We are pleased to announce that from 1 January 2024, MediKredit will be managing CMP’s chronic medicine benefits on behalf of the scheme.
Existing users of chronic medicine
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There will be no change to the existing chronic medicine benefits that have already been approved for members. There is no action required if you are already registered for the benefit.
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You will continue to get your medicine from the pharmacy you normally go to.
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We expect the pharmacy claiming process for members to be a more streamlined experience. MediKredit’s Pharmacy Benefit Management service allows for the pharmacists / doctors to contact them directly to discuss any script changes or substitutions, thereby improving the turnaround time for members.
Registration of chronic conditions from 1 January 2024
- You can only access benefits for chronic medication, for conditions listed below, if your prescribing/treating doctor or pharmacist registers your chronic condition(s) with CMP Medical Aid on 021 937 8300.
- Alternatively, your doctor’s rooms can now call Swift OnLine on 0800 132 345, to register your chronic condition.
- This applies to all chronic conditions recognised by CMP Medical Aid based on the approved scheme rules.
Once your condition is registered, action is only ever required from your doctor if:
- your current approval expires, or
- your doctor diagnoses you with a new chronic condition that needs new medicine, or
- the chronic medicine that you are taking is not included in the CONDITION MEDICINE LIST (CML) or the quantity required exceeds the default quantity for your registered condition.
Newly diagnosed chronic conditions
- If you are diagnosed with a new chronic condition, registration of the chronic condition with the scheme is required before access to the chronic medicine benefit will be granted.
- For registration, the scheme requires detailed clinical information, including the condition’s ICD 10 code (Diagnosis code). No chronic forms need to be completed.
Who can register a chronic condition?
- As detailed clinical information, including the condition’s ICD-10 code, is needed to register your chronic condition, your treating doctor is required to register your chronic condition.
- Certain products will only be authorised if prescribed by an appropriate specialist.
- All current CMP Medical Aid exclusions and limitations apply.
Condition Medicine List (CML)
Once your condition has been registered, you will have access to funding of medication on the Chronic Medicine List (CML) specific to your chronic condition. This is a list of drugs the scheme will fund that is appropriate for the treatment of the condition.
Some of the PMB CDL conditions have two lists of drugs. This is to accommodate drugs appropriate to the severity of the particular conditions. Y ou can only get drugs in the severity 2 list once specific clinical criteria are met. Additional information or reports may be required from the prescribing doctor.
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.
The Condition Medicine List does not list all medication that may be required to treat your condition.
Some medication requires specific pre-authorisation. Detailed clinical information is required to pre-authorise these drugs, and this can be emailed to chronic@cmp.co.za or given telephonically by calling Swift Online on 0800 132 345.
Pharmacy Network
Our Preferred Provider for chronic medication is any Clicks Pharmacy, Medipost Pharmacy, government/state facility, or any other pharmacy of your choice that has a dispensing fee of 34.2%/R34.20 and is capped at R36.80.
These pharmacies are a CMP initiative to ensure that our members have consistency with regards to dispensing fees and access to pharmacies that are prepared to assist in better managing our member’s benefits.
This does not mean that you must make use of the above Preferred Providers, however, you may be liable for a co-payment in respect of the difference between the scheme’s agreed rate and the dispensing fee charged by your own pharmacy, should you wish to make use of your pharmacy.
List of eligible chronic conditions
Chronic Disease List:
- - Addison’s Disease*
- - Asthma
- - Anti-coagulating therapy
- - Bipolar Mood Disorder*
- - Bronchiectasis
- - Cardiac Failure
- - Cardiomyopathy Disease
- - Chronic Obstructive Pulmonary Disorder
- - Chronic Renal Disease
- - Coronary Artery Disease
- - Crohn’s Disease*
- - Cushing’s Disease
- - Diabetes Insipidus*
- - Diabetes Mellitus Type 1 & 2
- - Dysrhythmias
- - Epilepsy
- - Glaucoma
- - Haemophilia*
- - HIV
- - Hyperlipidaemia
- - Hypertension
- - Hypothyroidism
- - Multiple Sclerosis*
- - Parkinson’s Disease
- - Rheumatoid Arthritis/ Juvenile Rheumatoid Arthritis
- - Schizophrenia*
- - Systemic Lupus Erythematosus*
- - Ulcerative Colitis*
Rules applicable to the Chronic Disease Benefit:
Chronic medication requests for certain conditions (*) will only be considered if prescribed by an appropriate specialist, as indicated in the table below:
| Condition | Specialist Authorisation Required |
|---|---|
| Addison’s Disease | Physician, paediatrician or endocrinologist |
| Bipolar Mood Disorder | Psychiatrist: If prescriber is a GP, DSM-IV or 5 criteria and sub-type must be specified (type I or II) |
| Crohn’s Disease | Physician, paediatrician, surgeon or gastroenterologist |
| Cushing’s Disease | Endocrinologist or physician |
| Diabetes Insipidus | Endocrinologist or physician |
| Haemophilia | Haematologist or physician |
| Multiple Sclerosis | Neurologist |
| Schizophrenia | Psychiatrist or paediatric psychiatrist |
| Systemic Lupus Erythematosus | Physician, paediatrician, or rheumatologist |
| Ulcerative Colitis | Physician, paediatrician, surgeon or gastroenterologist |
Note: Continuation prescriptions from General Practitioners will be considered once a patient has been stabilised by the appropriate specialist.
Exclusions
The following medicines are excluded from chronic cover:
- Vitamins and mineral preparations
- Homeopathic medication
- Hypnotics
- Mucolytics
- Antibiotics (except for patients with Bronchiectasis and Crohn’s disease)
- 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 meet the scheme’s criteria for chronic medication cover. Access to any medication as part of the chronic medication benefit is subject to clinical entry criteria, drug utilisation reviews.
Special benefit authorisations
Oncology
Medication requests must be referred to the CMP Case Management team.
Organ Transplant
Medication requests must be referred to the CMP Case Management team.
Case Management
Certain chronic conditions will require case management and approval by a Clinical Committee. These cases will be managed individually by CMP.
Please contact the CMP Case Management team on 021 937 8300.