Every registered medical scheme in South Africa must cover the diagnosis, treatment and medication for 26 chronic conditions on the chronic disease list (CDL) — regardless of plan tier. Here's what's actually on the list and where members trip up.
The 26 conditions on the CDL
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 and 2, dysrhythmias, epilepsy, glaucoma, haemophilia, hyperlipidaemia, hypertension, hypothyroidism, multiple sclerosis, Parkinson's disease, rheumatoid arthritis, schizophrenia, systemic lupus erythematosus, and ulcerative colitis.
You must register the condition
PMB cover doesn't happen automatically. You must register the chronic condition with your scheme and submit a scripted treatment plan. Without registration, claims pay from day-to-day benefits.
Formularies and co-payments
Schemes negotiate steep discounts on a formulary list of preferred medications for each condition. Off-formulary scripts can attract co-payments of 25–40%. Ask your GP whether a formulary-equivalent works — for most conditions, clinical outcomes are identical.
Designated service providers
Schemes can require you to use a designated GP, pharmacy or hospital for chronic care. Using a non-DSP for non-emergency chronic treatment can trigger a co-payment of up to 30%.
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