatment only for disease relapse or after partial
          response

any relevant 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

relevant specialist 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

any relevant 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

any relevant 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

any relevant practitioner 12

Indications marked with * are unapproved indications.

Inj 1 mg for ECP Baxter (Riximyo) 1 1.38 1.38 1.38 0.00000 Inj 100 mg per 10 ml vial Riximyo 2 275.33 275.33 275.33 0.00000 Inj 500 mg per 50 ml vial Riximyo 1 688.20 688.20 688.20 0.00000 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

relevant specialist any relevant practitioner 12

patient has no evidence of clinical disease progression

relevant specialist any relevant practitioner 12 Inj 100 mg prefilled pen Nucala 1 1 1638.00 1638.00 1638.00 0.00000 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 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 any relevant practitioner 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 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 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

any relevant 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 has not received an adequate response

dermatologist

Indications marked with * are unapproved indications.

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 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

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 The patient has experienced intolerable side effects The patient has received insufficient benefit from 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 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 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 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 leflunomide (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 3

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 initiation 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, sulfasalazine 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

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 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

rheumatologist 6

Following initial treatment, 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 has experienced at least a continuing 30% improvement in
               active joint count from baseline in the opinion of the treating physician

any relevant practitioner 2 Inj 40 mg per 0.8 ml prefilled pen Amgevita 2 1 375.00 375.00 375.00 0.00000 Inj 40 mg per 0.8 ml prefilled syringe Amgevita 2 1 375.00 375.00 375.00 0.00000 Inj 20 mg per 0.4 ml prefilled syringe Amgevita 1 1 190.00 190.00 190.00 0.00000 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 Infant is to be administered palivizumab
                            within a single calendar year 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

any relevant 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

any relevant practitioner 6

Ventilatory/respiratory support includes those on home oxygen, CPAP/VPAP and those with tracheostomies in situ managed at home
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
Mean pulmonary artery pressure more than 25 mmHg
LV Ejection Fraction less than 40%
Inborn errors of immunity include, but are not limited to, IFNAR deficiencies

Inj 100 mg per ml, 1 ml vial Synagis 1 1700.00 1700.00 1700.00 0.00000 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)

haematologist paediatric haematologist paediatric oncologist 3

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

Inj 5 mg vial Mylotarg 1 12973.00 12973.00 12973.00 0.00000 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 Inj 30 mg per ml, 1 ml prefilled pen Fasenra 1 1 3539.00 3539.00 3539.00 0.00000 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

any relevant 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

any relevant 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

any relevant 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

any relevant 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

any relevant 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

any relevant practitioner 12

Criterion marked with * is for an unapproved indication.

Inj 90 mg per ml, 1 ml pre-filled syringe Stelara 1 1 4162.00 4162.00 4162.00 0.00000 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

any relevant 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

any relevant 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

any relevant 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

any relevant 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

any relevant 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

any relevant practitioner 2

Indication marked with * is an unapproved indication.

Inj 300 mg vial Entyvio 1 3313.00 3313.00 3313.00 0.00000 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

any relevant 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

any relevant 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

any relevant 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

any relevant 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

any relevant practitioner 9 Inj 50 mg vial Adcetris 1 5275.18 5275.18 5275.18 0.00000 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)

any relevant practitioner 15

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 The 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

any relevant 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

any relevant 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

any relevant 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

any relevant 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

any relevant practitioner 12 Inj 150 mg vial Herzuma 1 100.00 100.00 100.00 0.00000 Inj 440 mg vial Herzuma 1 293.35 293.35 293.35 0.00000 Inj 1 mg for ECP Baxter 1 0.70 0.70 0.70 0.00000 Trastuzumab deruxtecan <range>Trastuzumab deruxtecan</range>

Patient is currently on treatment with trastuzumab deruxtecan and met all remaining criteria prior to commencing treatment 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

relevant specialist any relevant 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

relevant specialist any relevant practitioner 6

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

Inj 100 mg per ml, 1 ml vial Enhertu 1 2550.00 2550.00 2550.00 0.00000 Inj 1 mg for ECP Baxter 1 27.05 27.05 27.05 0.00000 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

any relevant practitioner 6

there is no evidence of disease progression

any relevant 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

any relevant practitioner 4

there is no evidence of disease progression

any relevant practitioner 4

Maximum of 6 doses The patient has recurrent respiratory papillomatosis The treatment is for intra-lesional administration

any relevant 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

any relevant practitioner 12

Ocular neovascularisation Exudative ocular angiopathy

any relevant practitioner Inj 25 mg per ml, 4 ml vial Vegzelma 1 69.00 69.00 69.00 0.00000 Inj 25 mg per ml, 16 ml vial Vegzelma 1 276.00 276.00 276.00 0.00000 Inj 1 mg for ECP Baxter 1 0.71 0.71 0.71 0.00000 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

relevant specialist any relevant 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

relevant specialist any relevant practitioner 4 Inj 1 mg vial Besponsa 1 14457.00 14457.00 14457.00 0.00000 Inj 1 mg for ECP Baxter 1 14457.00 14457.00 14457.00 0.00000 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

any relevant 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

any relevant 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

any relevant 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

any relevant practitioner 12 Inj 120 mg per ml, 0.24 ml vial Vabysmo 1 1565.00 1565.00 1565.00 0.00000 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

any relevant 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

any relevant practitioner 12 Inj 600 mg with trastuzumab 600 mg, 10 ml vial Phesgo 1 7707.00 7707.00 7707.00 0.00000 Inj 1,200 mg with trastuzumab 600 mg, 15 ml vial Phesgo 1 12894.00 12894.00 12894.00 0.00000 Programmed Cell Death-1 (PD-1) Inhibitors Nivolumab <range>Nivolumab</range>

