Medicine
Medicine for acute conditions
Acute medicine prescribed by a healthcare practitioner including injection materials, NAPPI coded medicine prescribed or dispensed by a registered homeopath, are subject to the Overall Out of Hospital Family Limit and Sublimit 2 (R5 830 per adult, R2 910 per child per year). Standard Care Plan offers a benefit for Pharmacist Advised Therapy (PAT): R135 per purchase, 5 purchases per family every 3 months, subject to Sublimit 2 and the Overall Out of Hospital Family Limit.
Pharmacists charge for medicine at the Single Exit Price (SEP), a set price for medicine, plus a dispensing fee. The Scheme promotes the use of generic medicine to minimise out-of-pocket expenses. If there is no generic medicine available, the Scheme may reimburse branded medicine at a level known as the therapeutic price for the class of medicine that has been prescribed.
Visit the knowledge library to learn more about Reference Pricing and how to avoid co-payments. To find out how we will cover your medicine, if co-payments will apply, or which alternative medicine you may use, please use our medicine search tool.
We encourage you to use pharmacies in our network so you do not pay more than you need to. To find a pharmacy in our network, call 0860 222 633 or use the Pharmacy Network look up function.
With the exception of the treatment of HIV/AIDS and diabetes, the Scheme does not ask members to use specific Designated Service Providers for medicine. We may review this in future.
Medicine for chronic conditions
Members of the Standard Care Plan with chronic conditions need to register their conditions with the Scheme to ensure appropriate funding. You have access to non-PMB and PMB chronic medication as listed. Once you register for a PMB condition, the Scheme's Administrator will send you a treatment plan.
You need to ensure the diagnosis code for the registered chronic condition (known as an ICD-10 code) reflects on all accounts. This is to ensure that you get cover from the correct benefit.
The Scheme will authorise one month's supply at a time and pays 100% of the Single Exit Price (SEP) and dispensing fee, subject to the Medicine Reference Price List. Generic medicine, where appropriate, will prevent co-payments. You can look up co-payments and generic alternatives here.
The funding of chronic medicine is subject to Scheme protocols and to registration by your doctor or pharmacist.
How to register for chronic medicine
Your healthcare provider or pharmacist must call 0860 222 633 to obtain authorisation. No chronic application forms are required, unless specifically requested.
We need the following information:
- Membership number and the name of the patient
- Details of the medicine prescribed
- Medical condition/diagnosis (ICD-10 code)
- Name and practice number of the prescribing healthcare provider
- The Scheme may require additional test results relevant to the chronic condition.
If you are currently registered and if you qualify for chronic benefits, you do not have to re-authorise the chronic condition or medicine, unless specifically requested to do so.
Your chronic medicine, consultations, diagnostics and other treatments relevant to a specific condition will automatically be renewed for the year ahead. You need to follow the Scheme's treatment protocols.
Legislation requires healthcare providers to renew prescriptions every six months. This does not mean that you need to renew your chronic medicine authorisation every six months, unless specifically requested.