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application for registration of medicine: chronic and prescribed minimum benefits (pmb) 2008 (version 1 updated 27 November 2007) section one: to be completed by the member

general information

details of principal member
details of patient
I declare and understand that my application shall be void if any information supplied by me should be false or incomplete. I grant permission to my doctor to state the diagnosis of my medical condition on this form and understand that the information on this application form will remain confidential at all times. Signature

section two: to be completed by the medical practitioner

details of medical practitioner

Type of practitioner (e.g. general practitioner) Signature

Members can apply for authorisation for chronic or PMB medicine for the following 25 chronic conditions on the chronic
disease list (CDL). It is imperative that a member meet the criteria as stipulated in the application form when applying for
benefits for these conditions.
Requirements (for Medihelp Plus, Dimension Elite and Dimension Prime benefit
PMB condition
options)
Serum cortisol levels and ACTH stimulation test for a newly-diagnosed condition
ICD-10 code and diagnosis by a specialist physician, paediatrician or
endocrinologist
ICD-10 code and diagnosis by a registered medical practitioner ICD-10 code and diagnosis by a paediatrician for children < three years for a newly-
diagnosed condition
Combination of asthma and COPD by a pulmonologist
ICD-10 code and DSM-IV diagnosis by a psychiatrist
ICD-10 code and diagnosis by a pulmonologist for a newly-diagnosed condition
Attach the most recent microscopic culture results and motivation if an antibiotic is prescribed ICD-10 code and diagnosis by a specialist physician or cardiologist for a newly-
diagnosed condition
ICD-10 code and diagnosis by a specialist physician or cardiologist for a newly-
diagnosed condition
ICD-10 code and diagnosis by a pulmonologist or specialist physician for a newly-
diagnosed condition
A lung function test indicating the FEV1/FVC and FEV1 post-bronchodilator values A motivation and supporting lung function test if corticosteroid inhalation is prescribed ICD-10 code and diagnosis by a specialist for a newly-diagnosed condition
Serum creatinine clearance results or glomerular filtration rate (GFR)
ICD-10 code and diagnosis by a specialist physician or cardiologist for a newly-
diagnosed condition
for a newly-diagnosed condition
ICD-10 code and diagnosis by a specialist physician, surgeon, gastroenterologist
or paediatrician
Positive water deprivation test for a newly-diagnosed condition
ICD-10 code and diagnosis by a specialist physician, paediatrician,
endocrinologist, neurosurgeon or neurologist
ICD-10 code, diagnosis and HbA1c report by a registered medical practitioner for a newly-diagnosed condition
Motivation and HbA1c report (not older than three months) if Lantus/Levemir is prescribed Fasting plasma glucose results and/or glucose intolerance test results for a newly-
diagnosed condition
ICD-10 code and diagnosis by any registered medical practitioner Motivation and HbA1c report (not older than three months) if Lantus/Levemir is prescribed Motivation from a specialist if Thiazolidinedione (Actos/Avandia) is prescribed
ICD-10 code and diagnosis by a specialist physician or cardiologist for a newly-
diagnosed condition
ICD-10 code and diagnosis by a neurologist for a newly-diagnosed condition
Findings of an EEG report as confirmation of diagnosis for a newly-diagnosed
condition by a registered medical practitioner
ICD-10 code and diagnosis by a registered medical practitioner Results of factor VIII or IX pathology tests for a newly-diagnosed condition
ICD-10 code and diagnosis by a registered medical practitioner application form for hyperlipidaemia in section four must be completed by the
ICD-10 code and diagnosis by a registered medical practitioner Latest lipogram only if the medicine or dosage change Requirements (for Medihelp Plus, Dimension Elite and Dimension Prime benefit
PMB condition
options)
application form for angiotensin-II-blockers (ARB) in section six must be
completed by the medical practitioner if an ARB is prescribed ICD-10 code and diagnosis by any registered medical practitioner Classify the severity of hypertension – complete section five
TSH and FT4 pathology results for a newly-diagnosed condition
C019 Hypothyroidism • ICD-10 code and diagnosis by a registered medical practitioner ICD-10 code and diagnostic report supported by MRI findings from a specialist
physician or neurologist
application form for beta-interferon in section seven if beta-interferon
ICD-10 code and diagnosis or therapy changes by a neurologist or specialist
physician for a newly-diagnosed condition
ICD-10 code and diagnosis by a specialist physician, rheumatologist or
paediatrician
Medicine history and motivation from a rheumatologist or specialist physician if
biologicals is prescribed
ICD-10 code and DSM-IV diagnosis by a psychiatrist or paediatric psychiatrist
ICD-10 code and diagnosis or therapy changes by a specialist physician,
rheumatologist or paediatrician
Colonoscopy or sigmoidoscopy report for a newly-diagnosed condition
colitis • ICD-10 code and diagnosis by a specialist physician, gastroenterologist or surgeon
Additional chronic
Requirements (for Medihelp Plus and Dimension Elite benefit options only)
conditions
ICD-10 code and diagnosis by a dermatologist Only severe grade of acne (previously defined as grade IV and V) will be considered ICD-10 code and diagnosis by a general practitioner Only cost-effective corticosteroid nasal sprays are considered ICD-10 code and diagnosis by a neurologist or psychiatrist, submitted with an initial Mini-mental report Follow-up authorisation: Mini-Mental report every six months ICD-10 code and diagnosis by a rheumatologist or orthopaedic practitioner ICD-10 code and diagnosis by a paediatrician, psychiatrist or neurologist If the diagnosis is made by a general practitioner the following are required: MEDICHRON questionnaire for attention-deficit disorder ICD-10 code and diagnosis by a general practitioner ICD-10 code and diagnosis by a urologist if Finasteride (Proscar) or Dutasteride (Avodart) or a combination of drugs are prescribed. ICD-10 code and diagnosis by a general practitioner Gastroscopy report not older than 12 months to confirm diagnosis ICD-10 code, diagnosis and motivation by a neurologist or ophthalmologist ICD-10 code and diagnosis by an endocrinologist ICD-10 code and diagnosis by a relevant specialist ICD-10 code and diagnosis by a dermatologist if combination therapy is prescribed ICD-10 code and diagnosis by a relevant specialist if aspirin or Warfarin cannot be used ICD-10 code, diagnosis and motivation by a specialist physician or cardiologist if ICD-10 code and diagnosis by a gynaecologist ICD-10 code and diagnosis by a general practitioner Additional chronic
Requirements (for Medihelp Plus and Dimension Elite benefit options only)
conditions
ICD-10 code and diagnosis by a general practitioner, specialist physician, surgeon or Gastroscopy report not older than 12 months to confirm diagnosis ICD-10 code and diagnosis by a relevant specialist ICD-10 code and diagnosis by a psychiatrist ICD-10 code and diagnosis by a general practitioner ICD-10 code and diagnosis by a cardiologist ICD-10 code and diagnosis by a relevant specialist ICD-10 code and diagnosis by a relevant specialist ICD-10 code and diagnosis by a general practitioner Annual pathology report not older than 12 months ICD-10 code and diagnosis by a general practitioner ICD-10 code and diagnosis by a general practitioner Only TAD and SSRI’s (registered MIMS normal average dosage) by a general practitioner Combination therapy as well as other antidepressants must be prescribed by a psychiatrist ICD-10 code and diagnosis by an ear nose and throat specialist ICD-10 code and diagnosis by a general practitioner Motivation if Tibolone (Livifem®) Raloxifene (Evista®) or Angeliq® is prescribed ICD-10 code and diagnosis by a general practitioner ICD-10 code and diagnosis by a neurologist ICD-10 code and diagnosis by a neurologist ICD-10 code and diagnosis by a neurologist ICD-10 code and diagnosis by a psychiatrist ICD-10 code and diagnosis by a relevant specialist ICD-10 code and diagnosis by a general practitioner Motivation required if a COX-2 inhibitor is prescribed ICD-10 code and diagnosis by a general practitioner BMD report and an indication of the relevant risk factors ICD-10 code and diagnosis by a relevant specialist ICD-10 code and diagnosis by a dermatologist ICD-10 code and diagnosis by a relevant specialist ICD-10 code and diagnosis by a general practitioner ICD-10 code and diagnosis by a gynaecologist ICD-10 code and diagnosis by a dermatologist ICD-10 code and diagnosis by a pulmonologist ICD-10 code and diagnosis by a relevant specialist ICD-10 code and diagnosis by a relevant specialist ICD-10 code and diagnosis by a neurologist section three: to be completed by the medical practitioner

