Chronic Medication

Chronic Medication

Q: What is Chronic medication?

A: Medication that is taken on a daily basis for a period exceeding 6 months is defined as Chronic medication.
Medical aids are obliged to pay for chronic medication when such medication forms part in the treatment of a PMB CONDITION  

Q: How do I register for Chronic meds?

A: Most medical aids have chronic application forms that have to be completed and signed by both the applying patient as well as the treating doctor. Some medical aids only require a script to be mailed to their chronic department. Our staff (Lukrisha & Bev) have been trained in this aspect and will assist you with your application. Chronic applications are best done on your day of discharge – or if you are an out patient, at the end of your consultation (This will aid in avoiding unnecessary delays in having medication paid by your chronic benefit.)

Q: Is there an administrative cost when applying for Chronic Meds?

A: Yes.

Q: Do Medical Aids cover all medication under Chronic benefit?

A: No, only medication related to the treatment of conditions listed in the CHRONIC DISEASE LIST are covered. Medication that are usually not covered by medical aids are : Vitamins, Minerals, Health products & Homeopathic remedies, Ant-acids and meds for gastric reflux / ulcers, Pain medication not related to listed conditions, Psychiatric medication not related to above listed conditions, Fibromyalgia.

Q: Do Medical Aids cover all medication under Chronic benefit?

A: No only medication related to the treatment of conditions listed in the CHRONIC DISEASE LIST are covered. Medication that are usually not covered by medical aids are : Vitamins Minerals Health products & Homeopathic remedies Anti acids and meds for gastric reflux / ulcers Pain medication not related to listed conditions Psychiatric medication not related to above listed conditions Fibromyalgia

Q: Can my scheme make me pay for a PMB from my savings account?

A: No, your scheme cannot charge you a co-payment or levy on a PMB if you follow the scheme formulary and protocol. However, if your scheme appoints a Designated service provider (DSP) and you voluntarily use a different provider, your scheme may charge you the difference between the actual cost and what it would have paid if you had used the DSP or the percentage co-payment as registered in the scheme rules. A Designated Service Provider (DSP) is a healthcare provider (doctor, pharmacist, hospital, etc) that is a medical scheme’s first choice when its members need diagnosis, treatment or care for a PMB condition. If you choose not to use the DSP selected by your scheme, you may have to pay a portion of the bill as a co-payment. This could either be a percentage co-payment or the difference between the DSP’s tariff and that charged by the provider you went to. Medical schemes have to ensure that it is easy for beneficiaries to get to the DSPs. If there is no DSP within reasonable distance of your work or home, then you can visit any provider and the scheme is obliged to pay. When you suffer an emergency condition, or are involved in an accident, you may go to the nearest healthcare facility for treatment, even if it is not a DSP. Your scheme will have to cover the costs. Schemes also have to ensure that the DSPs of their choice can deliver the services needed and without members having to wait unreasonably long. Where a DSP is unable to accommodate or treat a member, the medical scheme remains liable for all the costs of treating the PMB condition at a non-DSP. The State’s healthcare facilities can be, but are not necessarily, DSPs. Before they can be listed as such, schemes have to make sure that their beneficiaries can get to the facilities and that the required treatment, medication and care are listed for.

Q: What is a PMB condition?

A: Prescribed Minimum Benefits (PMB) is a set of defined benefits enabling all medical scheme members to have access to certain minimum health services. This benefit is available to all patients, irrespective of the plan you have chosen. These conditions were identified to ensure that patients suffering from specific conditions are adequately covered by their respective medical aids for continuous, uninterrupted care. PMBs are a feature of the Medical Schemes Act, in terms of which medical schemes have to cover the costs related to the diagnosis, treatment and care of:

Emergency medical conditions

Limited set of 279 medical conditions defined in the Diagnosis Treatment Plan

25 Chronic conditions defined in the Chronic Disease List

Chronic Disease List:
Addison’s disease
Cardiac failure
Chronic obstructive pulmonary disorder
Chronic renal disease
Coronary artery disease
Crohn’s disease
Diabetes insipidus
Diabetes mellitus types 1 & 2
Multiple sclerosis
Parkinson’s disease
Rheumatoid arthritis
Systemic lupus erythematosus
Ulcerative colitis
Bipolar Mood Disorder

Q: Why are some chronic illnesses covered and some not?

A: The diseases that have been chosen are the most common, they are life-threatening, and are those for which cost-effective treatment would sustain and improve the quality of the member’s life.

Q: Can my scheme refuse to cover my medication? What if it is a different brand?

A: Yes, the medical scheme may refuse to cover a part of the expenses. Your scheme may draw up what is known as a formulary – a list of safe and effective medicines that can be prescribed to treat certain conditions. The scheme may state in its rules that it will only cover your medication in full if your doctor prescribes a drug on that formulary. Generally speaking, schemes expect their members to stick to the formulary medication. Often the medicines on the list will be generics – copies of the original brandname drug – that are less expensive but equally effective. If you want to use a brandname medicine that is not on the list, your medical scheme may foot only part of the bill and you will have to pay either the difference between the price of the medication you use and the one on the formulary, or a percentage co-payment as registered in the scheme rules. If you suffer from specific side-effects from drugs on the formulary, or if substituting a drug on the formulary with one you are currently taking affects your health detrimentally, you can put your case to your medical scheme and ask the scheme to pay for your medicine. You can also appeal to the scheme if the formulary drug is ineffective and does not have the desired effect. If your treating doctor can provide the necessary proof and the scheme agrees that you suffer from side-effects, or that the drug is ineffective, then the scheme must give you an alternative and pay for it in full.

Q: Can my scheme still set a chronic medicine limit?

A: Yes, your scheme can set a limit for your chronic medicine benefit. Any chronic medication you claim for will then reduce that limit, regardless of whether or not it is one of the PMB chronic conditions. However, if you exhaust your chronic medicine limit, your scheme will have to continue paying for any chronic medication you obtain from its DSP for a PMB condition.