BANKMED MEDICAL SCHEME
MEDICINE ADVISORY SERVICES (Chronic Medicine Benefit)
GENERAL INFORMATION
 LIST OF CHRONIC CONDITIONS
Conditions covered under Bankmed’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 Bankmed, via Swift Online® chronic condition medicine
management on 0800 BANKMED (0800 226 5633)/ 0800 132 345. 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;
or

where a co-payment exists, the member may ask the prescribing doctor to call the number
listed above:
o
for a list of alternatives that require no co-payment
o
to motivate for full reimbursement, subject to clinical review
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Bankmed Medical Scheme
Chronic Medication General Information Letter
2016
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.
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 0800 132 345. No
chronic forms need be completed.
 ICD 10 CODES
A detailed list of all the ICD 10 diagnostic codes applicable to Bankmed’s eligible chronic condition
list is available on the MediKredit website: www.medikredit.co.za.
 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.
Please Note:
 Reference Price

Bankmed applies two types of Reference Pricing:
o
MMAP refers to the maximum price that the Scheme will pay for generic drugs
and this price is the same per product for all plan options.
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Bankmed Medical Scheme
Chronic Medication General Information Letter
2016
o

Therapeutic Reference Pricing refers to the maximum price that the Scheme will
pay for a specific therapeutic category of drugs. This reference price is based
on the cost of drugs from the same, or a similar, drug class listed on the CML.
The therapeutic reference price differs from one plan option to another.
The Scheme applies both reference pricing systems simultaneously and will only reimburse
a product at the lower of the two prices applicable to the particular plan option. If a
product is prescribed that is above any of the relevant reference prices, you will be
required 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
www.medikredit.net 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 ability
to search for possible generic or therapeutic alternatives.
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Bankmed Medical Scheme
Chronic Medication General Information Letter
2016
LIST OF PMB CDL CHRONIC CONDITIONS
TABLE 1: PRESCRIBED MINIMUM BENEFIT CHRONIC CONDITIONS
(Available on the PLUS, COMPREHENSIVE, TRADITIONAL and CORE SAVER 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
TABLE 2: LIST OF NON-PMB CHRONIC CONDITIONS
(Available on the PLUS, COMPREHENSIVE and TRADITIONAL PLANS)
1
Acne *
15
Menopause
2
Allergic Rhinitis
16
Motor neuron disease *
3
Ankylosing Spondylitis *
17
Myasthenia Gravis *
4
Anxiety Disorder (Chronic)
18
Osteoarthritis
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Bankmed Medical Scheme
Chronic Medication General Information Letter
2016
5
Atopic Dermatitis (Eczema)
19
Osteoporosis #
6
Attention deficit disorder *
20
Paget’s disease *
7
Benign Prostatic Hypertrophy
21
Peptic ulcer
8
Cardiac arrhythmias (non-PMB)
22
Psoriasis
9
Cystic Fibrosis *
23
Schizo-affective disorder
10
Gastro-oesophageal reflux disease
24
Spinal cord injuries (Paraplegia/ Quadriplegia)*
11
Depression
25
Stroke
12
Gout **
26
Transient Ischaemic Attack
13
Hyperthyroidism
27
Urinary incontinence & Enuresis
14
Hypoparathyroidism *
Note that the above non-PMB chronic conditions are subject to annual chronic limits.
Rules applicable to the Chronic Benefit
Chronic medication requests for certain conditions (*) will only be considered if prescribed by an
appropriate specialist:

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




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A dermatologist’s prescription is required for chronic medication for Acne
A specialist physician, paediatrician or endocrinologist’s prescription is required for chronic
medication for Addison’s disease.
A physician or rheumatologist’s involvement or report is required for authorisation of medication
for Ankylosing Spondylitis.
For Attention Deficit Disorder applications will only be considered if prescribed by a
paediatrician, neurologist or psychiatrist.
Diagnosis must be confirmed by a psychiatrist for Bipolar Mood Disorder.
Chronic medication for Cystic fibrosis will only be considered if prescribed by a paediatrician,
physician or pulmonologist.
A specialist physician, paediatrician, surgeon or gastroenterologist’s prescription is required for
chronic medication for Crohn’s Disease and Ulcerative Colitis.
An endocrinologist or physician’s prescription is required for chronic medication authorisation for
Diabetes Insipidus and Hypoparathyroidism.
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Bankmed Medical Scheme
Chronic Medication General Information Letter
2016
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A haematologist or physician’s prescription is required for medication for Haemophilia.
A neurologist or physician’s prescription is required for authorisation of chronic medication for
Multiple Sclerosis, Motor neuron Disease, Myasthenia Gravis and Paget’s disease.
A psychiatrist or paediatric psychiatrist’s prescription is required for chronic medication for
Schizophrenia.
A neurologist, neurosurgeon or physician’s involvement/report is required for authorisation of
Spinal Cord Injuries (Paraplegia/Quadriplegia).
A specialist physician, paediatrician, or rheumatologist’s prescription is required for chronic
medication for Systemic Lupus Erythematosus.
NB: Continuation prescriptions from general practitioners will only be considered once a patient has
been stabilised by the appropriate specialist.
Gout (**)
Only allopurinol and probenicid-containing products will be considered.
Osteoporosis (#)
Chronic medication will only be considered on submission of a Bone Mineral Density (BMD) scan
indicative of osteoporosis. Other factors e.g. pathological fractures will be taken into consideration in
accordance with the South African guidelines.
Exclusions
The following medicines are exclusions from the chronic disease benefit:

Vitamins and mineral preparations (including calcium, except for patients with Osteoporosis)

Homeopathic medication

Hypnotics

Mucolytics

Antibiotics (except for patients with Bronchiectasis, Crohn’s disease and Cystic Fibrosis)

Muscle relaxants (except for patients with Multiple Sclerosis)
NOTE
Although your condition may be defined as chronic by the prescribing doctor, this condition may not
fulfil the scheme criteria for chronic medication benefits.
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Bankmed Medical Scheme
Chronic Medication General Information Letter
2016
Access to any chronic medication as part of the chronic medication benefit is subject to clinical entry
criteria, drug utilisation review, reference pricing and, in the case of non-PMB chronic conditions,
annual chronic limits.


SPECIAL BENEFIT AUTHORISATIONS
Oncology - medication requests must be referred to the Oncology disease management team on
0800 BANKMED (0800 226 5633)

Organ Transplant –medication requests must be referred to the Organ Transplant management
team on 0800 BANKMED (0800 226 5633)

HIV/AIDS – medication requests must be referred to the HIV management team on
0800 BANKMED (0800 226 5633)
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Bankmed Medical Scheme
Chronic Medication General Information Letter
2016