Prescribed Minimum Benefits

Prescribed Minimum Benefits entitle you to many benefits regardless of what medical scheme or option you have and covers tests, x-rays, consultations and medication. Not all tests and treatments (such as PET scans and biological drugs) are covered in full but it does mean access to treatments available in a state facility.

What is a PMB?

Since 2004 all schemes must cover 270 specified conditions and 26 diseases (listed on the Council of Medical Schemes website, www.medicalschemes.com) regardless of exclusions and benefit limits, if the treatment is available in a state facility. This proviso helps schemes stay financially viable and ensures treatment for the listed conditions without running out of benefits. While you have Oncology benefits, treatment will be paid from that benefit. Once your oncology benefits are depleted treatment can continue within the specified State Protocol.

Is everything covered in full?

To get accounts paid from PMB and Oncology Benefits you need to ensure the doctor submits histology reports to confirm diagnosis. The medical scheme will then register you for the condition. Any tests available at a state facility, for example CT scans; MRIs; xrays and pathology, will be covered in full without scheme stipulated co-payments.

PMBs related to breast cancer:

Breast cancer per se is not a PMB. Breast cancer that has not spread (metastisised) to other organs (except lymph nodes), and where the overall survival rate is less than 5 years, is a PMB. Once you run out of your oncology benefit and your breast cancer is a PMB then your doctor can get your treatment authorized, as long as the treatment is available at state facilities. If it falls outside the PMB markers the scheme may enforce the Oncology Benefit and no more. Where a scheme has benefits for PMB cancer only, there is no further cover for curative intent if it has spread.

Most schemes attach Oncology Benefit sub-limits to cover biological medication such as Herceptin and Tykerb. Unfortunately these medications are not available in State facilities so once you run out of Biological Benefits you either need to cover the treatment yourself or you can approach the medical scheme for assistance or ex gratia benefits. Remember this is not always approved and is a lengthy process.

Managed Health Care Tools

To make your benefits last longer whilst ensuring that you receive the best treatment medical schemes now use Managed Health Care tools including:

a) Designated Service Providers (DSP)

b) Pre-authorising of tests and treatments

c) Protocols regarding tests and treatment (efficiency and frequency)

d) Medication Formularies.

What is a DSP?

Designated Service Providers are groups of doctors and hospitals contracted to medical schemes to provide cost effective treatment at pre-agreed rates and use scheme specific protocols and formularies. Most schemes will impose co-payments (a specific percentage or the difference between Non-DSP and DSP cost) for medication or consultations if you use a non-DSP Doctor, unless you don’t have a DSP within a 50km radius of your home, or the DSP cannot provide the treatment that you require. The co-payment is not covered by your day-to-day savings.

Pre-authorisation

Regardless of diagnosis the scheme rules for pre-authorisation stand. If you are admitted to hospital, have an MRI or CT scan, the pre-authorization rules of the scheme apply. If you do not pre-authorise the scheme may not pay the account. Tests are usually scheme, benefit and protocol specific. For example pathology, MRIs and xrays are available in state facilities but PET scans are not, so there are strict protocols attached to authorising PET scans.

Medication Formulary

Protocols and formularies will not provide inferior medication or treatment and are not put in place simply to save money. They enable schemes to better manage oncology benefits and their risk. Formularies are in line with public sector protocols and regulations and, in most cases, are tabled by qualified oncologists and specialists. If your treatment falls outside protocols it should be sent to the oncology DPS review committee, and to the schemes Medical Advisor, for them to decide whether they will cover it. If the medication requested is not registered with the Medicines Control Council for breast cancer treatment it cannot be used. This is called “Off label use” and is normally a scheme exclusion. If a generic medicine on the formulary does not, for a MEDICAL reason, agree with you – then you can request scheme approval of the original medication. Your doctor must provide medical supporting documentation and submit forms to the related pharmaceutical company to make them aware of this complication. Personal preference is not a reason and you will be liable for a co-payment to cover the cost between the generic and original.

Important things to remember

Education and knowledge is power!!! Know your ICD-10 code (breast cancer is C50) and ensure that is appears on EVERY account RELATED to your cancer treatment.

Read your current benefit guide! Benefits, rules and co-payments change annually. Know what medication you can and can’t use. Take note of changes regarding DSPs. It is your responsibility.

Inform your doctor of your benefits and limits when they put your treatment plan together so that medication and treatment is not denied causing unnecessary delays and distress.

If you don’t understand something, or have questions, contact your medical scheme’s Oncology Department . Don’t wait until accounts are rejected or co-payments requested.

Written by Gillian Warren

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