The Chronic Illness Benefit covers authorised medicine for the 26 Prescribed Minimum Benefit (PMB) Chronic Disease List (CDL) conditions. Authorised medicine on the Chronic Illness Benefit medicine list (formulary) will be funded in full up to the Fund Rate. Medicines not on the medicine list will be funded up to the Maximum Medical Aid Price (MMAP).
You have further cover for Additional Disease List (ADL) conditions. There is no medicine list (formulary) for the ADL conditions. Approved medicine for these conditions will be funded up to the MMAP.
If you want to access cover from the Chronic Illness Benefit, you must apply for it. You must complete a Chronic Illness Benefit application form with your doctor and submit it for review. If your doctor uses HealthID, your doctor can apply for cover online, provided you gave your consent.
You need to meet the benefit entry criteria for your condition to be registered on the Chronic Illness Benefit. You or your doctor may need to provide certain test results or extra information and motivation to finalise your application. Please ensure that these documents are submitted with your application to avoid any delays in the process.
If your PMB CDL condition is authorised, the Chronic Illness Benefit will cover a limited number of selected tests, procedures and specialist consultations for the ongoing management of your condition. You also have cover for four (4) GP consultations related to your approved PMB CDL condition(s) per year. Please refer to the Prescribed Minimum Benefit treatment baskets document to view what is covered for your approved PMB CDL condition.
If you were recently diagnosed with and authorised for cover for a PMB CDL condition, the expenses related to the diagnosis of the condition may be funded from the Chronic Illness Benefit and not from other available benefits, provided that you were an active and valid member of the Scheme when the diagnosis of your condition was made.
Your doctor may follow an appeals process to request for additional funding for medicine, tests, procedures and consultations for your approved PMB CDL condition. Your doctor needs to complete a Request for additional cover for approved Chronic Disease List conditions form and submit it for review. It is important to note that an appeals process does not guarantee an automatic authorisation for the additional cover.
You may get only one month’s supply of chronic medicine at a time. However, if you are travelling overseas and need up to six month’s supply of medicine, please complete a Request for extended supply of medicine and submit it for review.