Managed Care
Medicine Risk Management Programme
The Medicine Risk Management (MRM) Programme was established to provide a service to patients who require treatment for their chronic medical conditions. The MRM Programme is dedicated to managing chronic medication usage and ensuring quality care through integrated healthcare and holistic patient management.
Chronic benefits are available to all members on the Pick n Pay Medical Scheme Plus Option according to the Scheme rules. All 26 conditions that make up the chronic disease list (CDL), certain prescribed minimum benefit (PMB) conditions which incorporate medicine management and some non-PMB conditions are covered by the Scheme.
Pre-authorisation
Pre-authorisation is required for medication to treat these conditions so that it can be paid from your chronic benefits. If your chronic condition does not meet the clinical criteria, then it will not be paid from your chronic benefit, and you will be liable for the cost of any related treatment, services and medication. Refer to the Medicine Risk Management Programme information leaflet below which provides detail of the process.
Note!
The chronic authorisation process may be done telephonically by your treating/prescribing doctor. If additional information is required, the MRM team will request this from the doctor. Your doctor may request and complete the Medicine Risk Management application form, if they insist on a written application. Your treating doctor/pharmacist may contact us on 0860 767 633 to obtain authorisation or request the application form.
One month's supply of certain medication which may be used to treat a PMB condition will be paid once only from your Medical Spending Account (MSA). According to legislation/Scheme rules, PMB medication taken on a chronic basis may not be claimed from a member’s MSA. You will need to obtain authorisation for these medications to be paid from the chronic benefit.
Medication for diabetes
Medication for treating diabetes type 1 and 2 must be authorised with the Centre for Diabetes and Endocrinology (CDE) Diabetes Management Programme. If not authorised with CDE, the medication claims will be rejected and will not be paid from the Medical Spending Account (MSA).
Advance supply of chronic medication
Should you have any circumstances, such as plans to travel outside of the country for an extended period, and you need an advance supply of medication from your doctor/pharmacy, you may complete the Chronic medication advance supply request form below. Please provide supporting documentation as proof, such as flight and accommodation bookings.
Chronic medication formulary
Click here to access the chronic medication formulary.
Pharmacy network
Pick n Pay Medical Scheme has partnered with the administrator, Momentum Health Solutions, to provide a pharmacy network to minimise the high costs incurred by members on medical claims. Members are encouraged to obtain their medication from these pharmacies to avoid unnecessary co-payments.
To find a network pharmacy, please click here.
This information is correct at the time of publication but may be subject to change. Please contact the Client Service Department to confirm network healthcare providers.
Definitions
The Chronic disease list (CDL) refers to 26 chronic conditions that are covered by PMB legislation.
Prescribed minimum benefits (PMBs) are a set of defined benefits that South African medical schemes are legally required to cover for their members to access certain minimum healthcare services, regardless of their benefit option.