Discovery is leaving chronically ill patients without essential medication while departments pass the buck

I am absolutely livid, frustrated & deeply disappointed with Discovery Health.

We have been long-standing Discovery members & several of our conditions are already registered & approved chronic conditions. When our specialists prescribe new medication for these existing conditions, the normal process is straightforward: the prescription is submitted to Discovery for approval & once approved, the medication is collected from the pharmacy under the chronic benefit.

That is exactly what has happened here....except Discovery is now refusing to process the medication through Chronic & has referred EVERYTHING to Ex Gratia.

The medication in question includes medication that is listed on Discovery's formulary for the patient's already-approved chronic diagnosis.

So please explain to me....WHY is medication that is listed on the formulary for an approved chronic condition being pushed into an Ex Gratia process?

I understand that genuine Ex Gratia requests require supporting documentation such as financial information, bank statements, medical motivations, quotations, etc. I have never disputed that & I am prepared to provide that but it will take time AS YOU KNOW SPECIALISTS CHARGE HEFTY FEES FOR MOTIVATION LETTERS. So if one can't even afford necessary medication, where will we get ridiculous amounts for motivation letters???

But that is NOT the issue....

The issue is that Discovery appears to have lumped everything together....including medication for existing registered chronic condition & is telling us that it must all go through Ex Gratia.

Today, I was contacted by Zukiswa from the Chronic Department & I was specifically told that they have advised her that all requests are Ex gratia & that the matter must be dealt with by Ex Gratia.

This is completely unacceptable!!!

There is a fundamental difference between asking Discovery for discretionary assistance with an expense that falls outside the normal benefits & asking Discovery to correctly process prescribed medication for an already-approved chronic condition where the medication is on the applicable formulary.

Those 2 things should not simply be thrown into the same basket!

What makes this even more outrageous is that we are currently without medication.

I was admitted to hospital AGAIN & required High Care, which is why I have only been able to respond to Discovery now. We are already dealing with serious & ongoing medical circumstances & now patients are being left without prescribed medication while we are expected to spend time gathering extensive Ex Gratia documentation.

Yes, I will provide the requested information. But how long are patients expected to go without essential medication while Discovery departments pass the responsibility from one department to another?

Medication is prescribed to manage chronic conditions & prevent deterioration. Interrupting treatment can result in complications, deterioration & further or prolonged hospital admissions.

And here is the irony: Discovery will spend thousands upon thousands of rands treating patients in hospital after their conditions deteriorate, yet is refusing to approve medication that could potentially help manage those conditions OUT OF HOSPITAL at a fraction of the cost.....Where is the logic in that?

Prevention & appropriate outpatient management should surely be in the interests of both the patient AND the Scheme.

Our MSA is exhausted, which is why we approached Discovery for assistance. But an exhausted MSA should not suddenly mean that existing chronic benefits are ignored or that formulary medication is automatically treated as an Ex Gratia request.

We have provided prescriptions from treating specialists & have explained the diagnoses & treatment required. We are not asking Discovery to randomly pay for medication.

We are asking Discovery to correctly assess the medication under the appropriate benefit.

What is particularly disturbing is the response & handling from Benefits & Ex Gratia Dep, which demonstrates either a serious lack of understanding of the distinction between Chronic Illness Benefit medication & Ex Gratia requests, or a complete failure to properly assess the information provided.

Instead of resolving the issue, the matter was simply redirected.....

This is not patient-centred care....

Staff dealing with chronic medication & seriously ill patients need to have the necessary knowledge, training & understanding to correctly interpret & process these matters.

Your staff are a reflection of your brand & unfortunately this experience reflects extremely poorly on Discovery Health.

Patients who are genuinely ill should not be left without essential prescribed medication because departments cannot correctly determine which benefit should deal with the request.

I am asking Discovery publicly:

1. Why is formulary medication for an already-approved chronic condition being refused by the Chronic Department? 2. Why is it being redirected to Ex Gratia instead of first being assessed under the existing Chronic Illness Benefit? 3. What specific rule or benefit exclusion is being re**** upon to refuse the medication? 4. Why are patients expected to remain without medication while an entirely separate Ex Gratia process....which requires substantial documentation ( & can take months )....is being completed? 5. Who is taking responsibility for resolving this instead of simply passing the matter between departments?

I am absolutely willing to provide the financial documentation & medical motivations required for genuine Ex Gratia requests.....but again, this can't happen overnight. On my email, I have expressed that I am unemployed due to ill health & my recurring & lengthy hospital admissions will confirm that ( you have all records )

I will not accept the blanket treatment of all our outstanding medication as Ex Gratia simply because our MSA is depleted.

Discovery needs to go back, look at each prescription, look at the approved diagnosis, the applicable formulary & the existing chronic authorisation & properly determine what benefit should apply.

This is not about wanting something for free. This is about patients receiving the medication that has been prescribed for their existing medical conditions & about Discovery correctly administering the benefits for which members are covered.

I am extremely disappointed & frankly, angry that I have had to fight this hard while already dealing with another hospital admission, High Care & recovery

Discovery Health, this is unacceptable. Please stop passing the buck between departments & actually resolve the issue.