BANKMED MEDICAL SCHEME. MEDICINE ADVISORY SERVICES (Chronic Medicine Benefit) GENERAL INFORMATION

Transcription

1 BANKMED MEDICAL SCHEME MEDICINE ADVISORY SERVICES (Chrnic Medicine Benefit) GENERAL INFORMATION LIST OF CHRONIC CONDITIONS Cnditins cvered under Bankmed s chrnic medicatin benefit are detailed belw. REGISTRATION OF CHRONIC CONDITIONS Patients can nly access chrnic medicatin if their prescribing/treating dctr r pharmacist has REGISTERED their chrnic cnditin(s) with Bankmed, via Swift Online chrnic cnditin medicine management n 0800 BANKMED ( )/ This applies t all eligible chrnic cnditins. Once the chrnic cnditin has been registered, the patient will have access t the CONDITION MEDICINE LIST (CML). This is a list f apprpriate drugs that d nt require pre-authrisatin they are autmatically authrised. The chrnic apprval will remain in place until its expiry date. Once the chrnic cnditin is registered, actin is nly ever required frm the dctr/pharmacist if: the current apprval expires; r the dctr diagnses a new chrnic cnditin that requires new medicine; r the chrnic medicine that is prescribed is nt included in the CML fr the registered cnditin; r where a c-payment exists, the member may ask the prescribing dctr t call the number listed abve: fr a list f alternatives that require n c-payment t mtivate fr full reimbursement, subject t clinical review 1

2 Newly diagnsed chrnic cnditins: If, during the curse f the year, the patient is diagnsed with a new chrnic cnditin listed n the table belw, registratin f the chrnic cnditin is required befre access t chrnic medicatin benefits will be granted. Wh can register the chrnic cnditin? Detailed clinical infrmatin, including the cnditin s ICD 10 cde (diagnsis cde) and severity status are required in rder t register a chrnic cnditin. The treating dctr r pharmacist is required t register the patient s chrnic cnditin by calling SwiftOnline n N chrnic frms need be cmpleted. ICD 10 CODES A detailed list f all the ICD 10 diagnstic cdes applicable t Bankmed s eligible chrnic cnditin list is available n the MediKredit website: CONDITION MEDICINE LIST (CML) Once a patient s cnditin has been registered, the patient will have access t the CONDITION MEDICINE LIST (CML). This is a list f drugs cvered by the scheme that are apprpriate fr the cnditin being treated. Sme f the PMB CDL cnditins have tw CMLs, in rder t accmmdate drugs fr different severities f the particular cnditin. Access t drugs in the severity 2 list can nly be btained nce specific clinical criteria are met and, t this end, additinal infrmatin r reprts may be required frm the prescribing dctr. Please Nte: Reference Price Bankmed applies tw types f Reference Pricing: MMAP refers t the maximum price that the Scheme will pay fr generic drugs and this price is the same per prduct fr all plan ptins. 2

3 Therapeutic Reference Pricing refers t the maximum price that the Scheme will pay fr a specific therapeutic categry f drugs. This reference price is based n the cst f drugs frm the same, r a similar, drug class listed n the CML. The therapeutic reference price differs frm ne plan ptin t anther. The Scheme applies bth reference pricing systems simultaneusly and will nly reimburse a prduct at the lwer f the tw prices applicable t the particular plan ptin. If a prduct is prescribed that is abve any f the relevant reference prices, yu will be required t pay the difference in price at the pint f dispensing. The CML is nt a fixed list f prducts. It is cnstantly revised and updated in accrdance with new prducts registered, discntinued prducts, price changes as well as changes t prduct registratin details. Please refer t the MediKredit website at t search fr a specific prduct per plan ptin. The search will prvide the maximum scheme liability, whether a c-payment applies as well as the ability t search fr pssible generic r therapeutic alternatives. 3

4 LIST OF PMB CDL CHRONIC CONDITIONS TABLE 1: PRESCRIBED MINIMUM BENEFIT CHRONIC CONDITIONS (Available n the PLUS, COMPREHENSIVE, TRADITIONAL and CORE SAVER PLANS) 1 Addisn s Disease * 14 Epilepsy 2 Asthma 15 Glaucma 3 Biplar Md Disrder * 16 Haemphillia * 4 Brnchiectasis 17 Hyperlipidaemia 5 Cardiac Failure 18 Hypertensin 6 Cardimypathy 19 Hypthyridism 7 Chrnic Obstructive Pulmnary Disrder 20 Multiple Sclersis * 8 Chrnic Renal Disease 21 Parkinsn s Disease 9 Crnary Artery Disease 22 Rheumatid Arthritis 10 Crhn s Disease * 23 Schizphrenia * 11 Diabetes Insipidus * 24 Systemic Lupus Erythematsus * 12 Diabetes Mellitus Type 1 & 2 25 Ulcerative Clitis * 13 Dysrhythmias 26 HIV (Human Immundeficiency Virus) TABLE 2: LIST OF NON-PMB CHRONIC CONDITIONS (Available n the PLUS, COMPREHENSIVE and TRADITIONAL PLANS) 1 Acne * 10 Gut ** 2 Allergic Rhinitis 11 Mtr neurn disease * 3 Ankylsing Spndylitis * 12 Myasthenia Gravis * 4 Anxiety Disrder (Chrnic) 13 Ostearthritis 4

