Discovery Medical Scheme/Insurance

[Livvy]

Hi, I'm on Discovery (coast to coast + gap cover) but they refuse to pay my Epitec!!! The neurologist wrote a letter to them because out of all the eppilepsy drugs only Epitec works for me. They refuse to pay it and to put is on my chronic. Can anyone assist me on this matter because I'm paying my medical aid + the gap cover + R600.00(Epitec) eash month. I recently had a baby and can not afford the R600 + every month.
I do not know what to do or who to talk to anymore!!

Please.

Thanks

[Nickolai Naydenov]

Hi Livvy, epilepsy is covered as PMB (prescribed minimum benefits) on any medical aid, you should be receving a generic medication every month, as this is what the peocedure is. Should the generic be not good enough, your doctor should write a motivation and send it to your medical aid who then should authorize it. If they refuse to do so you will have to take it further with them and if again you have no luck then escalate the issue to the council for medical schemes as they regulate the medical aid industry. In the mean time you will be able to get your chronic medication from a government hospital free of charge.

[adrianh]

What reason do they give for not covering it?
Get the exact reason, could it be because the plan that you are on doesn'tallow for expensive chronic meds?

Epitec (Lamotrigine) is indicated for the treatment of epilepsy and is available under various trade names world wide. If the neurologist was prescribing it for off label treatment such as depression then I canunderstand it being an issue.

Like I said, get the exact reason for them not wanting to pay for it and then decide on course of action from there. My bet is on the fact that your chronic med funds are either depleted or your plan doesn't cover it.