ICON FORMULARY LIST 2012
icon formulary list 2012 quarter 1 - Spectramed Medical Scheme
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QUARTER 1<br />
<strong>ICON</strong> <strong>FORMULARY</strong> <strong>LIST</strong> <strong>2012</strong><br />
TREATMENT GENERIC NAME NAPPI CODE NAPPI DESCRIPTION MANUFACTURER TYPE<br />
5-AZACITIDINE 712413001 VIDAZA 100MG KEY ONCOLOGICS ENHANCED<br />
5-AZACITIDINE<br />
ALDESLEUKIN 868620009 CHIRON IL-2 18MIU VIA KEY ONCOLOGICS ENHANCED<br />
ALDESLEUKIN<br />
ALEMTUZUMAB 709167001 MABCAMPATH 30MG/ML INJ GENZYME BIOPHARMACEUTICALS ENHANCED<br />
ALEMTUZUMAB<br />
ANAGRELIDE 710080001 THROMBOREDUCTIN 0.5MG CAP KEY ONCOLOGICS ENHANCED<br />
ANAGRELIDE 875112005 AGRYLIN 0.5MG CAP TEMA MEDICAL ENHANCED<br />
ANAGRELIDE<br />
ANASTROZOLE 715703001 ACCORD ANASTROZOLE 1MG TAB MYLAN STANDARD<br />
ANASTROZOLE 715720001 STRADEXA 1MG TAB EUROLAB STANDARD<br />
ANASTROZOLE 716226001 ANASTROZOLE SANDOZ 1MG TAB SANDOZ STANDARD<br />
ANASTROZOLE<br />
BETAMETHASONE 826928005 BETANOID 0.5MG TAB ASPEN-PHARMACARE STANDARD<br />
BETAMETHASONE 839361009 BETANOID 4MG 1ML INJ ASPEN-PHARMACARE STANDARD<br />
BETAMETHASONE 899124006 BETAMETHASONE MICRO 4MG/ML INJ MICRO HEALTHCARE STANDARD<br />
BETAMETHASONE<br />
BEVACIZUMAB 706042002 AVASTIN 100MG ROCHE PRODUCTS ENHANCED<br />
BEVACIZUMAB 706041002 AVASTIN 400MG ROCHE PRODUCTS ENHANCED<br />
BEVACIZUMAB<br />
BICALUTAMIDE 715721001 CALOXA 50MG TAB EUROLAB STANDARD<br />
BICALUTAMIDE 716181001 BICADEX 50MG TAB CIPLA-MEDPRO PHARMACEUTICALS STANDARD<br />
BICALUTAMIDE 869872001 CASODEX 150MG TAB ASTRAZENECA STANDARD<br />
BICALUTAMIDE<br />
BLEOMYCIN 703658003 BLEOLEM 15U TEVA PHARMACHEMIE STANDARD<br />
BLEOMYCIN 704145001 BLENAMAX 15 IU VIA TEVA PHARMACHEMIE STANDARD<br />
BLEOMYCIN<br />
KEY<br />
Standard<br />
Enhanced Scheme rules apply / May need special motivation<br />
Page 1
QUARTER 1<br />
<strong>ICON</strong> <strong>FORMULARY</strong> <strong>LIST</strong> <strong>2012</strong><br />
TREATMENT GENERIC NAME NAPPI CODE NAPPI DESCRIPTION MANUFACTURER TYPE<br />
BORTEZOMIB 706787001 VELCADE 3.5MG/10ML JANSSEN PHARMACEUTICALS ENHANCED<br />
BORTEZOMIB<br />
BUSERELIN 886819006 SUPREFACT 3 MONTH DEPOT 9.9MG IMP SANOFI AVENTIS STANDARD<br />
BUSERELIN<br />
BUSULPHAN 745413005 MYLERAN 2MG TAB ASPEN-PHARMACARE STANDARD<br />
BUSULPHAN 705472001 BUSULFEX 60MG VIAL TEMA MEDICAL STANDARD<br />
BUSULPHAN<br />
CAPECITABINE 870072005 XELODA 150MG TAB ROCHE PRODUCTS STANDARD<br />
CAPECITABINE 870080008 XELODA 500MG TAB ROCHE PRODUCTS STANDARD<br />
CAPECITABINE<br />
CARBOPLATIN 711367001 ACCORD CARBOPLATIN 150MG 15ML INJ MYLAN STANDARD<br />
CARBOPLATIN 711368001 ACCORD CARBOPLATIN 450MG 45ML INJ MYLAN STANDARD<br />
CARBOPLATIN<br />
CARMUSTINE 802581005 BICNU 100MG INJ BM SQUIB STANDARD<br />
CARMUSTINE<br />
CETUXIMAB 710034001 ERBITUX 2MG/ML 50ML VIAL MERCK ENHANCED<br />
CETUXIMAB 715052001 ERBITUX 5MG/ML 20ML VIAL MERCK ENHANCED<br />
CETUXIMAB<br />
CHLORAMBUCIL 737887001 LEUKERAN 2MG TAB ASPEN-PHARMACARE STANDARD<br />
CHLORAMBUCIL<br />
CISPLATIN 708896001 PLATOSIN 10MG/10ML INJ TEVA PHARMACHEMIE STANDARD<br />
