Useless

Good day,

Before joining the scheme, I spoke to a broker and carefully considered my options, I have bipolar, and I needed to ensure that the scheme I was selecting offered the necessary benefits. From the get-go I ensured that there was a basket authorization for the required medication as well as a treatment plan to cover any consultations and pathology required. The amount for the consultations has been honored, however any pathology (as prescribed by my psychiatrist) have been paying from my savings. I am due to test my Tegretol levels (again as per my psychiatrist), but I am unable to do so as my benefits are depleted. From the beginning of the year, I have sent all my scripts to be authorized so that my medication will pay from the allocated PMB benefits. However, 90% of my medication was still subtracted from my savings. I have used my medical aid mostly for my medication and I was still paying in between R1000 – R1500 on a monthly basis. I was prescribed Flauxnol which you simply refuse to cover, the reason being that I am using a similar product. However, the psychiatrist prescribed it as the meds I was using was not having the desired effect. As a trained professional I am pretty sure she knows what she is doing, not to mention I was given no aid or alternative by the scheme (after several requests) of how to go about authorizing an alternative or to find a way around it – even if it meant writing a motivation or using another product. My Tegretol was authorized for a dosage of 600m every evening, again the script was sent for authorization. Instead of authorizing the 600mg I was authorized for 90 of the 200mg. This meant that all the Tegretol claimed as from the beginning of the year has been deducted from my savings account. This is medication for a PMB condition meaning that the scheme should cover it from the PMB benefit. I have spoken to Dischem as well as the scheme and neither one of the parties as willing to assist in reversing or resubmitting the claims so that they pay from the correct benefit. As a member that means that other than my premium, I am left forking out money every month to pay for medication that should have been covered in the first place. I had an appointment with my psychiatrist that she had to move due to unforeseen circumstances, this meant that there would be a period where I would not have any medication. The psychiatrist issued me a script for emergency medication to tide me over until I was able to see her. When I went to collect my medication, I was told that it’s an early refill and that the pharmacy should reverse the initial claim, put through the full quantity and issue me the difference. I requested the pharmacy to process the claims as advised and was issued a bill of a staggering R 2400.00 that I had to pay cash just to get my medication. The scheme covered nothing of the medication claimed. I have been using Epitec 200mg since I started with the medical aid, the dosage is insufficient, and the doctor decided that we should increase the dosage. The new prescription that I submitted was for a gradual increase on the Epitec. You cannot just move up the dosage as you need to determine if its working with the patient first. The increase was 2 weeks to 250mg and the remaining two weeks on the 300mg, even though the Epitec 200mg has been authorized for more than 2 years you now don’t pay for it AT ALL. As a medical aid I would think that gradually increasing medication is a standard practice yet here I am R2500 out of pocket that I really can afford considering I am paying my monthly contribution you as well. I sent my latest prescription because the medication that I was taking was not having the desired effect and the physiatrist saw the need to change the medication. In case you are unaware bipolar is manic episodes may include symptoms such as high energy, reduced need for sleep, insomnia and loss of touch with reality. Depressive episodes may include symptoms such as low energy, low motivation, and loss of interest in daily activities. Mood episodes last days to months at a time and may also be associated with suicidal thoughts. Yet as the scheme you are not covering the antidepressants or the sleeping tablets, as you can imagine the up and down is difficult to deal with, but you don’t cover anything for anxiety either. I simply cannot see the sense in paying for something that yields no benefits. I specifically asked about the medication as well as a treatment plan to ensure I don’t end up in the situation I am now where I am unable to receive my required medication. I was misled in my understanding of the benefits not to mention no help from the scheme themselves. I cannot afford to pay R2 500.00 for basic health benefits that should be covered by the medical aid. I have raised the issue of the co-payments with you several times with no joy, but this month the co-payment was simply ridiculous. I would like someone to investigate this and refund the exorbitant amount that I have paid. I would also like for you to reinstate the benefits you so happily deducted which now means I have no benefits at all. I have advised several of my friends and family members to consider you as a scheme and they have since signed up. Based on the service that I have received I will strongly advise them to reconsider other options in the future.