Pharmaceutical Benefit Management (PBM)
What is Pharmaceutical Benefit Management (PBM)?
PBM is the management of medicine benefits for Bestmed members whilst ensuring easy access to medicines for all members. The Bestmed medicine programme is managed by qualified pharmacists supported by clinical staff who ensure that appropriate, cost – effective and quality treatment is provided to all members according to Scheme rules and defined benefits. Formularies and protocols are developed and applied to ensure the most appropriate use of medicine for the registered condition/s. Some of the mechanisms utilised in the management of medicine benefits are:
- Drug Utilisation Review (DUR) – means the constant reviewing of medicines on the South African market and what they are used for. This ensures that appropriate, cost–effective medicines are used.
- Clinical expertise – Doctors and pharmacists review and update funding guidelines by reviewing clinical studies, pharmacoeconomic data and health outcomes.
- On–line authorisations – The prescribing doctor can update or change a medicine authorisation, within a few minutes, by contacting the dedicated number.
- Protocols and guidelines – Evidence based formularies and guidelines are used to ensure appropriate and cost effective medicine usage.
Which conditions and formularies are covered under the chronic benefit?
2015
How does one apply for chronic medicine benefits?
The patient and the treating doctor will be required to complete a chronic medicine application form. It is advisable that one presents the treating doctor with a copy of the medicine formulary as it applies to the specific Bestmed Scheme option and the specific chronic condition.
For all Beat and Pace options:
Call 086 000 2378 for an application form or log onto www.bestmed.co.za – Completed application forms can be sent to: (Fax) 012 472 6760 or e-mailed to medicine@bestmed.co.za
For Pulse1 option:
Consult your CareCross GP to confirm your diagnosis. Once confirmed, the CareCross GP will complete a chronic application form to register you for chronic medicine. You will be notified via sms as soon as the application has been processed. Should you have any enquiries contact the CareCross Call Centre on 0860 103 491.
*All existing chronic medicine authorisations will be evaluated by CareCross and approved accordingly to the CareCross formularies, protocols and funding guidelines.
For Pulse2 option:
Call 086 010 3491 for an application form or log onto www.carecross.co.za – Completed application forms can be sent to: (Fax) 021 673 1811 or e-mailed to bestmed@onecarehealth.co.za
Are there specific requirements in registering for CDL or non–CDL conditions?
Some of the CDL and non–CDL chronic conditions require additional clinical information in order to qualify for registration. Before Bestmed can approve the application, it is necessary for them to receive a report from the appropriate treating specialist, together with specific clinical information. The conditions where additional information is needed, with the specific information required for each chronic condition, are listed below.
| CONDITION |
SPECIFIC REQUIREMENT |
| Acne |
Prescription required from a Dermatologist |
Attention Deficit Disorder (ADD)
Attention Deficit Hyperactivity Disorder (ADHD) |
Prescription required from a Psychiatrist or Paediatrician |
| Alzheimer’s Disease |
Mini-mental state examination (MMSE) initially required together with a prescription from the relevant specialist |
| Chronic Obstructive Pulmonary Disease (COPD) |
COPD questionnaire to be completed |
| Diabetes |
Diabetes questionnaire to be completed and submitted together with the HbA1c blood test results and/or fasting blood glucose results, pre-treatment value and current values |
| Epilepsy |
EEG report must be submitted with the application or a prescription from the Neurologist |
| Eczema and Psoriasis |
Prescription required from a Dermatologist |
| Hyperlipidaemia |
Hyperlipidaemia questionnaire to be completed. Lipogram results (initial and most recent) to be submitted with the application |
| Osteoporosis |
Osteoporosis questionnaire to be completed. Bone Density (BMD) test results to be submitted (initial and most recent) |
| Parkinson’s Disease |
The first application is to be completed by a Neurologist |
| Psychiatric conditions |
Psychiatric questionnaire to be completed by a Psychiatrist |
| Rheumatoid arthritis |
Rheumatoid arthritis questionnaire to be completed initially by a Rheumatologist |
Note: Some of the specific requirements listed above can be captured on the Chronic Application Form in the section relevant to the specific disease.
What are formularies and co–payments related to medicine?