CISPLATIN 840858019 CISPLATIN 10MG 10ML INJ PFIZER LABORATORIES STANDARD<br />
CISPLATIN 709157001 PLATOSIN 50MG/50ML INJ TEVA PHARMACHEMIE STANDARD<br />
CISPLATIN 710401001 CISPLATIN-HEXAL 50MG/100ML SOLUTION FOR INF SANDOZ STANDARD<br />
CISPLATIN<br />
CLADRIBINE 710351001 LITAK 10MG/5ML INJ KEY ONCOLOGICS STANDARD<br />
CLADRIBINE<br />
KEY<br />
Standard<br />
Enhanced Scheme rules apply / May need special motivation<br />
Page 2
QUARTER 1<br />
<strong>ICON</strong> <strong>FORMULARY</strong> <strong>LIST</strong> <strong>2012</strong><br />
TREATMENT GENERIC NAME NAPPI CODE NAPPI DESCRIPTION MANUFACTURER TYPE<br />
CYCLOPHOSPHAMIDE 723274002 ENDOXAN 50MG TAB SANOFI AVENTIS STANDARD<br />
CYCLOPHOSPHAMIDE 723304009 ENDOXAN 1G INJ SANOFI AVENTIS STANDARD<br />
CYCLOPHOSPHAMIDE 723282014 ENDOXAN 500MG INJ SANOFI AVENTIS STANDARD<br />
CYCLOPHOSPHAMIDE<br />
CYPROTERONE 791970019 ANDROCUR 10MG TAB BAYER SCHERING PHARMA STANDARD<br />
CYPROTERONE 704144001 CYPROPLEX 50 MG TAB TEVA PHARMACHEMIE STANDARD<br />
CYPROTERONE 836281004 ANDROCUR 100MG TAB BAYER SCHERING PHARMA STANDARD<br />
CYPROTERONE 792462009 ANDROCUR DEPOT 300MG 3ML INJ BAYER SCHERING PHARMA STANDARD<br />
CYPROTERONE<br />
CYTARABINE 708729001 LARACIT 100MG INJ TEVA PHARMACHEMIE STANDARD<br />
CYTARABINE 811777007 ALEXAN 100MG 5ML VIAL PHARMAFRICA STANDARD<br />
CYTARABINE 708730001 LARACIT 500MG INJ TEVA PHARMACHEMIE STANDARD<br />
CYTARABINE 811785010 ALEXAN 500MG 10ML VIAL PHARMAFRICA STANDARD<br />
CYTARABINE<br />
DACARBAZINE 715939001 DACIN 100MG/10ML INJ KEY ONCOLOGICS STANDARD<br />
DACARBAZINE 721514014 DTIC-DOME 200MG INJ BAYER SCHERING PHARMA STANDARD<br />
DACARBAZINE<br />
DACTINOMYCIN 709262001 COSMEGEN 0.5MGML 1ML INJ KEY ONCOLOGICS STANDARD<br />
DACTINOMYCIN<br />
DASATINIB 711441001 SPRYCEL 20 MG TAB BM SQUIB ENHANCED<br />
DASATINIB 711442001 SPRYCEL 50 MG TAB BM SQUIB ENHANCED<br />
DASATINIB 711443001 SPRYCEL 70 MG TAB BM SQUIB ENHANCED<br />
DASATINIB<br />
DAUNORUBICIN 717738019 DAUNOBLASTIN 20MG INJ PFIZER LABORATORIES STANDARD<br />
DAUNORUBICIN<br />
DEXAMETHASONE 709148001 DEXAMETHASONE 0.5MG TAB PHARMAPLAN STANDARD<br />
DEXAMETHASONE 708412001 DEXAMETHASONE 1MG TAB PHARMAPLAN STANDARD<br />
KEY<br />
Standard<br />
Enhanced Scheme rules apply / May need special motivation<br />
Page 3
QUARTER 1<br />
<strong>ICON</strong> <strong>FORMULARY</strong> <strong>LIST</strong> <strong>2012</strong><br />
TREATMENT GENERIC NAME NAPPI CODE NAPPI DESCRIPTION MANUFACTURER TYPE<br />
DEXAMETHASONE 701589001 MICRO DEXAMETHASONE 4MG/1ML INJ MICRO HEALTHCARE STANDARD<br />
DEXAMETHASONE<br />
DOCETAXEL 710737001 DOCETERE 20MG INF WINTHROP PHARMACEUTICALS STANDARD<br />
DOCETAXEL 715749001 CIPLA-DOCETAXEL 20MG/0.5ML INF CIPLA-MEDPRO PHARMACEUTICALS STANDARD<br />
DOCETAXEL 710740001 DOCETERE 80MG INF WINTHROP PHARMACEUTICALS STANDARD<br />
DOCETAXEL 715807001 CIPLA-DOCETAXEL 80MG/2ML INF CIPLA-MEDPRO PHARMACEUTICALS STANDARD<br />
DOCETAXEL<br />
DOXORUBICIN 713679001 DOXORUBICIN "EBEWE" 10MG 5ML INJ KEY ONCOLOGICS STANDARD<br />
