Chronic Medication Application Form - …

1 Name of Eligible Member:Full Name of Covered Beneficiary (if Eligible member is not claiming): Employer:Date of Birth:Contact Cell: Please complete this applica on form as follows: The member of the plan must fill in all personal and membership details in Sec on 1 & 2. Please make sure you complete both these sec ons in full, in order to effec vely process your applica on. The doctor must fill in all medical informa on required in Sec on 3 & 4 of the applica on form. Please fax or Email your applica on to the following: Fax Number: 086 666 1048 Email: Surname: Title: Prof Dr Mr Mrs Miss Ms Mst First Names Date of Birth: Iden ty Number Tel No Home Tel No WorkCell: Rela onship to MemberGender Dependant Code Mass Kg Height (cm) Do you smoke?

2 If yes how many cigare es a day? How long have you smoked for? Do you consume alcohol? If yes, state type and quan tyIf you have any Chronic medica on queries please call the Chronic Helpdesk / Customer Services: Tel. 0861 00 11 31ID Number:Home:SECTION 1: PERSONAL DETAILS (ELIGIBLE MEMBER)Work:ID Number:SECTION 2: IMPORTANT PATIENT INFORMATIONCHRONIC Medication BENEFIT Application FORMN ational Bargaining Council for the Road Freight and Logistics IndustryYour Road Freight Medication Application Form DDMYYMYNF unding from the Chronic Medica on Benefit is subject to clinical entry criteria, the medica on acquisi on rules and formulary determined by Affinity Health (Pty) Ltd and agreed to by the scheme.

3 Please Note: AFFINITY HEALTH (PTY) LTD adopts a medica on reimbursement policy adhering to the single exit pricing structure for all generic and brand name medica on. This policy will be implemented at all points of service across all benefit plans and no excep on shall be made except where prior authorisa on has been obtained from AFFINITY HEALTH (PTY) LTD. Should a non-preferred medica on be required to treat an approved Chronic condi on, your GP is required to give mo va on for this medica on via our Medica on Appeals Procedure. Medica on not pre-authorised as Chronic by AFFINITY HEALTH (PTY) LTD may be eligible for reimbursement from the Chronic Medica on Benefit. I hereby give permission for the GP to state my diagnoses and other relevant clinical informa on on this form.

4 By applying for the Chronic Medica on Benefit, I agree that my condi on may be subject to disease management interven ons. Signed Principal Pa ent (Unless a Minor) Date DDMYYMYYYYLife AssuranceLion OF AFRICAA ffinity Health (Pty) Ltd (the Product Supplier); Na onal Risk Managers (Pty) Ltd (the Underwri ng Manager); Lion of Africa Life Assurance Company Ltd FSP 15283 (the Insurer) and its Services Providers reserve the right to decline any applica on for cover. This policy shall be voidable in the event of misrepresenta on, mis-descrip on or non-disclosure by or on behalf of an insured person of any par cular material fact to this insurance. Terms and condi ons as contained in the policy document apply.

5 SECTION 3: RULES APPLICABLE TO Chronic Medication BENEFIT (CMB) 1. All personal and medical details must be submi ed accurately by the GP and the pa ent where specifically requested. Certain Chronic condi ons require addi onal clinical informa on to be submi ed with this applica on form. Following Drug U lisa on Review, addi onal clinical informa on may also be requested. 2. Certain Chronic conditions require addi onal clinical informa on to be submi ed with this Application form. Following Drug Utilisa on Review, additional clinical informa on may also be requested. Chronic Diagnosis Cardiac Failure Cardiomyopathy Coronary Artery Disease Dysrhythmias Hypertension BP Reading Hyperlipidaemia Addi onal Informa on - Hyperlipidaemia Exercise BP Reading Smoking If yes, how many cigarettes a day?

