The Medication Benefit Explained

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Unlimited Medication on an Extensive Formulary

1 Month Waiting Period
Single Benefit Level
Nationwide Network

When your network doctor prescribes medication, your benefit helps cover the costs. As often as is medically needed, no limit.

Limited Over-the-Counter benefit also lets you get schedule 0, 1 & 2 medication without a prescription as well as a flu shot.

The Day-to-Day collection of benefits has cover for all of this and more.

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What is Covered?

The Medication benefit is designed to give you access to a wide range of medication prescribed by a doctor. The formulary is extensive and favours generics where possible.

It includes limited Over-the-Counter medication and flu vaccinations at approved pharmacy clinics.

The benefit is unlimited which means that, in general, there is no limit as to how many times you may get medication (as long as it fits the prescription and formulary). However, you are only allowed to claim 3 times per year for prescriptions not issued by a network doctor.

Note that your doctor may prescribe something that is not on the formulary which will not be covered. We do not interfere with the treatment plans of the medical providers.

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Do I Need to Have a Prescription?

To get unlimited medication cover you will need a prescription from a network doctor.

Limited Over-the-Counter medication is available without a prescription.

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What is on the Formulary?

The formulary of medication is very extensive and favours generic medication.

The full list of medication available is not generally published online by the product administrator because it is extensive and is constantly updated as medical protocols change. If you are unsure or need to know about a specific medication then you are welcome to speak to us and we will assist.

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Is Chronic Medication Covered?

Yes, it is covered under the Chronic Medication benefit which also forms part of the Day-to-Day plan.

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How is OTC Medication Covered?

Over-the-Counter (OTC) medication includes schedule 0, 1 & 2 medication on our formulary as well as flue shots. It excludes items like multi-vitamins, minerals and laxatives.

There is a limit of R100 allowed per event and annual limits of:

  • R350 for Single policies
  • R750 for Family policies

OTC medication is available without a prescription.

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Are there Co-Payments?

There are two cases where you may be required to make up a shortfall in a medication claim.

  • Dispensing fees
  • Co-payments

Dispensing fees are sometimes charged by a few pharmacists. We can't control this practice and do not cover dispensing fees. Fortunately, they are not large amounts.

Co-payments may apply to specific medication. The benefit is unlimited, meaning it can be used as often as is necessary, but certain medication is capped in the amount that is covered. Other medication is fully covered.

If you are unsure or would like to know about a specific medication then you can always ask your network doctor for guidance or speak to us.

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Answers to Your Questions

What does "unlimited" benefit mean?

When a health insurance benefit is "unlimited" it means that the benefit can be used as many times as you need without any specific annual limits.

The only conditions are that the claim or consultation is medically necessary.

For medication, the benefit is limited to 3 times per year if the script is issued by a specialist or a non-network doctor.

What is the Medication benefit waiting period?

The waiting period on the Medication Benefit is 1 month.

This means that after the first month of your policy's inception, you can use the benefit and get access to formulary medication.

Where I can find the network pharmacists?

The Network page has all the information needed to find a provider on the network.

How are claims paid?

Claims are paid directly to the medical providers. You can find all the details on our claims page.

What are the age limits?

All new members joining a policy must be younger than 65 years on date of application.

Child dependants must be younger than 21 years before they will need to start their own policy.

However, if your child is still a registered full-time student and unmarried, then they may stay on the policy as a child dependant until they turn 26.

How many people can be on a policy?

Episodic health insurance policies can include:

  • you
  • your spouse/partner
  • up to 6 children