Prescribed Minimum Benefits (PMBs) ensure medical scheme members have access to essential healthcare services, regardless of their benefit options. PMBs, as per the Medical Schemes Act No 131 of 1998, cover the diagnosis, treatment and care of 26 chronic conditions, for example High Blood Pressure, Asthma, Diabetes and HIV. The aim of PMBs is to make medical care more affordable.
What you should know about the medication for chronic conditions
Qualifying criteria: Medical schemes will require certain qualifying criteria and although they will only fund specific medication types to treat specific conditions, they may allow other medications that they are prepared to fund in full (typically generic medication).
Approved list of medication: If your specific medication is not on the list, the medical scheme might contribute an agreed amount, however, a co-payment could be required from you. In certain instances, members must use a designated service provider to avoid co-payments.
Some medical schemes also have a rand amount limit for chronic medication.
How qualifying for chronic medication works
| How / when | Diagnosis / application / chronic medication |
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When do you qualify / need this?
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When your treating doctor or specialist has diagnosed a condition which is deemed life threatening and requires ongoing treatment, in line with the scheme rules. |
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Medication process / application
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Application is made to the scheme for chronic medication, via the treating provider, by submitting an application form. |
| How will this be funded? | Chronic medicines are paid from risk benefits and will not affect your savings or day-to-day benefits. |
| Treatment period | Chronic medication prescriptions need to be reissued by the treating provider every 6 months and submitted to the pharmacy to renew the cycle. |
Remember: Prevention, like healthy living programmes, screenings, and taking prescribed chronic medication regularly, can reduce chronic illness disease risks.
Get in touch with your medical scheme for more information regarding the chronic application process and check which of your medical scheme’s benefits and rules will apply.
Health Connect 6/2025
In case you have missed it, click here to read our previous issue – Protecting your budget from rising costs