CHRONIC MEDICINE PROGRAMME GENERAL INFORMATION LETTER

Transcription

1 RAND WATER MEDICAL SCHEME RAND WATER MEDICAL SCHEME CHRONIC MEDICINE PROGRAMME GENERAL INFORMATION LETTER LIST OF CHRONIC CONDITIONS Conditions covered under s chronic medication benefit are detailed below. REGISTRATION OF CHRONIC CONDITIONS Patients can only access chronic medication if their prescribing/treating doctor or pharmacist has REGISTERED their chronic condition(s) with, via chronic@medikredit.co.za on , or by completing the chronic medicine benefit application form. This applies to all eligible chronic conditions. Once the chronic condition has been registered, the patient will have access to the CONDITION MEDICINE LIST (CML). This is a list of appropriate drugs that do not require pre-authorisation they are automatically authorised. The chronic approval will remain in place until its expiry date. Once the chronic condition is registered, action is only ever required from the doctor/pharmacist if: the current approval expires; or the doctor diagnoses a new chronic condition that requires new medicine; or the chronic medicine that is prescribed is not included in the CML for the registered condition Newly diagnosed chronic conditions: If, during the course of the year, the patient is diagnosed with a new chronic condition listed on the table below, registration of the chronic condition is required before access to chronic medication benefits will be granted

2 Who can register the chronic condition? Detailed clinical information, including the condition s ICD 10 code (diagnosis code) and severity status are required in order to register a chronic condition. The treating doctor or pharmacist is required to register the patient s chronic condition by calling SwiftOnline on Alternatively, the patient and doctor can complete the chronic medicine benefit form and it to chronic@medikredit.co.za for processing. CONDITION MEDICINE LIST (CML) Once a patient s condition has been registered, the patient will have access to the CONDITION MEDICINE LIST (CML). This is a list of drugs covered by the scheme that are appropriate for the condition being treated. Some of the PMB CDL conditions have two CMLs, in order to accommodate drugs for different severities of the particular condition. Access to drugs in the severity 2 list can only be obtained once specific clinical criteria are met and, to this end, additional information or reports may be required from the prescribing doctor. Maximum Medical Aid Price (MMAP ) Maximum Medical Aid Price (MMAP ) refers to the maximum price that Medical Scheme will pay for drugs where generic alternatives are available. If a product is prescribed that is above MMAP, you will need to pay the difference in price at the point of dispensing. The CML is not a fixed list of products. It is constantly revised and updated in accordance with new products registered, discontinued products, price changes as well as changes to product registration details. Please refer to the MediKredit website at to search for a specific product per Plan Option. The search will provide the maximum scheme liability, whether a co-payment applies as well as the availability to search for possible generic alternatives

3 LIST OF ELIGIBLE CHRONIC CONDITIONS Table 1: PRESCRIBED MINIMUM BENEFIT CHRONIC CONDITION LIST (PMB CDL) (Available on the Option A and Option B plus PLANS) 1 Addison s Disease * 14 Epilepsy 2 Asthma 15 Glaucoma 3 Bipolar Mood Disorder * 16 Haemophillia * 4 Bronchiectasis* 17 Hyperlipidaemia 5 Cardiac Failure 18 Hypertension 6 Cardiomyopathy 19 Hypothyroidism 7 Chronic Obstructive Pulmonary Disorder 20 Multiple Sclerosis * 8 Chronic Renal Disease 21 Parkinson s Disease 9 Coronary Artery Disease 22 Rheumatoid Arthritis 10 Crohn s Disease * 23 Schizophrenia * 11 Diabetes Insipidus * 24 Systemic Lupus Erythematosus * 12 Diabetes Mellitus Type 1 & 2 25 Ulcerative Colitis * 13 Dysrhythmias* 26 HIV (Human Immunodeficiency Virus) Table 2: OTHER CHRONIC CONDITIONS (Available on Option A only) 1 Acne ** 14 Interstitial Fibrosis 2 Allergic Rhinitis** 15 Iron Deficiency Anaemia 3 Alzheimer s Disease** 16 Major Depression 4 Ankylosing Spondylitis 17 Meniere s Disease** 5 Benign Prostatic Hypertrophy (BPH) 18 Menopausal Disorder 6 Cushing s Disease** 19 Migraine 7 Cystic Fibrosis** 20 Myasthenia Gravis** 8 Deep Vein Thrombosis 21 Osteoporosis#

