The Liberty Health Chronic Medicine Management Programme aims to facilitate access to a medicines benefit that allows members to manage their individual chronic disease in a way that is most appropriate for their needs.
The key principle of this programme is the implementation of evidence–based medicine principles, to ensure that patients are cared for in the most clinically sound way possible – while ensuring that member benefits and scheme financial resources are used efficiently. In order to achieve this balance, Liberty Health’s Chronic Medicine Management offering makes use various managed care tools such as:

• Formularies
• Maximum Medicine Reference Pricing (MMRP)
• Funding Protocols

All medicines used to treat chronic conditions are subject to funding protocols. A team of clinical experts has used evidence–based medicine principles in defining these protocols – this ensures that members have access to the most clinically appropriate, quality therapeutic options for managing their specific conditions. Medicines reviewed for inclusion in a funding protocol can be classified as:

• Medicines that will always be funded (based on local and international guidelines, these are considered accepted treatment for a specific condition and will be reimbursed subject to generic reference pricing at the Designated Service Provider (DSP), where applicable);
• Medicines that will be funded in certain clinically appropriate circumstances; or
• Medicines that are excluded from benefits or those that do not offer value for money relative to comparative products.

A formulary is created once the above funding decision has been made.

A formulary is a list of medicines that have used the funding protocols as the basis for their definition. Products contained on this list are those that Liberty Medical Scheme will fund, provided that you have registered yourself on the Chronic Medicine Management Programme and have met certain clinical criteria. Medicines listed on the formulary can be categorised in one of three ways:

• In Formulary (IF): IF product claims will be funded subject to generic reference pricing.
• Motivation Required (MR): These products require specific clinical criteria to be met prior to authorisation. A team of clinical experts reviews the requests and motivations to ensure the appropriate use of these medicines and that the rules of the scheme are adhered to. Once a request for an MR drug has been approved, claims will be funded subject to generic reference pricing.
• Out–of–Formulary (OF): Out–of–Formulary medicines are products not favoured by the scheme for managing a specific chronic condition. Usually, these medicines are premium-priced compared with preferred therapeutic options, yet they do not offer any additional clinical benefit. Liberty Health members wishing to use these medicines will incur an out–of–formulary co-payment of 50%.

There are 3 formularie applicable to LMS members:

• The extended formulary applies to Platinum Complete, Platinum Saver and Platinum Focus options.
• The standard formulary applies to Titan, Gold Saver and Gold Focus options.
• The CareCross formulary applies to the Bona Plus option.

Generic reference pricing is the maximum amount that a scheme will pay for medicines contained within generically similar groupings and is a tool used to balance scheme financial risk with patient access to medicines.

In the Liberty Medical Scheme context, Maximum Medicine Reference Pricing (MMRP) is applied. The objective of generic reference pricing is to ensure that all patients enjoy access to a wide range of medicines, while managing the costs associated with products that possess generic equivalents.

Generic reference pricing allows for the marketing of competitor products that are identical in key respects – active ingredient, strength and dosage form – and is therefore designed to manage and contain costs associated with expensive medicines where the patent for the original product has expired.

Depending on your benefit option, a varying number of chronic diseases are covered from your chronic medicines benefit. While all benefit options provide access to treatment for the 27 Prescribed Minimum Benefit (PMB) conditions, they may vary in terms of the number of non–PMB conditions covered.

The 27 Chronic conditions are:

• Addison´s Disease
• Asthma
• Bipolar Mood Disorder
• Bronchiectasis
• Cardiac Failure
• Cardiomyopathy
• Chronic Obstructive Pulmonary Disease (COPD)
• Coronary Heart Disease
• Chronic Renal Failure
• Crohn´s Disease
• Diabetes Insipidus
• Diabetes Mellitus, type 1
• Diabetes Mellitus, type 2
• Dysrhythmias
• Epilepsy
• Glaucoma
• Haemophilia
• Hyperlipidaemia
• Hypertension
• Hyperthyroidism
• Multiple Sclerosis
• Parkinson´s Disease
• Rheumatoid Arthritis
• Schizophrenia
• Systemic Lupus Erythematosus
• Ulcerative Colitis
• HIV/Aids

Access to the medicine available for these conditions is governed by the formulary (restricted or comprehensive) applied to your specific benefit option. Disease lists can be viewed per benefit option.

Your doctor or pharmacist should contact the Liberty Chronic Medicine Management Department with the relevant member information (member and beneficiary number, diagnosis – with an ICD10 code – and details of prescribed medication). The written prescription can then be faxed to us on
+27 (21) 657 7681 or emailed to chronicmed@libertyhealth.co.za, for record purposes. Please feel free to call us on 0860 002 163, should you require more information.

Your application will then be reviewed in the context of the diseases covered by your benefit option, the formulary applied and current funding protocols. If further information is required, a Chronic Medicine Management consultant will contact you or your doctor. Please be aware that, where the requested medicine is subject to a co–payment, the consultant may suggest alternatives in order to help manage costs while still ensuring you get the quality care you need.

Once all of the specific requirements have been met, you will be granted a disease–specific authorisation. This means that you no longer need to have a specific medicine authorised, unless under exceptional circumstances. You may now access any other in–formulary product linked to the diagnosis, without having to have your authorisation amended. This means you can conveniently change product and/or strength when you need to, without further contact with the Chronic Medicine Management Department.