Medical Scheme Reimbursement Rates and contracts

Transcription

1 Administrator & Notes Medical scheme Scheme options DISCOVERY Closed DSP for ARVs (optipharm) and for Delta option chronic (MedXpress) with 20% penalty copay. DSP includes Delta option. Non-DSP pharmacies Medical Scheme Reimbursement Rates and s Non-SEP (including VAT) Acute (including VAT) Chronic (including VAT) DSP or PP NonDSP Penalty Copay Contract with: ProPMB Anglo (new claiming codes 01 Jan 2014) All options 36%maxR % capped at R59.40 at R % capped at R33.06 at R100 PP MediKredit Anglovaal All options 36%maxR %maxR %maxR59.40 PP 20% ARVs Discovery BMW All options 36%maxR %maxR %maxR59.40 PP 20% ARVs Discovery Discovery Keycare Keycare 36%maxR %maxR18.24 min R %maxR18.24 min R7.00 PP 20% ARVs Discovery are reimbursed at 26/26. Non- SEP and surgical paid at 36% Discovery Delta Delta 36%maxR %maxR29.64 MedXpress = chronic DSP PP *Chronic DSP* DH - acute only capped at R59.40 across all Discovery Health Medical schemes and plans. Keycare Scheme All other options 36%maxR %maxR %maxR59.40 PP 20% ARVs Discovery has an acute formulary. IBM (SA) Delta option Delta 36%maxR %maxR %maxR29.64 PP 20% ARVs Discovery LA Health Keyplus Keycare 36%maxR %maxR18.24 min R %maxR18.24 min R7.00 PP 20% ARVs Discovery 20% on chronic & ARVs LA Health Medical Scheme All options 36%maxR %maxR %maxR59.40 PP 20% ARVs Discovery Lonmin Keycare Keycare 36%maxR %maxR18.24 min R %maxR18.24 min R7.00 PP 20% ARVs Discovery Lonmin Medical scheme All other options 36%maxR %maxR %maxR59.40 PP 20% ARVs Discovery Naspers (Media24) MMED option 36%maxR %maxR %maxR59.40 PP 20% ARVs Discovery Naspers Medical fund All options 36%maxR %maxR %maxR59.40 PP 20% ARVs Discovery Quantum Keycare Keycare 36%maxR %maxR18.24 min R %maxR18.24 min R7.00 PP 20% ARVs Discovery Quantum Medical Aid Society All options 36%maxR %maxR %maxR59.40 PP 20% ARVs Discovery Remedi All options 36%maxR %maxR %maxR59.40 PP 20% ARVs Discovery Retail All options 36%maxR %maxR %maxR29.64 No PPN 20% ARVs No MEDIKREDIT TFG (Foshini) Medical Scheme All options 36%maxR %maxR %maxR59.40 PP 20% ARVs Discovery Tsogo Sun All options 36%maxR %maxR %maxR59.40 PP 20% ARVs Discovery University KZN Medical Scheme All options 36%maxR %maxR %maxR59.40 PP 20% ARVs Discovery Afrox Medical Aid Society 36%maxR %maxR59.40 at R165 36% capped at R59.40 at R165 PP MediKredit 20% Co-Pay on ARV's DSP Bankmed All options 36%maxR % capped at R59.40 at R165 36% capped at R59.40 at R165 PP 20% ARVs MediKredit CAMAF All options 36% 36% capped at R59.40 at R165 36% capped at R59.40 at R165 PP MediKredit Pick 'n Pay All options 36%maxR % capped at R59.40 at R165 36% capped at R59.40 at R165 PP MediKredit Profmed All options 36%maxR % capped at R59.40 at R165 36% capped at R59.40 at R165 PP MediKredit