DOXORUBICIN 823619002 DOXORUBICIN PCH 10MG INJ TEVA PHARMACHEMIE STANDARD<br />
DOXORUBICIN 823635008 DOXORUBICIN RTU 10MG 5ML INJ TEVA PHARMACHEMIE STANDARD<br />
DOXORUBICIN 713680001 DOXORUBICIN "EBEWE" 50MG 25ML INJ KEY ONCOLOGICS STANDARD<br />
DOXORUBICIN 823627005 DOXORUBICIN PCH 50MG INJ TEVA PHARMACHEMIE STANDARD<br />
DOXORUBICIN 823643019 DOXORUBICIN RTU 50MG 25ML INJ TEVA PHARMACHEMIE STANDARD<br />
DOXORUBICIN 837008019 DOXORUBICIN RTU 200MG/100ML INJ TEVA PHARMACHEMIE STANDARD<br />
DOXORUBICIN<br />
EPIRUBICIN 715147001 EPIRUBICIN-LEMERY 10MG TEVA PHARMACHEMIE STANDARD<br />
EPIRUBICIN 715148001 EPIRUBICIN-LEMERY 50MG TEVA PHARMACHEMIE STANDARD<br />
EPIRUBICIN 716228001 ACCORD EPIRUBICIN 10 2MG/ML INJ ACCORD HEALTHCARE STANDARD<br />
EPIRUBICIN 716240001 EPICORD 10 2MG/ML INJ ACCORD HEALTHCARE STANDARD<br />
EPIRUBICIN 710406001 EPIRUBICIN-HEXAL 10MG/5ML INJ SANDOZ STANDARD<br />
EPIRUBICIN 714218001 ASPEN EPIRUBICIN 10MG/10ML INJ ASPEN-PHARMACARE STANDARD<br />
EPIRUBICIN 714241001 ASPEN EPIRUBICIN 10MG/5ML INJ ASPEN-PHARMACARE STANDARD<br />
EPIRUBICIN 710408001 EPIRUBICIN-HEXAL 50MG/25ML INJ SANDOZ STANDARD<br />
EPIRUBICIN 714219001 ASPEN EPIRUBICIN 50MG/30ML INJ ASPEN-PHARMACARE STANDARD<br />
EPIRUBICIN 714220001 ASPEN EPIRUBICIN 50MG/25ML INJ ASPEN-PHARMACARE STANDARD<br />
EPIRUBICIN<br />
ERLOTINIB 712628001 TARCEVA 25MG TAB ROCHE PRODUCTS ENHANCED<br />
KEY<br />
Standard<br />
Enhanced Scheme rules apply / May need special motivation<br />
Page 4
QUARTER 1<br />
<strong>ICON</strong> <strong>FORMULARY</strong> <strong>LIST</strong> <strong>2012</strong><br />
TREATMENT GENERIC NAME NAPPI CODE NAPPI DESCRIPTION MANUFACTURER TYPE<br />
ERLOTINIB 712633001 TARCEVA 100MG TAB ROCHE PRODUCTS ENHANCED<br />
ERLOTINIB 712634001 TARCEVA 150MG TAB ROCHE PRODUCTS ENHANCED<br />
ERLOTINIB<br />
ETOPOSIDE 805157018 VEPESID 50MG CAP BM SQUIB STANDARD<br />
ETOPOSIDE 775525006 VEPESID 100MG CAP BM SQUIB STANDARD<br />
ETOPOSIDE 850926010 EPOSIN 100 MG INJ TEVA PHARMACHEMIE STANDARD<br />
ETOPOSIDE<br />
EXEMESTANE 700482003 AROMASIN 25MG TAB PFIZER LABORATORIES STANDARD<br />
EXEMESTANE<br />
FILGRASTIM 894081001 NEUPOGEN PREF SYR 30MU 0.5ML INJ ROCHE PRODUCTS STANDARD<br />
FILGRASTIM 894087002 NEUPOGEN PREF SYR 48MU 0.5ML INJ ROCHE PRODUCTS STANDARD<br />
FILGRASTIM<br />
FLUDARABINE 710159001 FLUDARA ORAL 10MG TAB GENZYME BIOPHARMACEUTICALS STANDARD<br />
FLUDARABINE 820997005 FLUDARA 50MG INJ GENZYME BIOPHARMACEUTICALS STANDARD<br />
FLUDARABINE<br />
FLUOROURACIL 711136001 DISC FLURACEDYL 500MG I TEVA PHARMACHEMIE STANDARD<br />
FLUOROURACIL 711679001 DISC FLURACEDYL 250MG IN TEVA PHARMACHEMIE STANDARD<br />
FLUOROURACIL 703564001 FLUOROURACIL-FAULDING 50MG/1ML INJ PHARMAPLAN STANDARD<br />
FLUOROURACIL 711364001 FLORACOR 250MG INJ MYLAN STANDARD<br />
FLUOROURACIL 711366001 FLORACOR 500MG INJ MYLAN STANDARD<br />
FLUOROURACIL 706683001 FLURACEDYL 1000MG INJ TEVA PHARMACHEMIE STANDARD<br />
FLUOROURACIL 706684001 FLURACEDYL 5000MG INJ TEVA PHARMACHEMIE STANDARD<br />
FLUOROURACIL<br />
FLUTAMIDE 701389001 FLUTAPLEX 250MG TAB TEVA PHARMACHEMIE STANDARD<br />
FLUTAMIDE<br />
FOLINIC ACID 788503006 RESCUVOLIN 15MG TAB TEVA PHARMACHEMIE STANDARD<br />
FOLINIC ACID 827541008 RESCUVOLIN 15MG INJ TEVA PHARMACHEMIE STANDARD<br />
KEY<br />
Standard<br />
Enhanced Scheme rules apply / May need special motivation<br />
Page 5
QUARTER 1<br />
<strong>ICON</strong> <strong>FORMULARY</strong> <strong>LIST</strong> <strong>2012</strong><br />
TREATMENT GENERIC NAME NAPPI CODE NAPPI DESCRIPTION MANUFACTURER TYPE<br />
FOLINIC ACID 846627019 ISOVORIN RTU 25MG INJ WYETH S A (PTY) LTD STANDARD<br />
FOLINIC ACID 788511009 RESCUVOLIN 50MG/VIAL INJ TEVA PHARMACHEMIE STANDARD<br />
FOLINIC ACID 846635003 ISOVORIN RTU 175MG INJ WYETH S A (PTY) LTD STANDARD<br />
FOLINIC ACID<br />
FULVESTRANT 707442001 FASLODEX 250MG INJ PREFILL ASTRAZENECA ENHANCED<br />
FULVESTRANT<br />
GEMCITABINE 715323001 CYTIGEM 1G/50ML EUROLAB STANDARD<br />
GEMCITABINE 715322001 CYTIGEM 200MG/10ML EUROLAB STANDARD<br />
GEMCITABINE 713874001 ACCORD GEMCITABINE 200MG/10ML MYLAN STANDARD<br />
GEMCITABINE 715251001 GEMTAZ 200MG/5ML INJ PHARMAPLAN STANDARD<br />
GEMCITABINE 815799004 GEMZAR 200MG INJ ELI-LILLY SA (PTY) LTD STANDARD<br />
GEMCITABINE 713873001 ACCORD GEMCITABINE 1G/50ML MYLAN STANDARD<br />
GEMCITABINE 715252001 GEMTAZ 1G/25ML INJ PHARMAPLAN STANDARD<br />
GEMCITABINE 815802005 GEMZAR 1G INJ ELI-LILLY SA (PTY) LTD STANDARD<br />
GEMCITABINE<br />
GOSERELIN 781215005 ZOLADEX DEPOT 3.6MG INJ ASTRAZENECA STANDARD<br />
GOSERELIN 834270005 ZOLADEX DEPOT 10.8MG INJ ASTRAZENECA STANDARD<br />
GOSERELIN<br />
HYDROCORTISONE SODIUM SUCCINAT 765074001 SOLU-CORTEF 100MG 2ML INJ PFIZER LABORATORIES STANDARD<br />
HYDROCORTISONE SODIUM SUCCINAT 765120003 SOLU-CORTEF 500MG 4ML INJ PFIZER LABORATORIES STANDARD<br />
HYDROCORTISONE SODIUM SUCCINAT<br />
HYDROCORTISONE-TABS 716693003 COVOCORT 10MG PER 100 BOX ADCOCK GENERICS STANDARD<br />
HYDROCORTISONE-TABS<br />
HYDROXYUREA 731706005 HYDREA 500MG CAP BM SQUIB STANDARD<br />
HYDROXYUREA<br />
IBRITUMOMAB 705892001 ZEVALIN INJECTION BAYER SCHERING PHARMA ENHANCED<br />
IBRITUMOMAB<br />
KEY<br />
Standard<br />
Enhanced Scheme rules apply / May need special motivation<br />
Page 6
QUARTER 1<br />
<strong>ICON</strong> <strong>FORMULARY</strong> <strong>LIST</strong> <strong>2012</strong><br />
TREATMENT GENERIC NAME NAPPI CODE NAPPI DESCRIPTION MANUFACTURER TYPE<br />
IDARUBICIN 842451005 ZAVEDOS 5MG CAP PFIZER LABORATORIES STANDARD<br />
IDARUBICIN 788651005 ZAVEDOS 5MG INJ PFIZER LABORATORIES STANDARD<br />
IDARUBICIN 788678019 ZAVEDOS 10MG INJ PFIZER LABORATORIES STANDARD<br />
IDARUBICIN<br />
IFOSFAMIDE 731285018 HOLOXAN 500MG INJ SANOFI AVENTIS STANDARD<br />
IFOSFAMIDE 731293002 HOLOXAN 1000MG INJ SANOFI AVENTIS STANDARD<br />
IFOSFAMIDE 731307003 HOLOXAN 2000MG INJ SANOFI AVENTIS STANDARD<br />
IFOSFAMIDE<br />
IMATINIB 705491001 GLEEVEC 100MG TAB NOVARTIS ENHANCED<br />
IMATINIB 705490001 GLEEVEC 400MG TAB NOVARTIS ENHANCED<br />
IMATINIB<br />
INTERFERON ALFA-2A 84012<strong>2012</strong> ROFERON-A PREFILL 3MIU 0.5ML INJ ROCHE PRODUCTS STANDARD<br />
INTERFERON ALFA-2A 840130015 ROFERON-A PREFILL 4.5MIU 0.5ML INJ ROCHE PRODUCTS STANDARD<br />
INTERFERON ALFA-2A 840149018 ROFERON-A PREFILL 6MIU 0.5ML INJ ROCHE PRODUCTS STANDARD<br />
INTERFERON ALFA-2A 840157010 ROFERON-A PREFILL 9MIU 0.5ML INJ ROCHE PRODUCTS STANDARD<br />
INTERFERON ALFA-2A 787485004 INTRON A 10MIU INJ MSD STANDARD<br />
INTERFERON ALFA-2A 893110019 ROFERON-A CARTRIDGE 18MIU 0.6ML INJ ROCHE PRODUCTS STANDARD<br />
INTERFERON ALFA-2A 869325019 INTRON A REDIPEN 18MIU 1.2ML INJ MSD STANDARD<br />
INTERFERON ALFA-2A 869341006 INTRON A REDIPEN 60MIU 1.2ML INJ MSD STANDARD<br />
INTERFERON ALFA-2A 707923001 PEG INTRON REDIPEN 80MCG INJ MSD STANDARD<br />
INTERFERON ALFA-2A 704052001 PEG INTRON 100MCG 2ML INJ MSD STANDARD<br />
INTERFERON ALFA-2A 704053001 PEG INTRON 150MCG 2ML INJ MSD STANDARD<br />
INTERFERON ALFA-2A<br />
IRINOTECAN HCL-INJ 712643001 IRINOTAS 40MG/2ML INJ EUROLAB STANDARD<br />
IRINOTECAN HCL-INJ 716182001 CIPLA-IRINOTECAN 40MG/2ML INF CIPLA-MEDPRO PHARMACEUTICALS STANDARD<br />
IRINOTECAN HCL-INJ 712873001 IRINOTAS 100MG/5ML INJ EUROLAB STANDARD<br />
IRINOTECAN HCL-INJ 716183001 CIPLA-IRINOTECAN 100MG/5ML INF CIPLA-MEDPRO PHARMACEUTICALS STANDARD<br />
KEY<br />
Standard<br />
Enhanced Scheme rules apply / May need special motivation<br />
Page 7
QUARTER 1<br />
<strong>ICON</strong> <strong>FORMULARY</strong> <strong>LIST</strong> <strong>2012</strong><br />
TREATMENT GENERIC NAME NAPPI CODE NAPPI DESCRIPTION MANUFACTURER TYPE<br />
IRINOTECAN HCL-INJ<br />
KETOCONAZOLE-TAB 704910001 SANDOZ KETOCONAZOLE 200 MG TAB SANDOZ STANDARD<br />
KETOCONAZOLE-TAB 875368018 KETAZOL 200MG TAB ASPEN-PHARMACARE STANDARD<br />
KETOCONAZOLE-TAB<br />
LETROZOLE 715704001 ACCORD LETROZOLE 2.5MG TAB MYLAN STANDARD<br />
LETROZOLE 715718001 LARADEX 2.5MG TAB EUROLAB STANDARD<br />
LETROZOLE<br />
LEUCOVORIN 781525004 LEUCOVORIN 10MG/1ML 5ML INJ TEVA PHARMACHEMIE STANDARD<br />
LEUCOVORIN 704608001 ABIC LEUCOVORIN 100 MG/10ML INJ TEVA PHARMACHEMIE STANDARD<br />
LEUCOVORIN 704609001 ABIC LEUCOVORIN 200 MG/20ML INJ TEVA PHARMACHEMIE STANDARD<br />
LEUCOVORIN 704610001 ABIC LEUCOVORIN 300 MG/30ML INJ TEVA PHARMACHEMIE STANDARD<br />
LEUCOVORIN<br />
LEUPROLIDE ACETATE 806382007 LUCRIN - 3,75MG INJ ABBOTT LABORATORIES SA STANDARD<br />
LEUPROLIDE ACETATE 785504001 LUCRIN PATIENT PACK 5MG/ML 2.8ML INJ ABBOTT LABORATORIES SA STANDARD<br />
LEUPROLIDE ACETATE 875295002 LUCRIN VIAL 11.25MG INJ ABBOTT LABORATORIES SA STANDARD<br />
LEUPROLIDE ACETATE<br />
MANNITOL 802018009 OSMITROL 20% AFD5633 INF ADCOCK INGRAM CRITICAL CARE STANDARD<br />
MANNITOL 862762006 OSMITROL 5% AFB7367 INF ADCOCK INGRAM CRITICAL CARE STANDARD<br />
MANNITOL 815179014 MANNITOL 20% 500ML INJ FRESENIUS KABI STANDARD<br />
MANNITOL 833010018 MANNITOL 25% 50ML INJ FRESENIUS KABI STANDARD<br />
MANNITOL<br />
MEDROXYPROGESTERONE ACET 500MG 725579005 FARLUTAL 500MG TAB PFIZER LABORATORIES STANDARD<br />
MEDROXYPROGESTERONE ACET 500MG<br />
MELPHALAN 701998008 ALKERAN 2MG TAB ASPEN-PHARMACARE STANDARD<br />
MELPHALAN 797774009 ALKERAN 50 50MG INJ ASPEN-PHARMACARE STANDARD<br />
MELPHALAN<br />
MERCAPTOPURINE 758302002 PURINETHOL 50MG TAB ASPEN-PHARMACARE STANDARD<br />
