After enrolling and paying the premium, you will receive a policy document and your own Daman card showing your policy details and personal particulars. You can use these to access your health coverage benefits.
Your benefits are outlined in your policy’s Schedule of Benefits and wording document. Present your card at the provider to receive your benefits. Please be sure to comply with any administrative requirements from the provider.
Certain services require pre-authorisation by Daman. This is to enable suitable choices to be made and avoid unnecessary treatment.
A physician’s recommendation, performance of a procedure or the fact that it is the only option available for treatment does not automatically guarantee that it will be covered.
For clarity on liability for payment for a particular procedure, please inquire at your healthcare provider.
When you first arrive at the healthcare provider, please present your card prior to any services being rendered.
Inpatient and day-treatment services must be pre-authorised. Emergencies do not require prior approval, but Daman must be notified within 24 hours. In non-emergencies, the healthcare provider will contact us regarding coverage.
Receive information about Daman’s health insurance plans and services including but not limited to health insurance plan benefits, exclusions, policy terms and conditions, Pharmacy Benefit Management (PBM) services, details of network providers (including hospitals, pharmacies, dental clinics etc.), online services, list of medications covered under your health insurance plan (Drug List) and your rights and responsibilities.
Be treated with respect and dignity and have the right to privacy.
Preserve the confidentiality of your treatment records to the extent protected by Federal and Emirate laws in the UAE. You are also entitled to receive an explanation regarding exceptions to confidentiality.
Make verbal complaints or to appeal to Daman on benefits offered, claim settlement, services offered, PBM services or any other grievance.
Be provided, upon request, with information about your plan's benefits including limitations and exclusions applicable and details related to your health plan Drug List.
Receive services in English and Arabic when contacting Daman Customer service.
Make suggestions and give comments on ways Daman can improve its services.
Exercise your rights in accordance with the health insurance laws of the Emirate of Abu Dhabi.
As a Daman member, your responsibilities are:
To read your insurance policies for the details of benefits, exclusions,and other terms and conditions applicable under your health insurance plan. If you do not understand the information, you should contact Daman Customer Service for explanations on the covered benefits, limitations and authorisation procedures.
To present your Daman card (health insurance card) when accessing covered health services from our network providers.
To know how to access covered health services and pharmacy benefits you are entitled to as part of your health insurance plan benefits.
To pay any applicable co-insurance and deductible at the time of utilising a health service.
To demonstrate mutual respect and courtesy towards providers (including hospitals, pharmacies, dental clinics etc.) and Daman personnel.
We at Daman pride ourselves on offering you world class healthcare solutions and services. One of our recent additions is the introduction of Pharmacy Benefit Management, implemented across our wide range of health insurance solutions.
Pharmacy Benefit Management will help us enhance our service quality by following established frameworks, and best practices related to drug prescription and dispensing.
What is Pharmacy Benefit Management (PBM)?
PBM is an internet-based interface between Daman and your pharmacy within Daman’s provider network in Abu Dhabi. It is designed to manage your pharmaceutical benefits better.
What are the advantages of PBM?
PBM will help Daman improve the safety measures around your pharmacy benefit, through:
Control checks on drugs prescribed for consistency with your diagnosis and age.
Reducing overall claim costs.
Checks for possible negative drug-to-drug interactions. The checks are performed on the patient prescription history that is held by Daman.
Automated checks for covered drugs, benefits and plan limits and any other conditions relevant to your health insurance plan.
Monitoring prescription claims for fraud, waste and abuse.
Can I opt out of PBM?
It is not possible to opt out of PBM. Health Authority – Abu Dhabi has mandated PBM be used by all insurance companies. PBM is compliant with the Health Authority’s established standards and ensures better management of your pharmaceutical benefits.
Can a claim be rejected under PBM?
PBM works on many principles, which have been incorporated to supplement various safety measures around your pharmacy benefit. PBM might reject your case if any of those principles are not complied with.
Examples of reasons for rejecting your case are listed below:
Diagnosis-to-drug indication: The prescribed drug is not indicated for the diagnosis mentioned in the prescription issued to you.
Drug-to-drug interaction: The prescribed drugs have a high possibility of interacting with each other.
Drug-to-age contraindication: The prescribed drug is not appropriate for your age.
Drug-to-gender inconsistency: The drug is inconsistent with your gender.
Sub-limit exhaustion: The prescription might exceed the applicable pharmaceutical sub-limit of your policy.
