|
|
MEDISCOR
(PTY) LTD |
NOTIFICATION 57OF2011 |
23
December 2011
|
|
Medical Scheme |
Pharos Medical Plan |
|
Administrator |
Private Health
Administrators |
|
Information Relevant to |
Benefits and Options 2012 |
|
Effective Date |
1 January 2012 |
With effect 1 January 2012, Mediscor will
be applying the scheme rules for PHAROS Medical Plan as outlined below.
Herewith the detail for submitting medicine claims to
Mediscor:
|
1. |
Scheme Code (PCN) |
1. |
MDS0016 |
|
2. |
Switch Destination Code |
2. |
PVPH0000 |
|
3. |
EDI Activation Code (Dispensing Doctors) |
3. |
583P |
|
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. |
10 Numerical |
|
16. |
Payments to providers |
16. |
Private Healthcare
Administrators |
|
17. |
Chronic pre-authorisation |
17. |
Mediscor ChroniLine™ |
|
18. |
Reimbursement structure – Dispensing Doctors |
18. |
SEP + 30%/R20
|
|
19. |
Reimbursement structure –
Pharmacies |
19. |
SEP + 26%/R26
|
|
20. |
Over the counter (OTC) |
20. |
SEP + 16%/R16
|
- SEP (VAT
Incl.) and dispensing fee (VAT Excl.)
- Reimbursement structure applied on scheduled
medicines (0 – 8) = SEP + 26%/R26 and unscheduled products = 31% + mark-up.
- 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 effective from 1
January 2012:
|
Pharos Options: |
|
|
·
Rainbow
Comprehensive |
|
|
|
|
·
Rainbow
Primary |
|
|
·
Paladin
Comprehensive |
|
|
·
Footprint
Comprehensive |
|
|
·
Footprint
Primary |
|
|
·
Methcare |
|
|
BENEFITS APPLICABLE |
LEVY / CO-PAYMENT |
MRP® |
EXCLUSIONS |
|
Acute (excluding Rainbow Primary and Footprint Primary) |
No
Levy Methcare: 20% Levy |
Rainbow Plus (except Acute and OTC) Rainbow Primary Paladin Comprehensive Footprint
Comprehensive Footprint Primary Methcare |
3-7,
11, 14, 15, 19, 21-25, 27, 30, 31, 40, 41, 43-45, 48, 50, 51, 53, 61, 62 |
|
Chronic (excluding Rainbow Plus / Rainbow Primary / Footprint
Comprehensive / Footprint Primary |
Rainbow Comprehensive:
No
Levy Paladin Comprehensive
and Methcare Formulary products: No Levy Non-Formulary products: 30% Levy |
||
|
OTC (excluding Rainbow Primary / Footprint Primary) |
No
Levy/R126 max per script |
||
|
Prescribed
Minimum Benefits (PMB) |
Rainbow Comprehensive:
No
Levy Rainbow Primary /
Footprint Comprehensive / Footprint Primary Formulary products:
No
Levy Non-Formulary product:
Reject Rainbow Plus / Paladin
Comprehensive / Methcare Formulary products: No Levy Non-Formulary products:30% co-payment |
||
|
HIV
/ AIDS |
No
Levy |
||
|
Oncology |
Rainbow Comprehensive
/ Rainbow Plus / Rainbow Primary / Footprint Comprehensive / Footprint
Primary / Paladin Comprehensive No
Levy Methcare: 20% Levy |
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 |
Kind Regards
Jack Perel