Reference Pricing

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What is Reference Pricing?

Reference pricing is a managed healthcare tool that is applied when purchasing medication.

Profmed applies a generic reference pricing model to acute medicines, and both generic and therapeutic reference pricing to medicines used in the management of chronic conditions on the Condition Medicine List (CML). The reference price differs from one option to another and is most restrictive on the ProActive options and progressively least restrictive on the more comprehensive options.

If the cost of the medication you are using is more than the applicable reference price, you will be required to pay the difference between the reference price and the actual cost of your medication at the point of sale.

To assist you in avoiding a co-payment, make use of the medication search functionality on the Medikredit website at www.medikredit.net.

What is the difference between generic and therapeutic reference pricing?

Generic Reference Pricing – MMAP®

MMAP® (Maximum Medical Aid Price) is a reference price model that serves as a guide to determine the maximum medical aid price that medical schemes will reimburse for medication. MMAP® applies to chronic and acute medication.

MMAP® applies to generic medication that has the same active ingredient, strength and dosage form as the original medication. MMAP® does not apply to medication that does not have a generic equivalent.

Therapeutic reference pricing

Profmed applies therapeutic reference pricing to all chronic medications. A therapeutic reference price applies to medication that falls in the same medication class or medication that has a similar action on the body, and is not limited to medicines with generic equivalents.

Single exit price

The Single Exit Price (SEP) is determined by legislation and is the maximum price at which scheduled medicines can be sold.

Pharmacy dispensing fees

A dispensing fee is the fee paid to a pharmacy for the professional service provided in dispensing medication. Dispensing fees are legislated and are the minimum that the pharmacy can charge for their services. Profmed has a Preferred Provider Network (PPN) of pharmacies and negotiates higher dispensing fees for these providers. The fee that Profmed negotiates with this network of providers is the maximum these pharmacies may charge for their services. Dispensing fees apply to all medication.

Dispensing cycles

Dispensing cycles apply to the claiming of both acute and chronic medication. Acute medication scripts may be claimed again after three days from the last dispensing date, and chronic medication after 24 days from the last dispensing date.

If you’re travelling and require an extended supply of chronic medicine, please contact the Scheme at least 7 days prior to departure to make appropriate arrangements for you to have access to the medication from your benefits.