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Chronic Medicine Management

The Chronic Medicine Benefit is managed using a clinical pre-authorisation process that is governed by a formulary (a set of drugs) and disease specific guidelines, developed and reviewed by the Health Policy Unit (HPU). The objective is to encourage the best use of the Chronic Medicine Benefit by ensuring:

  • the appropriate use of medicines both clinically and based on cost, and
  • adherence to Scheme rules covering chronic medicine benefit use.

Drug utilisation review:

This is the application of guidelines through interventions or non-authorisation, either by the clinical team or through the built-in system intelligence that considers the following reasons:

  • Exclusion of non-evidence based medicine
  • Evaluation of new drug products
  • Therapeutic interchange
  • Generic substitution
  • Duration of authorisation limited pending review/motivation/special investigations
  • Authorisation only considered on motivation/special investigations/specialist prescription
  • Drug-to-drug interaction
  • Drug-disease interaction

Disease Authorisations:

Some of our Schemes utilise this improved way of approving chronic medicine, which is indicated on your chronic approval letter. Disease Authorisation makes management of changes easier for you, your pharmacist and your doctor. When you apply for chronic medicine, you are approved for treatment of your chronic condition which will give you access to a list of pre-approved medicine, referred to as a basket. This means that when you need to change or add a new medicine for your condition, you can do this quickly and easily at your pharmacy with your new prescription. It is important to note that not all conditions are managed this way.

You will need to contact the Chronic Medicine Management department if:

  • you are registering for the first time on the chronic program; or
  • your medicine is not in the basket; or
  • you are diagnosed with a new chronic condition; or
  • you need a quantity or dosage of a medicine that is more than the quantity listed in the basket.

Pre-approved medicine in the basket will still be subject to the Medicine Price List (MPL) and formulary co-payments viewable on this page.

To view the baskets, log in as a Member on the top right-hand side of this website with your username and password. Click My Authorisations and select Disease Basket Lookup. If you are a first-time user, you will need to first Register via this member login zone.

How to apply for Chronic Medicine Management:

Chronic updates and new registration can be done telephonically during the Scheme operating hours or online anytime of the day. Once the process has been completed you may receive an immediate response. Where more clinical information is required, our clinical team will review the information supplied and correspond with you and your doctor – either telephonically or in writing – on the information required and or outcome of the medicine requested.

When members or healthcare professionals contact us, it is important to have the:

  • membership number
  • date of birth of the person applying
  • copy of the current prescription (no need to send your prescription to CMM, but you will need to present it to your pharmacy )
  • ICD 10 code
  • doctor’s practice number

To authorise certain medicine members may also need to supply their:

  • previous medicine details
  • clinical examination data, e.g. weight, height, BP readings, smoking status, allergy information
  • test results, e.g. Lipogram results, Hba1c, lung function tests
  • motivation provided by their prescribing doctor

Telephonically:

  • Healthcare professionals may contact the Chronic Medicine Management (CMM) department on 0861 100 220, whilst members and brokers may contact the CMM department via their dedicated client service number listed below.
  • Follow the prompts by selecting the appropriate option for your call to be routed through to a clinical consultant who will guide you through the process.
  • You will be informed of any possible co-payments or outstanding information.

Online:

  • Go to the Medscheme website (www.medscheme.com)
  • On the top right-hand side of the website, login as a Member with your username and password. If you are a first time user you will need to Register.
  • Go to My AuthorisationsMy Chronic Application. Click on a dependant code to continue and select Chronic.

Chronic medicine management contact details:

Member Call Centre: Contact your Scheme call centre number.
Click here to look up the number.
Healthcare Professional Managed Care Call Centre: 0861 100 220

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