april 2010 CO-PAYMENTS ON CHRONIC MEDICATION Medication for one or more of the chronic conditions listed under Our Investment Our Health Our Future the Higher Plan Chronic List and Lower Plan Chronic List will be funded from the chronic benefit in 2010. The prescribed medication must be medication. Should a reference in line with the chronic medication price be set for a medication, rules, guidelines and protocols, patients are entitled to make including the POLMED formulary, use of any medication within before it will be approved. this pricing limit, but will be required to make a co-payment What will attract a co- on medication priced above the payment on chronic pricing limit. medication? Two kinds of reference pricing E Obtaining medication from exist: a non-designated service 1. Generic reference pricing Important: provider (DSP) pharmacy (POLMED Maximum Price) E always ensure that your doctor To avoid a 20% co-payment on The Scheme applies reference includes the correct ICD-10 your chronic medication, the pricing known as the POLMED code(s) on your Chronic medicine medication must be obtained Maximum Price (PMP). This management application Form from either one of the following means that there is a preset or prescription. pharmacy DSPs: maximum price that the Scheme E medication for conditions not • Courier pharmacies: will pay for your medication, Medipost equivalent to the average price listed on the chronic disease Pharmacy Direct of the generic alternatives list will not be covered from the • Retail pharmacies: in that range. The PMP list chronic benefit. Clicks Pharmacies contains products that are Dis-Chem Pharmacies generically identical, i.e. the Family Care Pharmacies generic medication is identical to the original, brand-name E Using medication outside the medication in dosage, strength, set reference pricing consumption, quality, safety, The POLMED Maximum efficacy and intended usage. Allowed Cost (MAC) funding Although they are chemically principle will apply to acute, identical, generic medication over-the-counter and chronic is typically much cheaper and medication. This means that therefore allows you to use your there is a maximum price the chronic medication benefit in a Scheme will pay for a particular more cost-effective way. Continued overleaf E CO-PAYMENTS ON CHRONIC MEDICATION – CONTINUED The pMp list and pOlMED formulary (list of generic medication that will be funded from the chronic benefit) can be viewed on our website at www.polmed.co.za under the ‘Managed Care’ tab. 2. Therapeutic reference pricing (TRP) Therapeutically similar products contain different active ingredients but give the same therapeutic outcome. Therapeutic reference pricing will only be implemented for selected categories of medication where there is no convincing evidence of superiority of one agent over another. please discuss therapeutic reference pricing with your doctor. Your doctor may contact pOlMED’s pharmacist-on-line call centre to discuss and obtain authorisation for alternative treatment in line with the Scheme’s rules and benefit design. DENTAL IMPLANTS: 2010 bENEfITS POLMED has made certain changes to its dental benefits for 2010. Dental implants are amongst the dental procedures that have been affected by these changes. What are dental implants? prosthetic phase of implant procedures, i.e. the placement of Dental implants are procedures the final prostheses such as crowns, used to replace one or more missing dentures or a bridge that will be teeth. The difference between supported by the implants. implants and other replacement procedures is that missing teeth are are there any alternative replaced as three different parts and treatment procedures that in three different phases. can be used? As a result of the new benefit Yes. The following treatment structure, all implant-related options are available: procedures, with the exception of E Root canal or endodontic the final phase (third/prosthetic treatment may be used to try phase), are Scheme exclusions as and save a tooth, provided the from 1 January 2010. This means natural tooth is still in place. that the first and second phases of Root canal treatment involves dental implant procedures are not the removal of the dental pulp covered in the dental benefit for (nerves and blood vessels) from 2010. These include the following: the root canals of teeth. The E costs for the material used in canals are cleaned and shaped implants placement (screws) and a root filling is placed to seal NOTE E any other procedures used for the canals. A root canal treated the purpose of preparing for tooth may then be restored with a normal filling, inlay/onlay Consult your dentist the placement of implants, e.g. bone augmentation procedures or a crown, depending on the regarding the various and sinus lifts. amount of tooth structure lost. tooth replacement E A bridge or partial denture is an methods. Should you choose to use implant alternative to a dental implant procedures, the Scheme will and may be sufficient for your only cover the final phase (third/ needs if you have missing teeth.