2 SABMAS (ex Essential from chronic) excl Castellion option 36%maxR % capped at R59.40 at R165 36% capped at R59.40 at R165 PP MediKredit SAB Essential Chronic 22.8%maxR22.80 N/A 22.8%maxR22.80 No PPN No Contract MEDSCHEME Fedhealth Maxima Standard Net Fedhealth Tier Fedhealth Tier pp Medscheme Fedhealth Tier: <R243 - Blue Door DSP DSP Medirite Medscheme 41.04%, R243-R700 R %, Maxima Basis DSP DSP Pharmacy Direct Medscheme R700-R760 R %, >R760 R Maxima Standard Fedhealth Tier Fedhealth Tier Medirite Medscheme Maxima Core DSP DSP Above limits Medirite Medscheme Maxima Plus Fedhealth Tier Fedhealth Tier Medirite Medscheme Maxima Exec Fedhealth Tier Fedhealth Tier Medscheme Ultima 200 B Fedhealth Tier Fedhealth Tier Medscheme Ultima 300 A Fedhealth Tier Fedhealth Tier Above limits Medirite Medscheme Ultima Fedhealth Tier Fedhealth Tier Medscheme Exclude Value Option AECI All options 20% 34.2%maxR %maxR36.48 PPN Medscheme 40% penalty copay nondsp for Boncap & lower Bonitas options Bonitas All options 22.80% 34.2%maxR %maxR36.48 PP 40% on some options Medscheme 30% penalty copay nondsp GEMS All options 27.5%maxR %maxR27.50 MPN 30% for nonmpn phys Universal Healthcare Glencore (formerly Xstrata) All Options 23% 34.2%maxR %maxR36.48 PP Medscheme 30% penalty copay nondsp MBMed all options 22.80% 34.2%maxR36.48 DSP = CMD DSP for chronic 30% on Chronic Medscheme SABC All options as per Fedhealth rates as per Fedhealth rates PP Medscheme SANLAM Eternity Private Health Admin Commed All options 31.92%maxR %maxR31.92 Care Cross Malkor All options 31.92%maxR %maxR31.92 no ALLCARE ADMIN PG Bison All options 31.92%maxR %maxR31.92 Allcare METROPOLITAN HEALTH Engen Medical Benefit Fund All options 34.2%max %max34.20 Metropolitan HG

3 Metropolitan Medical Scheme All Option 34.2%max %max34.20 Metropolitan HG NIMAS All Option 34.2%max %max34.20 Metropolitan HG Rand Water All options 36% capped at R59.40 at R165 36% capped at R59.40 at R165 PP Metropolitan HG SAMWUMED All options 36% 36% capped at R59.40 at R165 36% capped at R59.40 at R165 Metropolitan HG Wooltru Healthcare Fund All Option 34.2%max %max34.20 Metropolitan HG UNIVERSAL HEALTHCARE via Mediscor AECI Value option (T) %maxR %maxR31.92 UPN Universal BCIMAF Building & Construction Industry M/Aid All options 31.92%maxR %maxR31.92 UPN Universal Networx 25% co-pay - nonformulary drug Compcare All options 31.92%maxR %maxR31.92 UPN options acute = DSP Universal GEMS All opions 27,5%maxR ,5%maxR27.50 MPN 30% penalty nondsp GEMS Grintek Electronics - GEMAS All options 31.92%maxR %maxR31.92 UPN Universal Makoti All options 36.48%maxR %maxR36.48 Enablemed 25% co-pay - nonformulary drug Massmart All options 20% 34,2%maxR34.20 Phy Direct - DSP Chronic DSP 25% penalty non DSP Universal NBCRFLI - Nat Bargain Council Road Freight Logs All options 31.92%maxR %maxR31.92 UPN Universal Tiger brands All options 31.92%maxR %maxR31.92 UPN Universal Transmed State Plus Network 31.92%maxR %maxR31.92 UPN Universal Umvuzo Std & Ultra affordable 31.92%maxR %maxR31.92 UPN Universal Universal Worker Plan Workerplan 31.92%maxR %maxR31.92 UPN Universal V-MED Liberty open scheme All options 29.64%maxR %maxR29.64 Scriptpharm Libcare staff scheme All options 29.64%maxR %maxR29.64 No 40% penalty co-pay for non- DSP Spectramed All options 31.92%maxR %maxR31.92 DSP Optipharm; Optime and Medirite PROVIDENCE Impala medical Plan All options as per Providence rate as per Providence rate Providence >R75 SEP + R4 + 33% Medimed All options 20% as per Providence rate as per Providence rate Providence

