SAMWUMED recognises the importance of Managed Care in the provision of quality healthcare for our members. As such, we have contracted Medscheme as our Hospital Benefit Management, Oncology Benefit Management and Pharmacy Benefit Management Service Provider and Aid for AIDS as our HIV/AIDS Management Service Provider.
Medscheme is responsible for the following Hospital Benefit Management services:
- hospital pre-authorisation and case management
- hospital claims adjudication
For Hospital Pre-authorisation contact 0860 33 33 87
For doctor claims related to your hospital authorisation contact the scheme directly on 0860 104 117
Under normal circumstances and in line with the Scheme rules, Medscheme requires pre-authorisation to be completed before any planned admission to hospital at least 1 business day before the procedure is performed or within 1 business day following an emergency admission. Not obtaining authorisation for an admission may result in a R1 000 co-payment being applied.
Remember to have the following information available when requesting a hospital authorisation:
- member name and surname
- member number and beneficiary code
- treatment date
- treating provider’s practice number
- place of service practice number
- relevant diagnosis and/or procedure codes
Medscheme is responsible for the following Pharmacy Benefit Management services:
- chronic medication authorisation and enquiries
- medicine claims clinical adjudication
For Chronic Medicine Authorisation contact 0860 33 33 87
AfA is responsible for all HIV/AIDS related clinical services
For HIV/AIDS contact 0860 100 646
This is the list of acute medicine payable from the Primary Healthcare Benefit should the Acute and Over-The-Counter (OTC) benefits be depleted. Remember to ask the pharmacist to include the appropriate diagnosis (ICD10) code when submitting the claim.
This formulary applies to clinically appropriate and cost effective medicine used for the 26 PMB chronic conditions. Other chronic conditions like depression, eczema, Gastro-Oesophageal Reflux Disease (GORD) and gout are not subject to a formulary.
This formulary applies to medicine used for some of the 270 Diagnosis Treatment Pairs (DTP’s) like endometriosis, menopause, polycystic ovarian syndrome and stroke.
This is a list of medication that are excluded from funding for various reasons, including:
- Medicines that have not been proven to have relevant clinical value
- Medicines that are more expensive compared to equally effective, safe and cheaper alternatives
- Some expensive chronic medicines that require pre-authorisation
- Some combination products, where it is more appropriate to use single ingredients products
- Newly registered products under review
This is a list of antidepressants that are excluded from the routine benefit. Funding will only be considered from the chronic medicine benefit.
This is a list of analgesics with a limited quantity that can be claimed per annum. Quantities above the specified limit will have to be motivated for.