Risk factors

CHRONIC MEDICINE BENEFIT APPLICATION FORM – 2013
(To be used by Nedgroup Hospital, Traditional, Savings and Platinum members only) Please complete the application in black ink One application form must be completed per patient Please attach a copy of the Dr's prescription to the application form (original not required) Applications will not be processed unless the appropriate sections are completed and relevant documents are
attached. The completed and signed application form may be faxed to 086 679 1579, emailed to
or posted to Scriptpharm Risk Management, P.O. Box 653590, Benmore, 2010
Clinical entry criteria must be met before medication for Prescribed Minimum Benefit (PMB) or chronic conditions will be authorised. See Section H. Please note that Chronic medication approved but not claimed for at least 6 consecutive months will be
terminated and the member will have to re-apply for the benefit with all the relevant tests and a new
application form.
Contact the call centre on 010 591 0150 for further assistance
SECTION A. PRINCIPAL MEMBER'S DETAILS
Membership Number Scheme and Option Telephone numbers Email Address (will be treated as private) SECTION B. PATIENT'S DETAILS
Telephone numbers Email Address (will be treated as private) Please circle the preferred method of communication (if patient is under the age of 16 years, communication
will be sent to the main member)
Please ensure that relevant details have been provided for the communication option selected
SECTION C. DECLARATION BY PATIENT (or member if patient is a minor)
I hereby authorise my doctor to furnish and/or disclose any relevant clinical information required to review my application. I understand that the application is subject to formulary guidelines as well as Scheme rules. I also understand that generic equivalents will be authorised where applicable and co-payments will apply if I choose not to accept the substitution. Patient signature (unless a minor)

Patient name and surname Membership number SECTION D. CARDIOVASCULAR RISK (to be completed by doctor when applying for PMB
benefits for hypertension, hyperlipidaemia, diabetes mellitus type 2 and cardiac failure)
Patient height in metres Does the patient smoke? Yes/No Is microalbuminuria present or is the GFR less than 60ml/min? Yes/No If there is target organ damage and/or cardiovascular disease, please tick the appropriate box Myocardial Infarction Hypertensive Retinopathy Left Ventricular Hypertrophy Peripheral Arterial Disease Chronic Renal Disease Transient Ischaemic Attack For cardiac failure, please provide either the NYHA classification: Class _, or the stage of cardiac failure according to the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines: Stage SECTION E. APPLICATION FOR HYPERTENSION
Please complete in conjunction with Section D

A specialist must complete this section for patients below the age of 30 years diagnosed with
hypertension
1. Current blood pressure / _mmHg
2. When did the patient commence drug therapy for
hypertension? 3. For all newly diagnosed patients and those diagnosed in the last 6 months, please supply the 2 initial blood pressure readings (before drug therapy), performed at least 2 weeks apart Date
4. Please provide additional clinical information if there are compelling indications for use of drug classes
that are not first or second line therapy, such as Angiotensin Receptor Blockers.

SECTION F. APPLICATION FOR HYPERLIPIDAEMIA
Please complete in conjunction with Section D

Please attach a copy of a recent full lipogram.

1. Please list the signs of Familial Hyperlipidaemia, if present 2. Is there a family history of premature arteriosclerotic disease? Yes/ No If the answer is YES, please provide the following details: Description of event Age at time of first event 3. When did your patient commence drug therapy for hyperlipidaemia? 4. In terms of the European Guidelines adopted by the South African Heart Association, patients falling in the following categories are not required to be risk scored. Please provide supporting clinical evidence or pathology results to confirm the health status of the patient. 1. Established atherosclerosis: a. Coronary Heart Disease b. Cerebrovascular atherosclerotic disease c. Peripheral vascular disease 2. Diabetes Type 2 3. Diabetes Type 1 with microalbuminuria or proteinuria


5. For patients with primary hyperlipidaemia, please assess your patient's risk using the following
table. Kindly indicate the score by marking the appropriate percentage risk
Estimate of 10-year risk for MEN
Estimate of 10-year risk for WOMEN
Age (years)
Age (years)
Cholesterol
Age (years)
Cholesterol
Age (years)
(mmol/ L)
(mmol/ L)
Age (years)
Age (years)

Estimate of 10-year risk for MEN
Estimate of 10-year risk for WOMEN
HDL (mmol/L)
HDL (mmol/L)
Systolic BP
Systolic BP (mmHg)
If untreated
If treated
If untreated
If treated
Estimate of 10-year risk for MEN
Estimate of 10-year risk for WOMEN
Total Points
10-year risk %
Total Points
10-year risk %
10-year risk _%
10-year risk _%

Framingham scoring system for calculating the 10-year risk of major coronary events in adults without diabetes.
HDL denotes high-density lipoprotein cholesterol & BP blood pressure. All age ranges are given in years.
Reprinted from National Institutes of Health, National Heart, Lung and Blood Institute. Third Report of the National Cholesterol Education Program
(NCEP) Expert Panel on Detection, Evaluation and Treatment of High blood cholesterol in Adults (Adult Treatment Panel III). Executive Summary. NIH
Publication No. 01-3670; May 2001.
6. Based on the information supplied in Section F:
 For patients below the age of 60 years: Does your patient have a 20% or greater risk of a coronary
event in the next ten years? (Please circle Yes/No) Yes No
 For patients above the age of 60: Does your patient have a 30% or greater risk of a coronary event
in the next ten years? (Please circle Yes/No) Yes No

