Benefits: Chronic Medicine

What is a chronic condition?

A chronic condition is one that requires on-going, long-term or continuous medical treatment. However, the Scheme’s chronic medicine benefit does not necessarily cover all these conditions.

Which basic chronic conditions are covered by all Plans?

Prescribed Minimum Benefits (PMB) Chronic Conditions

There are 26 PMB chronic conditions that must be covered in terms of the regulations governing medical schemes, referred to as the PMB Chronic Conditions – see PMB Chronic Conditions listed in the table below. To manage the risk and ensure that appropriate standards of health are applied, treatment algorithms were developed for these PMB Chronic Conditions. These algorithms, which have been published in the Government Gazette, can be regarded as benchmarks, or minimum standards, for treatment. This means that the treatment your medical scheme must cover is not allowed to be inferior to the published algorithms.

If you have one or more of the 26 PMB chronic conditions and meet the clinical entry criteria, your medical scheme will cover your chronic medication and issue a PMB treatment plan indicating your cover for any GP consultations and relevant tests. The Scheme may make use of protocols, formularies (list of specified medicines) and Designated Service Providers to manage this benefit.

The Scheme also covers Diagnosis and Treatment Pairs (DTP). A DTP links a specific diagnosis to a treatment and therefore broadly indicates how each of the approximately 270 PMB conditions should be treated.

Where the DTP includes chronic medicine as the appropriate treatment, the DTP will be covered by the Scheme (subject to protocols, formularies and the use of DSPs). The following conditions are part of the DTP list:

  • Deep vein thrombosis
  • Hormone replacement therapy
  • Hypofunction of the pituitary gland
  • Hyperthyroidism
  • Hypoparathyroidism

To better understand this benefit, it helps to be familiar with the following terms and what they mean:

Chronic Medicine Formularies

A formulary is a list of cost effective evidence-based medicines that the Scheme will cover for the treatment of your chronic condition. These lists are compiled by the Scriptpharm Risk Management and are reviewed quarterly.

Reimbursement is subject to clinical guidelines and protocols. The Scheme applies a Standard Formulary and an Advanced Formulary as part of the guidelines.

  • The Standard Formulary, applicable to the Hospital and Savings Plans, contains a list of medicines that provide cover for the listed chronic conditions.
  • The Advanced Formulary, applicable to the Platinum, Comprehensive and Traditional Plans, provides access to a wider range of medicines than the Standard Formulary.

If you choose to use a medicine that is not on your Plan’s formulary, and you do not have a motivation for this non-formulary medicine (which would then be reviewed and considered for approval), you will have to pay for it from your own pocket. The formularies are updated throughout the benefit year. Any products that are removed from the formulary will be communicated to you during the year. It is important for you to discuss changing to an alternative medicine with your treating doctor, or the medication will be covered from your available Everyday Services Benefits and thereafter will be for your own account.

THE OFFICIAL PMB CONDITIONS
  1. Addison’s disease
  2. Asthma
  3. Bipolar mood disorder
  4. Bronchiectasis
  5. Cardiac failure
  6. Cardiomyopathy
  7. Chronic renal disease
  8. Chronic obstructive pulmonary disease (emphysema)
  9. Coronary artery disease (angina pectoris and ischaemic heart disease)
  10. Crohn’s disease
  11. Diabetes insipidus
  12. Diabetes mellitus type 1 & 2
  13. Dysrhythmias
  14. Epilepsy
  15. Glaucoma
  16. Haemophilia
  17. HIV/AIDS*
  18. Hyperlipidaemia (high cholesterol)
  19. Hypertension (high blood pressure)
  20. Hypothyroidism
  21. Multiple sclerosis
  22. Parkinson’s disease
  23. Rheumatoid arthritis
  24. Schizophrenia
  25. Systemic lupus erythematosus
  26. Ulcerative colitis

* Please refer to the HIV and AIDS management programme for more information on benefits available.
 
 

ADDITIONAL SCHEME-APPROVED CHRONIC CONDITIONS

The Scheme covers the following approved chronic conditions on the Platinum, Comprehensive, Traditional and Savings Plans.

ADDITIONAL SCHEME-APPROVED CHRONIC CONDITIONS
  1. Acne (cystic nodular)
  2. Allergic rhinitis (no criteria for Platinum, Comprehensive and Traditional Plans, while for Savings Plan will only be approved for children under the age of 12 years, or for patients on concurrent asthma therapy)
  3. Anxiety (if linked to another approved psychiatric chronic condition)
  4. Attention deficit syndrome (if prescribed by a specialist and under the age of 18 years)
  5. Behcet’s Disease
  6. Depression/Mood disorders
  7. Eczema
  8. GORD
  9. Gout
  10. Hypofunction of the pituitary gland
  11. Insomnia (sleep disorders) (if linked to another approved psychiatric chronic condition)
  12. Migraine prophylactics (prevention)
  13. Obsessive Compulsive Disorder
  14. Paget’s Disease
  15. Psoriasis
  16. Sjogren’s Disease

In addition, for Platinum, Comprehensive and Traditional Plans: Alzheimer’s disease, Urinary tract infections, Cystitis, Chronic Sinusitis, Osteoarthritis and Osteoporosis

 

How are chronic medicine benefits covered under each Plan?

