Clinical criteria for registration on the chronic benefit 2025

Clinical criteria for registration on the chronic benefit (all options) 

Prescribed Minimum Benefit Chronic Disease List (CDL)  conditionsFurther information or tests required
Addison’s diseaseDiagnosis by a specialist physician, paediatrician or endocrinologist
Asthma (adult) Diagnosis confirmed by a GP or specialist
Asthma (child <7 years)Diagnosis made or confirmed by a specialist paediatrician
Bipolar affective disorderPsychiatrist prescription. Benzodiazepines excluded on Chronic Benefit
BronchiectasisDiagnosis confirmed by a specialist (entry criteria for pre-existing conditions will apply eg COPD)
Cardiac failureDiagnosis confirmed by a specialist physician
Cardiac dysrhythmiaDiagnosis confirmed by a specialist physician
CardiomyopathyDiagnosis confirmed by a specialist physician
Chronic obstructive pulmonary diseaseDiagnosis confirmed by a GP or specialist. Emailed copy of Lung function test performed to American Thoracic Society (or similar) criteria demonstrating FEV1/FVC<70% and FEV1 post bronchodilator <70% of predicted
Chronic renal diseaseDiagnosis confirmed by a GP or specialist. Copy of lab results required: serum creatinine clearance value <30ml/min or a Glomerular Filtration Rate estimate of <30ml/min
Coronary artery diseaseDiagnosis confirmed by a specialist physician
Crohn’s diseaseDiagnosis by a specialist physician, paediatrician, surgeon or gastroenterologist
Diabetes insipidusDiagnosis by a specialist physician, paediatrician, neurologist, neurosurgeon or endocrinologist
Diabetes mellitus type 2Diagnosis confirmed by a GP or specialist physician. Confirmatory lab results: 
  •  HbA1c >6% or 
  •  x2 random glucose >11mmol/l or 
  •  x2 fasting blood >7mmol/l or 
  •  x1 blood glucose >I5mmol/l or
  •  GTT (fasting glucose of 7mmol/l or more and/or 2 hours post prandial glucose load of 11.1mmol/l or more)
Diabetes mellitus type 1Specialist initiation and confirmatory lab results as above
Epilepsy Diagnosis confirmed by a GP, specialist physician, neurologist or neurosurgeon
GlaucomaDiagnosis confirmed by an ophthalmologist
HaemophiliaDiagnosis confirmed by a specialist physician. Copy of lab results of Factor VIII or Factor IX levels of 5% or less
HyperlipidaemiaDiagnosis confirmed by a GP or specialist physician. Copy of lipogram results and documentation related to the risk assessment (Framingham Risk Score). Details of patient history: established vascular disease and details of any procedure performed eg angioplasty, stent, etc. Details of family history from prescribing doctor (to include details of cardiovascular events in member’s first degree relatives, including age of onset)
HypertensionDiagnosis by a GP or specialist physician
HypothyroidismDiagnosis confirmed by a GP or specialist
Multiple sclerosisDiagnosis confirmed by a specialist physician or neurologist. Initial application must be accompanied by a motivation which details disease progress, the EDSS score and an MRI report.
Parkinson’s disease Diagnosis confirmed by a neurologist
Rheumatoid arthritisDiagnosis confirmed by GP and a tick sheet to be completed, or diagnosis confirmed by a specialist physician, paediatrician or rheumatologist. We also require the following clinical information: Serum rheumatoid factor (RF), anti-CCP, ESR or C-reactive protein (CRP) and relevant x-rays
SchizophreniaDiagnosis confirmed by a psychiatrist or paediatric psychiatrist
Systemic lupus erythematosusDiagnosis by a specialist physician, paediatrician or rheumatologist
Ulcerative colitisDiagnosis by a specialist physician, surgeon or gastroenterologist

  

Non-Prescribed Minimum Benefit  Chronic Disease List (CDL) conditionsFurther information or tests required
AcneAuthorised for maximum of 6 months at a time. Soaps and cleansers will not be allocated benefit on Chronic.
Allergic rhinitisEither nasal corticosteroids (preferred) or oral antihistamine
Ankylosing spondylitisSpecialist prescription
Aplastic anaemiaSpecialist prescription
Attention deficit hyperactivity disorderDiagnosis confirmed by a paediatrician, psychiatrist or neurologist
Benign prostatic hypertrophyUrologist prescription
Cushing’s diseaseSpecialist prescription
Cystic fibrosisSpecialist prescription
DermatomyositisSpecialist prescription
EczemaDermatologist prescription required for immunosuppressants. Benefits allocated for 6 months at a time
GoutDiagnosis confirmed by a GP or specialist
HypoparathyroidismSpecialist prescription
Major depressionBenefits allocated for 6 months at a time. Benzodiazepines excluded on Chronic Benefit
MenopauseHormone profile for patients < 50 years unless prescribed by a gynaecologist or hysterectomy done
Motor neurone diseaseSpecialist prescription
Muscular dystrophy Specialist prescription
Myasthenia gravisSpecialist prescription
Narcolepsy Specialist prescription
Obsessive compulsive disorderPsychiatrist prescription
OsteopeniaDexa scan results required indicating osteopenia and fracture history if applicable
OsteoporosisDexa scan results required indicating osteoporosis
ParaplegiaLetter of motivation detailing clinical history from prescriber
PemphigusDermatologist prescription
Pituitary micro-adenomasSpecialist prescription
Post-traumatic stress syndromePsychiatrist prescription
PsoriasisA dermatologist prescription will be required for immunosuppressants
QuadriplegiaLetter of motivation detailing clinical history from prescriber
SclerodermaSpecialist prescription
StrokeSpecialist prescription
Systemic sclerosisSpecialist prescription
Thromboangiitis obliteransSpecialist prescription
Thrombocytopenic purpuraSpecialist prescription