Perscribed Minimum Benefits

 

Chronic medicines are for prolonged illnesses that are often life-long. To ensure that the most appropriate and cost-effective treatment is prescribed, payment of medicines for such conditions must be approved by your medical scheme.

The Chronic Medicine Management Programme authorises payment of appropriate, high-quality and cost-effective medicine from the Chronic Medicine Benefit. The diseases that such medicines are authorised for, are determined by your specific scheme option and medical scheme legislation. Medicines for illnesses listed on the Government Chronic Disease List (CDL) have to be paid irrespective of the scheme option a member belongs to.

Each application for authorisation of medicine from the Chronic Medicine Benefit is subject to the current Chronic Medicine Management’s Clinical Guidelines and Protocols. Authorisation and payment of medication from the Chronic Medicine Benefit is also subject to scheme rules, waiting periods, exclusions and available benefits, as amended from time to time.

How to apply:

At Medshield Medical Scheme, we’re continually looking for ways to better your experience with us, and to ensure we are Always there for You. When you’re suffering from a chronic illness, the last thing you want to deal with is the hassle of sorting out cover for your medication. So we’re happy to inform you of the new, more convenient Chronic Medicine Management application process.

It’s really simple. Just a call away.

Your doctor or pharmacist will call the Chronic Medical Management department where a clinical consultant will ask him or her for your information. This is similar to the needed on the Chronic Medicine Management Application Form before. You need to make sure that your doctor has your membership number and the beneficiary’s date of birth.

Your doctor or pharmacist will then pass this on to the consultant along with all the examination results, codes, details and motivations where necessary. Everything is approved on the spot so there are no hassles whatsoever, and no long waiting periods.

 

To register Chronic Medication, just call the Chronic Medicine Management department on 0860 100 608.

Once your application has been approved:

– Once your application has been approved and you are registered, you will receive a Medicine Access Card listing the medicines to be paid from your Chronic Medicine Benefit

– The Access Card will also indicate which medicines are on the Medicine Price List (MPL) and medicines that will attract formulary co-payments (if applicable)

– If the medicine authorised differs from the medicine requested, a letter of explanation will be attached to your Access Card and a copy will be sent to the prescribing doctor

– You will need a hand-written repeat script from your doctor for the medicines listed on the card. The Access Card is not a prescription and cannot be used to have medicines dispensed

– Your doctor determines the number of repeats and will advise you how often he needs to see you to monitor your condition

– Whenever you need to have your medicine dispensed, produce a valid doctor’s prescription together with the Access Card

– The duration of authorisation varies from medicine to medicine – some medicines may be authorised as ongoing, while others may only be authorised for a limited period. The Access Card will indicate the duration for which the medicine has been authorised

 

What if your medicine request has been declined?

– If any medicine request has been declined, e.g. requesting a less costly alternative, a letter of explanation will be sent to you and a copy will be sent to the prescribing doctor

– Please ensure that the appropriate doctor provides the requested clinical information (where relevant)

– For online clinical decisions, your doctor should contact the Chronic Medicine Management Call Centre

– Your request will be reconsidered once all the relevant information has been received

 

What if your authorised chronic medication changes?

– If your chronic medication changes in any way, Chronic Medicine Management needs to be advised

– The quickest and simplest way would be for the prescribing doctor or dispensing pharmacist to contact the Call Centre and advise the clinical staff of the change. The change is then processed (as per the current Chronic Medicine Management Clinical Guidelines and Protocols) within 24 hours.

– If approved, a temporary Access Card can be faxed to the dispenser, enabling him to dispense the medicine without delay.

– An updated Access Card will be mailed to you and if the medicines authorised differ from the medicines requested, you will need a valid doctor’s prescription which matches the new Access Card to enable your pharmacy to dispense the medication.

– Should you wish to fax through an updated script to Chronic Medicine Management, the toll-free fax number may be used. These requests will take approximately 5 working days to process.

 

Chronic Medicine Management Contact Details:

Call Centre number: 086 010 0608
Fax: 080 022 3670/80
E-mail: cmm@medscheme.co.za