The individual is currently on treatment with nivolumab for
                    neoadjuvant treatment of resectable stage IIIB, IIIC, IIID or IV melanoma and
                    met all remaining criteria prior to commencing treatment 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 The individual has ECOG performance score
                        0-2 Treatment must be initiated prior to
                        complete surgical resection Neoadjuvant nivolumab must be administered in combination
                        with ipilimumab Nivolumab to be administered for maximum of two cycles prior
                        to surgical resection

relevant specialist any relevant practitioner 4

The individual has received funded neoadjuvant treatment with
                        nivolumab in combination with ipilimumab Adjuvant treatment with nivolumab is required Treatment must be initiated within 13 weeks of complete
                        surgical resection, unless delay is necessary due to post-surgery
                        recovery Nivolumab must be administered as monotherapy Nivolumab to be discontinued at signs of disease recurrence
                        or at completion of 12 months total treatment duration including any
                        systemic neoadjuvant treatment (equivalent to 11 adjuvant cycles at 480 mg
                        every 4 weeks plus initial 2 neoadjuvant treatment cycles) The individual has received neoadjuvant treatment with
                        nivolumab and ipilimumab The individual has unresectable or metastatic melanoma
                        (excluding uveal) stage III or IV The individual meets initial application criteria for
                        nivolumab for unresectable or metastatic melanoma The individual has received neoadjuvant treatment with
                        nivolumab and ipilimumab The individual has received treatment with nivolumab for
                        unresectable or metastatic melanoma The individual meets the renewal criteria for nivolumab for
                        unresectable or metastatic melanoma

relevant specialist any relevant practitioner 4

Stage IIIB, IIIC, IIID or IV melanoma defined as per American Joint Committee on Cancer (AJCC) 8th Edition.
Disease must be completely resectable and amenable to curative intent surgery, including stage IV disease.

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
                            indvidual 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 as monotherapy at a maximum
                        maintenance dose of 240 mg every 2 weeks (or equivalent)

any relevant 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

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 Nivolumab is to be used as monotherapy at a maximum dose of 240
                    mg every 2 weeks (or equivalent) and discontinued at disease progression

any relevant practitioner 4 Inj 1 mg for ECP Baxter 1 27.22 27.22 27.22 0.00000 Inj 10 mg per ml, 4 ml vial Opdivo 1 1051.98 1051.98 1051.98 0.00000 Inj 10 mg per ml, 10 ml vial Opdivo 1 2629.96 2629.96 2629.96 0.00000 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 initial application 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 renewal 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 initial application 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 renewal criteria for pembrolizumab for
                        unresectable or metastatic melanoma

relevant specialist any relevant practitioner 4

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

Stage IIIB, IIIC, IIID or IV melanoma defined as per American Joint Committee on Cancer (AJCC) 8th Edition
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 initial application 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 renewal 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 score of 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 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 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 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 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 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 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)

relevant specialist 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)

relevant specialist any relevant practitioner 6 Inj 1 mg for ECP Baxter 1 47.74 47.74 47.74 0.00000 Inj 25 mg per ml, 4 ml vial Keytruda 1 4680.00 4680.00 4680.00 0.00000 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

relevant specialist any relevant 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

relevant specialist any relevant practitioner 4 Inj 50 mg per ml, 2.4 ml vial Imfinzi 1 1128.00 1128.00 1128.00 0.00000 Inj 50 mg per ml, 10 ml vial Imfinzi 1 4700.00 4700.00 4700.00 0.00000 Inj 1 mg for ECP Baxter 1 9.59 9.59 9.59 0.00000 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 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 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 any relevant practitioner 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

any relevant practitioner 6

there is no evidence of disease progression

any relevant practitioner 6 Inj 60 mg per ml, 20 ml vial Tecentriq 1 9503.00 9503.00 9503.00 0.00000 Inj 1 mg for ECP Baxter 1 8.08 8.08 8.08 0.00000 Ipilimumab <range>Ipilimumab</range>

The individual is currently on treatment with ipilimumab for
                    neoadjuvant treatment of resectable stage IIIB, IIIC, IIID or IV melanoma and
                    met all remaining criteria prior to commencing treatment 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 The individual has ECOG performance score
                        0-2 Treatment must be prior to complete
                        surgical resection Neoadjuvant ipilimumab must be administered in combination
                        with nivolumab Ipilimumab to be administered for maximum of two cycles prior
                        to surgical resection

relevant specialist any relevant practitioner 4

Stage IIIB, IIIC, IIID or IV melanoma defined as per American Joint Committee on Cancer (AJCC) 8th Edition.
Disease must be completely resectable and amenable to curative intent surgery, including stage IV disease.

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.

any relevant practitioner 4 5 Inj 5 mg per ml, 10 ml vial Yervoy 1 5000.00 5000.00 5000.00 0.00000 Inj 5 mg per ml, 40 ml vial Yervoy 1 20000.00 20000.00 20000.00 0.00000 Inj 1 mg for ECP Baxter 1 106.00 106.00 106.00 0.00000 Other Immunosuppressants Tacrolimus <range>Tacrolimus</range>

The individual is an organ transplant recipient The individual is receiving induction therapy for an organ transplant

relevant specialist

Subsidy applies for either primary or rescue therapy.

