MedXpert
Making sense of...
Chronic
Medication
Benefits
How to manage your chronic medication benefits
and prevent out-of-pocket payments?
Is this information for you?
If you answer ‘yes’ to the following questions you will benefit from reading this:
- Are you taking medication daily?
- Do you have an out-of-pocket payment when you collect your medication at the pharmacy?
- Do you run out of benefits in your Acute Medicine Benefit before year end?
When does medication qualify as chronic medication?
All Medical Scheme Benefit Options have to cover the 26 Chronic Disease List (CDL) conditions as specified in the Medical Schemes Act. Cover for the medication to treat these conditions will not be paid from the day-to-day acute medicine benefit or medical savings account.
The 26 CDLs are covered by the chronic medication benefit and no annual Rand limit can be applied, as per the legislation.
Medical Scheme Benefit options that only provide benefits for in-hospital events also provide cover for the 26 Chronic Disease List (CDL) conditions.
The more expensive Benefit Options will provide benefits for an additional list of chronic conditions.
How to prevent out-of-pocket payments on chronic medication
Medical Schemes must pay for the 26 CDL conditions and they cannot apply a Rand limit to help manage expenditure. To prevent abuse of benefits and save costs, they contract Designated Service Providers (DSPs) to supply the medication for these conditions to their members.
Another method implemented by Medical Schemes to manage costs is the application of a formulary (List of approved medications) to each chronic condition.
In most cases, the Rand amount Medical Schemes pay out towards medication is amongst the highest claims categories across all benefits. These managed healthcare efforts are necessary to prevent high premium increases.
Out-of-pocket payments of up to 40% can occur when:
- You purchase your chronic medication at a non-DSP
- The medication you are using is not on the formulary (List of approved medication)
Get informed and understand your benefits to prevent unnecessary out-of-pocket payments
Out-of-pocket payments of up to 40% can occur when:
- You purchase your chronic medication at a non-DSP
- The medication you are using is not on the formulary (List of approved medication)
