Formularies

Facts:

The purpose of a formulary (medicine list) is to:

Provide a list of fully covered medicine options when a member is diagnosed with a condition and approved for Prescribed Minimum Benefits.
Facilitate member awareness that there are generic medicines available that could be cheaper (ie, cost preferential generic medicines).
Evaluate and ensure high quality generic medicines.
Ensure an appropriate scope of cover clinically.
Focus on the preferentially priced generics and is selected based on 'the first line entry level' and preferentially priced products, which is part of the Council for Medical Schemes' (CMS) algorithm. For example, when looking at the algorithm for hyperlipidaemia medicines, if the first line of treatment is statins, the most cost-effective medicine and statins are added to the formulary (medicine list). This ensures that the member is fully covered to treat their hyperlipidaemia, which is recognised as a chronic condition on the Remedi Chronic Illness Benefit (CIB) list.

Formularies are designed to:

Create benefit option differentiation between members' available benefit options to choose from.
Ensure enough stock in the market before adding a product onto the formulary (medicine lists), which allows for continuation of availability and funding.
Promote competitive pricing between manufacturers who wants their products to be listed on the formulary (medicine lists).

What to do if a medicine on the formulary has failed (for example, severe side effects) in treating the patient:

The treating doctor must complete a clinical appeal form that must be submitted to CIB_APP_FORMS@discovery.co.za.
Based on the clinical appeal, and where the motivation is successful, an alternative medicine may be prescribed and will be funded in full.

Industry information has demonstrated that:

70% of claims are based on the pharmacists' intervention and are influenced by the choice of medicine.
Some brand name medicines costs as much as 4 to 5 times more than the generic equivalent. To ensure long-term sustainability and keep medical scheme contributions at affordable levels, a reference price protects medical schemes and its members against adverse and increased costs that could result in medical schemes becoming unaffordable.

Remedi Medical Aid Scheme offers members three benefit options to choose from and provides cover based on the chosen benefit option.

The Standard Option provides cover for entry-level medicine, which is equivalent to what state hospitals and clinics provide. Depending on the feedback received from providers and the clinical outcomes achieved, as well as the CMS algorithms, which are updated on a regular basis and allows for additional medicines to be added to the Standard Option formulary (medicine list). This ensures that members registered on this benefit has access to more cover than what is available at state hospitals and clinics. Where members willingly choose not to use the formulary medicine, Remedi will fund the medicine up to a Therapeutic Reference Price (TRP) or the Chronic Drug Amount (CDA), as may be applicable.
The Classic and Comprehensive benefit options have access to a more enhanced formulary list of medicines, which are referred to as 'non-formulary drugs'. We fund medicines on this benefit options up to the Chronic Drug Amount, which is an amount of money that has been allocated to each medicine category each month for a specific condition. This will also include the dispensing fees.
The Comprehensive benefit option also has access to innovation drugs and medicines available through the Remedi Specialised Medicine Benefit (SMB).

Chronic Drug Amounts are determined:

By considering the drug class that medicine can be categorised into and comparing medicines that falls within the same drug class that are available on the formulary (medicine list) and those not available on the formulary (non-formulary drugs).
To set financial responsible limits for funding, limiting the financial risk.
To allow funding in some instances in full, while in other instances members may have a co-payment depending on the medicine prescribed or chosen and how its price compares to the weighted cost of the formulary (medicine list) alternative.

The difference between generic medicines and therapeutic reference priced medicines

Generic medicines are medicines that are exactly the same in terms of their active ingredient, strength and form. Therapeutic reference priced medicines cover a much broader list of medicines. In other words, a therapeutic reference price applies to medicine that falls in the same drug class or has a similar action on the body and is not limited to medicines with generic equivalents.

Actions:

Familiarise yourself with the difference in cover of the benefit options by visiting our website at www.yourremedi.co.za. Go to Find a document > Benefit brochures to find your Remedi brochure, available in English or Afrikaans.
Reach out to AlexForbes, appointed by Remedi to provide free advisory services to Remedi members. Book your appointment today and find out which benefit option is most ideal to provide you with comprehensive cover to meet your needs.