Surname and initials of member

Instructions:
Complete one application form per patient. Incomplete application forms will not be processed.
If the medicine has changed for a registered condition, a new application form should be completed, indicating the relevant changes with ICD-10 codes. Fax the completed and signed application form to 012 334 2466 or post it to PO Box 26042, ARCADIA, 0007.
Registration with MEDICHRON or changes to an authorisation schedule will only be valid from the date of approval.
Authorisation schedules will under no circumstances be backdated.
If you have any further enquiries please phone Medihelp’s Contact Centre on 086 0100 678.
The Contact Centre is available Mondays to Thursdays from 7.00 to 18.00 and Fridays from 8.00 to 16.00. Specify:
Diagnosis
ICD-10 code
Chronic or
Quantity
Prescribed medicine and strength
(compulsory)
(compulsory)
per month
authorisation
Type of practitioner (e.g. cardiologist) Signature

Surname and initials of member

section four: application form for hyperlipidaemia

If a baseline lipogram is not available please indicate the values as recorded in the patient’s file:

Is the patient on treatment for hypertension? Positive family history of premature vascular event in: First-degree male relative < 55 years First-degree female relative < 65 years Please specify the medicine for which you are applying section five: hypertension

Please classify the severity of hypertension:

section six: angiotensin-II-blockers (ARB) application form

Please fax the relevant pathology results to confirm the diagnosis of microalbuminuria.

Which ACE inhibitor(s) did the patient use? Please specify the period of use as well as the strength and dosage. Is the patient intolerant to ACE inhibitors? If the patient is intolerant to ACE inhibitors, which side effects did the patient experience? Please specify and describe the severity of the side effects. Specify which anti-hypertensive medicines, except ACE-inhibitors or angiotensin-II-blockers, were used previously and indicate the reason why the medicine was discontinued. Please specify the medicine, duration of use, strength and dosage. Does the above patient have any of the following diseases?
Microalbuminuria (confirmed by three different microalbuminurea: creatinin ratio reports) Please specify the angiotensin-II-blocker for which you are applying section seven: beta-interferon application form
Please include the following most recent pathology reports on relapsing remitting multiple sclerosis (RRMS):
Full blood count and liver function
Has the patient been using beta-interferon prior to this application? If “Yes”, please complete the following: Period on beta-interferon therapy: From date ____/____/_______ to date ____/____/_______ Did the patient experience any adverse events? Please specify: Give details of relapses during the last 12 months of treatment with beta-interferon. Secondary progressive MS without relapses Please indicate the patient’s current EDSS: Is the patient able to walk 100 metres without assistance? Is the patient currently in the remission phase? Did the patient have any confirmed clinically significant relapses meeting the McDonald criteria over the past two years (or over the two years prior to treatment with beta-interferon if the patient has been treated previously)? If “Yes”, please indicate the number of relapses and hospitalisations and date(s). Please indicate if there has been a change in EDSS as a result of above relapses and give details of the impact on disability.

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