4 9 Gastro Oesophageal Reflux Disease (GORD)# 22 Paraplegia/ Quadriplegia# 10 Gout# 23 Peripheral Vascular Disease 11 Hyperkinetic Disorders (ADHD)** 24 Osteoarthritis 12 Hyperparathyroidism 25 Urinary Incontinence 13 Hyperthyroidism 26 Stroke/ Cerebrovascular Accident Benefit will be provided for both plans and above the PMB DTP entitlement. Rules applicable to the Chronic Disease Benefit: Chronic medication requests for certain conditions in table 1 (*) will only be considered if prescribed by an appropriate specialist: Diagnosis to be confirmed by a psychiatrist for Bipolar Mood Disorder. If diagnosed by a GP, DSM-IV criteria and sub-type must be specified (type I or II). A neurologist prescription is required for authorisation of chronic medication for Multiple Sclerosis. An endocrinologist or physician prescription is required for chronic medication authorisation for Diabetes Insipidus A haematologist or physician s prescription is required for medication for Haemophilia. A specialist physician, paediatrician, surgeon or gastroenterologist s prescription is required for chronic medication for Ulcerative Colitis and Crohn s Disease. A specialist physician, paediatrician, or rheumatologist prescription is required for chronic medication for Systemic Lupus Erythematosus. A psychiatrist or paediatric psychiatrist is required for chronic medication for Schizophrenia. A specialist physician, paediatrician or endocrinologist s prescription is required for chronic medication for Addison s disease. NB: Continuation prescriptions from General Practitioners will be considered once a patient has been stabilized by the appropriate specialist

5 The conditions marked in table 2 are subject to the authorisation criteria detailed below. Chronic medication requests for certain conditions (**) will only be considered if prescribed and motivated by an appropriate specialist, e.g.: A dermatologist prescription and motivation is required for chronic medication for acne. A neurologist or psychiatrist prescription and motivation is required for chronic medication for Alzheimer s disease. For Allergic Rhinitis, applications will only be considered if prescribed and motivated by an Ear Nose & Throat (ENT) specialist, paediatrician or physician. For Attention Deficit Hyperkinetic Disorder (ADHD), applications will only be considered if prescribed and motivated by a paediatrician, neurologist or psychiatrist. General practitioners with a certificate of competence will also be considered. Chronic medication for Cystic Fibrosis will only be considered if prescribed by a paediatrician, physician or pulmonologist An endocrinologist or physician prescription is required for chronic medication authorisation for Cushing s disease. An ENT or neurologist prescription and motivation is required for chronic medication for Meniere s disease. A neurologist prescription and motivation is required for chronic medication for Myasthenia Gravis. Special Benefit authorisations: The following conditions (#) require special authorization as specified below: For GORD, standard dose PPIs only for 3 months, thereafter only low dose PPIs or H2- antagonists will be considered for maintenance treatment. Diagnostic gastroscopy reports are required for double dose PPIs, and new / follow-up gastroscopy required for continuation of standard dose PPIs beyond 3 months For Gout, only allopurinol and probenecid-containing products may be considered. Chronic medication for Osteoporosis may only be considered on submission of a Bone Mineral Density (BMD) scan indicative of osteoporosis. Other factors eg: pathological fractures will be taken into consideration in accordance with the South African guidelines Chronic medication for paraplegics and quadriplegics may be considered for urinary and bowel complications. EXCLUSIONS The following medicines are exclusions from the chronic disease benefit: Vitamins and mineral preparations (including calcium, except for patients with Menopause or Osteoporosis) Homeopathic medication Hypnotics Mucolytics Antibiotics (except for patients with bronchiectasis and Crohn s disease ) Muscle relaxants (except for patients with multiple sclerosis)

6 NOTE Although your condition may be defined as chronic by the prescribing doctor, this condition may not fulfill the scheme criteria for chronic medication benefits. Access to any chronic medication as part of the chronic medication benefit is subject to clinical entry criteria & drug utilisation review. In addition, specific drugs may only be authorised and prescribed by the relevant specialist. SPECIAL BENEFIT AUTHORISATIONS Oncology - medication requests must be referred to Oncology disease management team on HIV/AIDS medication requests must be referred to HIV authorisation line on