INTERMEDIA APRIL 2009

We are pleased to advise that with effect from 1 May 2009, Fedhealth will introduce a private Designated Service Provider (DSP) for chronic medication. This will significantly enhance the benefit that members receive, especially after chronic medicine benefit limits have been reached. Up until now, members on certain options have been required to obtain their Prescribed Minimum Benefit (PMB) chronic medication from any state facility once their chronic benefit limits have been reached. This arrangement has been inconvenient for our members and has made it difficult for you, the broker, to present Fedhealth as a competitive option in many instances.

After long negotiations, Fedhealth has concluded an arrangement with the MEDI-Rite pharmacy group to provide members with convenient, easy access to their chronic medication in the private sector.

ARE MEMBERS ON ALL OPTIONS AFFECTED?

Members on the Maxima Plus, Ultimax and Ultima 300 options will NOT be affected by this change. Members on these options have always been able to obtain their medication from a pharmacy of choice even after their chronic medicine benefit limits have been exhausted. This continues unchanged.

The changes will affect members on the Ultima 200, Maxima Standard, Maxima Basis and Maxima Core options.

The tables below illustrate the impact of these changes on the various affected options:

MAXIMA BASIS AND MAXIMA CORE OPTIONS:

1. If your member still has chronic medicine benefits available

CURRENTLY	EFFECTIVE 1 MAY 2009
Members can use a pharmacy of their choice.	Members have to obtain their chronic medication from the MEDI-Rite group of pharmacies. A 40% co-payment will apply if they do not make use of a MEDI-Rite pharmacy. This co-payment is non-refundable.
No formulary applies & medicine is covered up to 100% of MPL.	The Fedhealth Restrictive formulary will apply. Members currently using medication not on the formulary will be required to change to an in-formulary medication. A 40% co-payment will apply if medication is claimed that is not on the formulary. This co-payment is non-refundable. MPL will still apply.

2. If your member has run out of chronic medicine benefits

CURRENTLY	EFFECTIVE 1 MAY 2009
Cover continues at a state facility for the 25 PMB conditions only.	PMB conditions will continue to be covered unlimited as per point 1 above. Members may continue to use the state if convenient.

MAXIMA STANDARD AND ULTIMA 200 OPTIONS:

1. If your member still has chronic medicine benefits available

CURRENTLY	EFFECTIVE 1 MAY 2009
Members can use a pharmacy of choice	Unchanged, however the scheme encourages members to use a MEDI-Rite pharmacy
No formulary applies & medicine is covered up to 100% of MPL	The Fedhealth Comprehensive formulary will apply. Members currently using medication not on the formulary will be required to change to a formulary medication. A 40% co-payment will apply to medication not on the formulary. This co-payment is non-refundable. MPL will also apply.

2. If your member has run out of chronic medicine benefits

CURRENTLY	EFFECTIVE 1 MAY 2009
Cover continues for 25 PMB conditions	Unchanged
Members have to obtain their medication from any state facility	Members have to obtain their medication from the MEDI-Rite group of pharmacies. A 40% co-payment will apply if they do not make use of a MEDI-Rite pharmacy. This co-payment is non-refundable.
Medicine is restricted to what is available in the state facilities	The Fedhealth Restrictive formulary for PMB conditions will apply. (This is not the same formulary that applies while members have benefits available). A 40% co-payment will apply if medication is claimed that is not on the formulary. This co-payment is non-refundable.

To assist you in answering questions your members may have, we have compiled the following FAQ, which will be forwarded to all affected members during the course of the week:

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WHO IS THE MEDI-RITE GROUP?

The MEDI-Rite pharmacy group is the in-store pharmacy chain for the Shoprite group. There are currently 74 in-store pharmacies throughout the country, which ensures convenient access for our members.

•

DO I HAVE TO OBTAIN MY CHRONIC MEDICATION FROM THE MEDI-RITE GROUP?

Maxima Basis and Maxima Core options

Yes, with effect from 1 May 2009, you will be required to obtain all your chronic medication from a MEDI-Rite pharmacy. If you obtain your medication for a chronic condition from any other pharmacy, you will have to pay a 40% co-payment. However, if you currently make use of a state facility and this is convenient for you, you may continue to do so and no co-payment will apply.

Maxima Standard and Ultima 200 options

With effect from 1 May 2009, once you have exhausted your chronic benefit, you will be required to obtain your chronic medication for PMB chronic conditions from a MEDI-Rite pharmacy. If you obtain your medication from any other pharmacy, you will have to pay a 40% co-payment. However, if you currently make use of a state facility and this is convenient for you, you may continue to do so and no co-payment will apply.

•

WHAT DO I NEED TO DO TO OBTAIN MY MEDICATION FROM A MEDI-RITE PHARMACY?

