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FAQs

What is a Chronic Disease List (CDL) condition?

The CDL is a list of chronic illness conditions for which a Scheme must provide cover for the medicine and treatment. These are conditions such as hypertension, asthma and diabetes.

What is a non-CDL condition?

Non-CDL conditions are additional chronic conditions which may be covered by the Scheme, depending on the chosen benefit option. It is not compulsory for the Scheme to fund treatment of these conditions. These are conditions such as gout and acne. Refer to the Comparative Guide for the list of conditions covered per option.

What are Prescribed Minimum Benefits (PMBs)?

PMBs is a set of minimum benefits which, by law, must be provided to all medical Scheme members and include the provision of diagnosis, treatment and costs of ongoing care.

What is a formulary?

A formulary is a pre-determined list of medicines that will be covered for the CDL, non-CDL and PMB conditions. These lists of covered medicines vary from option to option. Bestmed makes use of formularies for each condition. These formularies are compiled and maintained by a team of professionals on the basis of evidence-based medicine, considering cost effectiveness and affordability.

Bestmed allows flexibility in terms of every member and dependant’s choice of medicine. If a member chooses to make use of a product that is not on the formulary, a co-payment will be applicable. This co-payment varies between the different benefit options, and forms part of Bestmed’s Scheme Rules. 

What is an ICD-10 code?

An ICD-10 code is a diagnosis code, indicating the illness condition for which treatment is being received and is, therefore, compulsory on all medicine applications and prescriptions.

What supporting documentation is required to apply for chronic medicine benefits?

CONDITION

SPECIFIC REQUIREMENT

Addison’s disease

Prescription required from endocrinologist or physician

Ankylosing spondylitis

Prescription required from a rheumatologist or physician

Anaemia

Most recent laboratory report required

Attention deficit disorder (ADD) and Attention deficit hyperactivity disorder (ADHD)

Prescription required from a psychiatrist, paediatrician or neurologist

Alzheimer’s disease

Mini-mental state examination (MMSE) required together with a prescription

Blepharospasm

Prescription required from a neurologist together with a motivation

Autism

Prescription required from a paediatrician, paediatric neurologist or child psychiatrist

Bronchiectasis, cystic fibrosis and pulmonary interstitial fibrosis

Prescription required from a pulmonologist or physician, or a paediatrician (in the case of a child)

Collagen disease/scleroderma and Paget’s disease

Prescription required from a physician

Crohn’s disease and ulcerative colitis

Prescription required from a gastroenterologist or physician together with motivation and supporting documentation

Chronic obstructive pulmonary disease (COPD)

Lung function test (LFT) report is required, which includes the FEV1/FVC and FEV1 post bronchodilator use.

When applying for oxygen authorisation, the following is required:

For initial applications:

  • A valid prescription
  • Blood gas report including oxygen saturation

For extension of authorisation:

  • Compliance report (average daily oxygen use)

Chronic renal disease

Application form must be completed by a nephrologist or physician. Attach supporting laboratory reports

Diabetes mellitus (Type 2)

Submit HbA1c blood test results and/or fasting blood glucose results, pre-treatment value and current values

Diabetes insipidus

Application form must be completed by an endocrinologist or physician

Epilepsy

EEG report must be submitted with the application or a prescription from the neurologist is required or a paediatrician (in the case of a child)

Haemophilia

Prescription required from physician.

For initial applications: attach a laboratory report, reflecting factor VIII or IX levels.

For medicine fill release: dosing chart is required.

Hyperlipidaemia

Lipogram results required

Multiple sclerosis

Prescription required from a neurologist together with supporting scans for initial applications.

Attach a report from a neurologist for applications for beta interferon indicating:

  • a. Relapsing – remitting history
  • b. Extended disability status score (EDSS)

Osteoporosis

Most recent bone mineral density (BMD) test results required

Polyarteritis nodosa/psoriatic arthritis and Sjogren’s syndrome

Application form must be completed by a rheumatologist or physician

Psychiatric conditions

Prescription is required from a psychiatrist. A family practitioner may prescribe the following active ingredients: fluoxetine, citalopram, escitalopram and tricyclic anti-depressants

Rheumatoid arthritis

Prescription required from a rheumatologist. A family practitioner may also submit a prescription together with the pathology report


What is a treatment plan?

For every CDL and PMB chronic condition, where medicine is approved, there is a basic treatment plan that is also loaded. The treatment plan differs from condition to condition and can include consultations, pathology and radiology. These services are paid from Scheme benefits and not from the savings account. For each approved service, there is a maximum allowed per year. 

