Medicine for acute conditions
Acute medicine incl. NAPPI coded medicine, prescribed or dispensed by a registered homeopath, are subject to the Overall Out Of Hospital Family Limit and Sublimit 2 (R4 760 per adult, R2 380 per child per year).
Standard Care Plan offers a benefit for Pharmacist Advised Therapy (PAT): R105 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. Once you register, 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.
Prescribed Minimum Benefits (PMB) chronic conditions
The Scheme will pay for medicine for the 26 PMB chronic conditions according to a medicine reference price list and a defined list of medication. By using a medicine reference price list for chronic medicine, Anglo Medical Scheme will pay a specific price for the prescribed medicine. If you choose to use a prescribed drug that costs more than the reference price, you will have to pay the difference.
PMB chronic conditions
- Addison's Disease
- Bipolar Mood Disorder
- Cardiac Failure
- Chronic Renal Disease
- Chronic Obstructive Pulmonary Disease
- Coronary Artery Disease
- Crohn's Disease
- Diabetes Insipidus
- Diabetes Mellitus Type 1
- Diabetes Mellitus Type 2
- Multiple Sclerosis
- Parkinson’s Disease
- Rheumatoid Arthritis
- Systemic Lupus Erythematosus
- Ulcerative Colitis
To confirm which other non-related PMB chronic conditions Anglo Medical Scheme covers and how we classify them, please view eligible chronic conditions here.
Non-PMB chronic conditions
All members who receive medicine for listed non-PMB chronic conditions must register the condition with the Scheme. Registration will also ensure that we pay for non-PMB chronic medicine from the chronic medicine benefit rather than the acute medicine benefit, thus helping benefits last longer. We will pay for medicine for non-PMB chronic conditions according to the medicine reference price list, subject to an annual limit of R4 370 per beneficiary per year.
Consultations and procedures for non-PMB chronic conditions will be paid subject to Sublimit 2 for consultations, visits and acute medicine out of hospital included in the Out Of Hospital Services Family Limit.
The Scheme does not supply medicine; its function is to authorise payment for medicine. Members may use their regular pharmacy or mail order service to obtain medicine for chronic conditions (excluding HIV/AIDS and diabetes medicine).
Non-PMB chronic conditions covered on Anglo Medical Scheme include:
- Allergy Management
- Alzheimer’s Disease
- Ankylosing Spondylitis
- Anxiety Disorder
- Atopic Dermatitis (Eczema)
- Attention Deficit Disorder
- Auto-immune Disorders
- Cystic Fibrosis
- Cystitis (chronic)
- Degeneration of the Macula
- Fibrous Dysplasia
- Gastro-oesophageal Reflux
- Gout (chronic)
- Hidradenitis Suppurativa
- Huntington’s Disease
- Liver Disease
- Meniere’s Disease
- Motor Neuron Disease
- Muscular Dystrophy and other inherited myopathies
- Obsessive Compulsive Disorder
- Paget’s Disease
- Pancreatic Disease
- Peptic Ulcer
- Pulmonary Interstitial Fibrosis
- Restless Leg Syndrome
- Systemic Sclerosis
- Tourette’s Syndrome
- Trigeminal Neuralgia
- Urinary Calculi
- Urinary Incontinence
Chronic Medicine Management
The Scheme has a dedicated management team of registered pharmacists and clinicians whose job it is to manage chronic medicine benefits and to assess members' eligibility for chronic condition funding.
Guidelines are maintained in conjunction with medical specialists, as well as local and international treatment protocols. The vigorous authorisation process has been designed to ensure that chronically ill members maintain their optimum health levels by taking the appropriate medicine in the correct dosages. An effectively managed chronic illness will result in fewer acute or long-term medical complications or side-effects.
To contact the medicine management team, please call 0860 222 633