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*

relevant specialist

Indications marked with * are unapproved indications

Cap 1 mg Tacrolimus Sandoz 100 84.30 84.30 84.30 0.00000 Cap 5 mg Tacrolimus Sandoz 50 248.20 248.20 248.20 0.00000 Cap 0.5 mg Tacrolimus Sandoz 100 49.60 49.60 49.60 0.00000 Cap 0.75 mg Tacrolimus Sandoz 100 99.30 99.30 99.30 0.00000 Ciclosporin Cap 100 mg Neoral 50 177.81 177.81 177.81 0.00000 Cap 25 mg Neoral 50 44.63 44.63 44.63 0.00000 Oral liq 100 mg per ml Neoral 50 198.13 198.13 198.13 0.00000 Cap 50 mg Neoral 50 88.91 88.91 88.91 0.00000 Sirolimus <range>Sirolimus (Rapamune)</range>

The drug is to be used 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)

any relevant 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

any relevant 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

any relevant 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 age potential are not required to trial phenytoin sodium, sodium valproate, or 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

Tab 1 mg Rapamune 100 749.99 749.99 749.99 0.00000 Oral liq 1 mg per ml Rapamune 60 449.99 449.99 449.99 0.00000 Tab 2 mg Rapamune 100 1499.99 1499.99 1499.99 0.00000 Everolimus <range>Everolimus</range>

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

neurologist oncologist 4

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

any relevant practitioner 4

there is no evidence of disease progression

any relevant practitioner 4 Tab 5 mg Afinitor 30 4555.76 4555.76 4555.76 0.00000 Tab 10 mg Afinitor 30 6512.29 6512.29 6512.29 0.00000 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

any relevant practitioner 7

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

any relevant 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

any relevant 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

any relevant 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

any relevant 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

any relevant 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

any relevant practitioner 6

PCDAI score has reduced by 10 points from 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

any relevant 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

any relevant 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

any relevant practitioner 2 Tab modified-release 15 mg Rinvoq 28 1271.00 1271.00 1271.00 0.00000 Tab modified-release 30 mg Rinvoq 28 2033.00 2033.00 2033.00 0.00000 Tab modified-release 45 mg Rinvoq 28 3049.00 3049.00 3049.00 0.00000 Respiratory System and Allergies Antiallergy Preparations Allergic Emergencies Adrenaline

Additional prescriptions limited to replacement of up to two devices prior to expiry, or replacement of used device for treatment of anaphylaxis.

<range>Adrenaline</range>

Patient has experienced an 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 Patient is not to be prescribed more than two
                    devices in initial prescription

any relevant practitioner Inj 0.15 mg per 0.3 ml auto-injector Epipen Jr 1 1 85.50 85.50 85.50 0.00000 Inj 0.3 mg per 0.3 ml auto-injector Epipen 1 1 85.50 85.50 85.50 0.00000 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

any relevant practitioner 12 Inj 10 mg per ml, 3 ml prefilled syringe Firazyr 1 1 2668.00 2668.00 2668.00 0.00000 Icatibant Lupin 1 1 479.00 479.00 479.00 0.00000 Allergy Desensitisation <range>Bee or wasp venom allergy treatment</range>

RAST or skin test positive Patient has had severe generalised reaction to the sensitising agent

