Pharmacy Benefit Management (PBM) manage medication benefits to ensure funding of cost-effective medication from the appropriate benefit within the Scheme’s respective Service Level Agreements (SLA’s). Pharmacy Benefit Management (PBM) offers acute and chronic medicine management for Suremed Please contact our dedicated pharmacy call centre on 086 172 7773.
Chronic medication benefit:
PMB and Extended chronic medication benefit.
PMB chronic medication benefit:
Prescribed Minimum Benefits (PMBs) are a set of defined benefits to ensure that all medical scheme members have access to certain minimum health services, regardless of the benefit option they have selected. This benefit covers the conditions which are listed below:
• Addison's Disease
• Asthma
• Bipolar Mood Disorder
• Bronchiectasis
• Cardiac Failure
• Cardiomyopathy
• Chronic Obstructive Pulmonary Disease
• Chronic Renal Failure
• Coronary Artery Disease
• Crohn's Disease
• Diabetes Insipidus
• Diabetes Mellitus Type I
• Diabetes Mellitus Type Il
• Dysrhythmias
• Glaucoma
• Epilepsy
• Haemophilia
• Hyperlipidaemia
• Hypertension
• Hypothyroidism
• Ischaemic heart disease
• Multiple Sclerosis
• Parkinson's Disease
• Rheumatoid Arthritis
• Schizophrenia
• Systemic Lupus Erythematosus
• Ulcerative Colitis
Extended chronic medication benefit:
The scheme provides cover for additional chronic conditions for certain options (for non-PMB conditions or PMB conditions where treatment fall outside of the treatment algorithm). All such conditions meeting approval criteria may be authorised as per Scheme rules. Approved medicine may be paid up to the benefit limit of the respective option. Once your benefit limit has been reached, any further claims from this benefit for the approved medicine will be rejected. Kindly note that the Extended chronic medication does have a limit that can be reached during the year.
Extended Chronic conditions for the Challenger option:
• Ankylosing spondylitis
• Narcolepsy
• Obsessive Compulsive Disorder
• Major Depression
• Osteoporosis
• Psoriasis
Suremed Navigator, Shuttle, and the Explorer option: Benefit only covers CDL conditions, no Extended Chronic Medication.
Members are encouraged to make use of Designated Service Provider (DSP) Pharmacies and, opt for the more cost-effective alternatives where applicable, when claiming medicine; so that member out-of-pocket expenses may be avoided.
Please Click Here to view the Designated Service Provider (DSP) Pharmacies
Please Click Here to view the Suremed Challenger and Navigator_Momentum TYB Standard Care CDL Formulary.
Please Click Here to view the Suremed Challenger_Momentum TYB Standard Care non-CDL Formulary.
Please Click Here to view the Suremed Explorer_Momentum TYB Managed Care CDL Formulary.
Please Click Here to view the Suremed Shuttle_Momentum TYB Managed Care CDL Formulary.
Please Click Here to download the Chronic Medication Benefit Application Form.
Please send the completed Chronic Medication Benefit Application Form to: chronic@suremedhealth.co.za.
The turnaround time is between 24 and 48 hours, excluding Saturdays, Sundays, and public holidays.
Acute medication benefit:
Acute medication is prescribed for a short period of time often to combat a temporary illness. Acute medication must be prescribed by a registered healthcare provider.
The Acute Medication Benefit is subject to applied limits, levies, and reference pricing or exclusions that may be applicable.
Quantity limitations are applied to certain medicines, categorised by drug category and dosage form. However, quantity limitations do not apply to medicine authorized as chronic medication.
To avoid any co-payments or levies, ask your pharmacist to dispense cost-effective alternatives when required.