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KeyHealth Member Information

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Medication Benefits

Medication is a critical part of members’ healthcare and treatment. KeyHealth caters for over-the-counter, acute, and chronic medication.

medication hero

KeyHealth caters for:

  • Over-the-counter medication (self-medication): Medicine with a NAPPI code that can be received at a pharmacy without a prescription.
  • Acute medication: Once-off medication, prescribed by a medical practitioner for conditions not recognised as chronic by the Scheme.
  • Chronic medication: Medicine that is used continuously for 3 or more months for the PMB Chronic Disease List (CDL) conditions, for example, asthma, diabetes, etc. And / or the additional conditions on Platinum, Gold, Silver and Equilibrium options.

A member diagnosed with a chronic condition must register the condition before access to the chronic medication benefit will be granted.

Important Information

woman pharmacist holding medicine pharmacy shop

Condition Medicine List

The Condition Medicine List (CML) is KeyHealth’s approved list of clinically appropriate medicines for the treatment of various diseases. The CML is improved and changed continuously in line with industry improvements and price changes.

Beneficiaries are encouraged to use medicines that are on the CML, including generic medicines, as they will not have to pay additional money out of their pockets.

Search guidance:

The CML is on the MediKredit website. When you access the website, please follow these instructions:

  • Select your Scheme and Scheme Option
  • Select Yes for Chronic Authorisation
  • Choose Search by Product
  • Enter the drug name that you are currently claiming or newly prescribed drug name
  • Once the list is returned, click on Search Medication for your selected drug
  • Once your drug detail is returned, click on the drug
  • Then click on Click here to view all other conditions treated with this product, other available strengths or clinical alternatives.

Register for chronic medication

  • To register a chronic condition, a member’s treating doctor must call MediKredit on 0800 132 345.
  • The treating doctor must provide detailed clinical information, including the condition’s ICD-10 code and severity status.
  • Vitamins only qualify for cover as over-the-counter medication, even if they are prescribed by a doctor.
What is reference pricing?

Reference pricing

  • The reference price is the maximum amount that the Scheme is willing to pay for drugs from a similar drug class listed on the CML for that condition. This reference price may differ on each benefit option.
  • Reference pricing is about patient choice. Medication priced above the reference price may be substituted with a clinically appropriate alternative product (a generic substitute), where applicable, that is less expensive and does not incur any additional, out-of-pocket costs. However, if a member chooses to remain on the existing, more expensive product when appropriate alternatives are available, a co-payment will apply.
  • Reference prices are reviewed yearly. The review process considers new drug entries during the year, drug discontinuations, enhancements, clinical literature, licensed indications, price changes, generic influence, patent expiry, etc.
  • Please refer to MediKredit to determine the reference price of the medication currently used. If the medication displayed on the screen is above the reference price, the member will then be required to pay a co-payment at the dispensary.

 

Medicines: Frequently asked questions and definitions

Definitions

National Pharmaceutical Product Index (NAPPI) codification is used to identify ethical surgical or consumable products. NAPPI codes enable the electronic transfer of information throughout the healthcare delivery chain.

Single Exit Price (SEP) is the maximum price a pharmacy may charge for medicine.

Therapeutic Reference Price (TRP) is the price derived through MediKredit’s review of the available products in a therapeutic category and meta-analysis of clinical studies. These studies compare clinical efficacy and cost effectiveness of different therapeutic classes within the algorithm to treat a specific condition. Similar therapeutic products are then grouped together, and a price determined according to evidence-based principals that allow for products at a lower price lower than the set pricing, with proven effectiveness in treating the condition, and items at a higher price than the set pricing, which will incur a co-payment.

Maximum Medical Aid Price® (MMAP®) is medication chosen because they have been tried, tested, and approved by the Medicine Control Council. The approval is based on evaluation criteria, which determine that a product may be regarded as the pharmaceutical equivalent (also known as a generic equivalent) of an established branded medicine. The composition and medicinal effects of generic products are the same but differ in price.

A product that has the same active ingredient and salt combination, strength of the active ingredient(s), and dosage form (e.g. tablets versus capsules) as other pharmaceutical products that can be obtained from manufacturers or suppliers.

