Benefits: Chronic Medicine


What is a chronic condition?

A chronic condition is a condition that requires ongoing long-term or continuous medical treatment. However, not all these conditions are necessarily covered by the Society’s Chronic Medicine Benefits. The Society specifies the chronic conditions that qualify for this benefit.
 

What chronic conditions are covered by the Society?

There are two main categories of chronic conditions that are covered by the Society:

  • Chronic Disease List (CDL) of Prescribed Minimum Benefits (CDL PMB) conditions
  • Listed non-CDL conditions

 

Chronic Disease List (CDL) of Prescribed Minimum Benefits (CDL PMB) conditions
  1. Addison Disease
  2. Asthma
  3. Bipolar Mood Disorder
  4. Bronchiectasis
  5. Cardiac Failure
  6. Cardiomyopathy
  7. Chronic Obstructive Pulmonary Disease
  8. Chronic Renal Disease
  1. Coronary Artery Disease
  2. Crohn Disease
  3. Diabetes Insipidus*
  4. Diabetes Type 1 & 2
  5. Dysrhythmia
  6. Epilepsy
  7. Haemophilia*
  8. HIV/AIDS
  9. Hyperlipidaemia
  1. Hypertension
  2. Hypothyroidism
  3. Multiple Sclerosis*
  4. Parkinson Disease
  5. Rheumatoid Arthritis
  6. Schizophrenia
  7. Systemic Lupus Erythematosus
  8. Ulcerative Colitis

Medical conditions marked * will only qualify for benefits under specific circumstances. Please contact Mediscor for details in this regard.
 

In addition to the benefits available in respect of the chronic conditions included in the PMBs, beneficiaries may, subject to the conditions set out in the Benefit Schedule and other provisions of the Rules, be entitled to a chronic medication benefit in respect of the chronic conditions listed below (referred to as Listed non-CDL conditions).

Listed non-CDL conditions
  1. Acne
  2. Allergic Rhinitis
  3. Attention Deficit Hyperactivity Disorder
  4. Alzheimer Disease
  5. Ankylosing Spondylitis
  6. Benign Prostatic Hypertrophy
  7. Cushing Disease
  8. Cystic Fibrosis
  9. Deep Vein Thrombosis
  10. Reflux Disease
  1. Gout
  2. Hypoparathyroidism
  3. Hyperthyroidism
  4. Incontinence
  5. Depression
  6. Meniere’s Disease
  7. Menopausal and Perimenopausal Disorders
  8. Motor Neuron Disease
  9. Myasthenia Gravis
  10. Osteoarthritis
  1. Osteoporosis
  2. Paget’s Disease
  3. Paraplegia, Quadriplegia
  4. Peripheral Vascular Disease
  5. Pituitary Adenomas
  6. Psoriasis
  7. Pulmonary Interstitial Fibrosis
  8. Stroke / Cerebrovascular Accident
  9. Systemic Connective Tissue Disorders (incl. Scleroderma and Dermatomyositis)

In the case of the treatment of medical conditions reflected in the above table which may attract a PMB entitlement in terms of the diagnosis and treatment pairs as per Annexure A to the Regulations of the Act, they will be reimbursed a PMB as per Regulation 8.
 

When would it make sense to register for chronic medicine benefits?

If you use medicine for a chronic condition without being registered for chronic medicine benefits, it will be covered from your acute medicine benefit limit (or not covered at all) and you will probably exhaust this benefit limit quite quickly. On the other hand, by registering for chronic medicine benefits (if you have a qualifying chronic condition as provided for by the Society – see What chronic conditions are covered by the Society?, you have access to a far higher benefit limit for your chronic medicine.

Certain terms and conditions apply to the conditions covered, the medicine formularies available for those conditions, and the service providers through which you have to get the medicine [see the question ‘Where do I find a designated service provider (DSP)?’ below]. However, for most members the financial benefit of registering for chronic medicine benefits far outweigh the restrictions.
 

What is the benefit for chronic medicines?

A 100% benefit applies to chronic medicines dispensed for listed conditions (see earlier in this chapter), limited to the lesser of either the Formulary Reference Price (FRP Plus) or the Mediscor Reference Price (MRP) value applicable to the medicine. This is on condition that the medicine is included in the formulary for the authorised condition treated, is below the reference price applied and is obtained from one of the Society’s DSPs. If chronic medicine is obtained from a non-DSP a 30% co-payment will apply in addition to any FRP Plus and MRP co-payments.

CHRONIC MEDICINE
Overall cumulative benefit limit (both CDL PMB and listed non-CDL)
  • PRE-AUTHORISATION REQUIRED From the Society’s Managed-Care department
  • Limited to R41 450.
  • If this limit is reached before yearend, the CDL PMB chronic medicine will continue to be covered in terms of PMB protocols, provided a DSP is used to obtain the medicine and a valid authorisation exists.
  • Managed-care protocols apply.
Biologicals
  • PRE-AUTHORISATION REQUIRED From the Society’s Managed-Care department
  • Limited to R256 020.
  • Managed-care protocols apply.

 

Where do I find a designated service provider (DSP) for chronic medicine?

To receive the full chronic medicine benefit, you must obtain your chronic medicines from one of the Society’s approved DSPs. These are:

  • All Dis-Chem Retail Pharmacies,
  • Dis-Chem Direct (Dis-Chem’s Courier pharmacy),
  • Cullinan Health & Home Pharmacy,
  • The Namaqualand Pharmacy in Springbok, and
  • Dr HA Burger in Springbok.

How do I register for chronic medicine benefits?

Your doctor or pharmacist should contact Mediscor ChroniLine® on 086 011 9553 to obtain pre-authorisation for chronic medicine benefits. A Mediscor ChroniLine® pharmacist will check the request against the Society’s protocols and confirm whether the medicine is authorised.

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