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Medicine Risk Management

If you are diagnosed with a chronic healthcare condition, that is covered by the Scheme, you can obtain special benefits to help you better manage your health. Chronic cover for the 26 CDL (Chronic Disease Lists conditions) is unlimited with no co-payments or levy if the medicine is on the Scheme’s formulary and the price of the medicine is equal or less than the reference price for the product. A co-payment will apply if medicine is not on the formulary.
Prescribed Minimum Benefits (PMBs)
The prescribed Minimum Benefits require medical schemes to cover the diagnosis, medical management and medicine for a specified list of 26 chronic conditions known as the Chronic Disease List. This means that the medical scheme covers the medication, doctors’ consultations and tests related to the condition. The scheme makes use of protocols, formularies (lists of preferred medicines) and Designated Service Providers (DSPs) to manage this benefit. The reference pricing, i.e. the price the Scheme will cover, applies to authorised medication. Click here for the chronic medication formulary The 26 PMB conditions are:
  • Addison’s disease
  • AsthmaBipolar Mood DisorderBronchiectasisCardiac failure
  • CardiomyopathyChronic obstructive pulmonary disorder
  • Chronic renal disease
  • Coronary artery disease
  • Crohn’s disease
  • Diabetes insipidus
  • Diabetes mellitus types 1 & 2
  • Dysrhythmias
  • Epilepsy
  • Glaucoma
  • Haemophilia
  • HIV
  • Hyperlipidaemia
  • Hypertension
  • Hypothyroidism
  • Multiple sclerosis
  • Parkinson’s disease
  • Rheumatoid arthritis
  • Schizophrenia
  • Systemic lupus erythematosus
  • Ulcerative colitis

HOW TO APPLY

There are two methods that you can use to obtain your chronic medication authorisation:

Telephonic application process

  • Ask your doctor or the pharmacist to contact the MRM Pharmacist-on-line on 0860 100 078 for chronic medication.
  • Relevant details pertaining to the application will be obtained from your doctor.
  • Your application will be processed immediately.
Written application process
  • Contact the client services team on 0860 100 078. An application form and reference guide will be emailed on request. Alternatively, you can CLICK HERE to download a form
  • Complete the applicant’s section of the MRM Programme application form.
  • Ask your doctor to complete the practitioner’s section of the form.
  • Check that the application form is correctly completed and accompanied by test results or specialist reports as indicated on the application form. (An incomplete form will delay the processing of your application).
  • Send the application form, together with the requested information, to the MRM Department by either:
IMPORTANT

When members or healthcare professionals contact us, it is important to have the:

  • membership number
  • date of birth of the person applying
  • copy of the current prescription
  • ICD 10 code
  • doctor’s practice number

To authorise certain medicine members may also need to supply your:

  • previous medicine details
  • clinical examination data, e.g. weight, height, BP readings, smoking status, allergy information
  • test results, e.g. Lipogram results, Hba1c, lung function tests. 
  • motivation provided from your prescribing doctor

AUTHORISATION OF MEDICATION

Please request your doctor to submit a separate, handwritten prescription listing only your approved chronic medication.

To obtain your authorised medication, show both the medication authorisation letter and the doctor’s handwritten prescription to the dispensing pharmacist or doctor.

If you pay cash, please submit the receipt and a copy of your doctor’s prescription to the Scheme to ensure that you are refunded.

If your doctor wishes to add or discontinue the use

of certain medication or change the strength or dosage of your medication, your doctor is required to either complete a new application form or contact us for the change to be authorised. We may require additional information from your doctor or pharmacist to authorise treatment. Based on this information your chronic condition will be registered and the appropriate medicines will be authorised. You will also be informed if you are liable to pay any co-payment/s or if the medicines are not covered on your medical scheme option.

If you or a member of your family on the scheme Is HIV-Positive, contact Aid for Aids Disease Management confidentially on 0860 100 646 or email afa@afadm.co.za