5 5 Atpic Dermatitis (Eczema) 14 Osteprsis # 6 Attentin deficit disrder * 15 Paget s disease * 7 Cystic Fibrsis * 16 Psriasis 8 Depressin 17 Schiz-affective disrder 9 Gastr-esphageal reflux disease 18 Urinary incntinence & Enuresis TABLE 3: LIST OF NON-PMB CHRONIC CONDITIONS (Available n the PLUS and COMPREHENSIVE PLANS) 1 Alzheimer s * Nte that the abve nn-pmb chrnic cnditins are subject t annual chrnic limits. Rules applicable t the Chrnic Benefit Chrnic medicatin requests fr certain cnditins (*) will nly be cnsidered if prescribed by an apprpriate specialist: A dermatlgist s prescriptin is required fr chrnic medicatin fr Acne A specialist physician, paediatrician r endcrinlgist s prescriptin is required fr chrnic medicatin fr Addisn s disease. A physician r rheumatlgist s invlvement r reprt is required fr authrisatin f medicatin fr Ankylsing Spndylitis. Fr Attentin Deficit Disrder applicatins will nly be cnsidered if prescribed by a paediatrician, neurlgist r psychiatrist. Diagnsis must be cnfirmed by a psychiatrist fr Biplar Md Disrder. Chrnic medicatin fr Cystic fibrsis will nly be cnsidered if prescribed by a paediatrician, physician r pulmnlgist. A specialist physician, paediatrician, surgen r gastrenterlgist s prescriptin is required fr chrnic medicatin fr Crhn s Disease and Ulcerative Clitis. An endcrinlgist r physician s prescriptin is required fr chrnic medicatin authrisatin fr Diabetes Insipidus and Hypparathyridism. A haematlgist r physician s prescriptin is required fr medicatin fr Haemphilia. 5

6 A neurlgist r physician s prescriptin is required fr authrisatin f chrnic medicatin fr Multiple Sclersis, Mtr neurn Disease, Myasthenia Gravis and Paget s disease. A psychiatrist r paediatric psychiatrist s prescriptin is required fr chrnic medicatin fr Schizphrenia. A specialist physician, paediatrician, r rheumatlgist s prescriptin is required fr chrnic medicatin fr Systemic Lupus Erythematsus. NB: Cntinuatin prescriptins frm general practitiners will nly be cnsidered nce a patient has been stabilised by the apprpriate specialist. Gut (**) Only allpurinl and prbenicid-cntaining prducts will be cnsidered. Osteprsis (#) Chrnic medicatin will nly be cnsidered n submissin f a Bne Mineral Density (BMD) scan indicative f steprsis. Other factrs e.g. pathlgical fractures will be taken int cnsideratin in accrdance with the Suth African guidelines. Exclusins The fllwing medicines are exclusins frm the chrnic disease benefit: Vitamins and mineral preparatins (including calcium, except fr patients with Osteprsis) Hmepathic medicatin Hypntics Muclytics Antibitics (except fr patients with Brnchiectasis, Crhn s disease and Cystic Fibrsis) Muscle relaxants (except fr patients with Multiple Sclersis) NOTE Althugh yur cnditin may be defined as chrnic by the prescribing dctr, this cnditin may nt fulfil the scheme criteria fr chrnic medicatin benefits. Access t any chrnic medicatin as part f the chrnic medicatin benefit is subject t clinical entry criteria, drug utilisatin review, reference pricing and, in the case f nn-pmb chrnic cnditins, annual chrnic limits. 6

7 IMPORTANT INFORMATION ABOUT PMBS AND DSPS Medicines prescribed fr the treatment f the Prescribed Minimum Benefit cnditins are paid at 100% f Scheme Medicine Reference Price when the medicatin is btained via the Scheme s DSP (Bankmed GP Entry Plan Netwrk GP and Bankmed Pharmacy Netwrk). This medicatin is paid at 80% f Scheme Medicine Reference Price when the medicatin is btained via a nn-dsp n a vluntary basis. In the event that the medicatin is btained via a nn-dsp n an invluntary basis, the medicatin will be funded at 100% f Scheme Medicine Reference Price, subject t Scheme s review f a valid mtivatin. SPECIAL BENEFIT AUTHORISATIONS Onclgy - medicatin requests must be referred t the Onclgy disease management team n 0800 BANKMED ( ) Organ Transplant medicatin requests must be referred t the Organ Transplant management team n 0800 BANKMED ( ) HIV/AIDS medicatin requests must be referred t the HIV management team n 0800 BANKMED ( ) 7