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25 conditions your scheme must cover

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Medical schemes have to provide benefits that cover you for the diagnosis, treatment and care of these 25 chronic illnesses listed below. However, you should remember that a scheme does not have to pay for diagnostic tests that establish that you are suffering from a disorder that is not one of the 25 chronic ailments.

The inclusion of the 25 chronic conditions in the list of Prescribed Minimum Benefits (PMBs) is a major step towards helping people who have struggled to pay for their treatment of chronic diseases in the past, and have increasingly had to dip into their own pockets for this treatment.

In order to contain the costs of providing such cover, certain measures have been put in place to ensure that schemes can cover those members who need it, without putting the scheme at financial risk.

So schemes are entitled to expect you to obtain treatment for a PMB from certain providers, the so-called "designated service providers" - particular groups of hospitals, clinics, doctors, retail pharmacies, and so on. However, a scheme must state in its rules that you must use a designated service provider and you must be informed about where and how you can get medication and treatment from that provider.

Schemes that do not include these arrangements in their rules and do not inform members, risk having to pay for the cost of treatment from whichever provider you use.

If you do not abide by the rules about which providers to use, you face having to pay all or part of the cost of your treatment yourself.

The "treatment protocols" (guidelines for appropriate treatment) for each of the chronic conditions, which have been made PMBs, were published in the Government Gazette.

This is so that you may be assured of good quality treatment and your scheme can be sure that it will not have to pay for unnecessary treatment. Your doctor should know and understand the guidelines so that he or she can help you get the treatment you need for any of these conditions without incurring costs that your scheme does not cover.

25 Prescribed Minimum Benefits

Get more information on some of these conditions by clicking on the links.

Addison's disease
Asthma
Bipolar mood disorder*
Bronchiectasis
Cardiac failure
Cardiomyopathy
Chronic obstructive pulmonary disorder
Chronic renal disease
Coronary artery disease
Crohn's disease
Diabetes insipidus
Diabetes mellitus types 1 & 2
Dysrhythmias
Epilepsy
Glaucoma
Haemophilia
Hyperlipidaemia
Hypertension
Hypothyroidism
Multiple sclerosis
Parkinson's disease
Rheumatoid arthritis 
Schizophrenia
Systemic lupus erythematosus

* Will only be covered when an algorithm has been developed – when clinical protocols have been developed.
 

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