Over-the-counter medication

Over-the-counter medication - also known as self-medication - is medicine that does not require a prescription, but is dispensed by a pharmacist over the counter.

There are limits on this benefit and formularies and exclusions apply.

Acute medicine

Acute medicine is prescribed to alleviate the symptoms of an acute or temporary condition, such as colds, flu, infections, sprains etc.

There are limits on this benefit and formularies and exclusions apply.

Chronic medicine

Chronic medicine is when a chronic condition, illness or disease requires that medicine be taken for 3 months or longer for a life-threatening condition or to relieve symptoms of a condition that is ongoing and could seriously debilitate your health, such as hypertension, diabetes etc.

PMB conditions are covered subject to a treatment plan, PMB formularies and generic and therapeutic reference pricing. To see which PMB conditions are covered, please click here.

Other chronic conditions are subject to pre-authorisation by the Chronic Medicine Risk Management Department.

Transmed applies chronic medicine baskets or formularies, which are lists of medicines that consist of generic and original medicines, which will be reimbursed by the Fund, subject to clinical protocols. The medicines on a formulary make up a 'preferred' list, while the medicines that may attract co-payments are referred to as 'non-preferred' medicines. For a detailed explanation of how chronic condition medicine baskets work.

For a detailed explanation of how chronic condition medicine baskets work, please click here.

Formularies

A medicine formulary is a preferred list of prescription medicines that are reimbursed by the Fund for a specific chronic condition.

Transmed applies reference pricing to the medicine formularies in order to support access to cost-effective medicines.

Reference pricing is a pricing model that groups together products that are generically or therapeutically equivalent into reference-pricing groups and sets a maximum reimbursement price for such a group of products.

 If you obtain medicines that exceed the cost of the applicable reference price, you will be liable to pay the difference between the cost of the medicine and the reference price.

Generic reference price (GRP) sets a maximum reimbursement price for a list of generically identical products (products that contains the same active ingredient at the same strength and in the same dosage form).

Therapeutic or formulary reference price (FRP) sets a maximum reimbursement price for a list of therapeutically-equivalent products (products that have the same therapeutic effect in the body).

Example:

In the event that an original brand-name medicine (e.g. Panado®) has one or more generic alternatives available (e.g. Dolorol®, Painamol® and Adco-Paracetamol®), the generic reference pricing will be applied. Should you wish to use the original medicine (e.g. Panado®) or any other generic medicine that costs more than the GRP for this class, you will be liable for a co-payment (calculated as the difference in price between the generic and the original) at the point of sale. You are therefore encouraged to make use of generic medicines in order to prevent out-of-pocket expenses. Your pharmacist will be able to advise you on generic alternatives.

Reference pricing co-payments can be avoided by using medicines that fall within the reference price. The use of such appropriate alternatives should be discussed with you doctor or pharmacist.