Medicine claim rejected on formulary: what to ask your scheme
Your scheme says your medicine is not on the list it funds for your option. What that means, and the questions to put to the scheme in writing.
The scheme says the medicine claimed is not on the list it funds for your option.
The wording to look for
- “not on the formulary”
- “medicine list”
- “generic reference price”
- “MMAP”
Questions to put to your scheme in writing
- Please provide the formulary applicable to my option, showing the entry for the medicine claimed.
- Which alternative on that formulary does the scheme consider clinically appropriate for my condition?
- What is the scheme’s formulary exception process where the listed alternatives are not clinically suitable?
- Was the medicine claimed prescribed for a Prescribed Minimum Benefit condition, and how was that assessed?
Only you can answer these
- Whether your prescriber has recorded a clinical reason for this specific product.
- Whether you have tried the alternatives the scheme funds, and what happened.
Paste your rejection notice and build the letter. It is read on your own device and never uploaded.
See every reason a South African medical scheme gives.
Pryse is not a law firm and does not act for you. Nothing here is a determination of your rights or legal advice, and no registered scheme rule is quoted. The questions ask your scheme to provide its own.