|
|
MEDISCOR
(PTY) LTD |
NOTIFICATION 51OF2011 |
21
December 2011
|
|
Medical Scheme |
CompCare Wellness Medical Scheme |
|
Administrator |
Universal Health Administrators |
|
Information Relevant to |
Benefits and Options
for 2012 |
|
Effective Date |
1 January 2012 |
With effect 1 January 2012, Mediscor will
be applying the scheme rules for CompCare Wellness Medical Scheme as outlined
below.
Herewith the detail for submitting medicine claims to
Mediscor:
|
1. |
Scheme Code (PCN) |
1. |
MDS0014 |
|
2. |
Switch Destination Code |
2. |
SSCC0000
|
|
3. |
EDI Activation Code
(Dispensing Doctors) |
3. |
129P |
|
4. |
Reference Pricing |
4. |
Yes
|
|
5. |
Maximum supply of medicine |
5. |
30 Days |
|
6. |
Days supply of the
dispensed medicine |
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 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 diagnosis code |
13. |
Yes / Compulsory |
|
14. |
9 digit NAPPI code of
medicine dispensed |
14. |
Yes / Compulsory |
|
15. |
Membership number
requirements |
15. |
Minimum 3 digits |
|
16. |
Payments to Providers |
16. |
Universal Health |
|
17. |
Chronic pre-authorisation Mediscor
ChroniLine™ |
17. |
Yes |
|
18. |
Reimbursement structure –
Dispensing Doctors |
18. |
SEP + 30%/R23.40 |
|
19. |
Reimbursement structure –
Pharmacies |
19. |
SEP + 26%/R26 |
|
20. |
Over the counter (OTC) |
20. |
SEP + 26%/R26 |
·
SEP
(VAT Incl.) and Dispensing Fee (VAT Excl.)
·
Reimbursement
structure will be applied on scheduled medicines (0 – 8) and unscheduled
products.
·
Formulary
Reference Price (FRP) – information available on www.mediscor.net
·
Mediscor Reference Price (MRP®) – 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 CompCare Wellness Medical Scheme effective from 1 January 2012:
|
OPTIONS |
BENEFITS APPLICABLE |
LEVY / CO-PAYMENT |
MRP® / FRP |
EXCLUSIONS |
|
Pinnacle Dynamix Mumed Symmetry Axis Networx |
Acute
(Axis not applicable) |
Networx: Limited
to formulary Pinnacle / Dynamix /
Mumed / Symmetry: 25% co-pay on ethical’s where no generic exists. |
MRP |
3-5, 6-9, 11, 19-25, 27, 30, 32, 40-41, 43-45, 47-51,
60-62 |
|
Chronic (Mumed, Axis and
Networx not applicable) |
Pinnacle / Dynamix: Mediscor Standard Formulary Non-formulary products: 25%
co-payment Symmetry: Mediscor Basic Formulary Non-formulary products: 25%
co-payment |
MRP |
||
|
OTC (Axis, Networx not
applicable) |
Pinnacle: No
Levy Max
of R160 per prescription Dynamix : No
Levy Max
of R150 per prescription Symmetry / Mumed: No
Levy Max
of R130 per prescription |
MRP |
||
|
Oncology |
No
Levy |
MRP |
||
|
HV/AIDS |
No
Levy |
MRP |
||
|
Prescribed
Minimum Benefits (PMB) |
Pinnacle / Dynamix: Mediscor Standard Formulary Non-formulary products: 25%
co-payment Mumed / Symmetry: Mediscor Basic Formulary Non-formulary products: 25%
co-payment Axis: Mediscor Core Formulary Non-formulary products: 25%
co-payment |
MRP |
||
|
Networx: Mediscor Core Formulary Non-formulary products: No
co-payment (subject to Formulary Reference Price) |
FRP |
|||
|
Biological
Benefits (Networx not
applicable) |
Pinnacle: No
Levy Dynamix/ Symmetry /
Mumed / Axis : 25%
co-payment |
MRP |
||
|
Contraception |
Pinnacle / Dynamix: Max
of R100 per prescription Symmetry: Max
of R100 per prescription Mumed: Max
of R100 per prescription Networx: Max
of R70 per prescription |
MRP |
ADDITIONAL CUSTOMISED EXCLUSIONS:
1.
Nootropil™
2.
Phenolphthalein
laxatives™
3.
Phensydyl™ and
generic equivalents
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 |
: |
0860 113 238
or 0860 117 705 |
|
Mediscor ChroniLine™ Mediscor E-Mail |
: : |
0860 119 553 helpdesk@mediscor.co.za |
Kind regards.
JACK PEREL