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If you're suddenly having to make unexpected co-payments on your chronic medication since the beginning of January 2012, here's the reason.
The approved medicine list and the Chronic Drug Amounts on this list have been changed. The chronic drug amount has been capped per condition and quite a few medications removed from the list. Discovery Health will only pay per chronic condition up to the capped rand amount.
Disgruntled members speak
Of the 110 comments on the previous article Discovery Health: chronic meds shock, these two were fairly typical:
Janine 2012/01/24Comment #99: Two-faced Discovery
I changed my medication for high blood pressure to one that was on the Discovery formulary a few years ago. This was not by choice and the medication is not as effective. So guess what? It's no longer on the list. What do Discovery want? People chopping and changing chronic meds and not being able to manage their conditions so that they get worse and have increased medical costs?
Disgusted 2012/01/23Comment #9 - CDA
My wife went to pick up her anti-psychotics on Friday only to find out that Discovery suddenly pays R655 less! And that is for meds with no generic equivalent. Yes: six hundred and fifty five rand - per month! Where must I get that from? She is dependent on these pills to keep her going on a day to day basis and not relapse. It took us years to finally stabilize her and now this. There was no prior warning from Discovery. Discovery, you are playing with people's lives! Absolutely disgusting.
Background
Many Discovery Health medical scheme members have been confused: if the Chronic Benefit structure for 2012 has not changed, as has been said many times, why are they having to make more co-payments?
Discovery Health issued a statement in which their CEO, Dr Jonathan Broomberg, said the following, which summarises the situation:
"It is important to note that there has been no change to the Chronic Illness Benefit structure for 2012. The 2012 review of the approved medicine list and Chronic Drug Amounts forms part of our annual revision based on the pricing movements in the markets".
For many members this seemed contradictory. The truth is that legally the Chronic Illness Benefit structure is determined by law – 25 Prescribed Minimum Benefits for which all scheme members have to be covered. This has not changed – and may not be changed, except by law and with the permission of the Council for Medical Schemes.
What has changed
What has changed are the Approved medicine list and the Chronic Drug Amounts. The approved medicine list and the Chronic Drug amounts are revised every year.
Take a look at the whole list here.
"The chronic drug amounthas been capped in rand value for each condition", said Alain Peddle, head of Research and Development of Discovery, during a press briefing in Cape Town. "This amount is not quite the average price of the brand-name drugs, the generics, or the therapeutic equivalents, but generally a bit higher than the average. Quite a few of the more expensive brand-name drugs have been removed from the list – and that is the reason people are now having to make more co-payments".
On being asked whether the best drugs were chosen for the list, Peddle admitted that if there was a cheaper alternative, the most cost-effective drugs were chosen for the medicines formulary. The formulary drugs are fully covered. If you want to take a brand-name drug that is not on the list, you are going to have to pay the difference between the asking price and the rand-capped amount on the list.
When asked what members should do if they/their doctors find the generics or therapeutic equivalents either ineffective or to have bad side effects, he mentioned that there was an appeals process open to members. Here is a link to the form that needs to be filled in if you want to make an appeal to continue using brand-name medication.
Generics and therapeutic equivalents
Whereas generics are supposed to be the same as brand name medications, the same is not true for therapeutic equivalents: According to medical-dictionary.com, a therapeutic equivalent is a "drug that has essentially the same effect in the treatment of a disease or condition as one or more other drugs. A drug that is a therapeutic equivalent may or may not be chemically equivalent, bioequivalent, or generically equivalent".
How much of chronic medication costs do medical schemes have to carry? Who determines this?
The answer lies in this extract from Discovery Health's website:
Chronic Drug Amount (CDA)
The CDA is a monthly amount we pay up to for a medicine class. This applies to medicine that is not listed on the medicine list (formulary). The CDA includes VAT and the dispensing fee.
Prescribed Minimum Benefit conditions (PMB conditions)
These are conditions that the Council for Medical Schemes has determined for coverage by all medical schemes, in any setting, as per clinical guidelines.
Check out these FAQs on chronic medications from the website of the Council for Medical Schemes for more information on the rules medical schemes have to adhere to.
One general complaint from members was that they had not been informed of the changes, and that it then subsequently came as a surprise when they had to make co-payments.
"We did a terrible job at explaining things," said Alain Peddle,"but we did manage to contact 97% of the people affected by this telephonically".
Have you been affected by these changes? Feel free to comment below – also if you have had positive experiences.
(Susan Erasmus, Health24, February 2012)
