Clinical criteria for registration on the chronic benefit

The following information outlines the clinical criteria necessary for registration on the chronic benefit program.

Here is a comprehensive list of conditions included in the Prescribed Minimum Benefit Chronic Disease List (CDL):

Prescribed Minimum Benefit Chronic Disease List (CDL) conditions:

Addison’s diseaseFurther information/tests required: Diagnosis must be confirmed by a specialist physician, pediatrician, or endocrinologist.

Asthma (adult)Further information/tests required: Diagnosis should be validated by a general practitioner (GP) or a specialist.

Asthma (child <7 years)Further information/tests required: The diagnosis must be made or confirmed by a specialist pediatrician.

Bipolar affective disorderFurther information/tests required: A prescription from a psychiatrist is necessary. It is important to note that benzodiazepines are excluded from the Chronic Benefit program.

BronchiectasisFurther information/tests required: Diagnosis confirmation by a specialist is required, and entry criteria for pre-existing conditions such as Chronic Obstructive Pulmonary Disease (COPD) will apply.

Cardiac failureFurther information/tests required: Diagnosis must be confirmed by a specialist physician.

Cardiac dysrhythmiaFurther information/tests required: A diagnosis confirmed by a specialist physician is required.

CardiomyopathyFurther information/tests required: Diagnosis confirmation by a specialist physician is essential.

Chronic obstructive pulmonary diseaseFurther information/tests required: Diagnosis must be validated by a GP or specialist. An emailed copy of a lung function test performed according to American Thoracic Society or similar criteria is necessary, demonstrating a Forced Expiratory Volume in 1 second/Forced Vital Capacity (FEV1/FVC) ratio of less than 70% and FEV1 post-bronchodilator of less than 70% of predicted.

Chronic renal diseaseFurther information/tests required: Diagnosis must be confirmed by a GP or specialist. A copy of lab results is required, showing a serum creatinine clearance value of less than 30 ml/min or a Glomerular Filtration Rate (GFR) estimate of less than 30 ml/min.

Coronary artery diseaseFurther information/tests required: Diagnosis confirmation by a specialist physician is needed.

Crohn’s diseaseFurther information/tests required: Diagnosis must be made by a specialist physician, pediatrician, surgeon, or gastroenterologist.

Diabetes insipidusFurther information/tests required: Diagnosis must be confirmed by a specialist physician, pediatrician, neurologist, neurosurgeon, or endocrinologist.

Diabetes mellitus type 2Further information/tests required: Diagnosis should be confirmed by a GP or specialist physician, along with confirmatory lab results. These results can include an HbA1c greater than 6%, two random glucose measurements greater than 11 mmol/l, two fasting blood glucose levels greater than 7 mmol/l, a single blood glucose level greater than 15 mmol/l, or a Glucose Tolerance Test (GTT) indicating a fasting glucose of 7 mmol/l or more and/or a 2-hour post-prandial glucose load of 11.1 mmol/l or more.

Diabetes mellitus type 1Further information/tests required: Specialist initiation is necessary, along with confirmatory lab results as mentioned above.

EpilepsyFurther information/tests required: Diagnosis must be confirmed by a GP, specialist physician, neurologist, or neurosurgeon.

GlaucomaFurther information/tests required: Diagnosis confirmation is required from an ophthalmologist.

HaemophiliaFurther information/tests required: Diagnosis must be confirmed by a specialist physician, along with a copy of lab results indicating Factor VIII or Factor IX levels of 5% or less.

HyperlipidaemiaFurther information/tests required: Diagnosis confirmation is required from a GP or specialist physician, along with a copy of lipogram results and documentation related to the risk assessment (Framingham Risk Score). Additionally, details of the patient's history, including established vascular disease and any procedures performed (e.g., angioplasty, stent), as well as family history from the prescribing doctor (including cardiovascular events in the member’s first-degree relatives and age of onset), are necessary.

HypertensionFurther information/tests required: Diagnosis must be confirmed by a GP or specialist physician.

HypothyroidismFurther information/tests required: Diagnosis confirmation is required from a GP or specialist.