Prescribed Minimum Benefits (PMBs) are a set of defined benefits to ensure that all medical scheme beneficiaries have access to certain minimum health services, regardless of the benefit option they have selected.

Frequently Asked Questions

This is the term used for any brand-new drug molecule that is researched and developed. The pharmaceutical company receives a patent for the product and has exclusive rights to sell the drug under its brand name for the duration of the patent. This patent protects the manufacturer and allows them to earn back the high costs involved in researching and developing a brand-new drug.

A generic drug is a copy of the original drug that may be sold once a company’s patent on a brand-name drug has expired. Generic drugs have the same active ingredient(s), strength, and dosage form as the original drug. Generic drugs are typically cheaper than the original or brand-name drug, as they don’t have the research and development costs that are incurred by the originating company. Pharmaceutical companies that create generic drugs also create competition and thus drive down the costs of medicines.

The generic drug can have a different shape, colour, coating or flavouring than the original brand-name version. Generic medicines also usually cost less.

Yes. A medicine you can buy without a prescription can be sold under many different brand names and many different store brands, even though it contains the same active ingredient(s). For example, aspirin can be sold as Disprin® or Ecotrin®

Yes. A generic drug is the same as a brand-name drug in dosage, safety, strength, quality, the way it works, the way it is taken, and the way it should be used.

Generic drugs may have a different name and look or taste because of differing inactive ingredients, such as colouring, binding and flavouring. But, by law, the active ingredient(s) in the generic and brand-name products must be exactly the same.

There are stringent regulations around the registration of generic medicine in South Africa. The South African Health Products Regulatory Authority (SAHPRA) requires that generic drugs have the same high quality, strength, purity, and stability as brand-name drugs. SAHPRA also requires post-registration testing and assurance of maintained stability, so the quality, safety, and efficacy over the entire shelf-life period of the product is ensured.

SAHPRA inspects the manufacturing and packaging facilities of companies that produce generic drugs for compliance to international standards and good manufacturing practices. No drugs may be sold without SAHPRA approval.

Creating a drug costs lot of money. Since generic drug makers do not develop a drug from scratch, their cost to bring the drug to the market is less. That’s why generic drugs are usually less expensive than brand-name drugs. Generic drug makers must, however, show that their product performs in the same way as the brand-name drug.

Pharmaceutical companies that create generic drugs compete for market share, which drives down the costs of medicines. A cheap generic drug does not mean an inferior product, as market dynamics and competition often drive the price down, not the quality.

In May 2003, the Medicines and Related Substances Control Amendment Act 90 of 1997 was enacted. It requires that your pharmacist advise you on the availability and benefits of a generic equivalent drug. The pharmacist should dispense a generic equivalent drug unless:

  • Your doctor has specifically forbidden substitution of the prescribed medication with a generic equivalent.
  • The generic equivalent is more expensive than the prescribed medication.
  • The product has been declared non-substitutable by SAHPRA.


You, as the patient, decline the use of a generic product after being briefed by the pharmacist.

If you would like to save money by buying generic medicines instead of brand-name medicines, ask your doctor or pharmacist if there are generic medicines that can be used to substitute your current medication.

Any time you replace one medicine with another, for any reason, make sure you learn what the new medicine looks like and which brand-name medicine it is replacing. This is to avoid accidentally taking the same medicine twice because the brand name and generic pills look different.

Just as we manage costs within our personal budgets, medical schemes manage costs within the scheme budget. A good way to do this is by managing medication costs by using generic drugs.

Generic substitution can reduce the price of your medication and assist you in managing your medication benefit to ensure that you maximise the value of your medical scheme benefits. This helps to contain total medicine expenditure, which, in turn, limits annual contribution increases.

There can be a wide range in the prices of equivalent generic products – some generics are more expensive than others and may be above the MMAP®. By using the most cost-effective generic drug, you can avoid co-payments and your benefits will last longer.

KeyHealth Medical Scheme has chosen to apply MMAP®, an industry standard in generic reference pricing, to ensure that cost-effective, quality products are available to its members. The application of MMAP® stretches your “healthcare rand”, without compromising quality, and makes your benefits last longer.

Always ask your pharmacist or healthcare provider for the most cost-effective generic alternative. This will, in many cases, result in no co-payment or reduce any potential co-payments to you.