It is important to understand the different ways in which the Plans cover chronic medicine (for example, although Platinum Plan is a higher-cost plan with richer day-to-day benefits, it is typically not suited to members with both PMB and non-PMB chronic conditions).
 

PLATINUM
PMB chronic conditions All chronic medicine benefits (both PMB and non-PMB) are first covered from a set chronic medicine benefit limit (R11 730 per family per year for 2021).
Non-PMB chronic conditions small

 

SAVINGS
PMB chronic conditions All chronic medicine benefits (both PMB and non-PMB) are first covered from a set chronic medicine benefit limit (R11 730 per family per year for 2021).
Non-PMB chronic conditions small

 

TRADITIONAL
COMPREHENSIVE
Non-PMB chronic conditions small A set chronic medicine benefit amount is used to cover non-PMB conditions (R11 730 per family per year for 2021).
PMB chronic conditions PMB conditions are covered separately, and unlimited.

 

HOSPITAL
Non-PMB chronic conditions small A set chronic medicine benefit amount is used to cover Major Depression only (R4 580 per family per year for 2021).
Pharmacy Direct is the DSP.
PMB chronic conditions PMB conditions are covered separately, and unlimited.
Pharmacy Direct is the DSP.

 

  PLATINUM COMPREHENSIVE SAVINGS HOSPITAL
TRADITIONAL
26 PMB chronic conditions

Subject to pre-authorisation and approval of the chronic medicine

100% of medicine price for PMB and non-PMB chronic medicine subject to R10 790 per family per year, provided it is obtained from a DSP (Nedgroup Network pharmacy). Thereafter, chronic medicine claims will be paid from Routine Medical Benefit. Once Routine Medical Benefit is depleted, 100% of cost for chronic medication for the 26 PMB chronic conditions paid from PMB benefit, provided it is obtained from a DSP (Nedgroup Network pharmacy). Advanced Medicine Formulary applies. No further benefit for other Scheme-approved chronic conditions. 100% of cost for chronic medication paid from PMB benefit, provided it is obtained from a DSP (Nedgroup Network pharmacy).

Advanced Medicine Formulary list applies.

100% of medicine price for PMB and non-PMB chronic medicine, limited to R10 790 per family per year provided it is obtained from a DSP.

Once chronic medicine benefit limit for PMB and non-PMB chronic medicine is depleted, 100% of cost for chronic medication for 26 PMB chronic medicine paid from PMB benefit, provided it is obtained from a DSP (Nedgroup Network pharmacy).

Once chronic medicine benefit limit is depleted, other scheme-approved chronic medicines will be covered from your available savings provided it is obtained from a Nedgroup Network pharmacy.

Once your savings is depleted, you will be liable for payment from your own pocket.

Standard Medicine Formulary list applies.

100% of cost for chronic medication paid from PMB benefit, provided it is obtained from a DSP (Nedgroup Network pharmacy).

Standard Medicine Formulary list applies.

Other Scheme-approved chronic conditions

Subject to pre-authorisation and approval of the chronic medicine

100% of medicine price, limited to R10 790 per family per year, provided it is obtained from a DSP (Nedgroup Network pharmacy). Chronic medicine obtained from a pharmacy outside of the network will be paid from your Everyday Services Benefit. Once your Everyday Services Benefit is depleted, you will be liable for payment from your own pocket. Cover for Major Depression only.
100% of medicine price, limited to R4 215 per family per year provided it is obtained from a DSP (Nedgroup Network pharmacy).
Once benefits for other Scheme-approved Chronic Conditions for the year have been exhausted, additional costs are covered as follows
From your Routine Medical Benefit limit. If no more benefits are available, you will have to pay in full at the point of sale. From your Prescribed Medicines limit. If no more benefits are available, you will have to pay in full at the point of sale. From your Personal Medical Savings Account, if there are funds available. Otherwise you will need to pay in full at the point of sale. Other than for Major Depression, no benefit for other Scheme-approved Chronic Conditions. You will need to pay in full at the point of sale.
Medical Management of 26 PMB chronic conditions 100% of cost at DSP paid from PMB benefit, subject to the Scheme’s treatment protocols. If you choose a GP or specialist outside of the network, your claims will first be paid from your Everyday Services Benefit and thereafter be covered by the PMB benefit with a co-payment of 25% that you will need to cover from your own pocket. Nedgroup GP and Specialist network is the DSP for medical management of the 26 PMB chronic conditions. 100% of cost at DSP paid from PMB benefit, subject to the Scheme’s treatment protocols. If you choose a GP or specialist outside of the network, your claims will be covered by the PMB benefit, with a co-payment of 25% that you will need to cover from your own pocket.

Nedgroup GP or specialist network is the DSP for the medical management of the 26 PMB chronic conditions.

