FREQUENTLY ASKED QUESTIONS

Mediscor is an independent, specialist pharmaceutical benefit management (PBM) organisation with a proud track record of 28 years, dedicated to the effective management of medicine benefits. Mediscor has been a service provider of Moto Health Care since 2012.

Mediscor delivers the following services to the scheme and its members:

• Real-time and batch medicine claims processing,
• Formulary management,
• SMS messages on selective medicine claims.

The portion of the value of the medicine, in terms of the rules of the medical scheme, for which the beneficiary is personally responsible for payment to the provider. Co-payments can occur for the following reasons:

1. THE USE OF NON-NETWORK PHARMACIES (NON-DSP) FOR AUTHORISED MEDICINE
Non-DSP co-payments on authorised medicine may differ between options. The co-payment may be a set percentage and/or the difference between the provider dispensing fee and the default Moto Health Care dispensing fee.

2. USING MEDICINE ABOVE THE SET REFERENCE PRICE
Reference price co-payments apply to all medicine benefits across all Moto Health Care options. Reference pricing and non-Formulary co-payments can be applied concurrently.

3. USING NON-FORMULARY MEDICINE
Non-Formulary co-payments are either 20% or 100% (rejected) depending on the Moto Health Care option. Reference pricing and non-Formulary co-payments can be applied concurrently.

4. BENEFIT DEPLETION
The member will be liable for 100% of the medicine costs when benefits are depleted.

Generic medicines are copies of brand-name drugs that have exactly the same dosage, intended use, effects, side effects, route of administration, risks, safety, and strength as the original drug. In other words, their pharmacological effects are exactly the same as those of their brand-name counterparts.

Generic medicines are usually less expensive than the original brand. They are only cheaper because the manufacturers have not had the expenses of developing and marketing a new drug, after the patent of the original drug expired. Without the start-up costs for development of the drug, other companies can afford to make and sell it at a lower price.

MRP sets a maximum reimbursable price which the medical scheme will pay for certain medicine. It is usually calculated from the average price of several generic medicines which cost less than the original medicine.

If a member chooses to buy a medicine that costs more than the MRP, he/she may have to pay in the difference between MRP and the cost of the selected medicine. This is called a reference price co-payment (see “Levy or co-payment”). MRP can apply on both preferred and non-preferred medicines (see “Medicine Formulary” definition).

The co-payment on MRP can be avoided by choosing generic medicines that is less expensive than MRP. The use of the most appropriate alternative should be discussed with your doctor or pharmacist.

• Use pharmacies in the Moto Health Care preferred provider network (DSP) to obtain authorised medicine.
• Encourage your doctor to prescribe medicine listed on the Formulary for your option.
• Ask your pharmacist to dispense generic medicine that is below the reference price for the prescribed medicine.
• Manage and keep track of your available medicine benefits.

PMB’s are a set of minimum benefits which, by law, must be provided to all members by their medical schemes. PMB’s must be provided regardless of the benefit option that a member has selected. The medical scheme must pay for the costs of diagnostic tests, treatment and ongoing care.

The Council for Medical Schemes (CMS) has compiled a list of conditions, known as the CDL, for which appropriate medicines and other treatments have been specified. Medical schemes must cover the costs of the specified treatment of CDL conditions from PMB benefits.

The medical scheme may make use of clinical protocols, medicine formularies and designated service providers to manage PMB benefits. CDL PMB’s conditions are subject to pre-authorisation:

1. Addison disease
2. Asthma
3. Bipolar mood disorder
4. Bronchiectasis
5. Cardiac failure
6. Cardiomyopathy
7. Chronic renal disease
8. Chronic obstructive pulmonary disease
9. Coronary artery disease
10. Crohn disease
11. Diabetes insipidus
12. Diabetes mellitus type 1
13. Diabetes mellitus type 2
14. Dysrhythmias
15. Epilepsy
16. Glaucoma
17. Haemophilia
18. HIV/AIDS
19. Hyperlipidaemia
20. Hypertension
21. Hypothyroidism
22. Multiple sclerosis
23. Parkinson disease
24. Rheumatoid arthritis
25. Schizophrenia
26. Systemic lupus erythematosus
27. Ulcerative colitis.

Non-CDL PMB’s are a specified list of emergencies and 270 other specified conditions (besides the conditions on the CDL), for which medical schemes must cover the costs of the diagnosis and treatment from PMB benefits. More details about PMB’s can be found on the CMS website.

A member may be required to get authorisation from the medical scheme or administrator for selected medicines before the scheme will pay for those medicines from chronic or PMB benefits. Sometimes, the member may be required to register for a specific condition before the medical scheme will pay for the medicines that have been prescribed to treat that condition.

A clinical protocol is a set of evidence-based guidelines that provides details on the correct sequence of diagnostic testing and treatment for a specific condition. A medical scheme may use a clinical protocol to decide if a diagnostic test or treatment is appropriate, and whether the scheme will pay for the test or treatment.

A medicine formulary is a list of medicines, both generics and the originals, which will be reimbursed by a medical scheme. The medicines on a formulary make up a so-called preferred list of medicines. A medical scheme may only pay for medicines that are on this “preferred” list. Medicines that are not included in the formulary or preferred list are sometimes referred to as “non-formulary” or “non-preferred” medicines and may reject or attract a co-payment.

The following formularies are applicable for Moto Health Care related to PMB conditions:

A designated service provider (DSP) is a healthcare provider/s selected by the medical scheme concerned to provide healthcare services to its members. This may apply to pharmacies, doctors and hospitals. Moto Health Care may apply a co-payment on services obtained from a provider that is not a DSP.

Compliance refers to the regular and correct use of your chronic medication as prescribed by your treating doctor. It also includes undergoing regular check-ups and investigations, as determined by your treating doctor.

• Collect your medication from your pharmacy on a monthly basis, before your supply runs out. Certain inhalers, insulins and eye drops can be collected every two to three months, depending on the prescribed dosage.
• Ensure you take your medication every day at the same time, as per the dosage and quantity prescribed by your treating doctor and/or as advised by your pharmacist.
• Ensure that you do not miss a dose or use more than the prescribed quantity. If you are not clear on the dosage you need to take, always check with your doctor or the pharmacist.
• Keep to the Schedule of visits and tests as determined by your treating doctor, e.g. if you are taking medication for Hyperlipidemia or diabetes, you need to ensure that you have a cholesterol test (Lipogram) or HBa1C test for Diabetes every six months.
• Inform your treating doctor if you experience any side effects to the medication you use, or if you experience difficulties with taking certain medication.
• Contact Moto Health Care if you experience any problems with your claims being processed and paid.
• Make sure that you visit your General Practitioner at least twice a year, and remember to go for any tests that are recommended for monitoring purposes.

Your chronic condition will not be correctly controlled, which could potentially lead to complications and hospitalization, as well as development of other chronic conditions and, ultimately a poor Quality of life