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
- Bipolar mood disorder
- 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
- Multiple sclerosis
- Parkinson’s disease
- Rheumatoid arthritis
- Systemic lupus erythematosus
- Ulcerative colitis
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.
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.
- 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.