Co-payments
This is the difference between what the medication costs and what the scheme is prepared to pay (often referred to as the CDA – chronic drug amount). The main reasons why a customer may have a co-payment in a pharmacy are:
* Not using a network (preferred) pharmacy like Clicks.
* Medication prescribed is not on the formulary or is for a chronic condition not covered by the scheme.
* Your Clicks pharmacist can offer you a generic alternative which is covered by your Medical aid.
Prescribed minimum benefits
Prescribed Minimum Benefits (PMB) is a set of defined benefits to ensure that all medical scheme members have access to certain minimum health services, regardless of the benefit option they have selected. The aim is to provide people with continuous care to improve their health and well-being and to make healthcare more affordable.
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:
*any emergency medical condition;
*a limited set of 270 medical conditions (defined in the Diagnosis Treatment Pairs)
* 25 chronic conditions (defined in the Chronic Disease List)
Source: https://www.medicalschemes.com/medical_schemes_pmb/
PMB conditions
Addison’s disease, Asthma, Bipolar mood disorder , Bronchiectasis, Cardiac failure, chronic renal disease, Cardiomyopathy, Coronary artery disease, Chronic obstructive pulmonary disease, Crohn’s disease, diabetes, insipidus, Diabetes type 1 & 2, Dysrhythmias, Epilepsy, Glaucoma, Haemophilia, Hypertension, HIV and Aids (antiretroviral therapy), Hypothyroidism, Hyperlipidaemia (high cholesterol), Multiple Sclerosis, Parkinson’s Disease, Rheumatoid arthritis, Schizophrenia, Systemic lupus erythematosus, Ulcerative Colitis.
Designated Service Provider:
A Designated Service Provider (DSP) is a healthcare provider 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. Clicks has partnered with most medical aids ensuring you don’t pay more for your medication than you have to.
Can my scheme refuse to cover my medication if I need, or want, a brand other than that which the scheme says it will pay for?
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.
Can my scheme make me pay a co-payment or levy on a PMB?
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.
Can schemes still set a chronic medicine limit?
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.
