Chronic application_suremed (3).pdf

1. One application must be completed per beneficiary applying for Chronic Medication.
2. Allow 10 working days for the processing of your application.
3. The original prescription must be given to the provider who dispenses your medication.
4. It is essential that you submit all required information correctly and timeously as incomplete forms will not be processed.
5. The information required is for the clinical assessment of this application as well as for Risk Equalisation Fund (REF) purposes.
6. Approval of Chronic Medication is subject to the rules of the Scheme.
7. You may contact the Pharmacy Benefit Management (PBM) Team at (041) 395 4482 or email pbm@providence.co.za 8. Please fax the completed forms to (041) 3954598 or mail them to PO Box 1672, Port Elizabeth, 6000 C. PATIENT DETAILS (Beneficiary who requires Chronic Medication) By signing below, I hereby give permission for, acknowledge and/or agree to the following: • my (or my minor dependant's) doctor may provide clinical information regarding my/minor's condition to the PBM Team; • the successful approval of the Chronic Medication Benefit shall be subject to certain clinical criteria and formularies; • it may be a pre-condition to the approval of the Chronic Medication Benefit that I register and comply with the requirements of a Disease Management Programme and that non-compliance may lead to the withdrawal of this benefit; • my (or my minor dependant's) doctor retains the responsibility for my (or my minor dependant's) condition, based on the understanding that the I (or my minor dependant) also has a responsibility towards my (or my minor dependant's) own health concerns, irrespective of the outcome of this application; • the medication prescribed by my (or my minor dependant's) doctor may be substituted with an alternative medication provided it is of better or equal quality and efficacy to the medication prescribed and that the doctor has approved the substitution in the case of therapeutic equivalents; and • any information concerning this application will remain confidential at all times.
Patient Signature (or member if patient is a minor) E. PATIENT HEALTH INFORMATION (to be completed by attending doctor) The following information is required when applying for a new chronic condition Certain conditions which do not appear on the form below may be considered for approval on the Chronic Benefit, although not all long-term conditions, which a doctor may define as chronic, will fulfil the criteria for approval.
* Chronic conditions which may only be available on certain plans 1. Folstein's Mini Mental Examination State (MMSE) result.
1. Motivation for 2nd line agents (E.g. Avodart®, Flomax® and Xatral®) 1. Please classify according to NYHA or ACC-AHA Classification 1. Details of diagnosing specialist to be supplied 1. Details of diagnosing specialist to be supplied 1. Details of diagnosing specialist to be supplied 1. Prescriber to clearly indicate ICD-10 code 1. Supply initial diagnostic intra-ocular pressure 1. Diagnostic Gastroscopy or Barium Meal Swallow report 1. Haemophilia A (Factor VIII as % of Normal) 1. Haemophilia B (Factor IX as % of Normal) 1. Prescriber to complete Section G and I 1. Prescriber to complete Section G and H 1. Attach report showing T3, T4 and TSH levels 1. Motivation required for early-onset menopause (< 40yrs) and the prescription of Livifem ® 1. Extended disability status Score (EDDS) 1. DEXA bone mineral density (BMD) scan and report on any additional risk factors 1. Initial diagnostic test results confirming RA may be required where a "stepped therapy" approach has not 2. Initial Specialist Application and motivation for Enbrel® and Revellex® 1. Details of diagnosing specialist to be supplied G. CARDIOVASCULAR (to be completed by doctor when applying for Hypertension, hyperlipidaemia or diabetes mellitus type 2) Is the patient (if female) post-menopausal? Please indicate which of the following co-morbities/risk factors apply to this patient? Prior Coronary Artery Bypass Graft (CABG) If Heart failure is present, please indicate classification below: Ref: De Marco T, Delgado RM III, Agocha A. et al. J Cardiac Fail. 2004;10 H. HYPERTENSION (to be completed by attending doctor when applying for hypertension) Please supply two blood pressure readings, performed at least two weeks apart before intiating drug therapy, for newly diagnosed patient I. HYPERLIPIDAEMIA (to be completed by attending doctor when applying for hyperlipidaemia) Please attach a copy of the initial diagnosing lipogram (primary hyperlipidaemia) Is thre a family history of early-onset arteriosclerotic disease? Does the patient suffer from familial hyperlipidaemia? Family history of disorder/ heart attack at early age Please risk your patient as per the Framingham coronary prediction algorithm J. PSYCHIATRIC CONDITIONS (to be completed by doctor when applying for psychiatric disorders) M. CONDITION AND MEDICATION DETAILS (to be completed by attending doctor) Medication prescribed (Name, strength & dosage)

Source: http://www.suremedhealth.co.za/Documents/Chronic%20Application_Suremed%20(3).pdf