Medical Aid Prescribed Minimum Benefits (PMBs)
No matter what medical scheme or plan you decide on, there are some common benefits that apply to all members, on all medical schemes, on all plans.
In terms of the Medical Schemes Act 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
- 25 chronic conditions and
- A defined set of 270 diagnoses (a list of these is available here)
These conditions and their treatments are known as Prescribed Minimum Benefits (PMB).
For more information on Diagnosis and Treatment Pairs and PMBs, visit the Council of Medical Schemes’ website.
What are the Prescribed Minimum Benefits (PMBs)?
These are benefits contemplated in the Medical Schemes Act in respect of which medical schemes are compelled to provide cover for the diagnosis, treatment and care associated with these conditions, and without any co-payment or use of deductibles, providing that services are obtained from a designated service provider. In the case of PMB chronic medicine, the Scheme’s formulary and protocol must be complied with.
NOTE: These benefits are available, on application, to all members in addition to the benefits already offered by their chosen Option, once existing benefits have been exhausted.
5.2. What is a Designated Service Provider (DSP)?
It is a healthcare provider or group of healthcare providers whom the Scheme has selected as its preferred supplier in terms of rendering treatment and care for the Prescribed Minimum Benefits (PMB) conditions. These providers are:
- Public Healthcare System (state facilities)
- Optipharm Courier Pharmacy
- Clicks Direct Medicines Courier Pharmacy
- Script-Wise Courier Pharmacy
- Dischem Pharmacy
- Pick ‘n Pay Pharmacy
- MediRite Pharmacy
- ICON Oncology
- One Health Managed Care
- Clicks Pharmacist
NOTE: Even though these services are covered in full, the Scheme’s healthcare principles will still apply. You will still be required to obtain pre-authorisation for hospitalisation whilst admitted for a PMB condition and/or PMB chronic medicine and a relevant treatment plan.
5.3. What happens if these services are obtained from a provider other than a DSP?
A member will then be liable for an upfront 40% co-payment in respect of PMB which are voluntarily obtained from a provider, other than the DSP.
5.4. What happens in case of the following:
- The required service was not available from the DSP or would not be provided without unreasonable delay, OR
- There was no DSP available in a reasonable proximity from where the beneficiary resides or conducts business, OR
- Immediate emergency care was required under circumstances or at locations, which precluded the beneficiary from obtaining the treatment from the DSP?
If any of the above circumstances apply, the co-payment described under 5.3 will not apply, provided that the following documentation is submitted to and approved by the Scheme:
- Written communication proving the need – in case of all three of the above
- Comprehensive clinical report supporting the need for the emergency care
5.5. Which conditions and treatments are covered under the PMB’s
Approximately 270 conditions are covered under PMB in the event of complications which require hospital treatment. A list of all these conditions is available from the Scheme, on request.
As from 1 January 2004 provision has been made to provide for medical management, diagnosis and medicine of the following chronic conditions:
- Addison’s Disease
- Bipolar Mood Disorder
- Cardiac Failure
- Chronic Renal Disease
- Coronary Artery Disease
- Crohn’s Disease
- Chronic Obstructive Pulmonary Disorder
- Diabetes Insipidus
- Diabetes Mellitus Type 1 & 2
- Multiple Sclerosis
- Parkinson’s Disease
- Rheumatoid Arthritis
- Systemic Lupus
- Ulcerative Colitis
5.6. If I am already in possession of a chronic authorisation for treatment of a specific condition, will I be able to retain this authorisation?
Yes, however, benefits will be subject to the Scheme Rules of the specific Option. Kindly note that should you belong to an Option with specific sub-limits, both PMB and non-PMB treatment will accumulate to this specific limit until it is reached, whereafter only the PMB benefit will qualify for further benefits, provided the prescribed criteria is met.
5.7 Can Schemes still set a chronic medicine limit?
Yes, your Scheme can set a limit for your chronic medicine benefit. Any chronic medication you claim for will be paid from your chronic medicine limit, regardless of whether it is one of the PMB chronic conditions or not. However, if you exhaust your chronic medicine limit, your Scheme will still continue paying for any chronic medication you obtain from its DSP for a PMB condition.