Prescribed Minimum Benefits (PMBs)
PMBs are a set of defined benefits to ensure that all medical scheme members have access to certain minimum health services, regardless of the benefit option they have selected. The aim is to provide members with continuous care to improve their health and wellbeing, and to make healthcare more affordable. This includes medical management of the 25 most common chronic illnesses on the Chronic Disease List (CDL). To view the list of CDL conditions, please click here.
POLMED provides cover for the 25 CDL conditions. Chronic medication for these conditions are funded from the Chronic Medicine Benefit (a benefit that is separate from the acute medication benefit). In order to access this benefit, POLMED requires members to apply for authorisation via the Chronic Medicine Management Programme. To apply, you, your doctor or pharmacist can call us on 0860 765 633. You will need:
- Member details (including membership number and date of birth)
- Copy of a valid chronic prescription (including ICD-10 code, doctor’s practice number/details and medication details). Your doctor can email the prescription to email@example.com or fax it to 0860 000 320.
Upon registering your medication on chronic, a Care Plan will be generated for you. Ambulatory prescribed minimum benefit (aPMB) Care Plans give members access to out-of-hospital benefits for specific PMB CDL conditions. These Care Plans are for services that are likely to be needed by members to manage their conditions, such as doctor consultations, radiology and pathology tests.
Click the link below to view the aPMB Care Plan Management process.
POLMED aPMB Care Plan Management process
When you apply for chronic medication authorisation and the predefined criteria are met, you will receive a pre-authorisation for your chronic disease. This will give you access to a list of pre-approved medication, referred to as a basket. This means that changes for products included in a medicine basket previously pre-authorised will not require an update.
Medication not linked to a basket will require a motivation and pre-authorisation will be subject to meeting the clinical criteria. It is important to note that not all conditions are managed with disease authorisations.
- A chronic medication formulary is applied to PMBs; medication not included in the formulary will attract a 20% co-payment.
- A Designated Service Provider (DSP) will apply to chronic medication claims; if you utilise a pharmacy that is not a DSP, a 20% co-payment will apply.
- POLMED Reference Pricing will apply to all medicine claims; therefore, consult your pharmacy about a generic equivalent that will not attract a co-payment.
POLMED How to collect chronic medication with disease authorisations process
To view the applicable formularies/lists, please click on the links below:
POLMED CHRONIC MEDICINE MANAGEMENT
Tel (Members): 0860 765 633
Tel (Providers): 0860 104 111 / 0860 765 633
Fax: 0860 000 320