Avoiding co-payments

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You already pay medical scheme contributions, so you shouldn’t have to pay extra when you need a GP or specialist. This article tells you what we mean by certain terms and explains how you can avoid having to pay more than you have to. We call the amount we don’t cover and you have pay to the doctor, pharmacy or hospital a co-payment.

Full cover with network healthcare providers

As a medical scheme we can negotiate prices with healthcare providers like doctors, specialists, hospitals and pharmacies. Healthcare providers we have a payment agreement with become part of our network. We don’t choose them because they are the cheapest; they also have to meet our quality standards.

When we say you have full cover at our network providers, it means we pay them directly as long as you have benefits available. All you need to do is visit them and get your healthcare service. You see a good doctor or visit a quality hospital without having to pay part of the cost yourself.

For some benefits you always have to pay part of the cost yourself, even if you use a network provider. An example would be if you visit the casualty unit and are not admitted to hospital. In these cases it still helps to use a network provider since non-network providers tend to charge more, which means you have to pay more yourself. Please check your Benefit Brochure to find out what your plan covers and what co-payment to expect.

Find a healthcare provider we have an agreement with by logging in to www.tfgmedicalaidscheme.co.za or using the Discovery app.

Ask your doctor to prescribe the medicine on our list

The most expensive medicine is not always the best medicine. That’s why we’ve put together a list of medicine (formulary) with medicine that’s proven to work. We pay for the medicine on our list in full as long as you have benefits available.

Our list usually has the generic version of medicine, instead of the original. Original medicine is usually expensive, as it is a costly and lengthy process to get new medicine on the market. Generic medicine is a copy of the original medicine with the same active ingredient as the original. As a rule, it works just as well as the original.

Ask your doctor or specialist to prescribe medicine on our list to avoid co-payments. You can also ask the pharmacy if generic versions are available.

Ask us before you go to hospital or have a scan or procedure

We call the process of contacting us to confirm benefits before you go to hospital, have certain scans, or undergo certain medical procedures preauthorisation. This is important because you may have a co-payment if you do not get approval ahead of time. When we give you authorisation, we will also tell you how much you have to pay yourself.

If you do not get preauthorisation, we may not pay for the procedure and/or you may have to pay the hospital R2 000.

Avoid unnecessary co-payments by checking your benefits before going to hospital, and using our networks and medicine list.