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Chronic Conditions: How am I covered?

Author
Morne Nel
Category
Date
28 Apr 2022
2 min read

Medical schemes offer cover for a basket of benefits which include treatment and medication relating to 27 chronic conditions which are paid from risk. This means that the cover for chronic conditions will not affect day-to-day benefits, however, all chronic conditions need to be registered with the medical scheme and is subject to meeting clinical entry criteria and review processes.

Depending on the level of cover, certain medical scheme options have cover for additional chronic conditions. 

Medical schemes have formularies guiding members on which medications are available on their option. Co-payments may apply on non-formulary medication. 

Below is a list of the 27 PMB Chronic conditions covered on all medical scheme options:

Addison’s DiseaseDysrhythmias
AsthmaEpilepsy
Bipolar Mood DisorderGlaucoma
BronchiectasisHaemophilia
Cardiac FailureHyperlipidaemia
CardiomyopathyHypertension
COPDHypothyroidism
Chronic Renal DiseaseMultiple Sclerosis
Coronary Artery DiseaseParkinson’s Disease
Crohn’s DiseaseRheumatoid Arthritis
Diabetes InsipidusSchizophrenia
Diabetes Mellitus Type 1SLE (Lupus)
Diabetes Mellitus Type 2Ulcerative Colitis
HIV & AIDS

In terms of the Medical Schemes Act of 1998 (Act number 131 of 1998) and its Regulations, all medical schemes have to cover costs related to the diagnosis, treatment, and care of Prescribed Minimum Benefits. Where the treatment or the condition qualifies as a Prescribed Minimum Benefit, the treatment required must match the treatment in the defined benefits. Designated service providers may apply.


The content in this communication is for information purposes only and is not intended to be detailed advice. You should seek the advice of your physician or a qualified healthcare provider with any questions you may have regarding a medical condition.

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