10. Medicine Benefits and Processes

1. How does your Scheme define a "chronic condition"?

A condition for which medicine is used for an uninterrupted period of 3 months, and which appears on the Scheme's list of chronic diseases.

2. Who decides on the chronic list and why are some things excluded and others not?

We make use of medical and actuarial skills to determine how the risk associated with medicine expenditure should be managed. We have chosen the route of the life-sustaining type of disease conditions, as well as those which are very disabling. We cannot afford to cover all long-term disease conditions on chronic, without making the contribution unaffordable.

3. Who should apply for chronic medicine benefits?

Any member who belongs to an Option which offers chronic benefits and who suffers from any of the diseases as per the Approved List of Chronic Diseases.

4. What is a Reference Price?

It represents the maximum benefit payable by the Scheme for a specific chronic medicine or class of medicine used to treat a chronic condition. The reference price differs per option and if the cost of the medicine exceeds this price, a co-payment will apply. The reference price limit applies over a 30-day period and fully complies with the prescribed treatment of PMB chronic conditions.

5. What is MMAP (Maximum Medical Aid Price)?

It is the maximum price that a medical scheme will pay for a certain medicine where a generic equivalent exists for this medicine. Even if a brand name medicine is authorised on the chronic programme, you will still have to pay the difference between the brand price and the MMAP should you choose to take the brand medicine. MMAP applies to acute medicine only.

6. Can I claim for chronic medicine rejected under my acute medicine benefit?

Yes, you can. Provided that the medicine is not an exclusion in the Scheme Rules e.g. anti-obesity medicines, stimulants, etc.

7. When I have paid for my medicines myself, what is required from me in order to ensure that I receive a refund from the Scheme?

You must ensure that the invoice is accompanied by a receipt which proves that you have already paid the amount claimed. This will ensure that you, the member, are paid - and not the supplier of that medicine. Your membership number and name must appear on the invoice as well.

8. Can I arrange for more than one month's quantity of medicines to be supplied to me?

No - the Scheme Rules do not allow this. You must make arrangements with your pharmacist or dispensing doctor for delivery of the medicines to you on a monthly basis, should you happen to be away. Chronicare and Clicks Direct Medicines are courier pharmacies that can deliver your medicine anywhere in the RSA.