As required by legislation, your medical aid uses two medicine formularies to manage the high costs of medication for the chronic treatment of Prescribed Minimum Benefits (PMB) diseases.
What is a formulary within a medical management company?
A formulary is a list of cost effective, evidence-based medicines that the scheme will cover for the treatment of chronic conditions. These lists are compiled by Medscheme’s Chronic Medicine Management Department (CMM) and are constantly reviewed. Payment is subject to clinical guidelines and protocols, and the Medicine Price List (MPL).
Your scheme may apply either one or both of the following formularies:
The Restrictive Formulary
The Restrictive Formulary applies to basic or restrictive cover options. It lists medicines that provide adequate cover if you have been recently diagnosed, or your condition is mild to moderately severe. Products included on this formulary will require a co-payment if authorised by the CMM and obtained from the Designated Service Provider (DSP).
The Comprehensive Formulary
The Comprehensive Formulary applies to the more comprehensive medical aid options. The formulary provides access to a wider range of medicines for moderate to severe conditions. Products included on this formulary will not require a co-payment if authorised by CMM.
If you choose to continue to use medication that is “out of formulary” you may be required to pay a co-payment upfront at the point of dispensing. Your co-payment can also be affected if the cost of your medication is more than the price shown on the Medicine Price List.
Please also note that if you are required to visit a DSP to obtain your medication and you choose not to, a possible further co-payment may apply as determined by the scheme rules.
Both formularies include alternative products that will not require a co-payment so if you do not wish to incur any co-payments, please discuss alternative therapies with your treating doctor and ensure that you obtain your medication through the appropriate source.
For more CMM information on the chronic application registration, chronic conditions or the formularies, please contact CMM on 086 010 0608 or e-mail firstname.lastname@example.org.