Does Gap Cover Include Medicine?

December 19, 2021

Does a gap cover policy include the cost of medicine?

• Yes, a gap policy shares medicine costs with your medical aid.
• Depending on your cover, it will include co-payments.
• Medication must be in-hospital.
• Cover might include certain out-patient medications.
• Check with your particular gap cover provider to find out the details of your plan.

 

Medical expenses in this country can be high. Your medical aid must by law pay ONLY what the National Health Reference Price List recommends. This is a set of recommended fees that the Council of Medical Schemes and Department of Health compiles on an annual basis.

The problem is that while medical schemes must to pay at least these rates, the medical professionals do NOT have to charge them. They can, and do, charge amounts in excess of these laid down recommendations.

On average, medical practitioners charge as much as 300% of these rates. This can leave you in a tough situation. Think about it for a second – your medical aid is not obliged to pay anything above the rates as laid out in the National Health Reference Price List.

Doctors and other medical health professionals, however, usually charge more than these recommended rates. And someone has to pay the difference. And I am sure that you know who that person will be.

What Can You Do About it?

Do you hold thumbs and hope that your doctor charges a rate comparable to what the medical aid will pay? Or do you act proactively and get cover in case they don’t?

Gap cover is meant to bridge the gap – to cover the portion the medical aid does not. So, after the medical aid does its bit, the gap cover comes into effect.

Medicine Taken in Hospital

Gap cover will cover all costs related to hospitalization – from the cost of the specialist you see to the medication prescribed to you. Depending on the type of gap cover you have, you might be covered for follow-up consultations and medication as well.

Again, depending on the level of cover you have, you may also be able to apply for gap cover when medication sub-limits have been reached.

Do Gap Cover Providers Have Prescribed Minimum Benefits?

Prescribed minimum benefits are what medical schemes are legally compelled to provide members. The prescribed minimum benefits include emergency medical care and some chronic conditions as well. These must be provided to all members, no matter what level of cover they select initially.

Gap cover is an insurance product and so does not fall under the ambit of a medical scheme. Gap cover providers, therefore, do not have to provide prescribed minimum benefits.

Not a Medical Scheme

In fact, the cover is completely separate from your medical scheme and runs on its own. You don’t even need to get the cover from the same provider. (And, most likely won’t be able to anyway – medical schemes are not insurers.)

There is also a range of gap cover options available. You can choose very basic cover or fully comprehensive cover. It all depends on how much cover you want and how much you can afford to pay.

Next step: complete the form on this page to get a gap cover quote.
Don’t forget to submit the form once completed by clicking on Get a Quote!

All info was correct at time of publishing