KEY<br />
Standard<br />
Enhanced Scheme rules apply / May need special motivation<br />
Page 8
QUARTER 1<br />
<strong>ICON</strong> <strong>FORMULARY</strong> <strong>LIST</strong> <strong>2012</strong><br />
TREATMENT GENERIC NAME NAPPI CODE NAPPI DESCRIPTION MANUFACTURER TYPE<br />
MERCAPTOPURINE<br />
MESNA 784052018 UROMITEXAN 100MG/ML 4ML SANOFI AVENTIS STANDARD<br />
MESNA<br />
METHOTREXATE 712504001 ABITREXATE 2.5MG TAB TEVA PHARMACHEMIE STANDARD<br />
METHOTREXATE 782556019 ABITREXATE VIAL 20ML 25MG/ML INJ TEVA PHARMACHEMIE STANDARD<br />
METHOTREXATE 711328001 METHACOR 50MG 2ML INJ MYLAN STANDARD<br />
METHOTREXATE 825565007 EMTHEXATE RTU 50MG INJ TEVA PHARMACHEMIE STANDARD<br />
METHOTREXATE 825557004 EMTHEXATE RTU 500MG INJ TEVA PHARMACHEMIE STANDARD<br />
METHOTREXATE 782564003 ABITREXATE 1G 10ML INJ TEVA PHARMACHEMIE STANDARD<br />
METHOTREXATE 837830002 EMTHEXATE RTU 1000MG INJ TEVA PHARMACHEMIE STANDARD<br />
METHOTREXATE 701110001 ABITREXATE 100MG/1ML 50ML INJ TEVA PHARMACHEMIE STANDARD<br />
METHOTREXATE 828157006 EMTHEXATE RTU 5000MG INJ TEVA PHARMACHEMIE STANDARD<br />
METHOTREXATE<br />
METHYLPREDNISOLONE 741116006 MEDROL 4MG TAB PFIZER LABORATORIES STANDARD<br />
METHYLPREDNISOLONE 741124009 MEDROL 16MG TAB PFIZER LABORATORIES STANDARD<br />
METHYLPREDNISOLONE 765082004 SOLU-MEDROL 40MG 1ML INJ PFIZER LABORATORIES STANDARD<br />
METHYLPREDNISOLONE 718416007 DEPO-MEDROL 80MG/ML 1ML INJ PFIZER LABORATORIES STANDARD<br />
METHYLPREDNISOLONE 718475003 DEPO-MEDROL 40MG/ML 2ML INJ PFIZER LABORATORIES STANDARD<br />
METHYLPREDNISOLONE 765104008 SOLU-MEDROL 125MG 2ML INJ PFIZER LABORATORIES STANDARD<br />
METHYLPREDNISOLONE 718483006 DEPO-MEDROL 40MG/ML 5ML VIA PFIZER LABORATORIES STANDARD<br />
METHYLPREDNISOLONE 765066009 SOLU-MEDROL 500MG 8ML INJ PFIZER LABORATORIES STANDARD<br />
METHYLPREDNISOLONE 765155001 SOLU-MEDROL 1G 16ML INJ PFIZER LABORATORIES STANDARD<br />
METHYLPREDNISOLONE<br />
MITOMYCIN 744212006 MITOMYCIN-C 2MG VIA ASPEN-PHARMACARE STANDARD<br />
MITOMYCIN 744220009 MITOMYCIN-C 10MG VIA ASPEN-PHARMACARE STANDARD<br />
MITOMYCIN<br />
MITOXANTRONE 708724001 MITOXANTRONE-HEXAL 20MG/10ML QUESTMED (PTY) LTD STANDARD<br />
KEY<br />
Standard<br />
Enhanced Scheme rules apply / May need special motivation<br />
Page 9
QUARTER 1<br />
<strong>ICON</strong> <strong>FORMULARY</strong> <strong>LIST</strong> <strong>2012</strong><br />
TREATMENT GENERIC NAME NAPPI CODE NAPPI DESCRIPTION MANUFACTURER TYPE<br />
MITOXANTRONE<br />
NILOTINIB 200MG 714086001 TASIGNA 200MG TAB NOVARTIS ENHANCED<br />
NILOTINIB 200MG<br />
OCTREOTIDE 762350008 SANDOSTATIN 0.1MG/ML 1ML INJ NOVARTIS STANDARD<br />
OCTREOTIDE 762342005 SANDOSTATIN 0.05MG/ML 1ML INJ NOVARTIS STANDARD<br />
OCTREOTIDE 781452007 SANDOSTATIN 0.2MG/ML 5ML INJ NOVARTIS STANDARD<br />
OCTREOTIDE 704532001 SANDOSTATIN LAR PREFILL 10MG INJ NOVARTIS STANDARD<br />
OCTREOTIDE 704534001 SANDOSTATIN LAR PREFILL 20MG INJ NOVARTIS STANDARD<br />
OCTREOTIDE 708002001 SANDOSTATIN LAR PREFILL 30MG/5ML INJ NOVARTIS STANDARD<br />
OCTREOTIDE<br />
OXALIPLATIN 710319001 OXALIWIN 50MG/10ML RTU WINTHROP PHARMACEUTICALS STANDARD<br />
