Chronic Medicine

You have cover for chronic illnesses defined by the Prescribed Minimum Benefit on all five the Benefit Options.

Applying for the benefit

If you would like to get access to the cover from the Chronic Illness Benefit (CIB), you must apply for authorisation. You can get a copy of the latest application form here or you can call 0860 103 933 to get one. If necessary, you or your doctor may have to give extra motivation or information to the Scheme to finalise your application.

When cover starts on the Chronic Illness Benefit

Some important points to keep in mind

• If we get the application form within three months from the date the doctor completed it, cover will start on the date the doctor completed the form;
• If the doctor completed the form a month or more before the patient joined the Scheme, and we approve the application, cover will start from the date he or she joined the Scheme;
• If the doctor completed the form in the same month the patient joined the Scheme, and we approve the application, cover will start from the date he or she joined the Scheme;
• If we get the application form more than three months after the date the doctor completed it, cover will start on the date of approval of the request.
• If you leave out any information or do not provide the medical tests or documents needed with the application, cover will start only from the date we get the outstanding documents.

Rules to qualify for cover on the Chronic Illness Benefit

The condition must appear on the Scheme’s Chronic Illness Benefit list of approved conditions

1. Clinical rules apply
   This means we want to make sure the treatment meets the clinical rules as set by the Scheme, in line with local and international treatment guidelines.
   
2. Drug utilisation review
   This process makes sure the Chronic Illness Benefit covers appropriate and cost-effective medicine. The Chronic Illness Benefit mainly provides cover for disease-modifying therapy. This therapy changes or controls the progress of the disease. Therefore, the Chronic Illness Benefit does not automatically cover all medicines for a listed condition.

The Scheme sets its own drug utilisation review guidelines and policies, based on South African and international best practice. DiscoveryCare’s pharmacists review your prescription and, if needed, will discuss your treatment plan with your doctor. This helps to ensure you get high quality and cost-effective medicine. The Scheme reviews all applications in this way.

PMB Conditions covered by the Chronic Illness Benefit

You have cover for chronic illnesses as defined by the Prescribed Minimum Benefits on all five the Benefit Options.

Diagnosis, treatment and care for the Prescribed Minimum Benefit conditions

LA Health Medical Scheme will pay for the treatment, ongoing management and care for the Prescribed Minimum Benefit conditions in accordance with the legislative requirements concerning PMBs.

The benefits available for each of the Prescribed Minimum Benefit Chronic Disease List conditions are contained in a basket of care. Included in these baskets of care are tests and consultations (relating to GPs and specialists) that we cover during the year for both the diagnosis and ongoing management for each condition. Each basket of care also includes procedure codes for pathology and radiology claims.

Payment for the diagnosis and medical management of Prescribed Minimum Benefit Chronic Disease List conditions

You do not pay for the diagnosis and medical management costs provided in the baskets of care. These costs are paid for in accordance with the rules of the Scheme from your Major Risk Benefits. Unless approved with further motivation by your doctor, we will pay benefits exceeding those provided for in the baskets of care from your Day-to-day benefits.

The Scheme will pay in full (i.e. without any co-payments or deductibles, such as levies) for the diagnosis, treatment and care of Prescribed Minimum Benefit conditions, provided your treating doctor is a Network designated service provider and he/she includes the correct ICD-10 code on his/her account. If the correct code is not included, your claim will be treated as an ordinary day-to-day or out-of-hospital claim, and will be paid from your applicable Day-to-day benefits.

LA Comprehensive and LA Core members have cover for the Additional Disease List (ADL). Certain Limits apply as per the specific Benefit Option. 

Other Prescribed Minimum Benefit Diagnosis Treatment: 

The conditions below are covered on all Benefit Options and are referred to as DT PMB conditions - this means that the condition is paired with diagnostic treatment and is subject to certain clinical entry criteria. For a complete list, please visit www.medicalschemes.com

Additional Disease List (ADL) Conditions covered on LA Comprehensive and LA Core by the Chronic Illness Benefit 

On LA Comprehensive and LA Core you also have cover for other life-threatening or degenerative conditions that are listed on the Additional Disease List (ADL), as defined by the Scheme. These conditions are selected according to clinical and actuarial rules. This means that although your doctor may define a condition as chronic, it may not meet the rules for cover from the ADL benefit. In that case, you will be able to pay for the medicine from your available day-to-day benefits.

This benefit is limited and pays at 90% of the LA Health Medicine Rate. Please consult the benefit brochure about the applicable limits.