WHAT IS A PBM?
Pharmacy Benefits Managers (PBMs) are well known in the United States because they design, administer and control the pharmaceutical plans of insurance companies and employers. They do this by using advanced technological platforms that offer a fast and reliable service at a lower cost.
WHAT IS THE DIFFERENCE BETWEEN PBS AND PDSS?
The Basic Health Plan (PBS by its acronym in spanish) has a defined catalog with all the health services, the Health Services Plan (PDSS by its acronym in spanish) defines graduality in the delivery of those services, establishes co-payments, ceilings and moderate fees.
WHAT IS CO-PAYMENT?
It is the monetary contribution made by the member to a part of the total cost of the medicine, whose purpose is to regulate the use and stimulate the good use of the service.
Of the total amount of medicines covered by the PDSS, the insurance to which the affiliate belongs must cover 70% and the user 30%, it is a co-payment, the percentage is established by Law 87-01. (This only applies to the Basic Health Plan of the Dominican Republic).
WHAT ARE THE REASONS WHY MY PRESCRIPTION CAN BE REJECTED?
- Incomplete prescription.
- Validity period of the prescription.
- Illegible, crossed out or broken prescription.
- Your plan does not cover the prescription.
- You cannot take the prescribed medication because of your age or gender.
- The prescription drug interferes with any other medication you have purchased or is on the prescription. (The pharmacy can contact your doctor and verify this.)
- Not having your payments up to date.
WHAT DOCUMENTS DO I NEED TO PRESENT TO GET MY MEDICINES WITH MY PRESCRIPTION?
- Membership card.
WHAT IS THE VALIDITY OF MY PRESCRIPTION?
The validity of the prescription is according of its date of issue:
- Emergency 3 days or 72 hours
- Outpatient consultation: 30 days (1 month)
- Continued use: 90 days (3 months)
- Complementary plans up to 180 days (6 months)
WHAT IS THE ESSENTIAL INFORMATION IN MY PRESCRIPTION?
- Date of issue of the prescription.
- About the patient: Full first and last names;
- About the medicine: Name, concentration, pharmaceutical form, route of administration, posology, units per day, duration of treatment, other indications for the patient that the doctor considers convenient.
- About the prescriber: First and last names, exequatur, permission to prescribe controlled drugs, if applicable, signature and stamp.
WHAT ARE THE MAIN EXCLUSIONS?
The main drugs not covered by the outpatient plans are the following:
- Antiretrovirals, with the exception of Zidovudine used for vertical transmission of HIV. (Pregnant women with HIV)
- Medicines for nutritional treatments for esthetic purposes.
- Medications for Infertility Treatments.
- Drugs for use in treatments not recognized by the scientific medical associations, or which are of an experimental nature.
- Drugs for use in rest or sleep treatments.
- Drugs that are not on the PDSS Drug List.
ARE THERE ANY CONDITIONS FOR NEWBORNS WHO STILL DO NOT HAVE CARD?
Newborns will be covered with the mother's card only for the first month of their birth (30 days), during which time they must deposit the necessary documents for the issuance of the newborn's card with the insurance.