Specialised Medicine and Technology Benefit (SMTB)
Introduction of the new benefit on the Standard Care Plan and Managed Care Plan
The Scheme introduced a Specialised Medicine and Technology Benefit (SMTB) this year. In this article, we explore what this benefit is about and what you need to do to determine if and how the Scheme will fund specialised medicine and technology, as this might have a financial impact on you.
There are two categories that fall within the SMTB
Category 1 – medicine
The Scheme regards any medicine or technology with a cost equal to or above R5 000 per month, or as a once-off purchase, as specialised treatment. One of these expensive medicines might be a biologic (a product that is produced from living organisms or contains components of living organisms. Biologic drugs include a wide variety of products derived from human, animal or microorganisms using biotechnology). The Scheme will consider these medicines for all registered chronic conditions, for instance, rheumatoid arthritis, multiple sclerosis, and ankylosing spondylitis.
Examples of the medication used to treat these conditions are: Revellex, Humira, and interferon beta. The condition treated must be contained within the list of conditions covered by the Scheme. Refer to your Benefit Guide for this list. Some oncology medication will also fall within this expensive medicine category; however, the Scheme considers oncology treatment separately and not within this benefit.
Category 2 – technology (including medical devices)
Medical technology includes a wide range of healthcare products and is used to treat diseases and medical conditions. Medical technology may broadly include medical devices, information technology, biotech, and healthcare services.
The World Health Organization classifies medical device as “any instrument, apparatus, implement, machine, appliance, implant, reagent for in vitro use, software, material or other similar or related article, intended by the manufacturer to be used, alone or in combination, for human beings, for one or more of the specific medical purpose(s) of:
- diagnosis, prevention, monitoring, treatment or alleviation of
- disease,
- diagnosis, monitoring, treatment, alleviation of or
- compensation for an injury,
- investigation, replacement, modification, or support of the
- anatomy or of a physiological process,
- supporting or sustaining life,
- control of conception,
- disinfection of medical devices,
- providing information by means of in vitro examination of specimens derived from the human body”.
Examples of these devices and technologies are:
- Pacemakers for members diagnosed with atrial fibrillation (an irregular and often rapid heart rate)
- Internal nerve stimulators for conditions like Parkinson’s disease
- Spinal surgery prostheses
- Aortic valves for transcatheter aortic valve implantation (TAVI),
- a procedure that allows an aortic valve to be implanted using a long, narrow tube called a catheter
- Infusion pumps for insulin-dependent diabetics.
Further dedicated benefit limits for devices
Even though certain components may be regarded as devices, the Scheme will pay for some of these devices from other dedicated benefit limits. Examples of these are wheelchairs and hearing aids, which will be paid from the Hearing Aid and Wheelchair Benefit on the Managed Care Plan and from the Medical and Surgical Appliance Benefit on the Standard Care Plan. Devices that are implanted internally will first be funded from the Internal Surgical Prostheses Limit and then from the SMTB.
Possible financial impact on you as the member:
How SMTB is funded by the Scheme
You are required to contact the Call Centre on 0860 222 633 to obtain authorisation. If authorisation is granted, funding will be as follows:
Managed Care Plan:
The Scheme will pay for Scheme-approved SMTB products in full without any co-payment.
Standard Care Plan:
The Scheme will pay for approved SMTB products (medicines and technology) at 80% of the Scheme Reimbursement Rate. You will have a 20% co-payment from 1 January 2020 (even if your condition has been registered for some time). This could possibly have a financial impact for you. If it does, consider other options that might not incur a co-payment by consulting your healthcare provider