We acknowledge that there are limitations to the Framingham Risk Assessment Score Chart. In order to
assist with a funding decision, please motivate if you feel that your patient is negatively impacted by these
limitations.
The PMB benefit will not provide cover in patients with less than a 20% (<60 years) or 30%(>60 years) risk
of a coronary artery event within the next ten years. This is based on the local and international treatment
guidelines and is in line with the Medical Scheme Council Clinical Algorithm. This is a funding decision, to
ensure the long term sustainability of this benefit and does not in any way question your clinical decision.
SECTION G: APPLICATION FOR OSTEOPOROSIS (to be completed by Medical Practitioner. Please
attach a BMD report)
Osteoporotic fracture: If yes, please supply date of (Please circle Yes or No) most recent fracture: Yes No
Please indicate fracture

MEDICAL PRACTITIONER TO COMPLETE
MEDICAL PRACTITIONER'S DETAILS
BHF Practice Number (Not MP Number)
Telephone Number PATIENT'S DETAILS
Membership Number MEDICATION AND CONDITION DETAILS
Please ensure that all fields are completed to avoid delays in processing
Please note that in terms of the Medical Schemes Act, Scriptpharm Risk Management will apply a formulary (available on
. This is a funding decision to ensure the long-term sustainability of this benefit and does not question your clinical
judgement.
Diagnosis
Medication
Strength
How long has your
Quantity
patient been on this
medication?
Please ensure that all requested documentation is supplied.

Signature of medical

SECTION H. PRESCRIBED MINIMUM BENEFITS: CLINICAL ENTRY CRITERIA
1. Please note that your application will not be processed if the requested information is not supplied
2. Some conditions may require completion of the form by a relevant specialist
3. Each time you register for a new chronic disease, the information in the following table is required.
Once registered for a chronic condition, you may be required to submit further documentation if your medication is
changed.
SUBMISSION REQUIREMENTS
a. Application for a change in medicine where you are Section A, B and C and a copy of a valid prescription. currently registered for the same condition. b. Application for medication for a second condition Complete application form including clinical criteria and copy where you have already registered for a first. of valid prescription. c. If the condition applied for was approved by your Section A, B and C, a letter of motivation from the prescriber previous medical scheme, a report from your doctor and a copy of a valid prescription. stating the name of the condition, medication and duration of treatment is required. PMB CONDITION
CLINICAL ENTRY CRITERIA
Serum cortisol levels a. ACTH stimulation test to distinguish primary from secondary adrenal insufficiency. The PMB is only applicable to primary Addison's Disease
Addison's disease b. A specialist physician, paediatrician or endocrinologist must make the diagnosis. 1. A lung function test for adults and children older than 7 years 2. The South African Treatment Guidelines for asthma will be used to assess all applications 3. Applications for leukotriene inhibitors (e.g. Singulair ®) must be supported by a pre- and post lung function test to substantiate the additional benefit and must be from a Pulmonologist. Bipolar Mood Disorder
A psychiatrist prescription and written diagnosis are required. Please attach a report based on the findings of a radiological examination (Chest X-ray or CT scan) 1. Please indicate the level of functional incapacity according to the New York Heart Association's classification and/or 2. The stage of cardiac failure according to the American College of Cardiac Failure
Cardiology/ American Heart Association Task Force on Practice Guidelines (February 2002) Please record level/stage in Section D The diagnosis must be confirmed by a specialist physician or cardiologist Chronic Obstructive
Please attach a lung function test. The REF (risk equalisation fund) criteria are in Pulmonary Disease
line with the GOLD classification 1. A specialist physician must complete the application 2. Indicate the creatinine clearance 3. When applying for erythropoetin, a report indicating haemoglobin, Tsat Chronic Renal Disease
and ferritin levels must be provided. Please also state whether the patient is currently on or off drug therapy 4. A report indicating Tsat and ferritin must be provided when applying for iron supplementation Please attach a copy of the stress or exercise ECG report confirming the Coronary Artery Disease
diagnosis of coronary artery disease The application form must be completed by a gastroenterologist or specialist Crohn's Disease
physician. If the condition is managed by a general practitioner, a gastroenterologist must confirm the diagnosis

