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). Click here for more information on prescribed minimum benefits and the CDL conditions.
POLMED provides cover for the 25 CDL conditions. If you have been diagnosed with a chronic condition, it is important to claim your medication from the chronic medication benefit and not from the acute medication benefit. In order to access this benefit, POLMED requires members to apply for authorisation via the Chronic Medicine Management Programme.
Click the link below for an overview of the Chronic Medicine Management process:
Chronic Medicine Management
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 medication claims; therefore, consult your pharmacy about a generic equivalent that will not attract a co-payment.
To view the applicable formularies/lists, please click on the links below:
POLMED Chronic Medicine Management Programme
- Tel (Members): 0860 765 633
- Tel (Providers): 0860 104 111 / 0860 765 633
- Email: firstname.lastname@example.org
- Fax: 0860 000 320