Co-payments
Reference Pricing explained
Once you are diagnosed with a chronic condition, your pharmacist or doctor should register it with Anglo Medical Scheme. After approval, the treatment for the chronic condition will be paid from a chronic benefit and not from your day-to-day benefits. But, even after approval you might find that certain claims are not paid in full and you cannot understand why you have to make a co-payment.
To offer members a choice in the range of medications available, the Scheme has developed a pricing mechanism to minimise members’ out-of-pocket expenses. This is called Reference Pricing.
Anglo Medical Scheme applies two types of Reference Pricing simultaneously and will only reimburse a product at the lower of the two prices applicable to your plan option. If your doctor prescribes a product that is above any of the relevant reference prices, you will need to pay the difference in price at the point of dispensing.
The two types of Reference Pricing are:
- Maximum Medical Aid Price
This is the maximum price that the Scheme will pay for generic drugs. A generic drug is a copy of the original drug that may be sold once a company’s patent on a brand-name drug has expired. Generic drugs have the same active ingredient(s), strength and dosage form as the original drug. Generic drugs are typically cheaper than the original or brand-name drug as they don’t carry the research and development costs that are incurred by the originating company.
You might still incur a co-payment even if you are using a generic product as there might be a cheaper generic option available.
- Therapeutic Reference Pricing
This is the maximum price that the Scheme will pay for a specific class of drugs. Also referred to as the Anatomical Therapeutic Chemical Classification System (ATC) it is a way of classifying drugs according to their functions. Each therapeutic class is a group of similar drugs classified together because they treat the same medical condition or system of the body, such as the respiratory system. For the Therapeutic Reference Pricing it does not matter whether the drug is generic or a brand name.
If your doctor prescribes a more expensive drug and you choose to use it, you will remain responsible for the co-payment. If, in your doctor’s opinion, you cannot use any other drug due to risk factors, your doctor can contact the Anglo Medical Scheme on 0860 222 633 to consider your case.
Remember: Reference Pricing is adjusted every year, so your co-payment might change from year to year or you might incur a co-payment where you never had one.