PMBs are guided by a list of medical conditions as defined in the Medical Schemes Act of 1998 According to the Medical Schemes Act 131 of 1998 and its regulations, all medical schemes have to cover the costs related to the diagnosis, treatment and care of:
- Any life-threatening emergency medical condition
- A defined set of 271 diagnoses
- 27 chronic conditions (Chronic Disease List conditions).
There are standard treatments, procedures, investigations and consultations for each PMB condition on the 271 diagnostic treatment (DT) PMB list. These defined benefits are supported by thoroughly researched, evidence based clinical protocols, medicine lists (formularies) and treatment guidelines.
Please refer to the Council for Medical Schemes website, www.medicalschemes.co.za, for a full list of the 271 diagnostic treatment pairs.
The Scheme pays for confirmed PMBs in full if you receive treatment from a Designated Service Provider (DSP). Treatment received from a provider that is not a DSP may be subject to a co-payment and you will also be responsible for the shortfall if the healthcare provider charges more than the LA Health Rate.
There are different types of PMBs: PMB cover for in-hospital admissions, conditions covered under the Chronic Disease List, the out-of-hospital management of PMB conditions, and treatment of specific PMB conditions, such as HIV or oncology.
The person with the PMB or chronic condition must complete the relevant application form with the help of their treating doctor.
Each person with a PMB or chronic condition must register their specific conditions separately. You only have to register once for a chronic condition. If your medicine or other treatment changes, your doctor can let us know about these changes.
For new PMB conditions, you will have to register each new condition before we will cover the treatment and consultations from the Prescribed Minimum Benefits, not from your day-to-day benefits.
Chronic Illness Benefits
The Chronic Illness Benefit covers approved medicine for the 26 Prescribed Minimum Benefit Chronic Disease List (CDL) conditions. We will pay your approved medicine in full if it is on our medicine list (formulary). If your approved medicine is not on our medicine list, we will pay your chronic medicine up to a set monthly amount, called the Chronic Drug Amount (CDA), for each medicine class. The CDA does not apply to the LA KeyPlus Benefit Option. On this Option we cover up to the Generic Reference Price (GRP), which is up to the lowest cost medicine of the same kind on our medicine list for the condition.
If you use more than one medicine in the same medicine class, where both medicines are not on the medicine list, or where one medicine is on the medicine list and the other is not, we will pay for both medicines up to the one monthly CDA for that medicine class.
If you choose to use medicine that is not on our medicine list, you may have a co-payment. You will need to pay these co-payments yourself.
- If a condition is listed as a Prescribed Minimum Benefit, by law all medical schemes must cover the medicine and certain treatment and care for the condition.