Contributions for 2016

Over-the-counter (OTC) medication

Benefit for MRI and CT scans for 2016

Pick n Pay Medical Scheme’s Maternity Programme

newsletterapril 2016

Dear Member

to the first newsletter for 2016. We trust that the first quarter of the year has started wonderfully, and that it continues as the year goes on.

WELCOME

Flu vaccination – Boost your knowledge and your family’s immunity

Medical scheme benefits usage after resignation and the serious implications thereof

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CONTRIBUTIONS FOR 2016

Income category Principal member

Adult dependant

Child dependant

R0 – R2 800 R1 068 R1 068 R332

R2 801 – R6 010 R1 880 R1 880 R506

R6 011 – R8 990 R1 988 R1 988 R540

R8 991 – R12 021 R2 104 R2 104 R564

R12 022 – R15 000 R2 252 R2 252 R602

R15 001 – R18 031 R2 374 R2 374 R642

R 18 032 – R22 440 R 2 428 R2 428 R653

R22 441 – R31 910 R2 450 R2 450 R658

R31 911 + R2 462 R2 462 R662

Medical Spending Account

20% of the total contributions will be allocated to the Medical Spending Account (MSA) of the member.

The contributions payable in respect of a Member Family for benefits is based on the member’s monthly income. The rate for members, with the addition of adult dependants and child dependants, are set out in the table on the right.

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OVER-THE-COUNTER MEDICATION

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Has your pharmacy been unable to submit claims for your medication lately? This could be the reason…

With effect from 1 January 2016, Pick n Pay Medical Scheme introduced limits on medication, not only to ensure good clinical practice within the Scheme but also to ensure that you, our members, get appropriate care and use your medical spending accounts (MSA) wisely.

1 Hypnotics/sedatives

You will only be allowed to claim a 10-day supply within 90 days. These drugs are habit-forming medication and not indicated for long-term use. Rules have been implemented to prevent the continuous use of these medications, by only allowing enough medication for acute treatment with these drugs. Examples of medication that fall into this category are:

• Stilnox (active ingredient Zolpidem), its generics are Ivedal and Zolnox

• Imovane (active ingredient Zopiclone), its generics are Zopivane and Sandoz-Zopiclone.

2 Nexiam acute quantity limit

High doses of Proton Pump Inhibitors (PPI), for example Esomeprazole 40mg (Nexiam 40mg), should not be used long term as it carries a risk of Clostridium-related diarrhoea, which can be life threatening. These products are used for treating multiple conditions for example gastro-oesophageal reflux disease (GORD), peptic ulcer, erosive esophagitis, etc. Based on clinical evidence, long-term use also decreases bone mineral density. Esomeprazole 40mg must rather be used for a period of 6 months or less after which the possibility must be considered to lower the dose to the 20mg. Scheme rules were implemented to control long-term use of high doses of Esomeprazole. The generic substitutes for Nexium include Trustan, Nexmezol, Nexipraz, Nexomep, Nexiflux, Nesopram and Nectizole, which also has the same effects.

3 Codeine limits

There is a global trend towards the management of the growing problem of misuse and abuse of over-the-counter (OTC) products containing codeine. The amount of codeine that you take depends on the strength of the medicine. However, maximum registered doses should never be exceeded and, where possible, codeine use should be limited to the shortest necessary duration, or in accordance with your doctor’s or pharmacist’s instructions. The Scheme decided to implement monthly quantity limits on codeine products purchased over the counter. This is in line with responsible clinical practice and to ensure appropriate use of codeine in the best interest of the Scheme’s members. Since long-term use of codeine is harmful, codeine-containing pain medication should not qualify for chronic medicine benefits.

4 PAT/OTC – Maximum claim limit

A rule has been implemented to only allow a maximum of R200 per script per beneficiary per day on claiming Pharmacy Administered Therapy (PAT )and OTC medicines. This is to help members utilise their savings in an appropriate manner, effectively “stretching their healthcare rand” to ensure that they don’t run out of savings half way through the year.

The following new rules have been implemented:

The

Pick n Pay Pharmacy team

has undertaken to assist Pick n Pay Medical

Scheme members by enabling you to make the

right decision and by offering alternative

medication.

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PICK N PAY MEDICAL SCHEME’S MATERNITY PROGRAMME

BENEFIT FOR MRI AND CT SCANS FOR 2016As many of you are aware, there was a rule change for 2016 with regard to MRI and CT scan payments. This rule means that the claims for non-PMB MRI and CT scans will be approved and paid from your MSA.

This change has caused a few problems and the Board of Trustees then decided to review this rule change and the impact that it has had on members.

We are therefore in the process of submitting a rule change to the Council for Medical Schemes (CMS) that MRI and CT scans will be subject to pre-authorisation. This will be paid from the insured benefit, but there will be a R1500 co-payment. The good news is that if you’ve already had an MRI or CT scan done during 2016, which was paid from your MSA, your claim will be reprocessed in accordance with the new benefit.

MRI’s are very expensive scans and has a significant impact on the Scheme’s claims ratio. Please think twice before using this benefit and make sure that it’s absolutely necessary.

Having a baby is one of the most exciting, special and scary, times in a woman’s life, so to help you through this, Pick n Pay Medical Scheme has contracted Private Health Administrators (PHA), one of our managed care service providers, to offer our members a Maternity Programme to assist and support new moms-to-be through the excitement and nervousness of pregnancy. This is specifically designed to promote a healthy pregnancy, birth and post-natal support.