How are claims paid for a treatment plan?

  • On options that have a day-to-day limit (Beat4, Pace1, Pace2, Pace3 and Pace4), all services on the treatment plan are first pay from that limit and log to the applicable limit. For example, a claim for a consultation will first be paid from the day-to-day consultations limit. Once this limit is depleted, further claims against the treatment plan will be paid from Scheme risk with no monetary value limit, but the quantity limit on the treatment plan will still apply. 
  • Once the maximum on the treatment plan has been reached, any further claims will be covered from the normal day-to-day acute benefits. 
  • This maximum is refreshed on a yearly basis and, from January, the new allocations are made. 
 

What is biological medicine?

A biological is a substance that is made from a living organism or its products and is used in the prevention, diagnosis or treatment of diseases and chronic conditions.

Does Bestmed cover biological medicines?

Yes, but it depends on the chosen option, as well as the condition. Biological medicines are categorised as PMB biologicals and non-PMB biologicals. Approved PMB biological and non-PMB biological medicine costs will be paid from the biological limit first, on the options that have a biological limit (Pace2, Pace3 and Pace4). Once this limit is depleted, only PMB biological medicine costs will continue to be paid, unlimited, from Scheme risk.

General waiting periods and exclusions

If a member has a general three-month waiting period, the member is entitled to apply for CDL and PMB chronic benefits.

If a member has a 12-month condition specific exclusion, the member cannot apply or claim for any services relating to that condition for a period of 12 months. The member can also not apply for a PMB benefit if it relates to the specific condition.

Is the chronic medicine benefit applied automatically?

No. To access the chronic benefit, pre-authorisation is compulsory. Thus, it is the member’s responsibility to apply for chronic benefits.

How does one apply for chronic medicine benefits?

The member and the treating doctor will be required to complete a chronic medicine application form. It is advisable that one presents the treating doctor with a copy of the medicine formulary as it applies to the specific Bestmed Scheme option and the specific chronic condition.

  • Call 086 000 2378 for an application form or log onto www.bestmed.co.za
  • Completed application forms can be sent to:
    • Fax: 012 472 6760 
    • Email: medicine@bestmed.co.za

How long does approval of chronic benefits take?

Once a complete application is received by Bestmed, processing takes approximately two to three working days.

Can my doctor complete a telephonic application for chronic benefits?

Yes, only if the member is already registered on the Bestmed system for chronic medicine. If not, the doctor will need to complete the chronic application form with the relevant supporting documentation, where needed.

When doctors call in and complete a telephonic prescription with one of Bestmed’s pharmacists, it is seen as a legal prescription as the call is recorded. This will not be applicable to pharmacists calling from a dispensing pharmacy as they are not the prescriber.

How does the chronic limit work?

Approved CDL, , non-CDL and PMB medicine costs will be paid from the non-CDL chronic medicine limit first. Thereafter, approved CDL and PMB chronic medicine costs will continue to be paid (unlimited) from Scheme risk. 

Note:

  • Approved medicines for the following conditions are not subject to the non-CDL limit: organ transplant, chronic renal failure, multiple sclerosis, haemophilia. Medicine claims will be paid directly from Scheme risk. 
  • Approved medicine claims for major depression will continue to be funded from Scheme risk once the non-CDL limit is depleted.

What if I forget to send my chronic application in time for registration?

Chronic benefits will only be granted from the date the completed application/prescription is received. No retrospective authorisations will be granted.

What are generic medicines?

A generic medicine is a medicine that contains identical amounts of the same active ingredient in the same strength and in the same dosage form as the original medicine. Generic medicines are approved by the South African Health Products Regulatory Authority (SAHPRA), and must have the same quality and produce an equivalent effect in the body as the original medicine. Benefits of using generic medicines:

  • They are more affordable than the original product.
  • They help extend one’s acute and chronic medicine benefit through the year.
  • They help to prevent co-payments where generic alternatives are available for original medicine.
  • They reduce the rand value of co-payments as they are usually less expensive.

What is the Mediscor Reference Price (MRP)?

A generic reference price is a maximum set price a medical Scheme is prepared to pay for a specific generic molecule for a specific dosage. Bestmed uses the (MRP) as its reference. This allows the prescriber and the member a choice if they want to use a specific brand for whichever  reason. This means that a member may use the original medicine and pay the difference between the price of the chosen medicine and the applicable reference price (thus pay a generic co-payment). Alternatively, the member can use a generic alternative within the reference price range and pay no generic co-payment. Reference pricing is applicable to all medicines, including formulary and non-formulary chronic medicines, as well as acute and over-the-counter (OTC) medicines.

