|
|
MEDISCOR
(PTY) LTD |
NOTIFICATION 49OF2009 |
|
18/12/2009 |
|
Medical Scheme |
SPECTRAMED Medical Scheme |
|
Administrator |
Vmed |
|
Information Relevant to |
Benefits and Options
for 2010 |
|
Effective Date |
1 January 2010 |
As from 1 January 2010, SPECTRAMED Medical Scheme will be administered by
Vmed.
With
effect 1 January 2010, Mediscor will be applying the scheme rules for
SPECTRAMED Medical Scheme as outlined below.
Herewith the detail for submitting medicine claims to
Mediscor:
|
1. |
Scheme Code (PCN) |
1. |
MDS0062 |
|
2. |
Switch
Destination Code
|
2. |
ROSP0000 |
|
3. |
EDI Activation Code (Dispensing Doctors) |
3. |
522P |
|
4. |
MRP® / FRP/ FRP Plus |
4. |
Yes |
|
5. |
Maximum supply of medicine |
5. |
30 Days |
|
6. |
Days of supply of the dispensed medication |
6. |
Yes / Compulsory |
|
7. |
Membership number as per membership card |
7. |
Yes / Compulsory |
|
8. |
Dependant code as per membership card |
8. |
Yes / Compulsory |
|
9. |
Dependant first name as per the membership card |
9. |
Yes / Compulsory |
|
10. |
Dependant date of birth |
10. |
Yes / Compulsory |
|
11. |
Dependant’s gender (male/female) |
11. |
Yes / Compulsory |
|
12. |
Practice number of the prescriber |
12. |
Yes / Compulsory |
|
13. |
ICD-10 Diagnostic code |
13. |
Yes / Compulsory |
|
14. |
9 digit NAPPI code of medicine dispensed |
14. |
Yes / Compulsory |
|
15. |
Membership number requirements |
15. |
11 numerical |
|
16. |
Payments to ALL providers for 2009 and 2010 services |
16. |
Vmed |
|
17. |
Chronic pre-authorisation at Mediscor |
17. |
Yes |
|
18. |
Reimbursement structure - Pharmacies |
18. |
SEP + 26%/ R26 |
|
19. |
Reimbursement structure – Dispensing Doctors |
19. |
SEP + 30%/ R20 |
|
20. |
Reimbursement structure – Unscheduled and Schedule 0 Medicine |
20. |
SEP + 31% (Excl. VAT) |
·
FORMULARY
REFERENCE PRICE (FRP) – information available on www.mediscor.net
·
FORMULARY
REFERENCE PRICE PLUS (FRP PLUS) – information available on www.mediscor.net
·
MEDISCOR REFERENCE PRICE (MRP®) – information available on www.mediscor.net
·
MEDISCOR
FORMULARIES – information available on www.mediscor.net
·
ICD-10
CODES – information available on www.medicalschemes.com
IMPORTANT: The details below serve as a GUIDELINE ONLY. Due to the complexities of various Levy, Co-payment, Formulary and Exclusion criteria
SERVICE PROVIDERS MUST refer to our on-line responses to apply the
correct rules.
Herewith the scheme rules
for SPECTRAMED Medical Scheme effective from 1 January 2010:
Options for 2010:
·
SPECTRAAlliance
·
SPECTRAElite
·
SPECTRAHospitalelite
·
SPECTRAHospital
·
SPECTRAPlus
|
BENEFITS APPLICABLE |
LEVY / CO-PAYMENT |
MRP® / FRP |
EXCLUSIONS |
|
Acute (Spectra Hospital and Hospital Elite– no
benefit) |
Alliance - 20% levy Elite – 15% levy Plus – No levy |
MRP |
2, 3, 4, 5, 7, 8, 9, 10, 11, 14, 15, 16, 19, 20, 21,
22, 23, 24, 25, 26, 27, 30, 31, 32, 35, 40, 41, 43, 44, 45, 47, 48, 50, 51,
53, 60, 61. |
|
Non-CDL Chronic (Spectra Hospital / Hospital Elite– no
benefit) |
Spectra Alliance: Spectramed Alliance Formulary: 20% Levy Non-Formulary: 20% Levy plus FRP Spectra Elite: Spectramed Elite Formulary: 15% Levy Non-Formulary: 15% Levy plus FRP Plus Spectra Plus: Spectramed Plus Formulary: No Levy Non-Formulary: FRP Plus |
Spectra Alliance: FRP Spectra Elite / Spectra Plus: FRP Plus |
|
|
OTC (Spectra Hospital / Hospital Elite – no
benefit) |
Spectra Alliance: 20% Levy / Max of R75 per
script Spectra Elite: 15% Levy / Max of R100 per
script Spectra Plus: No Levy / Max of R100 per script |
MRP |
|
|
Oncology PMB |
DSP: No Levy Non-DSP: 20% co-payment |
MRP |
|
|
Oncology Non-PMB |
DSP: No Levy Non-DSP:
20% co-payment |
MRP |
|
|
Organ Transplant PMB |
No Levy |
MRP |
|
|
Organ Transplant Non-PMB |
No Levy |
MRP |
|
|
HIV/AIDS |
All options DSP: No Levy Non-DSP:
20% co-payment |
MRP |
|
|
Prescribed Minimum Benefits (PMB) |
Spectra Hospital and
Hospital Elite: Spectramed Hospital Formulary: DSP: No Levy Non-DSP: 20%
co-payment Spectra Alliance: Spectramed Alliance Formulary: DSP: No Levy Non-DSP: 20%
co-payment Spectra Elite: Spectramed Elite Formulary: DSP: No Levy Non-DSP: 20%
co-payment Spectra Plus: Spectramed Plus Formulary: No Levy No DSP |
Spectra Alliance / Spectra Hospital / Spectra
Hospital Elite: FRP Spectra
Elite / Spectra Plus: FRP Plus |
|
|
Ex-Gratia |
Can have one of the
following: No co-payment 10% co-payment 20% co-payment 25% co-payment 30% co-payment 40% co-payment 50% co-payment |
MRP |
·
FRP and FRP Plus
Members
will be liable for payment of the difference in price between the product they
selected to use and the formulary reference price on all non-formulary
products. Please refer to the real-time
response for all co-payment details.
PRESCRIBED MINIMUM BENEFITS (PMBs):
Members need to apply and register for PMBs and Chronic Medicine
Benefits with Mediscor ChroniLine™ on 0860 119 553.
IF YOU REQUIRE ANY ASSISTANCE, PLEASE CONTACT:
Mediscor’s Call Centre Helpline : 0860 11 32 38 or 0860 11 77 05
Mediscor ChroniLine™ : 0860 11 95 53
Kind regards.
JACK PEREL