AN EXPLANATION OF SELFMED’S APPLICATION OF PRESCRIBED MINIMUM BENEFITS (PMB’s):
The benefits as described in the benefit summaries of all the Selfmed Options as found under the Benefits/Contributions 2010 include benefits for PMB’s and these benefits may be obtained at any chosen service provider, unless specifically stated otherwise.
Where the above-mentioned benefits do not provide for PMB’s or only provide limited benefits in respect of PMB’s, a beneficiary is entitled to the following PMB’s benefits:
1. Beneficiaries are entitled to an unlimited benefit in excess of that provided elsewhere in the Option’s benefits and without the imposition of any restrictions or co-payments, provided that the treatment or medication is then obtained from the public healthcare system, Clicks Direct Medicines or Chronicare courier pharmacy, or such other Designated Service Provider, as approved by the Scheme, subject to the following condition:
1.1 Registration on the Scheme’s Prescribed Minimum Benefit Management Programme and in accordance with the Scheme’s management protocols, guidelines and medicine formulary, except in an Emergency.
2. Benefits will be covered in full if a Beneficiary Involuntarily obtains treatment or medication for PMB’s from a provider other than the public healthcare system or Chronicare courier pharmacy, under any of the following conditions:
2.1 The approved treatment and/or medication was not available from the Designated Service Provider, as approved by the Scheme; and/or
2.2 The approved treatment and/or medication could not be provided without unreasonable delay; and/or
2.3 Immediate medical or surgical treatment was required under circumstances which precluded the Beneficiary from obtaining such treatment or medication from the Designated Service Provider, as approved by the Scheme; and/or
2.4 No Designated Service Provider, as approved by the Scheme, is within reasonable proximity of the Beneficiary’s place of business or personal residence.
3. Beneficiaries will be liable for a 40% co-payment in respect of the cost of the treatment or medication received for PMB’s if any of the following conditions apply:
3.1 The Beneficiary knowingly declined a formulary drug that is clinically appropriate and effective and opted to use another drug for treatment of a PMB’s condition; and/or
3.2 The Beneficiary voluntarily elected to obtain the treatment or medication for PMB’s from a provider other than the Designated Service Provider.
4. Where diagnostic tests and examinations are performed but do not result in confirmation of a Prescribed Minimum Benefit diagnosis, except for an emergency medical condition, such diagnostic tests or examinations are not considered to be a Prescribed Minimum Benefit.
