The Chronic Illness Benefit

Chronic medicines are indicated for prolonged conditions that are often life-long. To ensure that the most appropriate and cost-effective treatment is prescribed, payment of medication of such conditions must be approved by the Scheme.

Medicine benefits for Prescribed Minimum Benefit (PMB) conditions

The Chronic Illness Benefit covers approved medicine for the 26 PMB chronic conditions. Out-of-formulary medicine may be authorised however will be subject to additional co-payments.

Medicine benefits for non-PMB conditions

You have further benefits for non-PMB conditions as per the Scheme's defined list. Formulary medication authorised to treat non-PMB conditions will be subject to lower co-payments than out-of-formulary medicine.

There is a combined limit of R27 000 per beneficiary for PMB and non-PMB chronic medication. Once the limit has been reached, continued benefits are only applicable to PMB conditions. For all conditions, you can refer to the Benefit and Contribution Schedule for more information on the Scheme's funding. You can also check with your pharmacist or refer to mediscor.co.za for more information regarding the prescribed medicine.

Your benefits for chronic conditions can be summarised as follows:

Applicable to cost of medication only

How to access the Chronic Illness Benefit

If you need to register for, or update, your chronic medicine authorisation, your healthcare provider, or pharmacist can do this telephonically by calling 0860 002 134 .

Where to obtain your chronic medicine

Members on the Comprehensive Network Option can obtain their medicine from any pharmacy. Members on the Restricted Network Option need to obtain their medicine from Medipost.

Treatment baskets for approved PMB conditions

If you have recently been diagnosed with and approved for cover for a PMB condition, we will pay for the diagnostic tests and procedures from the diagnostic treatment basket. We will also pay in full for the consultation with the healthcare provider who made the diagnosis. We will only pay for the tests, procedures, and consultation if you were an active and valid member of the Scheme at the time of the diagnosis and the relevant ICD-10 diagnosis codes are on the claim.

You will also receive cover for a limited number of selected tests, procedures, and specialist consultations each year for the ongoing management of your condition(s). You also have cover for four (4) GP consultations related to your approved PMB CDL condition(s) per year. Please refer to the PMB treatment baskets document to view what is covered for your approved PMB CDL condition(s) and how we fund for these.

To make sure that we pay your claims from the correct benefit, we need the claims from your healthcare providers to be submitted with the relevant ICD-10 diagnosis codes. Please ask your healthcare provider to include your ICD-10 diagnosis codes on the claims they submit and on the forms that they complete when they refer you to pathologists and radiologists for tests. This will enable pathologists and radiologists to include the relevant ICD-10 diagnosis codes on the claims they submit ensuring that we pay your claims from the correct benefit.

Request for additional cover for Chronic Disease List conditions on the Chronic Illness Benefit

Your healthcare provider may follow an appeals process to request for additional funding for tests, procedures, and consultations for your approved PMB condition(s). Your healthcare provider needs to complete a Request for additional cover for approved PMB conditions form and submit it for review. It is important to note that an appeals process does not guarantee an automatic approval for the additional cover.

Documents for Chronic Illness Benefit (CIB) cover:

Guide to treatment baskets for Chronic Disease List (CDL) conditions.