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.

* 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.

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).
 

	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).

	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).

A set chronic medicine benefit amount is used to cover non-PMB conditions (R11 730 per family per year for 2021).

PMB conditions are covered separately, and unlimited.

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 conditions are covered separately, and unlimited. Pharmacy Direct is the DSP.

Should you or one of your dependants be diagnosed with a chronic condition for which you are currently not registered on the Chronic Medicine Management programme, you should follow the steps below to apply for this benefit:

• Check the PMB and other Scheme-approved Chronic Conditions list to ensure that your condition is covered on your selected Plan. Refer to Which basic chronic conditions are covered by all Plans? for a full list of conditions covered.

• Complete a chronic medicine benefit application form. Application forms can be obtained from the ScriptPharm (ScriptNet) website or call ScriptPharm on 011 100 7557 to request an application form and it will be faxed, emailed or posted to you.

• Take note of the instructions on the application form and ensure that both you and your doctor(s) sign the application form.

• Certain diseases require additional test results, motivation and supporting documentation and in some cases a specialist must complete the application form.

• All completed applications should be posted, faxed or emailed (see details below).

• Incomplete application forms will cause a delay in processing your application.

• Do not submit the original prescription. It must be presented to your pharmacist to obtain the medication, once approval has been obtained.

Your application will be processed as follows

• Clinical Entry Criteria will be applied, which means that your application must meet certain clinical criteria before chronic medicine benefits will be authorised. ScriptPharm pharmacists, supported by medical advisers, will review your application to ensure that the most appropriate and cost-effective medication is authorised. The use of cost-effective medication ensures cost containment without compromising the quality of care.

• Medicines will be covered in full, without co-payments, if they are listed on the Chronic Medicines formulary. This list of cost-effective medicines is based on local and international studies, and complies with the criteria developed by the Council for Medical Schemes.

• Chronic medicines will be approved from the date of receipt of the prescription/application, provided that the application is fully completed and includes all supporting documentation. The Scheme will not backdate chronic medicine authorisations prior to the date of receipt of the prescription/ application.

• You will receive a confirmation letter indicating the outcome of your chronic medicine benefit application. Please read this letter and note the end date of the chronic medicine authorisation. The confirmation letter, together with a valid prescription, must be presented at a Nedgroup Network Pharmacy. Pharmacies will not dispense your chronic medication without a valid prescription.

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

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.

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.

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.

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.