4 R75-R250 SEP+R25+6% RUMED All options 20% as per Providence rate as per Providence rate Providence R250-R1K SEP+R33+3% Sisonke - was Goldfields All options 20% as per Providence rate as per Providence rate Providence >R1000 SEP+R50+1,5% Suremed Shuttle Opt 20% 29.64%maxR29.64 as per Providence rate Providence Suremed Challenger Navigation options 20% as per Providence rate as per Providence rate Providence MOMENTUM Call centre: Momentum Health All options 29.64%max R %maxR29.64 DSP Medipost MMSA Moto Health Care All options 31.92%maxR %maxR3192 DSP MMSA SHECHABA HIV 22.8%maxR22.80 Sizwe All options 29.64%maxR %maxR %maxR27.36 no penalty PPN copays Sechaba PRIVATE HEALTH ADMIN PHA Alliance Midmed Medical All options % max R %maxR31.92 PHA DISCONTNUED **Pharos Medical Plan Merging with Topmed as of 01 Jan 2014 Same Member #s no Topmed 31.92%max R %maxR31.92 PHA MEDISCOR Bestmed All options 37.62%max R %maxR37.62 Bestmed THEBE YA BOPHELO ThebeMed All options 31.92%maxR %maxR31.92 no SELF-ADMIN SCHEMES Bestmed All options 37.62%max R %maxR37.62 PP Bestmed 100% penalty copay Cape Medical Plan 29.64%maxR29.64 DSP - penalty co-pay DSP 100% copay no Genesis Medical Scheme All options 29.64%maxR29.64 Govt 4 tier Govt 4 tier no Keyhealth All options 29.64%maxR ,64%maxR ,36%maxR27.36 DSP Contract available Keyhealth Mamoth Health 36% 36%maxR %maxR59.40 MediKreditFned group Medihelp All options 35.91%maxR %maxR %maxR35.91 PPN nonppn 26/26 ex Medihelp Medshield Medical Scheme All options 29.64%maxR %maxR %maxR26.22 Medshield Nampak (SA) Merged with Discovery Health 01 March Nestle 36% Govt 4 tier Govt 4 tier 100% penalty copay nondsp Netcare Medical Scheme All options 29.64%max R29.64 DSP - reject thru IP Pharma cross 100% copay Primemed Max R120 for PAT Optimum [OPMED] All options 31.92%maxR %maxR %maxR31.92 PG Group Medical Scheme All options 29.64%max R %max R29.64 Momentum Platinum Health Medical scheme All options 29.64%maxR %maxR29.64

