Executive Plan - Reject Chronic cover for Xarelto

<p> I’m on the Executive Plan of Discovery. I chose to be on this plan not because the R 5500.00 rate is small change to me ( I make a lot of sacrifices) , but for the simple fact that I could have peace of mind that in this country if I ever had a medical emergency I wouldn’t be blindsided by hefty co –payment/ expenses as this plan should cover most of the medical emergencies in any private hospital up to 300% . During the last week of November 2016 a blood clot was discovered in one of my lungs quite by accident. By that time I had already booked a holiday to Australia leaving the 22nd of Dec. ( +/- 3 weeks before my holiday). The Physician told me I couldn’t get on that flight with a blood clot in my lung and he had to start me on some bloodclot treatment but I had a choice. He could put me on Warfarin that involves blood test (taking weekly/bi weekly trips to the Pathologists, draw blood and then based on some markers or counters they would tell me what dosage to use) and this is covered on Discovery’s chronic /PMB list , but as I was on my way to Australia that might be problematic and impractical. The only alternative was a new drug Xarelto where you only take one tablet a day for 6 months , no need for regular blood tests etc, but it was very expensive ( R 900,00 for 28 days for 6 months x 6 = R 5400.00!) AND Discovery does NOT cover it under their chronic PMB list (like Warfarin) even for Executive Members. So I basically had a choice, cancel my trip to Australia or pay R 5400.00 from my Savings account! Every specialists and pharmacist I’ve spoken to since coming back from holiday is raving over this drug as it has additional long term benefits over the Warfarin treatment not to mention not having to go for these regular blood tests. Discovery for reasons that they only know would rather force their members to use this antiquated Warfarin treatment (no other choice even in an emergency situation like me going overseas) or pay it from your savings account. I challenged Discovery on this as I felt they had offered me no alternative to Warfarin on their PMB list for my specific situation. Members on much lower plans are on chronic medication for years and mine was only for 6 months and it wasnt like bad eating habits have caused my blood clot! Their subsequent response: The ‘lab’ responded that my motivation that Warfarin was impractical to use with me going abroad was not valid. If I had notified them ‘in advance’ of my trip overseas they could’ve ‘adjusted ‘the dosage and that I didn’t have to go for blood tests during my holiday period. Was I supposed to know this detail? Must I blame the Physician now for leaving out this piece of detail ? Am I or the Physician I feel for that matter trained pathologists and experts in the administration of Warfarin? The ‘given notice in advance’ timeframe was not explained at all. I would’ve been on Warfarin for 3 weeks before my departure? Was it safe to adjust the dosage so soon?I still would have preferred Xarelto as an option even if they were only willing to subsidise R600.00 as I figured this is how much the Warfarin treatment cost adding in all the trips to pathologist. Discovery is not very transparent with their benefits and policies when you sign on. They’re quick to throw their ‘policies’ with all the fine print at you hiding behind automated mails once your claims are rejected and you start following up with supervising staff . Some junior staff at pre-uathorizations I have found are not trained well to advise you on what is covered or not covered with certain procedures. They expect you to know the detail, how many doctors /surgeons involved, what is covered by hospital benefit etc. They also make it so difficult to challenge them with all the red tape and dispute forms you and the doctor have to fill out that one eventually gives up as it’s a losing battle and a horrible waste of your and your doctor’s time!</p> <p> </p>