SAMWUMED recognises the importance of managed care systems 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.

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 *0860 104 117?*

Under normal circumstances and in line with the Scheme rules, Medscheme requires pre-authorisation to be completed before admission to hospital, preferably five (5) business days before the procedure is performed.

Medscheme has also been appointed to assist our members with the following processes:

  • Pharmacy Benefit Management and Chronic Medication Registration & Enquiries.

Exclusions

This formulary applies to DTP conditions, e.g. endometriosis, ITP, menopause, POS, stroke, etc.

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This is a list of antidepressants that are excluded from the routine benefit. Funding will only be considered from the chronic medicine benefit.

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This is a list of analgesics with a limited quantity that can be claimed per annum to prevent abuse. Quantities above the specified limit will have to be motivated for.

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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
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This is the Chronic Disease List medicine formulary used for both Option A and Option B. This formulary is only applicable to the CDL conditions. Other chronic conditions are not subject to a formulary, i.e. depression, eczema, GORD and gout.

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This is the list of medicine payable from the Primary Care Benefit.

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Please note that a formulary only applies to chronic medication and hence there is no acute medicine formulary.