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Sizwe offers cover for numerous chronic conditions including those defined as Prescribed Minimum Benefit (PMBs). This cover is in addition to your normal day-to-day benefits to ensure that during the year you do not run out of essential medical benefits to treat these PMB conditions. The treatment covered by PMBs refers to essential treatment of your condition and is subject to clinical and funding protocols. Members and Service Providers are encouraged to use cost-effective medication (generics where available), which Sizwe pays in full without any co-payments. |
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| What are PMBs? | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| Prescribed Minimum Benefits (PMB) is 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 people with continuous care to improve their health and well-being and to 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; – a limited set of 270 medical conditions (defined in the Diagnosis Treatment Pairs); and – 26 chronic conditions (defined in the Chronic Disease List). Medical emergency: An emergency medical condition means the sudden and, at the time, unexpected onset of a health condition that requires immediate medical treatment and/or an operation. If the treatment is not available, the emergency could result in weakened bodily functions, serious and lasting damage to organs, limbs or other body parts, or even death. |
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| What is a designated service provider (DSP)? | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| A Designated Service Provider (DSP) is a healthcare provider (doctor, pharmacist, hospital, etc) that is a medical scheme’s first choice when its members need diagnosis, treatment or care for a PMB condition. If you choose not to use the DSP selected by Sizwe, you may have to pay a portion of the bill as a co-payment. This could either be a percentage co-payment or the difference between the DSP’s tariff and that charged by the provider you went to. | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| What are diagnostic and treatment pairs? | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| The Regulations to the Medical Schemes Act in Annexure A provide a long list of conditions identified as Prescribed Minimum Benefits. The list is in the form of Diagnosis and Treatment Pairs (DTPs). A DTP links a specific diagnosis to a treatment and therefore broadly indicates how each of the approximately 270 PMB conditions should be treated. The treatment and care of PMB conditions should be based on healthcare that has proven to work best, taking affordability into consideration. Should there be a disagreement about the treatment of a specific case, the standards (also called practice and protocols) in force in the public sector will be applied. The treatment and care of some of the conditions included in the DTP may include chronic medicine, e.g HIV-infection and menopausal management. In these cases, the public sector protocols will also apply to the chronic medication. For a full list of the Diagnostic and Treatment Pairs (DTPs). | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| Medical Schemes council website | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| PMB Chronic disease list | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| Respective medical formularies and chronic benefit entry criteria for the conditions listed below, are available on request from CHAMPS. | ||||||||||||||||||||||||||||||||||||||||||||||||||||
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| What if I need or want a brand of medicine other than the one that Sizwe will pay for? | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| Sizwe has a formulary – a list of safe and effective medicines that can be prescribed to treat certain conditions. The formulary is applicable to PMB conditions. Sizwe will only cover the cost of the drug on the formulary where available. Often the medicines on the list will be generics, which are cheaper copies of the original brand name drug. If you want to use a brand name medicine that is not on the list, Sizwe will pay up to the price of the generic and you will be liable for the difference in price | ||||||||||||||||||||||||||||||||||||||||||||||||||||