relevant specialist 2

The treatment remains appropriate and the patient is benefiting from treatment

relevant specialist 2 Wasp venom allergy treatment Treatment kit (Yellow jacket venom) - 1 vial 550 mcg freeze dried vespula venom, 1 diluent 9 ml, 3 diluent 1.8 ml Albey 1 431.24 431.24 431.24 0.00000 Treatment kit (Paper wasp venom) - 1 vial 550 mcg freeze dried polistes venom, 1 diluent 9 ml, 3 diluent 1.8 ml Albey 1 382.23 382.23 382.23 0.00000 Treatment kit (Paper wasp venom) - 6 vials 120 mcg freeze dried venom, with diluent Venomil 1 305.00 305.00 305.00 0.00000 Treatment kit (Yellow jacket venom) - 6 vials 120 mcg freeze dried venom, with diluent Venomil 1 305.00 305.00 305.00 0.00000 Treatment kit (Yellow Jacket venom) - 1 vial 550 mcg freeze dried venom, with diluent Hymenoptera 1 305.00 305.00 305.00 0.00000 Treatment kit (Paper wasp venom) - 1 vial 550 mcg freeze dried venom, with diluent Hymenoptera 1 305.00 305.00 305.00 0.00000 Bee venom allergy treatment Treatment kit - 1 vial 550 mcg freeze dried venom, 1 diluent 9 ml, 3 diluent 1.8 ml Albey 1 334.39 334.39 334.39 0.00000 Maintenance kit - 6 vials 120 mcg freeze dried venom, with diluent Venomil 1 285.00 285.00 285.00 0.00000 Treatment kit - 1 vial 550 mcg freeze dried venom, with diluent Hymenoptera 1 305.00 305.00 305.00 0.00000 Maintenance kit - 1 vial freeze dried venom with diluent VENOX 1 305.00 305.00 305.00 0.00000 Initiation kit - 1 vial freeze dried venom with diluent VENOX 1 305.00 305.00 305.00 0.00000 Antihistamines Antihistamines Fexofenadine hydrochloride Tab 120 mg Fexaclear 30 3.49 3.49 3.49 0.00000 Tab 60 mg Telfast 20 4.34 8.23 4.34 0.19450 Tab 180 mg Fexaclear 30 4.10 4.10 4.10 0.00000 Dextrochlorpheniramine maleate Tab 2 mg Polaramine 20 1.01 5.99 1.01 0.24900 40 2.02 8.40 2.02 0.15950 Oral liq 2 mg per 5 ml Polaramine 100 1.77 10.29 1.77 0.08520 Promethazine hydrochloride Tab 10 mg Allersoothe 100 2.19 2.19 2.19 0.00000 Tab 25 mg Allersoothe 100 2.69 2.69 2.69 0.00000 Oral liq 1 mg per 1 ml Allersoothe 100 3.39 3.39 3.39 0.00000 Inj 25 mg per ml, 2 ml ampoule Hospira 5 1 21.09 21.09 21.09 0.00000 Loratadine Tab 10 mg Lorafix 100 6.02 6.02 6.02 0.00000 Loratadine Noumed 100 1.59 1.59 1.59 0.00000 Oral liq 1 mg per ml Haylor syrup 100 1.43 1.43 1.43 0.00000 Cetirizine hydrochloride Tab 10 mg Zista 100 1.71 1.71 1.71 0.00000 Oral liq 1 mg per ml Histaclear 200 3.99 3.99 3.99 0.00000 Inhaled Corticosteroids Inhaled Corticosteroids Fluticasone Aerosol inhaler, 50 mcg per dose Flixotide 120 7.19 7.19 7.19 0.00000 Aerosol inhaler, 125 mcg per dose Flixotide 120 13.60 13.60 13.60 0.00000 Aerosol inhaler, 250 mcg per dose Flixotide 120 24.62 24.62 24.62 0.00000 Powder for inhalation, 50 mcg per dose Flixotide Accuhaler 60 8.61 8.61 8.61 0.00000 Powder for inhalation, 100 mcg per dose Flixotide Accuhaler 60 7.81 7.81 7.81 0.00000 Powder for inhalation, 250 mcg per dose Flixotide Accuhaler 60 11.93 11.93 11.93 0.00000 Beclomethasone dipropionate Aerosol inhaler, 50 mcg per dose Qvar 200 14.01 14.01 14.01 0.00000 Aerosol inhaler, 100 mcg per dose Qvar 200 17.52 17.52 17.52 0.00000 Aerosol inhaler, 50 mcg per dose CFC-free Beclazone 50 200 8.54 8.54 8.54 0.00000 Aerosol inhaler, 100 mcg per dose CFC-free Beclazone 100 200 12.50 12.50 12.50 0.00000 Aerosol inhaler, 250 mcg per dose CFC-free Beclazone 250 200 22.67 22.67 22.67 0.00000 Budesonide Powder for inhalation, 100 mcg per dose Pulmicort Turbuhaler 200 17.00 17.00 17.00 0.00000 Powder for inhalation, 200 mcg per dose Pulmicort Turbuhaler 200 19.00 19.00 19.00 0.00000 Powder for inhalation, 400 mcg per dose Pulmicort Turbuhaler 200 32.00 32.00 32.00 0.00000 Inhaled Long-acting Beta-adrenoceptor Agonists Inhaled Long-acting Beta-adrenoceptor Agonists Salmeterol Powder for inhalation, 50 mcg per dose, breath activated Serevent Accuhaler 60 26.25 26.25 26.25 0.00000 Aerosol inhaler CFC-free, 25 mcg per dose Serevent 120 26.25 26.25 26.25 0.00000 Indacaterol Powder for inhalation 150 mcg Onbrez Breezhaler 30 61.00 61.00 61.00 0.00000 Powder for inhalation 300 mcg Onbrez Breezhaler 30 61.00 61.00 61.00 0.00000 Eformoterol fumarate dihydrate Powder for inhalation 4.5 mcg per dose, breath activated (equivalent to eformoterol fumarate 6 mcg metered dose) Oxis Turbuhaler 60 10.32 16.90 10.32 0.10967 Inhaled Corticosteroids with Long-Acting Beta-Adrenoceptor Agonists Budesonide with eformoterol Powder for inhalation 100 mcg with eformoterol fumarate 6 mcg Symbicort Turbuhaler 100/6 120 33.74 33.74 33.74 0.00000 Powder for inhalation 200 mcg with eformoterol fumarate 6 mcg Symbicort Turbuhaler 200/6 120 33.74 33.74 33.74 0.00000 Powder for inhalation 400 mcg with eformoterol fumarate 12 mcg Symbicort Turbuhaler 400/12 60 33.74 33.74 33.74 0.00000 Aerosol inhaler 100 mcg with eformoterol fumarate 6 mcg Vannair 120 18.23 18.23 18.23 0.00000 Aerosol inhaler 200 mcg with eformoterol fumarate 6 mcg Vannair 120 21.40 21.40 21.40 0.00000 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 41.50 41.50 0.00000 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 82.50 82.50 0.00000 Fluticasone with salmeterol Aerosol inhaler 50 mcg with salmeterol 25 mcg Seretide 120 25.79 25.79 25.79 0.00000 Aerosol inhaler 125 mcg with salmeterol 25 mcg Seretide 120 32.60 32.60 32.60 0.00000 Powder for inhalation 100 mcg with salmeterol 50 mcg Seretide Accuhaler 60 33.74 33.74 33.74 0.00000 Powder for inhalation 250 mcg with salmeterol 50 mcg Seretide Accuhaler 60 44.08 44.08 44.08 0.00000 Fluticasone furoate with vilanterol Powder for inhalation 100 mcg with vilanterol 25 mcg Breo Ellipta 30 44.08 44.08 44.08 0.00000 Beta-Adrenoceptor Agonists Beta-Adrenoceptor Agonists Salbutamol Oral liq 400 mcg per ml Ventolin 150 50.00 50.00 50.00 0.00000 Inj 500 mcg per ml, 1 ml Ventolin 5 1 130.00 130.00 130.00 0.00000 Infusion 1 mg per ml, 5 ml Ventolin 10 130.00 130.00 130.00 0.00000 Inhaled Beta-Adrenoceptor Agonists Salbutamol Nebuliser soln, 1 mg per ml, 2.5 ml ampoule Asthalin 20 8.96 8.96 8.96 0.00000 UK Cipla 20 1 8.96 8.96 8.96 0.00000 Nebuliser soln, 2 mg per ml, 2.5 ml ampoule Asthalin 20 9.43 9.43 9.43 0.00000 UK Cipla 20 9.43 9.43 9.43 0.00000 Aerosol inhaler, 100 mcg per dose CFC free Ventolin 200 4.18 7.45 4.18 0.01635 SalAir 200 4.18 4.18 4.18 0.00000 Terbutaline sulphate Powder for inhalation, 200 mcg per dose (equivalent to 250 mcg metered dose), breath activated Bricanyl Turbuhaler 120 22.20 22.20 22.20 0.00000 Anticholinergic Agents Anticholinergic Agents Ipratropium bromide Nebuliser soln, 250 mcg per ml, 2 ml ampoule Univent 20 11.73 11.73 11.73 0.00000 Accord 20 11.73 11.73 11.73 0.00000 Ipratropium Viatris 10 8.11 8.11 8.11 0.00000 Aerosol inhaler, 20 mcg per dose CFC-free Atrovent 200 16.20 16.20 16.20 0.00000 Inhaled Beta-Adrenoceptor Agonists with Anticholinergic Agents Salbutamol with ipratropium bromide Nebuliser soln, 2.5 mg with ipratropium bromide 0.5 mg per vial, 2.5 ml ampoule Duolin 20 11.04 11.04 11.04 0.00000 Combiprasal 60 96.50 96.50 96.50 0.00000 Aerosol inhaler, 100 mcg with ipratropium bromide, 20 mcg per dose CFC-free Duolin HFA 200 12.19 12.19 12.19 0.00000 Nebuliser soln, 2.5 mg with ipratropium bromide 0.5 mg per vial, 3 ml vial Cipla 30 16.56 16.56 16.56 0.00000 Long-Acting Muscarinic Antagonists Tiotropium bromide