Early refill: Any request for a prescribed drug is made before the previous supply of the same drug is consumed.
The drug is not in your Drug List or Drug Formulary. A Drug List or a Drug formulary is a list of drugs covered under your health insurance plan.
Are there any exceptions made for an early refill?
You should ask your pharmacist for a refill of your drugs only as prescribed by your doctor. However, in case of any emergencies or if you plan to go on a long vacation, or if lose your drugs, you may get a refill approved on an exceptional basis.
You may contact customer service on 800-4-32626 to log your request for an exception.
What can I do if my prescribed drug cannot be found in my network or in my Drug List or Formulary?
If the drug cannot be found in your network or does not exist in your Drug List or Drug Formulary, then you have the option to request exceptional consideration for coverage. Daman reserves the right to evaluate your request on merit and inform you of its decision.
To request an exception, please use the Appeal / Exception Request Form available on our website: www.damanhealth.ae.
Whom should I contact if I have more questions?
For any queries related to your pharmaceutical benefit, please call us toll-free on 800-4-32626. To view your latest Drug List or Drug Formulary, visit our website www.damanhealth.ae
Please specify why you believe the claim or service should be covered. Include any documentation that supports your appeal with the form.
Your request will be reviewed by an independent party not involved in the initial decision that can make corrective actions. Decisions will be based upon the terms of your benefit plan. A physician will be involved in any review that involves medically necessary cases.
You will be notified of the appeal decision after 30 calendar days. If you are not satisfied with Daman’s decision, you may request another review (2nd appeal) with additional comments detailing your position.
If the appeal involves a coverage decision based on issues of medical necessity or experimental treatment, a senior clinician will be involved in this review.
If you are not satisfied with our post-appeal decision, other remedies may be available to you. In such cases, you can appeal our decision by applying for an external review to Health Authority – Abu Dhabi as per HAAD’s appeals process. To learn more, call customer service on 800-432626.
Submitting an appeal:
In order to initiate the appeal process, you must submit the Appeal / Exception Request Form along with the following supporting documents:
Copy of Daman card
Copy of Emirates I.D. (or other official ID e.g. passport, driving license etc.)
Copy of prescription
Original itemised invoices with date /payment receipt
A drug formulary is a list of drugs covered under your health plan.
What are the benefits of having a drug formulary?
There are many prescription drugs available on the market. Many of these drugs contain the same active ingredient(s) and are chemically identical in strength, concentration, dosage form, and route of administration with the drug prescribed by your physician. However, they may differ significantly in their prices.
Drug formulary ensures the use of recommended drugs or their equivalent analogues appropriately and safely. It also allows you to purchase a cost-effective alternative for the prescribed drug.
Who is responsible for the drug formulary of my Basic Plan?
Drug formulary for Basic Plan is developed by the Health Authority of Abu Dhabi (HAAD) Pharmacy & Therapeutics Committee. The Committee consists of physicians, pharmacists and other health care professionals to decide on the list of drugs to be covered in the formulary for the Basic Plan.
To help members have the best possible health services, HAAD may add or delete drugs from the formulary or change coverage rules on some drugs. The details of your latest Drug formulary are available at www.damanhealth.ae or alternatively you can also check them at www.haad.ae.
Which drugs are not covered under my Basic Plan?
Drugs not listed in your drug formulary
Drugs used to treat medical conditions not covered under your health plan
Drugs used for cosmetic purposes
Drugs used for non-medically necessary reasons
Drugs used for experimental, investigational or unproven services and treatments.
Drug prescription dispensed by a non-network pharmacy.
Some drugs in the drug formulary may require additional checks to be performed by a pharmacist before the drug is dispensed, such as:
Pre-authorisation or prior approvals
Consistency with age
Limit on medication dispensed as per the physician’s prescription
Annual Benefit Limit of AED 1,500 for your pharmacy benefit
What can I do if my prescribed drug cannot be found in my network or in my drug formulary?
For cases where a drug cannot be found within your network or does not exist in your drug formulary, you have the option to request consideration for coverage. If your request is declined, you may further approach us through our appeal process. Daman will discuss the merits of your case internally and externally and will communicate the decision to you within 30 calendar days from the date of appeal. Details of the appeals process and the Appeals / Exception Request Form are available on our website www.damanhealth.ae
Whom can I contact in case of any queries?
You can call us tollfree on: 800-4-32626. Our customer service representatives are available around the clock to help you with any clarifications or queries.