PMB standard level of care treatment plan applies.

DSP for chronic medicine Nedgroup Network Pharmacies managed by Scriptpharm is the DSP for chronic medication.

 

How do I apply for the Chronic Medicine Benefit?

 

PRINT
Apply for the Chronic Medicine Benefit
 


Other chronic diseases

Authorisation for other chronic conditions, for example, medicines associated with the treatment of anaemia due to renal failure, organ transplant, life-sustaining conditions and major medical/post-hospitalisation medication, will continue to be managed by Medscheme.

Should you be diagnosed with one of the 270 medical conditions listed as PMB conditions, but that is not on the list of PMB chronic conditions, please contact ScriptPharm Risk Management:

Postal address:
ScriptPharm Risk Management
Postnet Suite No 230, Private Bag X19
Garden View, 2047

Telephone: 011 100 7557

Fax: 086 679 1579

Email: nedgroup@scriptpharm.co.za

Business hours: Monday to Friday 08:00 – 16:30

PLEASE NOTE

Even if your authorisation letter states that it is an ‘ongoing’ authorisation, it is still important for you to send in an updated prescription every six months, or after every visit to your doctor that relates to your approved chronic condition.

 

What if my prescription (medicine/dosage) changes?

If you need new, additional medication or have a change in your current medication strength and/or dosage for a registered condition, it is your responsibility to send these prescription changes/updates directly to ScriptPharm for your authorisation to be amended appropriately.

If the required changes are dosage related and are urgent, your medical practitioner or pharmacist may contact ScriptPharm to process your requested change. Please note that telephonic authorisations initiated by your medical practitioner or pharmacist should only be used in the case of an emergency. Unprocessed authorisation changes will result in your claims being rejected or being processed from your Everyday Services Benefit, or your Personal Medical Savings Account, or from your own pocket. Certain medicines require additional information for approval, and your doctor will be asked to submit this information. Please note that a copy of a valid prescription must be sent to ScriptPharm within seven working days following the telephonic authorisation.

If you have any queries, please call 011 100 7557. Alternatively, you may fax or post a copy of your new prescription to ScriptPharm. Please ensure that your membership number and details are clearly indicated on the prescription.

When a prescription changes, you should include the following information and submit the request to ScriptPharm:

  • Membership number
  • Member’s initials and surname
  • Patient’s initials and surname
  • Patient’s contact details; for example, telephone number, fax number, postal address and/or email address.

How do I obtain an additional month's supply of chronic medication?

If you are travelling and require an additional month’s supply of chronic medication, please supply the following information two weeks before departure:

  • A completed “Extended supply” application form (obtainable from ScriptPharm’s (ScriptNet) website) with a copy of your air tickets/itinerary attached.

If you don’t supply this information, there could be a delay in processing your request. Applications must be received for review at least two weeks before your date of departure.

Who are the Scheme's Designated Service Providers (DSPs) for chronic medication?

You must obtain your authorised chronic medication for PMB and other Scheme-approved chronic conditions from the Scheme’s Designated Service Providers (DSPs).

Hospital Network Plan
Pharmacy Direct has been appointed as the DSP. If members obtain PMB medication from any other pharmacy, there will be a 25% co-payment. If medication for major depression is obtained from any other pharmacy, the member will be liable for the full cost.

Platinum, Comprehensive, Traditional and Savings Plans
Pharmacies that form part of the Nedgroup Pharmacy Network are the DSP.

PMB medication obtained from non-network pharmacies will result in a 25% co-payment. In the case of non-PMB medication obtained from a non-network pharmacy, the member will be liable for the full cost.

How to get your chronic medicine

Pharmacy Direct and Clicks Pharmacy are now the Designated Service Providers for HIV medication.

You must register on the Chronic Medicine Management Programme before you can claim for chronic medicine from your Chronic Medicine Benefits.

To register, or for more information, contact ScriptPharm Risk Management:

Telephone: 011 100 7557

Fax: 086 679 1579

Email: nedgroup@scriptpharm.co.za

Website: www.scriptpharm.co.za
(click on Locate a Nedgroup Pharmacy)

COURIER PHARMACIES

If you do not live within a reasonable distance of a Nedgroup Network Pharmacy, you may use one of the following courier pharmacies as your DSP.

PHARMACY DIRECT
Postal address:
PO Box 7344
Centurion
0046

Telephone: 086 002 7800

Fax: 0866 11 4000/1/2/3

Email: care@pharmacydirect.co.za

Please call me: 083 690 8934

DIS-CHEM DIRECT
Postal address:
Private Bag X 21
Northriding
2162

Telephone: 011 589 2788

Fax: 086 719 4568

Email: direct@dischem.co.za

CLICKS DIRECT MEDICINES
Postal address:
PO Box 30480
Wibsey
1717

Telephone:

General fax line: 0861 44 44 14

Accounts fax line: 0861 44 44 12

Email: clicksdirectmedicines@dirmed.co.za

Web: clicksdirectmedicines.co.za

 

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