FOR INFORMATION PURPOSES ONLY – DO NOT SEND WITH APPLICATION
PMB CONDITION
CLINICAL ENTRY CRITERIA
1. An endocrinologist, specialist physician, paediatrician, neurologist or Diabetes Insipidus
neurosurgeon must complete the application form 2. The results of a water deprivation test are required Diabetes Mellitus Type I
Application form must be completed by a medical practitioner Diabetes Mellitus Type II
Section D must be completed by a medical practitioner. Blood results required. The medical practitioner must indicate the ICD 10 code. The PMB chronic benefit only provides cover for chronic atrial fibrillation and flutter (I48) and ventricular tachycardia (I47.2) 1. Please attach a detailed seizure history Epilepsy
2. Please attach an EEG report confirming the diagnosis of epilepsy Glaucoma (open and
Please provide the intra-ocular pressure at diagnosis. This is only required for closed angle)
newly diagnosed patients Haemophilia A: Please provide the Factor VIII level as a % of normal Haemophilia
Haemophilia B: Please provide the Factor IX level as a % of normal Please attach a copy of the diagnosing (for primary hyperlipidaemia) or current (for secondary hyperlipidaemia) lipogram. The medical practitioner must complete Sections D and F of the application form. Section D and E of the application form must be completed by the medical practitioner Please attach the diagnostic report that confirms the initial diagnosis of 1. A specialist physician or neurologist must complete the application form and indicate the specific type of multiple sclerosis 2. Please provide the following information when applying for chronic Multiple Sclerosis
medicine benefits for inteferon: a) Extended disability status score (EDSS) b) Relapsing-remitting history c) Number of relapses requiring IV cortisone treatment Applications for non-formulary products will only be considered if prescribed by a Parkinson's Disease
neurologist, or if the application is supported by a neurologist's motivation 1. Copies of the relevant blood test reports and supportive clinical history confirming the diagnosis of rheumatoid arthritis are required 2. Applications for COXIBs must be supported by a motivation indicating Rheumatoid Arthritis
the risk factors considered for their use over conventional anti-inflammatories 3. Applications for anti-inflammatories as monotherapy MUST be motivated
by a rheumatologist A psychiatrist prescription and written diagnosis is required Systemic Lupus
A rheumatologist, specialist physician or paediatrician must complete the Erythematosus (SLE)
application form and indicate the diagnostic criteria used
A gastroenterologist or specialist physician must complete the application form. If
Ulcerative Colitis
the condition is managed by a general practitioner, a gastroenterologist or specialist physician must confirm the diagnosis

FOR INFORMATION PURPOSES ONLY – DO NOT SEND WITH APPLICATION
SECTION I. NON-PRESCRIBED MINIMUM BENEFITS CHRONIC DISEASES
CHRONIC CONDITION
CLINICAL ENTRY CRITERIA REQUIREMENTS
For isotretinoin therapy, the patient's weight, date of commencement with Acne (Cystic nodular
treatment and duration of therapy is required. A dermatologist must initiate therapy Only covered in children under the age of 12 years, or in patients on concurrent Allergic Rhinitis
asthma therapy. A motivation or a specialist prescription is required for the combined use of inhaled nasal corticosteroids and antihistamines. Alzheimer's Type
Dementia
Please submit the results of a mini-mental state examination (MMSE) Only reviewed if member is approved for a PMB psychiatric condition Attention Deficit
A paediatrician, psychiatrist or neurologist must complete the application form. Disorder (ADHD or ADD)
This condition will only be covered in patients under the age of 18 years. Deep vein thrombosis
No clinical entry criteria Generic fluoxetine or citalopram will be funded as first-line therapy from a GP for Major Depression
6 months, pending review from a psychiatrist. An initial psychiatrist's prescription is required for all other anti-depressants and mood stabilisers. GORD will only be funded if the patient suffers from a GIT-related PMB condition, or is on oral corticosteroid treatment for another PMB condition. A gastroscopy report, including the Los Angeles Grading is required. Generic Reflux Disease (GORD)
omeprazole, cimetidine or ranitidine will be funded. Please submit a detailed, clinically relevant motivation for other products. Only patients whose Gout is associated with Diabetes and/or Hypertension Submit T3, T4 and TSH levels. Funding will be authorised for 6 months pending review A specialist physician or endocrinologist must complete the application form. Basal/stimulation test results required A specialist physician or endocrinologist must complete the application form. Basal/stimulation test results required A specialist physician or endocrinologist must complete the application form. Calcium, Phosphate and parathyroid hormone levels required. Hypotension
A pre and post medication blood pressure reading must be submitted Insomnia
Only if linked to another PMB psych condition (Bipolar or Schizophrenia) Tibolone will only be authorised on motivation from a gynaecologist. Motivation Menopause (HRT)
required if patients less than 40 years old Migraine
Only prophylaxis will be covered Applications for COXIBs must be supported by a motivation indicating the risk factors considered for their use over conventional anti-inflammatories 1. Applications must include a DEXA bone mineral density scan (BMD) 2. A short report on additional risk factors must be included (e.g. previous fractures, family history, long term oral corticosteroid use). Please complete Section G 3. An endocrinologist motivation is required for males, females under the age of 30, and children. Psoriasis
No clinical entry criteria FOR INFORMATION PURPOSES ONLY – DO NOT SEND WITH APPLICATION

Source: http://www.scriptnet.co.za/Forms/Nedgroup%20Chronic%20Application%20Form%202013.pdf