OXALIPLATIN 716224001 EXIPLAT 50MG/30ML INJ PHARMAPLAN STANDARD<br />
OXALIPLATIN 710317001 OXALIWIN 100MG/20ML RTU WINTHROP PHARMACEUTICALS STANDARD<br />
OXALIPLATIN 716225001 EXIPLAT 100MG/30ML INJ PHARMAPLAN STANDARD<br />
OXALIPLATIN<br />
PACLITAXEL 711892001 SANDOZ PACLITAXEL 30MG/5ML SANDOZ STANDARD<br />
PACLITAXEL 711900001 SANDOZ PACLITAXEL 100MG/20ML SANDOZ STANDARD<br />
PACLITAXEL 716179001 CIPLA-PACLITAXEL 100MG/16.7ML CIPLA-MEDPRO PHARMACEUTICALS STANDARD<br />
PACLITAXEL 711901001 SANDOZ PACLITAXEL 300MG/50ML SANDOZ STANDARD<br />
PACLITAXEL 704208001 ANZATAX 30MG/5ML INJ PHARMAPLAN STANDARD<br />
PACLITAXEL 714756001 PCH PACLITAXEL 30MG/5ML INJ TEVA PHARMACHEMIE STANDARD<br />
PACLITAXEL 716178001 CIPLA-PACLITAXEL 30MG/5ML INJ CIPLA-MEDPRO PHARMACEUTICALS STANDARD<br />
PACLITAXEL 712753001 ANZATAX 100MG/16.7ML INJ PHARMAPLAN STANDARD<br />
PACLITAXEL 714757001 PCH PACLITAXEL 100MG/16.7ML INJ TEVA PHARMACHEMIE STANDARD<br />
PACLITAXEL 704209001 ANZATAX 150MG/25ML INJ PHARMAPLAN STANDARD<br />
PACLITAXEL 712754001 ANZATAX 300MG/50ML INJ PHARMAPLAN STANDARD<br />
PACLITAXEL 714758001 PCH PACLITAXEL 300MG/50ML INJ TEVA PHARMACHEMIE STANDARD<br />
KEY<br />
Standard<br />
Enhanced Scheme rules apply / May need special motivation<br />
Page 10
QUARTER 1<br />
<strong>ICON</strong> <strong>FORMULARY</strong> <strong>LIST</strong> <strong>2012</strong><br />
TREATMENT GENERIC NAME NAPPI CODE NAPPI DESCRIPTION MANUFACTURER TYPE<br />
PACLITAXEL 716180001 CIPLA-PACLITAXEL 300MG/50ML INJ CIPLA-MEDPRO PHARMACEUTICALS STANDARD<br />
PACLITAXEL<br />
PEGYLATED DOXORUBICIN 867411007 CAELYX 20MG 10ML VIA MSD ENHANCED<br />
PEGYLATED DOXORUBICIN 899468001 CAELYX 2MG/ML 25ML INJ JANSSEN PHARMACEUTICALS ENHANCED<br />
PEGYLATED DOXORUBICIN<br />
PEMETREXED 705833001 ALIMTA 500MG ELI-LILLY SA (PTY) LTD STANDARD<br />
PEMETREXED<br />
PREDNISONE 703603003 PULMISON ORAL 5MG/ML 50ML SOL INGELHEIM PHARMACEUTICALS STANDARD<br />
PREDNISONE 752304119 PANAFCORT 5MG TAB ADCOCK GENERICS STANDARD<br />
PREDNISONE 788783009 PREDNISONE BE-TABS 5MG TAB RANBAXY - BE-TABS STANDARD<br />
PREDNISONE 818267038 TROLIC 5MG TAB GULF DRUG COMPANY STANDARD<br />
PREDNISONE 836826019 PULMISON 20MG TAB INGELHEIM PHARMACEUTICALS STANDARD<br />
PREDNISONE 742759008 METICORTEN 50MG TAB MSD STANDARD<br />
PREDNISONE<br />
PROCARBAZINE 746037007 PROCARBAZINE YUGOSUN MEDICAL STANDARD<br />
PROCARBAZINE<br />
RETINOIC ACID 820008001 VESANOID 10MG CAP ROCHE PRODUCTS STANDARD<br />
RETINOIC ACID<br />
RITUXIMAB 853224005 MABTHERA 10MG/ML 10ML INF ROCHE PRODUCTS ENHANCED<br />
RITUXIMAB 853232008 MABTHERA 10MG/ML 50ML INF ROCHE PRODUCTS ENHANCED<br />
RITUXIMAB<br />
SORAFENIB 708482002 NEXAVAR 200 MG TAB BAYER SCHERING PHARMA ENHANCED<br />
SORAFENIB<br />
SUNITINIB MALATE 710179001 SUTENT 12.5MG TAB PFIZER LABORATORIES ENHANCED<br />
SUNITINIB MALATE 710181001 SUTENT 25MG TAB PFIZER LABORATORIES ENHANCED<br />
SUNITINIB MALATE 710182001 SUTENT 50MG TAB PFIZER LABORATORIES ENHANCED<br />
SUNITINIB MALATE<br />
KEY<br />
Standard<br />
Enhanced Scheme rules apply / May need special motivation<br />
