Prescribed minimum benefits: what your medical aid must pay for

Prescribed minimum benefits, or PMBs, are a set of conditions that every medical scheme in South Africa must cover, whatever plan you are on. They are set by the Medical Schemes Act and its regulations, and the Council for Medical Schemes enforces them.

What counts as a PMB

• Any emergency medical condition
• 271 serious conditions, each paired with the treatment the scheme must pay for
• 26 chronic conditions on the Chronic Disease List, including high blood pressure, diabetes, asthma, epilepsy, HIV and high cholesterol

For these, your scheme must pay for diagnosis, treatment and ongoing care, and it may not pay this from your medical savings account.

The rules that come with it

Schemes are allowed to manage how PMBs are paid. Your scheme may ask you to:

• Register a chronic condition before it pays for the medicine
• Use its network of doctors, pharmacies and hospitals, called designated service providers
• Use medicine from its list, called a formulary, unless your doctor shows another medicine is needed

If you choose to go outside these rules when you did not have to, you may pay a co-payment. In an emergency, the scheme must pay even if you could not use its network.

How we help

If you have a chronic condition, we fill in the registration forms with you and use the right codes on every claim, so your scheme can see it is a PMB. If a claim is refused, ask your scheme to review it as a PMB. If that does not work, you can complain to the Council for Medical Schemes.

What PMBs do not cover

Everyday visits for things that are not PMBs, such as a cold or a check-up, are paid from your day-to-day benefits or savings, depending on your plan. Medicals for work or driving are usually not covered at all. Check your plan's benefits, and ask us for the procedure codes before a planned visit if you want to check first.

This guide is general information, not medical advice for your situation. Please speak to a doctor about your own health.