Medical Aid Members Urged To Check Formularies To Avoid Unexpected Co Payments

For many medical aid members, this moment, the unplanned co-payment, is one of the most frustrating parts of managing their health. What makes it worse is that it's often avoidable. The reason it happens, and the way around it, comes down to two things: whether your medicine appears on your benefit plan’s approved formulary, and whether you collect it from a designated network pharmacy.

What a formulary actually is

Medical aid schemes use a formulary, which is essentially a list of medicines that the scheme has approved for cover. Medicines on this list are selected because they are considered safe and clinically effective. It is also important to know that the formulary is not uniform across all benefit plans, the list of covered medicines can differ depending on your specific benefit option, meaning, what is covered on one plan may not be covered on another.

According to your medical aid’s scheme rules, when your doctor prescribes something outside of that list, or when you collect your medication from a pharmacy that is not part of your scheme's network, you may be asked to cover part of the cost yourself. That portion is called your co-payment.

The good news is that a little knowledge goes a long way. In most cases, a short conversation with your doctor or pharmacist is all it takes to avoid paying extra.

How medication tiers work, and why they matter

Most medical aid schemes classify medicines into tiers. Your tier determines how much your scheme covers, and how much, if anything, you pay.

While structures differ between schemes, the general framework looks like this:

• Tier 1 Preferred generics: These are cost-effective generic medicines that are usually fully covered with no formulary co-payment.
• Tier 2 Alternative generics: Still affordable but may require authorisation or partial co-payment depending on your benefit plan.
• Tier 3 Brand-name medicines: These may be covered in many cases, but if a generic alternative exists, you may be required to pay the price difference.
• Tier 4 Specialised medicines: High-cost medicines used to treat complex or rare conditions, which usually require authorisation before the scheme will cover them.

Understanding these tiers can help you make cost-effective treatment choices.

Five ways to reduce or eliminate your co-payment

1. Use a network pharmacy

   Medical aid schemes negotiate rates with designated pharmacy networks. Collecting your medication from one of these pharmacies generally means lower dispensing fees and full or higher coverage for formulary medicines.

   It is worth checking which pharmacy network applies to your specific benefit plan, as this can vary. Using a pharmacy outside the network can result in costs that are entirely avoidable.

2. Ask about generic alternatives

   Generic medicines contain the same active ingredients as their brand-name equivalents and are regulated to the same standards of safety and effectiveness. Because generics cost less to produce, they are typically placed on lower formulary tiers, which often means you pay little to no co-payment at all.

   For a member on a chronic prescription, switching from a brand-name medication to its generic equivalent could reduce a monthly co-payment to zero with no change in the quality of treatment.

   It is worth asking your doctor or pharmacist whether a generic option is available for any prescription you receive regularly.

3. Check your medicine against your scheme’s formulary

   Before filling a prescription, you can check whether the medicine appears on the scheme, and your specific chosen benefit plan’s approved formulary list. If it is not listed, speak to your doctor about a formulary alternative or a suitable generic.

   In many cases, a simple substitution to a formulary medicine can remove a co-payment.

4. Understand your tier before you reach the counter

   Knowing which tier your prescribed medicine falls into helps you anticipate costs. It is a good idea to have an informed conversation with your doctor before the prescription is written, not after you're already at the pharmacy. You can check your medicine’s tier by contacting your medical scheme’s contact centre to confirm which approved formulary tool applies to your plan and then searching it directly. Alternatively, you can ask your pharmacist to confirm the tier at the point of dispensing before any costs are finalised.

5. Apply for an exception if you have a clinical need

   There are cases where your condition genuinely needs a medicine that is not on the formulary. In these situations, most schemes offer a formal exceptions process. This usually requires your doctor to submit a clinical motivation explaining why the standard formulary option is not appropriate for your treatment.

   If approved, the scheme may cover the cost, reducing or removing the co-payment.

Why formularies exist

Formularies are not just cost-cutting tools; they help direct members towards medicines that are clinically proven and cost-effective, ensuring schemes are better able to remain sustainable and keep contributions manageable for all members over the long term.

The intent is not to limit access to good treatment; it is to ensure that good treatment remains accessible to everyone.

Making your prescription work harder for you

Prescription medicines are central to how millions of South Africans manage both short-term illness and long-term health conditions. Getting the most out of your medical aid cover means understanding the system well enough to work within it.

Medshield Medical Scheme maintains a formulary built around medicines that are clinically appropriate, safe, and cost-effective. Members can search the approved formulary list at https://www.mediscor.co.za/search-client-medicine-Formulary/, access the Scheme’s designated pharmacy networks on Medshield’s website, and speak to their healthcare provider about options that are aligned to the formulary when a prescription is issued.

The co-payment at the pharmacy counter is not always inevitable. In many cases, it is simply the cost of not knowing and that is easy enough to change.