Page 11
QUARTER 1<br />
<strong>ICON</strong> <strong>FORMULARY</strong> <strong>LIST</strong> <strong>2012</strong><br />
TREATMENT GENERIC NAME NAPPI CODE NAPPI DESCRIPTION MANUFACTURER TYPE<br />
TAMOXIFEN 735167028 KESSAR 10MG TAB PFIZER LABORATORIES STANDARD<br />
TAMOXIFEN 710403001 TAMOXIHEXAL 20MG SANDOZ STANDARD<br />
TAMOXIFEN 712610001 TAMOPLEX 20MG TAB TEVA PHARMACHEMIE STANDARD<br />
TAMOXIFEN<br />
TEMOZOLOMIDE 859931005 TEMODAL 5MG CAP MSD ENHANCED<br />
TEMOZOLOMIDE 859958019 TEMODAL 20MG CAP MSD ENHANCED<br />
TEMOZOLOMIDE 859494004 TEMODAL 100MG CAP MSD ENHANCED<br />
TEMOZOLOMIDE 859966003 TEMODAL 250MG CAP MSD ENHANCED<br />
TEMOZOLOMIDE<br />
TEMSIROLIMUS 714286001 TORISEL INJ 25MG/ML WYETH S A (PTY) LTD ENHANCED<br />
TEMSIROLIMUS<br />
THALIDOMIDE 709228001 THALIDOMIDE PHARMION 50MG CAPS KEY ONCOLOGICS STANDARD<br />
THALIDOMIDE 707983001 MYRIN (THALIDOMIDE) 50MG TAB PHARMAPLAN STANDARD<br />
THALIDOMIDE 707984001 MYRIN (THALIDOMIDE) 100MG TAB PHARMAPLAN STANDARD<br />
THALIDOMIDE<br />
TOPOTECAN 847909018 HYCAMTIN 4MG INF ASPEN-PHARMACARE ENHANCED<br />
TOPOTECAN<br />
TRASTUZUMAB 884055001 HERCEPTIN MULTIDOSE 440MG VIA ROCHE PRODUCTS STANDARD<br />
TRASTUZUMAB<br />
VINBLASTINE 827851007 VINBLASTINE RTU 10MG/5ML INJ TEVA PHARMACHEMIE STANDARD<br />
VINBLASTINE<br />
VINCRISTINE 840793006 P&U VINCRISTINE CSV 1MG/ML 1ML INJ PFIZER LABORATORIES STANDARD<br />
VINCRISTINE 713432001 ACCORD VINCRISTINE 2MG 2ML INJ MYLAN STANDARD<br />
VINCRISTINE 840785003 P&U VINCRISTINE CSV 1MG/ML 2ML INJ PFIZER LABORATORIES STANDARD<br />
VINCRISTINE 840769008 P&U VINCRISTINE CSV 1MG/ML 5ML INJ PFIZER LABORATORIES STANDARD<br />
VINCRISTINE<br />
VINORELBINE 700191001 NAVELBINE ORAL 20MG CAP TEMA MEDICAL STANDARD<br />
KEY<br />
Standard<br />
Enhanced Scheme rules apply / May need special motivation<br />
Page 12
QUARTER 1<br />
<strong>ICON</strong> <strong>FORMULARY</strong> <strong>LIST</strong> <strong>2012</strong><br />
TREATMENT GENERIC NAME NAPPI CODE NAPPI DESCRIPTION MANUFACTURER TYPE<br />
VINORELBINE 700192001 NAVELBINE ORAL 30MG CAP TEMA MEDICAL STANDARD<br />
VINORELBINE 715526001 TEVA VINORELBINE 10MG TEVA PHARMACHEMIE STANDARD<br />
VINORELBINE 715527001 TEVA VINORELBINE 50MG TEVA PHARMACHEMIE STANDARD<br />
VINORELBINE 712613001 VINOREL 10MG INJ PHARMAPLAN STANDARD<br />
VINORELBINE 715822001 ASPEN VINORELBINE 10MG/1ML INJ ASPEN-PHARMACARE STANDARD<br />
VINORELBINE 716184001 CIPLA-VINORELBINE 10MG/1ML INJ CIPLA-MEDPRO PHARMACEUTICALS STANDARD<br />
VINORELBINE 712611001 VINOREL 50MG INJ PHARMAPLAN STANDARD<br />
VINORELBINE 713083001 CARCYT 50MG IV TEMA MEDICAL STANDARD<br />
VINORELBINE 715821001 ASPEN VINORELBINE 50MG/5ML INJ ASPEN-PHARMACARE STANDARD<br />
VINORELBINE 716185001 CIPLA-VINORELBINE 50MG/5ML INJ CIPLA-MEDPRO PHARMACEUTICALS STANDARD<br />
VINORELBINE<br />
ZOLEDRONIC ACID 715952001 ZOBONE 4MG/5ML ZOLEDRONIC ACID PHARMAPLAN STANDARD<br />
ZOLEDRONIC ACID<br />
KEY<br />
Standard<br />
Enhanced Scheme rules apply / May need special motivation<br />
Page 13
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