Chronic Conditions
A condition is regarded as chronic if it persists for a long time. A chronic disease is one that lasts three months or more and (in some cases) cannot be cured.
Chronic diseases tend to be more common with ageing. Although common and costly, many chronic diseases, such as heart disease, cancer, diabetes and stroke, are also preventable. Certain chronic conditions are linked to bad lifestyle choices which are within your power to change. Eating nutritious foods, becoming more physically active and avoiding tobacco can help keep you from developing many of these diseases and conditions. Even if you already have diabetes, heart disease, arthritis or another chronic condition, eating healthier food and doing more exercise, whether it’s a brisk walk, a bike ride, a jog or a swim, can help you better manage your illness, avoid unnecessary complications and prolong your life.
AMS has embarked on a campaign to create awareness of the possibility that you or a dependant might suffer from a chronic condition, based on the medication you claim for from your Out-of-Hospital benefits. Please phone 0860 222 633 if you have received a letter from us informing you that you might have a chronic condition OR if you are claiming for medication for three months or more, to determine whether you are suffering from a chronic condition.
Bipolar disorder is an illness characterised by extreme changes in mood, energy, thinking and behaviour. These extreme mood swings take sufferers from grave depression to extreme mania in a matter of weeks. The length of these extreme highs and lows vary from person to person. While men and women are equally affected by the condition, men tend to have more manic episodes while women experience more depressive episodes.
Cover will not automatically be provided from the correct chronic benefit, as clinical entry criteria will still apply. Let’s look at an example: If your doctor diagnoses you with sugar diabetes, certain blood tests are needed to determine whether you do indeed suffer from this condition. In this instance, a blood glucose test and a test called an HbA1c will be done and depending on the results, you may or may not meet the entry criteria. If the condition meets the entry criteria, and the condition is recognised as a chronic condition, it will be registered and paid from a specific benefit.
In certain conditions, the Scheme will only register and pay for your chronic condition if you are diagnosed by a specialist, i.e. if you are diagnosed with cancer, rheumatoid arthritis, schizophrenia, etc.
What to do in the unfortunate event that you are diagnosed with cancer, kidney disease or need an organ transplant?
Firstly, ask your doctor to phone the pre-authorisation line on 0860 222 633 to register your condition. An application form with your relevant treatment plan will be submitted to the Scheme for approval. Once approved, you can start the treatment.
A VERY IMPORTANT POINT TO REMEMBER: Should the treatment prescribed by your doctor change in any way, you need to contact the pre-authorisation team again as treatment will be rejected if your treatment plan is not adjusted. PMB (Prescribed Minimum Benefits) chronic conditions like for instance, Asthma, high blood pressure, HIV also have a treatment plan that allows for selected pathology tests, doctors consultations or procedures etc. covered from the risk benefit and not your day-today benefits. Refer to your benefit booklet and the PMB chronic condition list.
Should you exceed the allocated treatment, these will be paid from available out-of-hospital benefits. Please be on the look-out for documentation that will be sent out shortly if you are registered for a chronic condition confirming your entitlement. It is important for you to go for these consultations and tests to ensure that your condition is well managed.
Once you are registered for a chronic condition covered by AMS, you can find out here on the Scheme website how we fund certain medication. Visit > Plans & Products > Standard or Managed Care Plan > Medicines.
Value Care Plan members must phone Primecure on 0861 665 665 to confirm your benefits.