Chronic Illness Benefit
Medicine
You have cover for the Prescribed Minimum Benefit Chronic Disease List (CDL) conditions including HIV and AIDS on all five Benefit Options offered by LA Health. The Scheme also covers medicine for certain Diagnosis Treatment Prescribed Minimum Benefits (DTPMB) on all Options, subject to clinical entry criteria, as determined by the Scheme.
Chronic Disease List (CDL)
This is a list of chronic diseases, including HIV and AIDS that the Prescribed Minimum Benefits cover. A list of these diseases or conditions is included below.
Chronic Illness Benefit (CIB)
Medicine prescribed by a registered practitioner, that is life sustaining, (that is medicine without which a person’s life would be endangered) and that has to be taken on an ongoing basis for a life threatening medical condition, is considered to be chronic medicine.
If you registered for a Prescribed Minimum Benefit condition, we are not allowed to pay your medicine and specific consultations and tests from your Medical Savings Account.
Baskets of care
A basket of care is a specific combination of services you may make use of for the treatment of your Prescribed Minimum Benefit (PMB) condition. These services are based on the treatment guidelines or protocols published by the Minister of Health.
The baskets of care are set for stable patients, and the services include:
- doctor’s visits (general practitioners and specialists);
- blood tests and other associated diagnostic treatment.
Formulary
A formulary is an approved, restricted list of medicine considered to be clinically appropriate and effective for the treatment of a disease or illness condition. Cover for treating Prescribed Minimum Benefit conditions is unlimited, subject to this fixed formulary.
If you choose to use medicine that is not deemed to be clinically appropriate and/or effective for the treatment of your Prescribed Minimum Benefit condition, as listed on the Prescribed Minimum Benefit formulary, without the approval of the Scheme, we will pay for the medicine to a maximum value, the Chronic Drug Amount (CDA), and you may have to make co-payments.
Preferred providers
The Scheme Medicine Rate is the Single Exit Price of the medicine PLUS a dispensing fee of 26% of the SEP to a maximum of R26.00 (VAT exclusive). The maximum dispensing fee paid by the Scheme is therefore R29.64.
There are several pharmacies and pharmacy groups that will only charge the Scheme Medicine Rate when you obtain the medicine from them. In that instance there will be no dispensing fee shortfalls, which you will have to pay from your own packet. If your Pharmacy charges a higher dispensing fee, you must the pharmacy you used the difference between the Scheme’s dispensing fee and/or any other related fees charged.
Please ask the Pharmacy whether they are one of the Scheme’s preferred providers.
Co-payments for Prescribed Minimum Benefit medicine will not apply if
- You or your treating doctor has submitted an application, supported by an adequate, written medical or clinical motivation, and received written approval for the continuation of medicine not listed on the formulary, or a substitution of the formulary medicine (in cases where the formulary drug would be ineffective or harmful);
- The formulary medicine is not available from the designated service provider appointed by the Scheme to supply such medicine, or would not be provided without unreasonable delay.
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.
On approval of your Prescribed Minimum Benefit chronic condition, a selection of codes will be loaded for the condition for each registered member and/or dependant.
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.