A formulary is a pre–determined list of medicines that will be covered for the CDL and non–CDL conditions. These lists of covered medicines vary from option to option. Co–payments may apply in a number of scenarios. The first is where a medicine is chosen for the treatment of a CDL or non–CDL condition that is not on the formulary. Another is where the chosen medicine is above the MRP price ceiling (see question on MRP). Should the member or the prescriber prefer using a medicine not listed on the CDL or non–CDL medicine formulary for the specific Scheme option, one will be liable for a co–payment. The quantum of co–payments varies between the different Scheme options. The table below highlights the different co–payments applicable per Scheme option for both the CDL and non–CDL conditions.
| Bestmed option 2015 |
Co-payments CDL medicine |
Co-payments non-CDL medicine |
| |
Formulary |
Non-formulary |
Formulary |
Non-formulary |
| Beat1 & Beat2 |
0% |
35% |
No benefit |
No benefit |
| Beat3 |
0% |
35% |
15% |
35% |
| Beat4 |
0% |
30% |
15% |
30% |
| Pace1 |
0% |
35% |
15% |
35% |
| Pace2 |
0% |
30% |
15% |
30% |
| Pace3 |
0% |
25% |
15% |
25% |
| Pace4 |
0% |
20% |
15% |
20% |
| Pulse2 |
0% |
25% |
15% |
25% |
What Scheme exclusions exist in terms of medicine and other products?
This is a list of preparations or medicines that will not qualify for any benefits, even if there is clinical reason for using it. The categories excluded from benefits for all Scheme options are:
- Preparations for the specific treatment of obesity, including dietary supplements
- Patent and household remedies
- Nutritional supplements (including patent and baby foods)
- Medicines used specifically to treat infertility
- Aphrodisiacs
- Sun–screen agents (medicated or otherwise)
- All soaps and shampoos (medicated or otherwise)
- Cosmetic substances and products
- Anti–habit substances (example products to quit smoking)
- Anabolic steroids
- Tonics, stimulants and biological substances
- Vitamins, minerals and combinations thereof (except for prenatal vitamins)
- Unregistered medicines – medicines not registered by the Medicines Control Council (MCC)
- Unregistered indications or “off label” use of medicines.
- Biological and Biotechnological substances for Pulse 1.
What are generic medicines?
A generic medicine is one that contains identical amounts of the same active ingredient in the same strength and in the same dosage form as the original medicine. Generic medicines are similarly approved by the South African Medicines Control Council (MCC). Generics must have the same quality and produce an equivalent effect on the body as the original medicine. Benefits of using generic medicines:
- They are more affordable than the original product
- They help extend one’s acute and chronic medicine benefit through the year
- They help to prevent one paying co–payments where generic alternatives are available for original medicine
- They reduce the rand value of co–payments as they are usually less expensive
What is the Mediscor Reference Price (MRP)?
A generic reference price is a maximum set price a medical scheme is prepared to pay for a specific generic molecule for a specific dosage. Bestmed uses the Mediscor Reference Price (MRP) to set the generic reference price. This allows the prescriber and the member choice, if they want to use a specific brand for some reason, whilst limiting the Scheme’s financial exposure. This means that a member may use the original medicine, but the Scheme will only reimburse the medicine at the MRP price. The member, however, has a choice when a generic reference price is applied. He/she can use the original medicine and pay the difference between the price of the original and that of MRP (thus have a co–payment); or the member can use a generic alternative within the MRP price range and have no co–payment. MRP is applicable to medicines, including formulary and non–formulary medicines, and on all medicine benefits. For Pace1 and Pace2 members, the MRP difference will be paid from the available funds in the Bonus account.
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Where can one get an application form for CDL and non–CDL medicine benefits?
Click on the item below to open the relevant document:
- Chronic medicine application form Download
Who are the Bestmed Pharmacy Designated Service Providers (DSP) and Preferred Providers (PP) for medicine?
The Bestmed Pharmacy Preferred Provider Network (PPN) offers you cost-effective services with minimised point-of-care co-payments. These pharmacies have committed to dispense medicines at very competitive rates, significantly lower than the Bestmed rate (fee structure), and will assist you in ensuring that you maximise your benefits. They have also undertaken not to charge you any additional administration fees. We recommend that you consider using these pharmacies. As a PPN and Designated Service Provider (DSP) for medicines, the pharmacies in this Network have committed to promoting the use of cost-effective medicines, especially for those members who are approved for chronic conditions. This Network is nationally distributed and includes many of the leading pharmacy groups – please visit our website (www.bestmed.co.za) for further details.
You may also receive your medicine from the Bestmed Pharmacy Scheme Rate Network, where participating pharmacies have agreed to dispense at the Bestmed rate (33% of the medicine price, up to a maximum of R33.00, excluding VAT), assuring you of receiving services with reduced co- payments. Pharmacies in this network will provide you with services consistent with your Scheme benefits. Some pharmacies may opt not to join either of these networks. You may still receive your medicines from these pharmacies however you may experience higher co-payments, thereby potentially using up your benefits sooner.
To view a full list of these providers, please click here.
What are the contact details for medicine related matters and queries?
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