Designated Service Provider
A Designated Service Provider (DSP) is a healthcare provider/s selected, by the medical scheme concerned, to provide healthcare services to its members. This may apply to pharmacies, doctors and hospitals. Your medical scheme may apply a co-payment on services obtained from a provider that is not a DSP. Refer to you medical scheme rules for more detail.
The World Health Organization defines a generic medicine as a pharmaceutical product that is intended to be interchangeable with an innovator product. The generic product is manufactured without a licence from the innovator company and marketed after the expiry date of the patent or other exclusive rights.
A medicine formulary is a list of medicines, both generics and the originals, which will be reimbursed by a medical scheme. The medicines on a formulary make up a so-called preferred list of medicines. A medical scheme may only pay for medicines that are on this “preferred” list. Medicines that are not included in the formulary or preferred list are sometimes referred to as “non-preferred” medicines and may attract a co-payment, depending on the particular scheme’s rules.
Mediscor Reference Price (MRP)
The MRP is the maximum price which a medical scheme will pay for a certain medicine. It is usually calculated from the average price of a number of generic medicines which cost less than the original medicine. If a member chooses to buy a medicine that costs more than the MRP, he or she may have to pay in the difference between MRP and the cost of the selected medicine. This is called a co-payment (see “Levy or co-payment”). MRP can apply on both preferred and non-preferred medicines (see “Medicine formulary”). The co-payment on MRP can be avoided by choosing generic medicines that cost less than MRP.
Pre-authorisation or condition registration
A member may be required to get authorisation from the medical scheme for selected medicines before the scheme will pay for those medicines from chronic benefits. Sometimes, the member may be required to register for a specific condition before the medical scheme will pay for the medicines that have been prescribed to treat that condition.
A clinical protocol is a set of guidelines that provides details on the correct sequence of diagnostic testing and treatment for a specific condition. A medical scheme may use a clinical protocol to decide of a diagnostic test or treatment is appropriate, and whether the scheme will pay for the test or treatment.
Medicines can be classified into different groups according to the organ or organ system on which they act, or according to their therapeutic or chemical characteristics. Such a group of medicines is known as a therapeutic class.
Levy or co-payment
The portion of the value of the medicine, in terms of the rules of the medical scheme, for which the beneficiary is personally responsible for payment to the provider.
Prescribed Minimum Benefits (PMBs) and the Chronic Disease List (CDL)
PMBs are a set of minimum benefits which, by law, must be provided to all members by their medical schemes. PMBs must be provided regardless of the benefit option that a member has selected. The medical scheme must pay for the costs of diagnostic tests, treatment and ongoing care.
The Council for Medical Schemes (CMS) has compiled a list of conditions, known as the CDL, for which appropriate medicines and other treatments have been specified. Medical schemes must cover the costs of the specified treatment of CDL conditions from PMB benefits. The medical scheme may make use of clinical protocols, medicine formularies and designated service providers to manage PMB benefits.
The CDL consists of:
• Addison disease
• Bipolar mood disorder
• Cardiac failure
• Chronic renal disease
• Chronic obstructive pulmonary disease
• Coronary artery disease
• Crohn disease
• Diabetes insipidus
• Diabetes mellitus type 1
• Diabetes mellitus type 2
• Multiple sclerosis
• Parkinson disease
• Rheumatoid arthritis
• Systemic lupus erythematosus
• Ulcerative colitis.
Besides the conditions on the CDL, medical schemes must also cover the costs of the diagnosis and treatment of emergencies and 270 other specified conditions from PMB benefits. More details about PMBs can be found on the CMS website at http://www.medicalschemes.com/medical_schemes_pmb/index.htm.
Reference pricing is a system that can be used to calculate the price at which a medical scheme will pay for a medicine. Using reference pricing, medicines that are generically or therapeutically the same are grouped together and a maximum price is calculated for that group. Different reference pricing models include the Mediscor Reference Price (MRP), Formulary Reference Price (FRP) and Maximum Medical Aid Price (MMAP®).
The member may have to pay a co-payment if he or she chooses a medicine that costs more than the reference price. The co-payment can be avoided if the member chooses a medicine that costs less than the reference price. The use of the most appropriate alternative should be discussed with a doctor or pharmacist.