It is advisable to register on this programme as early as possible in order for you to get the full benefit of the programme:

Step 1 Call 0860 767 633 and choose the option for the Maternity Programme (option 3)

Step 2 Speak to a qualified midwife

Step 3 You will be required to discuss any previous pregnancies, miscarriages or health problems. This will enable the case manager to get a full picture of your requirements and needs.

ORYou may e-mail pnpbaby@pha.co.za

Once you are registered on the programme, one of the PHA midwives will ask you some questions about your current pregnancy. The PHA midwife will call you regularly to discuss your progress, especially as you get closer to your delivery date. You can also call her at any time during office hours on the number above. If there is an emergency, you can call our 24-hour emergency line for assistance. She will also send you some helpful information, vouchers and samples.

When it is time to book your bed for the confinement, please call 0860 767 633 and choose option 2 for the hospital benefits department. The PHA midwife can also assist you with this should you prefer it. 

All information is strictly confidential at all times.

Please noteWhen you choose your doctor and hospital please be aware of the Pick n Pay Medical Scheme hospital network. Should you choose to have your baby at a non-DSP hospital; you will be liable for a R2000 co-payment at admission. This is non-refundable.

It remains your responsibility to discuss fees with your gynaecologist, anaesthetist and paediatrician, to determine any further shortfalls. Medical Schemes also do not cover booking fees as these are not medical services and fall outside of the Scheme rules.

FLU VACCINATION – Boost your knowledge and your family’s immunity

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What is flu?Influenza (also called “the flu”) is a viral infection in the nose, throat and lungs. Although influenza is generally not dangerous, it can cause serious complications, especially in the elderly and the very young. Typically, it affects 10% to 20% of the population each year, which leads to many lost man-hours and school days.

Who is at higher risk? All children aged six to nine

months All adults aged 65 years and

older People who have long-term

health problems Immune-suppressed people,

including those who are HIV positive Smokers, as they are more prone

to respiratory illnesses

Who should not be vaccinated? People who have a severe allergy

to eggs

People who have had a severe reaction to an influenza vaccination in the past

Children less than six months of age

People who have a moderate or severe illness with a fever should not be vaccinated until their symptoms lessen dramatically

Do flu vaccines work immediately?No. It takes about two weeks after vaccination for antibodies to develop in the body and provide protection against influenza virus infection. In the meantime, you are still at risk of getting the flu. That is why it is better to get vaccinated early in autumn, before the flu season really gets underway.

Can you receive vaccines if you are currently not well?You may not receive the vaccine if you have a febrile condition (illness with fever). It is always better to be in a healthy state when receiving a vaccination.

Are there side-effects that may occur?Side-effects usually consist of low-grade fever and mild flu-like symptoms, lasting 8 to 24 hours after immunisation. These symptoms occur due to the response of your immune system to the vaccine:

Mild soreness at the site of the injection is common – this will only last a day or two.

About 5% to 10% of people may experience fever, sore muscles and other symptoms resembling flu that can start within twelve hours of receiving the flu vaccine. It will only last 24 hours.

If you experience these symptoms for more than a day after you have been vaccinated, or if they last longer than two days, it is almost certainly an illness not related to the vaccine. Please consult your doctor or healthcare professional.

If you have any further questions, discuss them with your doctor, clinic sister or pharmacist.

DID YOU KNOW?The flu vaccine is

covered by the Scheme and benefit is limited to one vaccine per

beneficiary per annum.

important contact details

CLIENT SERVICE DEPARTMENTTel: 021 480 4801 or 0800 004 389Fax: 021 480 6842Postal address: PO Box 15774, Vlaeberg 8018E-mail: picknpay@mhg.co.zaInternet: www.pnpms.co.za

HOSPITAL AND ONCOLOGY PRE-AUTHORISATIONTel: 0860 767 633

MANAGED CARE PROGRAMMESTel: 0860 767 633

CHRONIC MEDICATIONTel: 0800 132 345 (doctors only)

CENTRE FOR DIABETES AND ENDOCRINOLOGY(Diabetes Management Programme)Tel: 011 712 6000 (office hours)Internet: www.cdecentr.co.za

ER24Emergency Transportation ServicesTel: 084 124

COUNCIL FOR MEDICAL SCHEMES CUSTOMER CARE CENTRE0861 123 2670861 123 CMSE-mail: information@medicalschemes.com ComplaintsFax: +27 12 431 0608E-mail: complaints@medicalschemes.com Postal addressPrivate Bag X34, Hatfield 0028

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DID YOU KNOW?You can log onto the Scheme’s website to access your member profile? All you need is your own personal PIN and you will have your member information at your fingertips, e.g., benefits available, claims paid and hospital authorisations, etc.

Visit www.pnpms.co.za to register – it takes 5 minutes.

You can also save paper by changing your communication preference to electronic and receiving your claims statement via e-mail.

MEDICAL SCHEME BENEFITS USAGE AFTER RESIGNATION AND THE SERIOUS IMPLICATIONS THEREOFAs a member of the Pick n Pay Medical Scheme, you have certain obligations; which includes:

Paying your contributions on time.

Checking your statements against doctor or hospital visits to ensure that the claims are being paid correctly.

Ensuring that all your membership details are correct and this includes details of your dependants, e.g. ID numbers.

Registering your newborn babies within 30 days to avoid any waiting periods.

Resigning dependants that no longer satisfy the conditions in terms of which he may be a dependant.

that the day of your resignation of employment,

will be the last day that you may use your medical

scheme benefits. Any claims submitted for services after the resignation date will be rejected. You will be held liable for this account.

Please note