Tiotropium treatment will not be subsidised if patient is also receiving treatment with subsidised inhaled glycopyrronium or umeclidinium.

Tiotropium bromide is subsidised only for patients who have been diagnosed as having COPD using spirometry if spirometry is possible, and the prescription is endorsed accordingly. Patients who had tiotropium dispensed before 1 October 2018 with a valid Special Authority are deemed endorsed.

Powder for inhalation, 18 mcg per dose Spiriva 30 50.37 50.37 50.37 0.00000 Soln for inhalation 2.5 mcg per dose Spiriva Respimat 60 50.37 50.37 50.37 0.00000 Glycopyrronium

Inhaled glycopyrronium treatment will not be subsidised if patient is also receiving treatment with subsidised tiotropium or umeclidinium.

Glycopyrronium powder for inhalation 50 mcg per dose is subsidised only for patients who have been diagnosed as having COPD using spirometry if spirometry is possible, and the prescription is endorsed accordingly.

Powder for inhalation 50 mcg per dose Seebri Breezhaler 30 61.00 61.00 61.00 0.00000 Umeclidinium

Umeclidinium will not be subsidised if patient is also receiving treatment with subsidised inhaled glycopyrronium or tiotropium bromide.

Umeclidinium powder for inhalation 62.5 mcg per dose is subsidised only for patients who have been diagnosed as having COPD using spirometry if spirometry is possible, and the prescription is endorsed accordingly.

Powder for inhalation 62.5 mcg per dose Incruse Ellipta 30 61.50 61.50 61.50 0.00000 Long-Acting Muscarinic Antagonists with Long-Acting Beta-Adrenoceptor Agonists

Combination long acting muscarinic antagonist and long acting beta-2 agonist will not be subsidised if 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

any relevant practitioner Glycopyrronium with indacaterol Powder for Inhalation 50 mcg with indacaterol 110 mcg Ultibro Breezhaler 30 81.00 81.00 81.00 0.00000 Tiotropium bromide with olodaterol Soln for inhalation 2.5 mcg with olodaterol 2.5 mcg Spiolto Respimat 60 81.00 81.00 81.00 0.00000 Umeclidinium with vilanterol Powder for inhalation 62.5 mcg with vilanterol 25 mcg Anoro Ellipta 30 77.00 77.00 77.00 0.00000 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

any relevant practitioner Powder for inhalation fluticasone furoate 100 mcg with umeclidinium 62.5 mcg and vilanterol 25 mcg Trelegy Ellipta 30 104.24 104.24 104.24 0.00000 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

any relevant practitioner Aerosol inhaler budesonide 160 mcg with glycopyrronium 7.2 mcg and formoterol 5 mcg per dose Breztri Aerosphere 120 79.15 79.15 79.15 0.00000 Antifibrotics Antifibrotics Pirfenidone

Note: Pirfenidone is not subsidised in combination with subsidised nintedanib.

<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 Note) 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.

Tab 801 mg Esbriet 90 3645.00 3645.00 3645.00 0.00000 Pirfenidone Sandoz 90 437.40 437.40 437.40 0.00000 Tab 267 mg Esbriet 90 1215.00 1215.00 1215.00 0.00000 Pirfenidone Sandoz 90 145.80 145.80 145.80 0.00000 Nintedanib

Note: Nintedanib not subsidised in combination with subsidised pirfenidone.

<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.

Cap 100 mg Ofev 60 2554.00 2554.00 2554.00 0.00000 Cap 150 mg Ofev 60 3870.00 3870.00 3870.00 0.00000 Leukotriene Receptor Antagonists Leukotriene Receptor Antagonists Montelukast Tab 4 mg Montelukast Viatris 28 3.10 3.10 3.10 0.00000 Tab 5 mg Montelukast Viatris 28 3.10 3.10 3.10 0.00000 Relonchem 28 3.10 3.10 3.10 0.00000 Tab 10 mg Montelukast Viatris 28 2.45 2.45 2.45 0.00000 Methylxanthines Methylxanthines Aminophylline Inj 25 mg per ml, 10 ml ampoule DBL Aminophylline 5 1 180.00 180.00 180.00 0.00000 Theophylline Tab long-acting 250 mg Nuelin-SR 100 25.65 25.65 25.65 0.00000 Oral liq 80 mg per 15 ml Nuelin 500 18.49 18.49 18.49 0.00000 Mucolytics Mucolytics 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 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 Nebuliser soln, 2.5 mg per 2.5 ml ampoule Pulmozyme 6 250.00 250.00 250.00 0.00000 Sodium chloride

Not funded for use as a nasal drop.

Soln 7% Biomed 90 25.73 25.73 25.73 0.00000 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

any relevant 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

Tab 150 mg Kalydeco 56 29386.00 29386.00 29386.00 0.00000 Oral granules 50 mg, sachet Kalydeco 56 29386.00 29386.00 29386.00 0.00000 Oral granules 75 mg, sachet Kalydeco 56 29386.00 29386.00 29386.00 0.00000 Oral granules 13.4 mg, sachet Kalydeco 56 29386.00 29386.00 29386.00 0.00000 Oral granules 25 mg, sachet Kalydeco 56 29386.00 29386.00 29386.00 0.00000 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

any relevant 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

Tab elexacaftor 50 mg with tezacaftor 25 mg, ivacaftor 37.5 mg (56) and ivacaftor 75 mg (28) Trikafta 84 27647.39 27647.39 27647.39 0.00000 Tab elexacaftor 100 mg with tezacaftor 50 mg, ivacaftor 75 mg (56) and ivacaftor 150 mg (28) Trikafta 84 27647.39 27647.39 27647.39 0.00000 Oral granules elexacaftor 80 mg with tezacaftor 40 mg, ivacaftor 60 mg (28) and ivacaftor 59.5mg (28), sachets Trikafta 56 27647.39 27647.39 27647.39 0.00000 Oral granules elexacaftor 100 mg with tezacaftor 50 mg, ivacaftor 75 mg (28) and ivacaftor 75 mg (28), sachets Trikafta 56 27647.39 27647.39 27647.39 0.00000 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

any relevant 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

Tab vanzacaftor 4 mg with tezacaftor 20 mg and deutivacaftor 50 mg Alyftrek 84 29029.76 29029.76 29029.76 0.00000 Tab vanzacaftor 10 mg with tezacaftor 50 mg and deutivacaftor 125 mg Alyftrek 56 29029.76 29029.76 29029.76 0.00000 Nasal Preparations Allergy Prophylactics Budesonide Metered aqueous nasal spray, 50 mcg per dose SteroClear 200 2.59 2.59 2.59 0.00000 Metered aqueous nasal spray, 100 mcg per dose SteroClear 200 2.89 2.89 2.89 0.00000 Ipratropium bromide Aqueous nasal spray, 0.03% Univent 15 5.23 5.23 5.23 0.00000 Fluticasone propionate Metered aqueous nasal spray, 50 mcg per dose Flixonase Hayfever & Allergy 120 2.57 2.57 2.57 0.00000 Respiratory Devices Respiratory Devices Peak flow meter Low range Mini-Wright AFS Low Range 1 9.54 9.54 9.54 0.00000 Normal range Mini-Wright Standard 1 9.54 9.54 9.54 0.00000 Spacer device 800 ml Volumatic 1 6.50 6.50 6.50 0.00000 220 ml (single patient) e-chamber Turbo 1 3.65 3.65 3.65 0.00000 510 ml (single patient) e-chamber La Grande 1 5.95 5.95 5.95 0.00000 Mask for spacer device

Only for children aged six years and under

Small e-chamber Mask 1 2.70 2.70 2.70 0.00000 Respiratory Stimulants Respiratory Stimulants Caffeine citrate Oral liq 20 mg per ml (10 mg base per ml) Biomed 25 16.91 16.91 16.91 0.00000 Sensory Organs Ear Preparations Ear Preparations Flumetasone pivalate Ear drops 0.02% with clioquinol 1% Locorten-Vioform 7.5 4.46 4.46 4.46 0.00000 Locacorten-Viaform ED's 7.5 4.46 4.46 4.46 0.00000 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 5.16 5.16 0.00000 Ear/Eye Preparations Ear/Eye Preparations Dexamethasone with framycetin and gramicidin Ear/Eye drops 500 mcg with framycetin sulphate 5 mg and gramicidin 50 mcg per ml Sofradex 8 4.50 9.27 4.50 0.59625 Framycetin sulphate Ear/Eye drops 0.5% Soframycin 8 4.13 8.65 4.13 0.56500 Eye Preparations

Eye preparations are only funded for use in the eye, unless explicitly stated otherwise.

Anti-Infective Preparations Chloramphenicol Eye drops 0.5%

Funded for use in the ear*.

Indications marked with * are unapproved indications.

Chlorafast 10 1.84 1.84 1.84 0.00000 Eye oint 1% Devatis 5 1.55 1.55 1.55 0.00000 Sodium Fusidate [fusidic acid] Eye drops 1% Fucithalmic 5 5.29 5.29 5.29 0.00000 Fucithalmic Spain 5 5.29 5.29 5.29 0.00000 Fucithalmic Canada (ON) 5 5.29 5.29 5.29 0.00000 Tobramycin Eye drops 0.3% Tobrex 5 11.48 11.48 11.48 0.00000 Eye oint 0.3% Tobrex 3.5 10.45 10.45 10.45 0.00000 Aciclovir Eye oint 3% ViruPOS 4.5 15.89 15.89 15.89 0.00000 Ciprofloxacin Eye drops 0.3%

When prescribed for the treatment of bacterial keratitis or severe bacterial conjunctivitis resistant to chloramphenicol; or for the second line treatment of chronic suppurative otitis media (CSOM)*; and the prescription is endorsed accordingly.

Note: Indication marked with a * is an unapproved indication.

Ciprofloxacin Teva 5 10.85 10.85 10.85 0.00000 Corticosteroids and Other Anti-Inflammatory Preparations 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 4.50 4.50 0.00000 Eye oint 0.1% with neomycin sulphate 0.35% and polymyxin b sulphate 6,000 u per g Maxitrol 3.5 5.39 5.39 5.39 0.00000 Lodoxamide Eye drops 0.1% Lomide 10 8.71 8.71 8.71 0.00000 Dexamethasone Eye drops 0.1% Maxidex 5 4.50 4.50 4.50 0.00000 Eye oint 0.1% Maxidex 3.5 5.86 5.86 5.86 0.00000 Ocular implant 700 mcg <range>Dexamethasone 700 mcg ocular implants</range>

Patient has 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

Patient has 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 Ozurdex 1 1444.50 1444.50 1444.50 0.00000 Diclofenac sodium Eye drops 0.1%, single dose Diclofenac Devatis 30 5.54 5.54 5.54 0.00000 10 1.85 1.85 1.85 0.00000 Fluorometholone Eye drops 0.1% FML 5 3.09 3.09 3.09 0.00000 Flucon 5 5.20 5.20 5.20 0.00000 Prednisolone acetate Eye drops 1% Pred Forte 5 7.00 7.00 7.00 0.00000 Prednisolone-AFT 10 6.92 6.92 6.92 0.00000 Sodium cromoglicate Eye drops 2% Allerfix 10 2.91 2.91 2.91 0.00000 Levocabastine Eye drops 0.5 mg per ml Livostin 4 8.71 10.34 8.71 0.40750 Prednisolone sodium phosphate <range>Prednisolone sodium phosphate</range>

Patient has severe inflammation Patient has a confirmed allergic reaction to preservative in eye drops

ophthalmologist optometrist 6

The treatment remains appropriate and the patient is benefiting from treatment

any relevant practitioner 6 Eye drops 0.5%, single dose (preservative free) Minims Prednisolone 20 43.26 43.26 43.26 0.00000 Glaucoma Preparations - Beta Blockers Timolol Eye drops 0.25% Arrow-Timolol 5 2.42 2.42 2.42 0.00000 Eye drops 0.5% Arrow-Timolol 5 2.50 2.50 2.50 0.00000 Glaucoma Preparations - Carbonic Anhydrase Inhibitors Acetazolamide Tab 250 mg Medsurge 100 13.96 13.96 13.96 0.00000 Dorzolamide with timolol Eye drops 2% with timolol 0.5% Dortimopt 5 3.58 3.58 3.58 0.00000 Brinzolamide Eye drops 1% Azopt 5 5.11 5.11 5.11 0.00000 Glaucoma Preparations - Prostaglandin Analogues Latanoprost Eye drops 0.005% Teva 2.5 2.08 2.08 2.08 0.00000 Travoprost Eye drops 0.004% Travatan 2.5 6.80 6.80 6.80 0.00000 Bimatoprost Eye drops 0.03% Lumigan 3 5.15 5.15 5.15 0.00000 Glaucoma Preparations - Other Pilocarpine hydrochloride Eye drops 1% Isopto Carpine 15 4.26 4.26 4.26 0.00000 Eye drops 2% Isopto Carpine 15 5.35 5.35 5.35 0.00000 Eye drops 4%

Subsidised for oral use pursuant to the Standard Formulae.

Isopto Carpine 15 7.99 7.99 7.99 0.00000 Pilocarpine nitrate Eye drops 2% single dose <range>Pilocarpine – Eye drops 2% single dose</range>

Patient has to use an unpreserved solution due to an
          allergy to the preservative Patient wears soft contact lenses

any relevant practitioner 2

The treatment remains appropriate and the patient is
        benefiting from treatment

any relevant practitioner 2 Minims Pilocarpine 20 35.90 35.90 35.90 0.00000 Brimonidine tartrate Eye drops 0.2% Arrow-Brimonidine 5 5.16 5.16 5.16 0.00000 Brimonidine tartrate with timolol maleate Eye drops 0.2% with timolol maleate 0.5% Combigan 5 7.13 7.13 7.13 0.00000 Latanoprost with timolol Eye drops 0.005% with timolol 0.5% Arrow - Lattim 2.5 4.95 4.95 4.95 0.00000 Mydriatics and Cycloplegics Atropine sulphate Eye drops 1% Atropt 15 18.27 18.27 18.27 0.00000 Cyclopentolate hydrochloride Eye drops 1% Cyclogyl 15 25.16 25.16 25.16 0.00000 Tropicamide Eye drops 0.5% Mydriacyl 15 20.52 20.52 20.52 0.00000 Eye drops 1% Mydriacyl 15 24.82 24.82 24.82 0.00000 Preparations for Tear Deficiency

For acetylcysteine eye drops refer Standard Formulae

Hypromellose with dextran Eye drops 0.3% with dextran 0.1% Poly-Tears 15 2.30 2.30 2.30 0.00000 Hypromellose Eye drops 0.5% Methopt 15 19.50 19.50 19.50 0.00000 Preservative Free Ocular Lubricants <range>Preservative Free Ocular Lubricants</range>

Confirmed diagnosis by slit lamp or Schirmer test of severe secretory dry eye Patient is using eye drops more than four times daily on a regular basis Patient has had a confirmed allergic reaction to preservative in eye drop

any relevant practitioner Sodium hyaluronate [Hyaluronic acid] Eye drops 1 mg per ml

Hylo-Fresh has a 6 month expiry after opening. The Pharmacy Procedures Manual restriction allowing one bottle per month is not relevant and therefore only the prescribed dosage to the nearest OP may be claimed.

Hylo-Fresh 10 13.58 13.58 13.58 0.00000 Polyethylene glycol 400 and propylene glycol Eye drops 0.4% and propylene glycol 0.3%, 0.8 ml Systane Unit Dose 30 10.78 10.78 10.78 0.00000 28 10.06 10.06 10.06 0.00000 Other Eye Preparations Naphazoline hydrochloride Eye drops 0.1% Albalon 15 5.65 5.65 5.65 0.00000 Paraffin liquid with wool fat Eye oint 3% with wool fat 3% Poly-Visc 3.5 3.63 3.63 3.63 0.00000 Olopatadine Eye drops 0.1% Olopatadine Teva 5 3.39 3.39 3.39 0.00000 Retinol palmitate Eye oint 138 mcg per g VitA-POS 5 3.80 3.80 3.80 0.00000 Various Various Various Pharmacy Services Brand switch fee

May only be claimed once per patient.

BSF Lyrica 1 4.50 4.50 4.50 0.00000 Agents Used in the Treatment of Poisonings Antidotes Naloxone hydrochloride Inj 400 mcg per ml, 1 ml ampoule DBL Naloxone Hydrochloride 5 1 13.29 13.29 13.29 0.00000 Acetylcysteine Inj 200 mg per ml, 10 ml ampoule DBL Acetylcysteine 10 1 42.99 42.99 42.99 0.00000 Inj 200 mg per ml, 10 ml vial Hikma Acetylcysteine 10 1 42.99 42.99 42.99 0.00000 Removal and Elimination Desferrioxamine mesilate Inj 500 mg vial DBL Desferrioxamine Mesylate for Inj BP 10 1 332.88 332.88 332.88 0.00000 Sodium calcium edetate Inj 200 mg per ml, 5 ml Calcium Disodium Versenate 6 1 53.31 156.71 53.31 17.23333 Charcoal Oral liq 50 g per 250 ml Carbosorb-X 250 59.85 59.85 59.85 0.00000 Deferiprone <range>Deferiprone</range>

The patient has been diagnosed with chronic iron overload due to congenital inherited anaemia The patient has been diagnosed with chronic iron overload due to acquired red cell aplasia

haematologist Tab 500 mg Ferriprox 100 533.17 533.17 533.17 0.00000 Oral liq 100 mg per 1 ml Ferriprox 250 266.59 266.59 266.59 0.00000 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 Tab 125 mg dispersible Exjade 28 276.00 276.00 276.00 0.00000 Tab 250 mg dispersible Exjade 28 552.00 552.00 552.00 0.00000 Tab 500 mg dispersible Exjade 28 1105.00 1105.00 1105.00 0.00000

INFLUENZA VACCINE

Measles, mumps and rubella vaccine