4. Medicine

4.1 Who should apply for the Chronic Medicine Benefit?

To qualify as an applicant, you must use the medicine for an uninterrupted period of at least three months. The medicine must be prescribed by a medical practitioner and should be prescribed for the treatment of conditions as listed on the Scheme’s list of approved chronic conditions. Your option should also provide a chronic medicine benefit.

4.1.1 List of Chronic Conditions

• Addison’s Disease
  
• Alzheimer’s Disease
  
• Angina
  
• Ankylosing Spondylitis
  
• Asthma
  
• Attention Deficit Disorder
  
• Benign Prostatic Hyperplasia
  
• Bronchiectasis
  
• Cancer
  
• Cardiac Arrhythmias
  
• Cardiomyopathy
  
• Chronic Renal Failure
  
• Congestive Cardiac Failure
  
• Conn’s Syndrome
  
• Chronic Obstructive Pulmonary Disorder (COPD)
  – Emphysema
  – Chronic Bronchitis
  
• Coronary Artery Disease (incl. Angina)
  
• Crohn’s Disease
  
• Cushing’s Syndrome
  
• Cystic Fibrosis
  
• Deep Vein Thrombosis
  
• Dermatomyositis
  
• Diabetes Insipidus
  
• Diabetes Mellitus
  
• Epilepsy
  
• Gastro-oesophageal Reflux Disease (GORD)
  
• Glaucoma
  
• Gout
• Haemophilia
  
• Hyperlipidaemia
  
• Hypertension
  
• Hypoparathyroidism
  
• Hypothyroidism
  
• Ischaemic Heart Disease
  
• Menopause (Hormone Replacement Therapy)
  
• Motor Neuron Disease
  
• Multiple Sclerosis
  
• Muscular Dystrophy
  
• Myasthenia Gravis
  
• Narcolepsy
  
• Organ Transplants (maintenance therapy)
  
• Osteoporosis
  
• Paget’s Disease of Bone
  
• Paraplegia/Quadriplegia (associated medicine)
  
• Parkinson’s Disease
  
• Polyarteritis Nodosa
  
• Psoriasis, incl. Psoriatic Arthritis
  
• Psychiatric Disorders
  – Anorexia Nervosa
  – Bipolar Mood Disorder
  – Bulimia Nervosa
  – Major Depression
  – Narcolepsy
  – Obsessive Compulsive Disorder
  – Panic Disorder, if diagnosed and treated by psychiatrist
  – Post-traumatic Stress Disorder
  – Schizophrenia
  – Tourette’s Syndrome
  
• Pulmonary Interstitial Fibrosis
  
• Rheumatoid Arthritis
  
• Sarcoidosis
  
• Scleroderma
  
• Stroke
  
• Systemic Lupus Erythematosus
• Thromboangitis Obliterans
  
• Thrombocytopaenic Purpura
  
• Ulcerative Colitis
  
• Zollinger-Ellison Syndrome
  

4.2 Application process

4.2.1 How to Register for Chronic Medication?

Your healthcare provider (doctor or pharmacist) can apply for chronic medicine authorisation on your behalf by phoning 0860 247 288.
A member may contact the Scheme on 0860 787 372 and request approval for chronic medicines to be paid from the chronic medicine benefit. It may be necessary to fax a prescription and other information required, such as pathology tests, to the Scheme. If any additional information is required, a pharmacist will contact the doctor. Please make sure that you supply the following information as part of the prescription: membership number and your contact details.

4.2.2 What must I do if my chronic medicine changes, authorisation expires or if I am diagnosed with another chronic ailment?
The quickest and simplest way to address the above would be for your health care provider to contact us and inform the Scheme’s pharmacist on 0860 247 288 of the change. The other option is to fax your new or updated prescription to 0860 633 277. Please remember to include your Selfmed membership number and contact details.

4.3 What is a Generic Reference Price?
It represents the maximum benefit payable by the Scheme for specific chronic medicine or a class of medicine used in the treatment of the chronic conditions as per the Scheme’s list in 4.1.1. The generic reference price differs per option and if the cost of the medicine exceeds this price, a co-payment will apply. The reference price applies over a 30-day period and complies with the prescribed treatment of PMB conditions, as dictated by legislation. Since the generic reference price is applied on a monthly basis, a member retains more control over his/her chronic medicine purchases during the approved period.

4.3.1 What will happen if the quantity of medication purchased in a specific 30- day period exceeds the quantity that was approved?
The reference price for the approved medication will be exceeded resulting in a co-payment by the member.
If, however, a medical practitioner prescribed a higher dosage, this must be motivated to the Scheme, whereafter the reference price will be increased accordingly.

4.4 How does the reference price differ from the generic (MMAP) price?

The MMAP price represents a form of generic reference pricing. A generic equivalent is a medicine that contains exactly the same active ingredients compared to the branded product. These medicines are manufactured by the same or another company once the patent on the branded product expires. As a result, the generic equivalents normally cost less than the branded version. A co-payment will also apply if the cost of the prescribed (branded)
product exceeds that of a generic equivalent.
The generic reference price is based on a medicine class that includes therapeutic equivalents. A therapeutic equivalent is a product that may not share the same active ingredients, yet can be used to treat the same condition and render the same therapeutic outcome. An example would be the
use of Panado (containing paracetamol) and Disprin (containing asprin) that are both used to enable pain relief.

4.5 When is a co-payment on medicine payable?
Any co-payment, regardless of whether it results from the generic reference price being exceeded, and/or a medicine limit being exhausted, and/or the pharmacy or doctor charging a dispensing fee that is higher than the Scheme’s tariff, will be payable at the point of purchase.

4.6 Take-home medicine (TTOs)
A maximum of seven days’ supply of medicine will be allowed on discharge from hospital. This benefit is payable from a member’s hospital benefit, provided the medicine is purchased on the date of discharge.

4.7 Non-prescribed medicine (PAT)

Most common ailments can be treated effectively by medicines available at a pharmacy without a doctor’s prescription. These medicines may be claimed from your PAT benefit. Please ask your pharmacist for advice. PAT is available on Selfmed 80% and Selfmed Selfsure options only.