What is a co-payment?

This is the portion of a claim that a member must pay out of pocket directly to the service provider. This co-payment cannot be paid automatically from the available savings account or vested savings account.

Chronic co-payments 2022

 Benefit option  Beat1  Beat2  Beat3  Beat4  Pace1 Pace2  Pace3   Pace4  Pulse1
 CDL/PMB Formulary  No co-payment
 CDL/PMB Non-Formulary 30% 30%  30%  20%  25%  20%  15%  10%  30% 
 Non-CDL Formulary N/A N/A 20% 10%  10%  10%  10%  0%  N/A
 Non-CDL Non-Formulary N/A N/A 30% 20% 25% 20% 15%  10% N/A

When do co-payments apply?

  • Where a medicine is chosen for the treatment of a CDL, non-CDL or PMB condition that is not on the formulary.
  • When the chosen medicine is above the MRP.
  • When the provider charges a higher dispensing fee than that which the Scheme reimburses.
  • Non-CDL conditions have standard co-payments for formulary medicine (except on Pace4).

Why do I still have a co-payment when I use generic medicine?

  • Medicine prices differ and some generic medicines are more expensive than others.
  • Some generics may be more expensive than the MRP.

Why does the co-payment differ from time to time?

The MRP is reviewed and updated on a regular basis, and is dependent on the availability of generic medicines, as well as new generics entering the market. Thus, the change in MRP can affect the co-payment amount.

Why is my medicine rejected even though the condition is covered on my benefit option?

Bestmed applies protocols and funding guidelines in their authorisation process. Should your requested treatment fall outside of these funding guidelines, it will not be approved.

What if I prefer not to use generic medicine?

Should you prefer to use the original product, Bestmed will only reimburse the claim up to the MRP amount. Thus, you will be responsible for the difference in price payable to the provider.

What should I do if my chronic prescription changes?

You need to submit a copy of your new prescription, including the ICD-10 code together with your member number to medicine@bestmed.co.za or fax 012 472 6760.

What must I do if my medicine authorization is about to expire?

One month prior to the date your medicine authorization expires, you must submit a copy of your latest prescription, including the ICD-10 code, with your member number to medicine@bestmed.co.za or fax 012 472 6760.

Please submit your renewed script timeously to Bestmed to ensure correct payment of claims as no retrospective authorisations will be granted.

How often should I submit a chronic prescription to Bestmed?

You should only submit your prescription to Bestmed if your medicine has changed or if your authorisation is about to expire. However, your pharmacy will require a new repeat prescription every six months in order to dispense your medicine.

How often can I claim for my approved chronic medicine?

Chronic medicine claims can be submitted every 24 days.

What happens if I need an advanced supply of my medicine?

a. Approval conditions

Bestmed can grant approval for a member to claim for an advanced supply of medicine in the following instances: 

  • If the member is going to a destination across the local border 
  • If the member is going overseas 
  • If the member is going to a destination where there is no pharmacy in the nearby vicinity (e.g. Kruger National Park) 
  • Please note that Bestmed will not grant approval for an advanced supply of medicine when members are travelling within the borders of South Africa.

b. Approval process

  • Complete the application form for medicine supply advance and return to Bestmed at least two weeks prior to the date of medicine collection.
  • Please attach the following to the completed form: 
    • A copy of the flight ticket or travel document
    • A copy of the prescription for the medicine required for collection 

This information can be emailed to medicine@bestmed.co.za or faxed to 012 472 6760.

Who are the preferred providers for medicine?

These are pharmacies that have committed to providing cost-effective medicines at competitive dispensing fees which are capped at a lower level than non-network pharmacies. Any pharmacy that charges a dispensing fee of not more than 33% with a maximum of R33 (excl. VAT), and charges no additional administration fees, can be regarded as a preferred provider. Bestmed has negotiated providers, that will charge a dispensing fee the same as, or lower than, the Bestmed fee structure. You are advised to obtain your medicine from one of these preferred providers to avoid any dispensing fee co-payments. 

Can my medicine be delivered to me?

Yes, medicine can be delivered to you by any postal pharmacy of your choice. Please refer to the preferred providers list to avoid any dispensing fee co-payments.

What are the contact details for chronic medicine enquiries or information?

Tel:  086 000 2378
Email: medicine@bestmed.co.za  
Fax: 012 472 6760