5 Resolution All options 36% capped at R59.40 at R165 36% capped at R59.40 at R165 PP KOSolutions 40% penalty co-pay nondsp Closed PMB for PMB meds Selfmed All options 34.2%maxR %max34.20 DSP UNDP 36% Govt 4 tier UNICEF 36% Govt 4 tier UNOPS 36% Govt 4 tier 40% penalty co-pay on PMB no UNV International/national volunteers 36% Govt 4 tier Witbank Coalfields Medical Scheme All options 29.64%maxR %maxR29.64 World Bank International/local active/retired 36% Govt 4 tier SCRIPTPHARM Bestmed All options 37.62%max R %maxR37.62 PP Scriptpharm 20% co-pay nonformulary Hosmed All options 31.92%maxR %maxR31.92 DSP Scriptpharm Wellness benefit R110 inc Imperial Group Medical Scheme 31.92%maxR %maxR31.92 Joint DSP Metropolitan HG Liberty Medical Scheme 29.64%maxR %maxR29.64 SEP 30% uncapped VAT inc, Liberty Bona Plus All options 34.2%maxR %maxR29.64 nonsep 30%maxR36.00 PP Scriptpharm Medshield Medical Scheme All options 29.64%maxR %maxR26.22 Excludes HIV & oncology DSP. Medshield MOU Transmed Medical Fund All Options 30%maxR %maxR %maxR23.94 DSP Scriptpharm Wellness Benefits - R95 Nedgroup Medical Aid Scheme All options 29.64%maxR %maxR %maxR29.64 Chronic DSP Scriptpharm DSP NO CONTRACTS Barloworld All options 29.64%maxR %maxR29.64 Medscheme BMW All options 20% Govt 4 tier rate Govt 4 tier rate Medscheme BP Medical Aid Society 29.64%maxR %maxR29.64 DSP Metropolitan HG [MSO] Med CIGNA SVS & Hatch Govt 4 Tier rate Govt 4 tier rate Govt 4 tier rate Services Org

6 Acute & chronic DSP De Beers Medical Benefit DSP closed <R20 R ,44% R20-R243 36% R243-R700 R ,10% >R700 R ,7% <R20 R ,44% R20-R243 36% R243-R700 R ,10% >R700 R ,7% DSP 30% De Beers Essential Med (Insurance) 29.64%maxR %maxR29.64 Day-1 Health Fishing Industry 29.64%maxR %maxR29.64 Metropolitan Golden Arrow Employees Medical Benefit Fund 29.64%maxR %maxR29.64 Metropolitan Hairdressing (Natal) 27.50% Horizon all options 34.2%max %maxR29.64 Medscheme International Monetary Fund 36% Govt 4 tier rate Govt 4 tier rate Medipos Medical Scheme All Option 31.92%maxR %maxR31.92 Metropolitan Metrocare All options 34.2%max %maxR34.20 Medscheme Old Mutual Staff Medical Aid Fund (OMSMAF) All options 29.64%maxR %maxR29.64 Medscheme Onecard Oneplan Adplan Govt 4 Tier rate Govt 4 tier rate Govt 4 tier rate Management Parmed All options Govt 4 tier rate Govt 4 tier rate Medscheme Polmed All options Govt 4 tier rate Closed DSP - penalty co-pay DSP for chronic 30% copay nondsp Metropolitan HG Sasolmed Rate: 0-R22.30 = R %. R22.31-R47.50 = R R47.51-R = 41.04%. R R = R %. >R700 = R % Sasolmed All options 20% as per Sasolmed rate as per Sasolmed rate TBC Medscheme PATIENT CHOICE NETWORK University of Witwatersrand All options 29.64%maxR %maxR29.64 Medscheme TEL FAX %maxR36 on non-sep items. BANKMED - basic and PMB options BESTMED - Pulse 1 & 2 options HORIZON - Major Medical Plan LIBERTY - Traditional Std option MOTOHEALTH - Custom & Essential Options Old Mutual Staff - Network Plan PAT= 37,2%max OPTIONS R %maxR %maxR29.64 DSP PATIENT CHOICE

7 Namibian Schemes Osca Care - Gold & silver options PLATIMUN Health - comprehensive & Platcap options REMEDI - Standard Option TOPMED - Network Plan WOOLTRU Healthcare - Core Option NAPOTEL SA Options 34.2%maxR %maxR %maxR34.20 Renaissance Prosperity SA Options 34.2%maxR %maxR %maxR34.20 RCC Life Insure SA Options 34.2%maxR %maxR %maxR34.20 Prosperity Life Insure SA Options 34.2%maxR %maxR %maxR34.20 Namdeb Medical SA Options 34.2%maxR %maxR %maxR34.20