Managed Care Programmes and Chronic Benefits
As part of our aim of identifying and managing beneficiaries’ disease risks in good time, there are a number of programmes that form part of our Managed Care approach. Certain chronic conditions are also covered across all plans.
Managed Care Programmes
This section outlines the details of the six programmes that form the core of OMSMAF’s Managed Care offering. (These benefits may differ across Plans.) Visit our Contact Us page for contact details.
Back and Neck Rehabilitation Programme
Oncology Benefit Management Programme for cancer patients
HIV and AIDS Management Programme
Mental Health
Programme
Active Disease Risk Management Programme
Mother and Baby Care Programme
Chronic Benefits
A chronic condition is a condition that requires on-going long-term or continuous medical treatment.
Contact 0860 100 076 if you are an OMSMAF member or 0860 100 076 (doctors & pharmacists) to check if a particular chronic condition is covered. Alternatively, you can email chronic@omsmaf.co.za.
PMB
All five Plans have an unlimited chronic medicine benefit for Prescribed Minimum Benefits (PMB) conditions specified in the Government Gazette by the Minister of Health.
In addition, you qualify for certain non-PMB (Prescribed Minimum Benefit) chronic conditions, depending on the Plan you have selected.
MMAP
All medicine claims are paid at 100% of the actual medicine price or the Maximum Medical Aid Price (MMAP), whichever is the lesser.
MMAP is a reference pricing system that uses a benchmark or reference price for generically similar products. The MMAP is updated regularly and there may be a change to the amount your Fund will pay for your medicine. Check in with your pharmacist regularly to keep up to date with the MMAP changes.
MMAP
All medicine claims are paid at 100% of the actual medicine price or the Maximum Medical Aid Price (MMAP), whichever is the lesser.
MMAP is a reference pricing system that uses a benchmark or reference price for generically similar products. The MMAP is updated regularly and there may be a change to the amount your Fund will pay for your medicine. Check in with your pharmacist regularly to keep up to date with the MMAP changes.
Chronic Medicine Formularies
A Formulary is a list of cost effective evidence-based medicines that the Fund will cover for the treatment of your chronic condition. These lists are compiled by the Universal Healthcare Chronic Medicine Programme and are constantly reviewed.
Reimbursement is subject to the following Universal Healthcare Chronic Medicine Programme clinical guidelines and protocols, and the Maximum Medical Aid Price (MMAP). The Fund applies an Universal Healthcare Restrictive Formulary and Comprehensive Formulary as part of the guidelines.
The Universal Healthcare Restrictive Formulary, applicable to the Hospital and Savings Plans, contains a list of medicines that provide cover for the listed chronic conditions.
The Universal Healthcare Comprehensive Formulary, applicable to the Traditional and Traditional Plus (including SELECT) Plans, provides access to a wider range of medicines than the Universal Healthcare Restrictive Formulary.