1. Bonita’s Chronic medicine authorisation process, for Prescribed minimum benefits (PMB’s).

1.1 We have been members of Bonitas since 2014. My wife has been diagnosed with Multiple Sclerosis (MS for short) during 2016 and it is one of the 27 common chronic conditions as per the prescribed minimum benefits of our Bonitas medical plan – Bonsave. According to my research and explanations from different doctors: The MS disease is in the same category as cancer or categorized as an autoimmune disease. MS is a condition in which your immune system mistakenly attacks your own body or eats away at the protective covering of nerves, through your entire body. With MS you can exercise your muscles, but your nerves are in effect making a “short” in your body, it is the same effect as when an electrical wire, makes a short. 1.2 I have also done some “INTERNET” research around PMB’s - Prescribed minimum benefits and according to my research; it can be explained best or summarized by the following: “Your medical scheme is obliged to pay for certain prescribed minimum benefits (PMBs) that enable you to get the right treatment and protection from big medical bills. PMBs cover medical emergencies, life - threatening conditions and certain common chronic conditions” 1.3 Bonitas has been paying for my wife’s MS medicine in the form of injections since she has been diagnosed during 2016, the cost of the original MS medicine was around R 12,000.00. My wife has since been moved to a different MS injections for many reasons – she has to inject herself every second day. As I understand it, there are a few different MS medicines available and no MS patient’s symptoms are exactly the same and each MS person reacts differently to these medicines, therefore I am not mentioning the names of the different injections/medicines that my wife has been using. Currently she is having a lot of allergic reactions to her MS injections and especially today, after her injection; she was shivering because of a fever and she was in terrible pain. So, I had enough of seeing her suffering and decided to complain about the Bonita’s authorization procedure. The current MS medicine cost around R 8,000.00 through the Bonita’s preferred Pharmacy. The cost of the injections decreased with time; for some reason. My wife was admitted to hospital during August 2019 after a serious MS relapse (she could not move her right leg at all). Our GP recommended a different specialist, the new specialist re-confirmed my wife’s MS chronic condition and prescribed “the 2nd level” MS medicine, which is in tablet form. I am not sure when the motivation for this new medicine called Tuvigin, was submitted to Bonitas, but during November (since August) I have received an email from Bonitas; stating that the authorization for the Tuvigin has been declined “Your current Bonitas option, does not provide for the requested treatment” And also that I should contact my broker. 1.4 After some time our broker said that the Bonita’s answer actually meant that they want us to move to the most expensive medical option, before covering this medicine. That made me think that this new prescribed medicine, must be very expensive, but upon investigation it cost less than R 10,000.00 at our local Pharmacy (not the Bonitas preferred supplier). So, I estimate the cost to be around the same as the current MS injection, when supp**** by Bonitas preferred supplier. So the cost cannot be the reason why Bonitas doesn’t want to pay for the new prescribed MS medicine! 1.5 So, I have done some more research myself. I referred back to the letter about the authorization that has been declined and it also refers to the Bonita’s website, where I am supposed to find a basket with pre-approved medicines and if the medicine is not in this basket, it will not be authorized. I could not find the basket on their website, but the letter also referred to “Formulary”, which I found on their website. Under formularies I found a list of exclusions and my wife’s newly prescribed medicine was not on this list. Also this exclusion list does not state on which plan, these medicines are excluded and the decline answer that we have received (via our broker – not per letter or email, only telephonically) stated that the Tuvigin will be paid for, if we move to the highest or most expensive plan. Certainly if there are exclusions per plans, there must be an exclusion list available per plan? Therefore I concluded that if this new medicine is not on the exclusion list, it might not have been tested or something like that and therefore Bonitas does not want to pay for this medicine. 1.6 Next I found a “Specialised Drugs List - December 2019”on the website and my wife’s current and past injection is on this list and also the newly prescribed Tuvigin! Once again, this list does not prescribe a certain Bonitas plan, which you need to belong to, before Bonitas will authorize the Tuvigin or any of the medicine on the “Specialised Drugs List - December 2019”. Based on the above, it still doesn’t makes sense to me, why Bonitas does not want to approve the newly prescribed medicine – Tuvigin and the Bonita’s approval process for specialised drugs does not make sense to me. It must be basically the same price as the injections and the exclusion list does not specifically exclude this Tuvigin. And upon further research it also seems to me that currently “exclusions” does not apply to PMB’s. The only exclusion that I could find is “cosmetic surgery”. I apologize in advance if I am wrong and if these websites didn’t provide the correct information. Furthermore how can Bonitas expect of us to move to the most expensive plan (That cost R 10,000 + more than our current medical aid plan), if my wife cannot even work because of this disease. This MS disease has basically left her crippled, she cannot walk without crutches and then her right leg drags behind her most of the time. Her eyesight has worsened to the extent that she has double vision and requires special lenses for her glasses. Also her hearing has worsened and many other small personal things, that I rather won’t mention. 2. I then heard of the Bonitas “Ex gratia system” and requested these application forms, by email from Bonitas. I still haven’t received any response about these forms. If I understand the “Ex gratia” system correctly, Bonitas have a secondary system, where patients received extra assistance on a case to case basis. I cannot find any other info on this system, the details seem to be hidden or confined to certain individuals. Then there is also a system, where you can still get the prescribed medicine and you as the patient must make a co-payment – but also we have not received any correspondence about that option from Bonitas. 3. When it comes to the authorization of these specialised medicine, a lot more must be done by Bonitas, because we as the patients don’t understand all these medical terms. If for example the Tuvigin has not been approved by Bonitas, then certainly Bonitas must be able to inform the doctor and the pasient about the equivalent according the formularies of the specific plan – I am now only referring to PMB conditions or diseases, not every disease, under the sun. Or once diagnosed with a chronic disease, then at least sent the patient a list of the approved medicines for the chronic condition, as per the medical aid plan that they are on. The patient can then hand it to their specialists and eliminate all the above problems. There are a lot of other lists under the formularies section of the website, but nothing per medical aid plan; so it also impossible to know what is actually meant by all these lists. 4. Then lastly, one of the main indicators of the deterioration of the MS disease can only be indicated by way of MRI’s and my wife’s first MS specialist advised us that an MRI must be done at least every second year and since last year we app**** for pre-approval for an MRI on the Bonita’s website and each time it was denied. Only after the MS relapse this year, my wife was taken up in Hospital and one of the first things that was done, was an MRI. So, certainly if an MRI is such an important part of proof of the deterioration of the MS disease, an MRI approval (at least for MS purposes) must be a standard pre-approved procedure. This disapproval of the MRI’s could maybe be linked to the Bonita’s 30% co-payment for certain hospitals, even though we are not on a network hospital plan. (For each of my wife’s hospital admissions, the co-payment has been s****ped afterwards, but the existence of the hospital co-payment does not make sense to me. It refers to the fact that where there is more than one hospital in a certain area, than some hospitals are specifically excluded, except if it is an emergency. The fact of the matter is that certain specialists of certain PMB conditions only practice in certain hospitals and except for when it is a emergency, then we are not allowed to go to the best specialists or recommended specialist, because he or she is practising from a hospital that are excluded as per the Bonitas lists. It is as if Bonitas wants to force each specialists to have rooms in every hospital – it doesn’t make sense to me) Please don’t get me wrong, I think Bonitas is a good medical aid, but they definitely must improve on their authorisation and correspondence about chronic medicine and specifically when it is about the medication for the 27 minimum PMB’s. If it was your wife, husband or child whose health is deteriorating on a daily basis and you know that there is a better medicine or drug available for their chronic condition, that cost the same as the medicine that they are currently using, you will also complain.