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PRESCRIBED MINIMUM BENEFITS

Prescribed minimum benefits (PMBs) are a set of benefits meant to ensure that all medical scheme members have access to certain minimum health services, regardless of their benefit option. The aim is to provide members with continuous care to improve their health and well-being and make healthcare more affordable.

PMBs are a feature of the Medical Schemes Act, in terms of which medical schemes have to cover the costs related to the diagnosis, treatment and care of:

  • any emergency medical condition that requires emergency treatment
  • a limited set of 270 medical conditions as defined in the Diagnosis and Treatment Pairs (DTPs)
  • 26 chronic conditions as defined in the Chronic Disease List (CDL).

CHRONIC DISEASE LIST (CDL)

  • Addison’s disease
  • Asthma
  • Bipolar mood disorder
  • Bronchiectasis
  • Cardiac failure
  • Cardiomyopathy disease
  • Chronic obstructive pulmonary disorder
  • Chronic renal disease
  • Coronary artery disease
  • Crohn’s disease
  • Diabetes insipidus
  • Diabetes mellitus type I and II
  • Dysrhythmias
  • Epilepsy
  • Glaucoma
  • Haemophilia
  • HIV/AIDS
  • Hyperlipidaemia
  • Hypertension
  • Hypothyroidism
  • Multiple sclerosis
  • Parkinson’s disease
  • Rheumatoid arthritis
  • Schizophrenia
  • Systemic lupus erythematosus
  • Ulcerative colitis

CARE PLAN

You and your treating doctor will receive a Care Plan to treat your condition.
Your doctor must submit the relevant ICD-10 and tariff codes when submitting claims.

The Care Plan is sent via email or post and contains details in respect of services that can be claimed from the PMB benefit.

Care Plan

All Claims and Claims related queries to be submitted to: polmedcurrentclaims@medscheme.co.za
ENQUIRIES: Tel: 0860 765 633 | Fax: 0860 000 320 | Email: polmedapmb@medscheme.co.za

MEDICINE MANAGEMENT

POLMED PHARMACY NETWORK

Polmed has established an open pharmacy network to provide acute, chronic and over-the-counter (OTC) medication.

Payment for acute, chronic and OTC medication will be subject to the medication included in the Polmed formulary. A 20% co-payment will be applied for voluntarily using a non-formulary product.

IMPORTANT!
If you have been diagnosed with a chronic condition, your medication must be authorised before your prescription is handed in at the pharmacy.

INFORMATION REQUIRED WHEN APPLYING FOR CHRONIC AUTHORISATION

Diagnosis: Valid ICD-10 code.
Date: The date on the prescription should not be older than six months from the date of issue by the service provider.
Doctor’s details: Practice name, practice number, telephone number, address and signature.
Patient’s details: Full name and surname.
Medication: Name, dosage, quantity, and directions for use.
Duration of treatment: How long the prescription is valid, e.g. repeat for six months.

DID YOU KNOW?

You or your treating doctor or pharmacist can call Polmed to obtain pre-authorisation for your chronic medication.

Chronic medicine department contact details

Treating doctor/pharmacist: Call 0860 104 11 1
Member: Call 0860 765 633
Email: polmedcmm@medscheme.co.za

NOTE

CO-PAYMENTS

  • Ensure your doctor prescribes items on the medication formulary to avoid a 20% co-payment.
  • If you obtain your medication from a non-network service provider, you will have a 20% co-payment.
  • If both the above scenarios are applicable, a maximum co-payment of 20% applies.

GENERIC REFERENCE PRICING

  • Generic reference pricing is applicable where equivalent generic medication is available.
  • Co-payments due to reference pricing may be avoided by using generic medication below the reference pricing – your pharmacist can suggest generic medication options.

 

Polmed Exclusions List – May 2025
Polmed Reference Price List – May 2025
Polmed Comprehensive PMB Formulary – May 2025
Polmed Acute Out of Formulary List – May 2025
Polmed Exclusions List – April 2025
Polmed Reference Price List – April 2025
Polmed Comprehensive PMB Formulary – April 2025
Polmed Acute Out of Formulary List – April 2025
Polmed Exclusions List – March 2025
Polmed Reference Price List – March 2025
Polmed Comprehensive PMB Formulary – March 2025
Polmed Acute Out of Formulary List – March 2025
Polmed Exclusions List – February 2025
Polmed Reference Price List – February 2025
Polmed Comprehensive PMB Formulary – February 2025
Polmed Acute Out of Formulary List – February 2025
Polmed Exclusions List – January 2025
Polmed Reference Price List – January 2025
Polmed Comprehensive PMB Formulary – January 2025
Polmed Acute Out of Formulary List – January 2025
Polmed Exclusions List – December 2024
Polmed Reference Price List – December 2024
Polmed Comprehensive PMB Formulary – December 2024
Polmed Acute Out of Formulary List – December 2024
Polmed Exclusions List – November 2024
Polmed Reference Price List – November 2024
Polmed Comprehensive PMB Formulary – November 2024
Polmed Acute Out of Formulary List – November 2024
Polmed Exclusions List – October 2024
Polmed Reference Price List – October 2024
Polmed Comprehensive PMB Formulary – October 2024
Polmed Acute Out of Formulary List – October 2024
Polmed Exclusions List – September 2024
Polmed Reference Price List – September 2024
Polmed Comprehensive PMB Formulary – September 2024
Polmed Acute Out of Formulary List – September 2024
Polmed Exclusions List – August 2024
Polmed Reference Price List – August 2024
Polmed Comprehensive PMB Formulary – August 2024
Polmed Acute Out of Formulary List – August 2024
Polmed Exclusions List – July 2024
Polmed Reference Price List – July 2024
Polmed Comprehensive PMB Formulary – July 2024
Polmed Acute Out of Formulary List – July 2024
Polmed Exclusions List – June 2024
Polmed Reference Price List – June 2024
Polmed Comprehensive PMB Formulary – June 2024
Polmed Acute Out of Formulary List – June 2024
Polmed Exclusions List – May 2024
Polmed Reference Price List – May 2024
Polmed Comprehensive PMB Formulary – May 2024
Polmed Acute Out of Formulary List – May 2024
Polmed Exclusions List – April 2024
Polmed Reference Price List – April 2024
Polmed Comprehensive PMB Formulary – April 2024
Polmed Acute Out of Formulary List – April 2024
Polmed Exclusions List – March 2024
Polmed Reference Price List – March 2024
Polmed Comprehensive PMB Formulary – March 2024
Polmed Acute Out of Formulary List – March 2024
Polmed Exclusions List – February 2024
Polmed Reference Price List – February 2024
Polmed Comprehensive PMB Formulary – February 2024
Polmed Acute Out of Formulary List – February 2024
Polmed Exclusions List – January 2024
Polmed Reference Price List – January 2024
Polmed Comprehensive PMB Formulary – January 2024
Polmed Acute Out of Formulary List – January 2024
Polmed Exclusions List – December 2023
Polmed Reference Price List – December 2023
Polmed Comprehensive PMB Formulary – December 2023
Polmed Acute Out of Formulary List – December 2023

Tel: 0860 765 633 or 0860 POLMED
Email: polmed@medscheme.co.za
Fax: 0860 104 114

Postal Address:

Polmed, Private Bag X16,
Arcadia, 0007

Emergency Services:

ER24 0800 727 772 or
084 124

Council for Medical Schemes:

www.medicalschemes.com
Polmed Fraud Hotline:
0800 112 811
SMS: 33490

information@whistleblowing.co.za
fraud@medscheme.co.za

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