Multiple sclerosisFurther information/tests required: Diagnosis must be confirmed by a specialist physician or neurologist. The initial application must be accompanied by a motivation detailing disease progress, the Expanded Disability Status Scale (EDSS) score, and an MRI report.

Parkinson’s diseaseFurther information/tests required: Diagnosis confirmation is necessary from a neurologist.

Rheumatoid arthritisFurther information/tests required: Diagnosis must be confirmed by a GP and a tick sheet completed, or by a specialist physician, pediatrician, or rheumatologist. Clinical information required includes serum rheumatoid factor (RF), anti-CCP, erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP), and relevant x-rays.

SchizophreniaFurther information/tests required: Diagnosis must be confirmed by a psychiatrist or pediatric psychiatrist.

Systemic lupus erythematosusFurther information/tests required: Diagnosis should be made by a specialist physician, pediatrician, or rheumatologist.

Ulcerative colitisFurther information/tests required: Diagnosis must be confirmed by a specialist physician, surgeon, or gastroenterologist.

Below is a list of conditions that are part of the Non-Prescribed Minimum Benefit Chronic Disease List:

Non-Prescribed Minimum Benefit Chronic Disease List conditions:

AcneFurther information/tests required: Authorized for a maximum of 6 months at a time. It is important to note that soaps and cleansers will not be allocated benefits under the Chronic program.

Allergic rhinitisFurther information/tests required: Treatment options include either nasal corticosteroids (preferred) or oral antihistamines.

Ankylosing spondylitisFurther information/tests required: A specialist prescription is needed.

Aplastic anaemiaFurther information/tests required: A specialist prescription is necessary.

Attention deficit hyperactivity disorderFurther information/tests required: Diagnosis must be confirmed by a pediatrician, psychiatrist, or neurologist.

Benign prostatic hypertrophyFurther information/tests required: A prescription from a urologist is required.

Cushing’s diseaseFurther information/tests required: A specialist prescription is necessary.

Cystic fibrosisFurther information/tests required: A specialist prescription is required.

DermatomyositisFurther information/tests required: A specialist prescription is necessary.

EczemaFurther information/tests required: A dermatologist's prescription is required for immunosuppressants. Benefits are allocated for 6 months at a time.

GoutFurther information/tests required: Diagnosis must be confirmed by a GP or specialist.

HypoparathyroidismFurther information/tests required: A specialist prescription is required.

Major depressionFurther information/tests required: Benefits are allocated for 6 months at a time. It is important to note that benzodiazepines are excluded from the Chronic Benefit program.

MenopauseFurther information/tests required: A hormone profile is required for patients under 50 years unless prescribed by a gynecologist or if a hysterectomy has been performed.

Motor neurone diseaseFurther information/tests required: A specialist prescription is necessary.

Muscular dystrophyFurther information/tests required: A specialist prescription is required.

Myasthenia gravisFurther information/tests required: A specialist prescription is necessary.

NarcolepsyFurther information/tests required: A specialist prescription is required.

Obsessive compulsive disorderFurther information/tests required: A prescription from a psychiatrist is necessary.

OsteopeniaFurther information/tests required: Dexa scan results are required, indicating osteopenia, along with a fracture history if applicable.

OsteoporosisFurther information/tests required: Dexa scan results are required, indicating osteoporosis.

ParaplegiaFurther information/tests required: A letter of motivation detailing clinical history from the prescriber is necessary.

PemphigusFurther information/tests required: A dermatologist's prescription is required.

Pituitary microadenomasFurther information/tests required: A specialist prescription is necessary.

Post-traumatic stress syndromeFurther information/tests required: A prescription from a psychiatrist is required.

PsoriasisFurther information/tests required: A dermatologist's prescription is required for immunosuppressants.

QuadriplegiaFurther information/tests required: A letter of motivation detailing clinical history from the prescriber is necessary.

SclerodermaFurther information/tests required: A specialist prescription is required.

StrokeFurther information/tests required: A specialist prescription is necessary.

Systemic sclerosisFurther information/tests required: A specialist prescription is required.

Thromboangiitis obliteransFurther information/tests required: A specialist prescription is necessary.

Thrombocytopenic purpuraFurther information/tests required: A specialist prescription is required.