If you live within 10km of a MEDI-Rite pharmacy:

You will be required to obtain your chronic medication from a MEDI-Rite pharmacy. Please click here to locate your closest or most convenient MEDI-Rite pharmacy. You will also need to obtain a copy of your current chronic medicine prescription and present this to your MEDI-Rite pharmacist. If you have any questions, you can contact MEDI-Rite on 021 983 5119/ 6.

If you live more than 10km from a MEDI-Rite pharmacy:

As with members who live within 10km of a MEDI-Rite pharmacy, you can also go directly to a MEDI-Rite pharmacy. Alternatively, you can contact MEDI-Rite on 021 983 5119/ 6 who will provide you with an application form which will allow them to forward your medication to your closest Shoprite store for collection. You will be notified of the Shoprite store to which your medication will be delivered. You will be able to collect this at the Financial Services counter in this store.

Since the introduction of a private DSP is a significant improvement in especially the provision of PMB medication to our members, Fedhealth has decided to introduce formularies to balance the cost of this benefit improvement, but without compromising the quality of healthcare that members receive.

•	WHAT IS A FORMULARY? A formulary is an approved list of medication for each of the chronic conditions covered by Fedhealth. These formularies in no way compromise the quality of healthcare that a member receives.
•	WHAT IF MY CURRENT MEDICATION IS NOT ON THE FORMULARY? With effect from 1 May 2009, you will be required to change your medication to a medication appearing on the formulary for the particular condition that you have.
•	WHAT WILL HAPPEN IF I CONTINUE TO USE MY CURRENT MEDICATION WHICH IS OUT-OF-FORMULARY? You will be required to pay a 40% co-payment on the cost of the medication. This co-payment cannot be refunded from your savings.
•	WHEN WILL I BE NOTIFIED OF THE REQUIRED CHANGES IN MY MEDICATION RELATING TO THE FORMULARY? Within the first week of May, you will receive an updated Medicine Access Card which will indicate which of your currently authorised medication is out-of-formulary, and would therefore need to be changed in order to avoid a 40% co-payment.
•	CAN MY PHARMACIST CHANGE AN OUT-OF-FORMULARY MEDICINE TO ONE WHICH IS IN-FORMULARY? No, but your pharmacist can contact your doctor and ask him/ her to change the prescription. In this instance, your doctor may charge you for a telephonic consultation. (Your pharmacist is only allowed to make a generic substitution without your doctor’s approval).
•	WOULD I NEED A NEW PRESCRIPTION IF MY MEDICATION IS CHANGED TO AN IN-FORMULARY MEDICATION? Yes. As only your doctor can make this change, he/ she will have to provide MEDI-Rite pharmacy with a new prescription.
•	WILL MY DOCTOR CHARGE ME A CONSULTATION FEE TO CHANGE MY OUT-OF-FORMULARY MEDICINE TO ONE WHICH IS IN- FORMULARY? Some doctors may charge you a telephonic consultation fee if the change is discussed over the phone (directly with you or with your pharmacist), although this is not always the case. If you make an appointment to see your doctor, normal consultation fees will apply.
•	DOES THE MEDICINE PRICE LIST (MPL) ALSO APPLY TO IN-FORMULARY MEDICATION? Yes. All drugs on the formulary are subject to the MPL, which is a reference pricing system. This means that although your medication is in-formulary, a co-payment could still apply which is the difference between the MPL price and the price of the medication. To avoid this co-payment, there is always an alternative available in each MPL group which will not attract a co-payment. Please ask your doctor or pharmacist to inform you about these alternatives.
•	CAN MY PHARMACIST CHANGE A MEDICINE TO ANOTHER ONE IN THE SAME MPL GROUP? Yes. Your pharmacist may make this change without a new prescription from your doctor.
•	WHAT HAPPENS IF I NEED MY MEDICATION AND HAVE NOT YET RECEIVED MY UPDATED MEDICINE ACCESS CARD? You will still be able to obtain your medication from a MEDI-Rite pharmacy, as long as you have a current prescription. MEDI-Rite will advise you if any out-of-formulary co-payment is applicable. If you want to know the formulary status of your current authorised medication before you obtain it from the pharmacy, you may e-mail the Chronic Medicine Management team (cmm@medscheme.co.za) with your query. Alternatively, you may call the Chronic Medicine Management call centre on 0860 100 608 for assistance.

Even though this new arrangement might cause some inconvenience to your members initially, we are confident that we are bringing Real Medical Aid closer to home by improved accessibility to the chronic medicine benefit and enhancing the scheme’s PMB chronic offering significantly.

Disclaimer:

The opinions, advice and products contained in articles supplied by contributors other than employees of Fedhealth do not necessarily reflect the policy, rules or opinions of Fedhealth Medical Scheme.

TR1551 Trillium

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