Chronic Medication
Criteria that qualify for chronic medication benefits
Although your doctor may define your condition as being chronic, the condition may not fulfil the Scheme criteria to qualify for benefits from the chronic medication benefit.
To qualify for the chronic medication benefit, specific clinical criteria and medication formularies apply. The conditions covered by the Scheme are listed in the Chronic Disease List (CDL) below.
In terms of the formularies for chronic conditions, only specific medication is funded from the chronic medication benefit. The Chronic Medicine List (CML) outlines the medication covered by Profmed medical aid scheme. Further information on the CML is available below. Medication not qualifying for the chronic medication benefit may be considered for funding from the acute medicine benefit.
Profmed may limit the treatment covered in accordance with gazetted therapeutic algorithms and Reference Pricing. Maximum Medical Aid Pricing (MMAP®) and the Single Exit Price for medication will also apply.
Unregistered drugs and “off-label” usage of drugs will not be funded. Off-label drugs are medicines used for a condition for which they are not specifically registered.
Certain PMB high-cost drugs which are not listed in the algorithms will only be covered on the ProPinnacle and ProPinnacle Savvy options, subject to protocols and Scheme rules.
It is vital that you are aware of the expiry date of your authorisation and to renew the authorisation timeously. Only your treating doctor or your pharmacist can authorise your chronic condition and medication by calling Chronic Authorisations on 0800 132 345.
If your chronic medication is not authorised before the expiry date, benefits will be paid from the acute medicine benefit, subject to the availability of funds.
Conditions that are covered
Chronic medication is funded from the Chronic Medication benefit, subject to available funds. The consultations, radiology and pathology related to these chronic conditions are funded from the available day-to-day benefits. Once day-to-day benefits are depleted, benefits will continue to be funded from risk.
Profmed medical aid scheme covers 26 CDL conditions on all options, and additional conditions on the more comprehensive options.
Chronic Conditions
A list of conditions that are covered in full in terms of the Scheme rules if services are rendered according to the Scheme’s benefits, treatment plans and protocols, CDL medication lists, and claimed with the correct diagnostic
(ICD-10) codes.
These conditions are covered on all Profmed’s options, but benefits will be more or less restrictive depending on the option the member has chosen.
| Addison’s Disease | Epilepsy |
| Asthma | Glaucoma |
| Bipolar Mood Disorder | Haemophilia |
| Cardiomyopathy Disease | Hypertension |
| Chronic Obstructive Pulmonary Disorder | Hypothyroidism |
| Chronic Renal Disease | Multiple Sclerosis |
| Coronary Artery Disease | Parkinson’s Disease |
| Chrohn’s Disease | Rheumatoid Arthritis |
| Diabetes Insipidus | Schizophrenia |
| Diabetes Mellitus Types 1 & 2 | Systemic Lupus Erythematosus |
| Dysrhythmias | Ulcerative Colitis |
Chronic Disease List (CDL)
The 271 conditions are listed in Annexure A of the Medical Schemes Act, which is available on the website of the Council for Medical Schemes at www.medicalschemes.co.za.
The Act obliged schemes from 1 January 2000 to provide minimum benefits for these conditions.