6 Lipogram Reading (Ini al/Diagnostic) Date of Lipogram: TCL: LDL: HDL: Triglycerides: Risk Factors: (Please indicate where applicable) Angina/Myocardial infarction Angioplasty/Stent Cerebrovascular Accident (CVA) Family History Peripheral Vascular Disease Transient Ischaemic A ack Addison s Disease Diabetes Insipidus Diabetes Mellitus 1 Diabetes Mellitus 2 Hypothyroidism Addi onal Informa on Diabetes Mellitus1or 2 Date: Glucose tolerance test: Date: Chronic Diagnosis ICD-10 Code Clinical / Laboratory Supporting Documentation Asthma Bronchiectasis Chronic Obstruc ve Pulmonary Disease (COPD) Stage 1 Stage 2 Stage 3 Ini al FEV 1 (spirometry report): Chronic Diagnosis ICD-10 Code Clinical / Laboratory Supporting Documentation Mul ple Sclerosis* * Please note that confirma on of diagnosis by MRI scan is required from a Neurologist Neurologist Prac ce Number: Systemic Lupus Erythematosus Fasting glucose.

7 DD20 MYYMYNYNICD-10 CodeClinical / Laboratory Suppor ng DocumentENDOCRINE DISEASES Chronic Diagnosis ICD-10 CodeClinical / Laboratory Suppor ng DocumentRESPIRATORY DISEASESAUTO IMMUNE DISEASES: Chronic Diagnosis ICD-10 Code Clinical / Laboratory Supporting Documentation Crohn s Disease* Ulcera ve Colitis GASTROINTESTINAL DISEASES: Chronic Diagnosis ICD-10 Code Chronic Diagnosis ICD-10 Code Clinical / Laboratory Supporting Documentation Epilepsy Parkinson s Disease GASTROINTESTINAL DISEASES:DD20 MYYMDD20 MYYMH ypothyroidismRheumatoid ErythematosusLife AssuranceLion OF AFRICAA ffinity Health (Pty) Ltd (the Product Supplier); Na onal Risk Managers (Pty) Ltd (the Underwri ng Manager); Lion of Africa Life Assurance Company Ltd FSP 15283 (the Insurer) and its Services Providers reserve the right to decline any applica on for cover.

8 This policy shall be voidable in the event of misrepresenta on, mis-descrip on or non-disclosure by or on behalf of an insured person of any par cular material fact to this insurance. Terms and condi ons as contained in the policy document apply. Glaucoma Chronic Diagnosis ICD-10 Code Clinical / Laboratory Supporting Documentation Chronic Renal Disease* Glomerular Filtration rate/Crea nine clearance AFFINITY HEALTH (PTY) LTD rules and exclusions will be applied during the review and authorisa on of requested Chronic medica on in respect of any Chronic illness. 2. Only approved General Prac oners within AFFINITY HEALTH (PTY) LTD s Provider Network may apply for Chronic medica on benefits on behalf of AFFINITY HEALTH (PTY) LTD members on the contracted Benefit Plans.

9 3. All approved Chronic medica on may only be obtained from a dispensary within the Medication Distribution Network authorised by AFFINITY HEALTH (PTY) LTD. 4. General Exclusions from Chronic Medication Benefit ( ) include these commonly requested medicines: Exclusions as detailed in the General Prac tioner Provider Manual 5. Access to any Medication through the is subject to Clinical Entry Criteria and Drug Utilisation Review. 6. Disease marked with * will exclude biological Medication . Diagnosis Medica on Name, Strength and Dosage Monthly Quan ty Dura on on Medication Repeats Years Months Are any of the above Diagnoses related to injury on duty?

10 If yes, please state: Date of Injury Injury on Duty (IOD) Number: Chronic Diagnosis ICD-10 Code Clinical / Laboratory Supporting Documentation OPHTHALMOLOGICAL DISEASES:SECTION 4: CURRENT Medication REQUIRED Year Diagnosis Medica on and Strength Dura on of use YIFDIFFERENTFROMCURRENTMEDICATION HISTOR Pa ent Allergies: State any other illnesses the pa ent suffers from: May current medica on be subs tuted with a generic if appropriate? DD20 MYYMYNYNH emophiliaOTHER DISEASES:Life AssuranceLion OF AFRICAA ffinity Health (Pty) Ltd (the Product Supplier); Na onal Risk Managers (Pty) Ltd (the Underwri ng Manager); Lion of Africa Life Assurance Company Ltd FSP 15283 (the Insurer) and its Services Providers reserve the right to decline any applica on for cover.