If you’ve been diagnosed with a chronic condition – usually a disease lasting more than three months for which you’ll need ongoing treatment – we’ll cover your treatment as long as it falls on our chronic disease list.
In order to get coverage for your chronic disease treatment, you or your doctor/pharmacist will need to apply for our Chronic Disease Benefit. Here’s what you need to do:
Step 1: Collect the relevant information
You’ll need the following to apply:
- Your Fedhealth membership number
- Dependant code
- ICD10 code
- Drug name, strength and quantity
- Your prescribing doctor’s practice number
- Diagnostic test results, e.g. Total Cholesterol, LDL, HDL, glucose tests, thyroid (depending on your condition).
If you need any help gathering this information, please contact us 0860 002 153.
Step 2: Apply
You have a few options for how you apply for our Chronic Disease Benefit:
- Call Chronic Medicine Management (CMM) on 0860 002 153 between 8.30am and 5pm on Monday to Thursday, and between 9am and 5pm on Fridays.
- Apply online at www.fedhealth.co.za. You’ll need to register on our website before you can apply. Once you’ve registered, click on “My Authorisations” and then select “My Chronic Application”. Select the person who’s applying, click the “Chronic Authorisation” button at the bottom of the page and then select “New Chronic Application”.
- Ask your doctor or pharmacist to apply on your behalf. They can either apply online or call our Provider Call Centre on 0860 100 220.
Step 3: We’ll give you a response straight away
If we need more information, we’ll let you, your doctor or your pharmacist know exactly what is missing. If we don’t approve your application, we’ll give you the reasons why, and you’ll have the opportunity to ask us to review our decision.
Step 4: You’ll get your medicine access card
If we approve your application for our Chronic Disease Benefit, we’ll give you a medicine access card. This card records the medical condition for which we’ve approved treatment.
Step 5: We’ll give you treatment guidelines
If you’ve applied for one of the 25 Prescribed Minimum Benefit chronic conditions, we’ve compiled treatment guidelines so that you’ll have access to appropriate treatment for your condition. You’ll receive details of these treatment guidelines with your letter from Chronic Medicine Management (CMM). This means if your doctor prescribes a new medicine for the condition, you may already be approved for it and can go straight to your pharmacy with your new script to collect your medicine.
What is a “chronic” condition?
A “chronic” condition is a persistent or long-developing syndrome, such as osteoporosis, diabetes, asthma, cancer and HIV/AIDS. This sort of condition is usually long lasting in its effects, or it’s a disease that develops over time. The term “chronic” is usually used when the course of the disease lasts for more than three months and will need ongoing treatment. Your option covers a list of conditions that include the 25 Prescribed Minimum Benefit chronic conditions as well as HIV/ Aids.
How do I know if my medicine is Chronic or Acute?
The best way to find this out is to ask your doctor. If you need to continue to take the medicine for a long period of time or indefinitely, then it’s probably a chronic problem that needs chronic medicine. If your doctor prescribes you a shorter-term treatment, for less than three months, for a new condition that will clear up or get better, it’s possibly acute.
What if there’s a co-payment on the chronic medication my doctor has prescribed?
If you find that the medicine your doctor has prescribed for you has a co-payment (because it costs more than the ceiling price given in the Medicine Price List), you can ask your pharmacist to change it to a generic medicine that the scheme covers in full. If your medicine has a co-payment because it isn’t in the formulary, discuss a possible alternative with your prescribing doctor.
What if I don’t register for my chronic condition?
It’s a good idea to register for the Chronic Disease Benefit, because if you don’t, the costs of your medicine will be paid from your day-to-day benefits. When your day-to-day benefits run out, you’ll need to pay for the medicine yourself. If you get sick with an acute condition, like a cold or the flu, you will not have any funds available in your day-to-day benefits to cover medicine for that condition.
What should I do if my chronic medication changes?
If your doctor decides to change your medication, you’ll need to advise Chronic Medication Management (CMM). The quickest and simplest way to do this is for your doctor to inform CMM telephonically on 0861 100 220. Within 24 hours, a temporary medicine access card will be sent to your pharmacy enabling them to dispense the medicine without delay. Alternatively, you can also apply for the change online at www.fedhealth.co.za. We’ll then mail a new medicine access card to you.
For more information on which chronic conditions are covered, please click the link below.
A formulary is an approved list of medicine for each of the chronic conditions covered by the Scheme. If a formulary applies to the Chronic Disease Benefit on your option, we only cover medicine that is listed on the formulary. The Medicine Price List (MP) also applies to medicines in a formulary.