The Chronic Illness Benefit
Medicine cover for Chronic Disease List conditions
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 paid in full up to the Fund Rate. Medicines not on the medicine list will be funded up to the Maximum Medical Aid Price (MMAP).
Medicine cover for Additional Disease List conditions
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.
Where to obtain your chronic medicine
You can obtain your chronic medicine from any pharmacy or from your dispensing doctor.
How to access the Chronic Illness Benefit
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 have given your consent.
You need to meet the benefit entry criteria for your condition(s) to be registered on the Chronic Illness Benefit. You or your doctor may need to provide certain test results or extra information as indicated on the CIB application form for the condition(s) you are applying for. Please ensure that these documents are submitted with your application to avoid any delays in the process.
Changes to your approved treatment plan
If you are already approved on the benefit, you do not need to complete a new CIB application form when your treating doctor makes changes to your treatment plan. However, you do need to let us know when your doctor makes these changes so that we can update your authorisation(s). You can do this by emailing a copy of the prescription to us or asking your doctor or pharmacist to do this for you. If your doctor uses HealthID, your doctor can make the treatment plan changes online, provided you have given your consent. If you do not let us know about changes to your treatment plan, we may not pay your claims from the correct benefit.
You need to complete a new CIB application form when you are diagnosed with a new chronic condition.
Treatment baskets for your approved Chronic Disease List (CDL) conditions
If you have recently been diagnosed with and approved for cover for a PMB CDL condition, we will pay for the diagnostic tests and procedures from the diagnostic treatment basket in full. Please ask your doctor to provide the date of diagnosis of your condition(s) on the CIB application form to assist us to pay your claims from the correct benefit. We will also pay in full for the consultation with the doctor who made the diagnosis. We will only pay for the tests, procedures and consultation if you were an active and valid member of the Fund at the time of the diagnosis and the relevant ICD-10 diagnosis code(s) are on the claim
The Chronic Illness Benefit will also cover 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 Prescribed Minimum Benefit treatment baskets document to view what is covered for your approved PMB CDL condition(s) and how we pay for these benefits.
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 code(s). Please ask your doctor to include your ICD-10 diagnosis code(s) on the claims they submit and on the forms that they complete when they refer you to pathologists and/or radiologists for tests. This will enable the pathologists and radiologists to include the relevant ICD-10 diagnosis code(s) on the claims they submit ensuring that we pay your claims from the correct benefit.
Request for additional funding for CDL conditions
Your doctor may follow an appeals process to request additional funding for medicine, tests, procedures and consultations for your approved PMB CDL condition(s). 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.
Extended supply of medicine
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.