The Chronic Illness Benefit covers approved medicine for the 26 Prescribed Minimum Benefit (PMB) Chronic Disease List (CDL) conditions. Approved medicine on the Chronic Illness Benefit medicine list (formulary) will be funded in full up to the Scheme Rate. Medicines not on the medicine list will be funded up to the Maximum Medical Aid Price (MMAP).
You have further cover for 2 non-PMB CDL conditions, Depression and Attention deficit hyperactivity disorder. A medicine list (formulary) applies to Depression. For this condition approved medicine on the medicine list will be funded in full up to the Scheme Rate. Medicines not on the medicine list will be funded up to the Maximum Medical Aid Price (MMAP).
A medicine list (formulary) does not apply to Attention deficit hyperactivity disorder. For this condition, approved medicine will be funded up to 80% of the Scheme Rate.
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 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 approved, 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 approved 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 approval 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.
Documents for your Chronic Illness Benefit (CIB) cover: