Prescribed Minimum Benefits are the legal floor under every registered medical scheme option in South Africa. Knowing what sits inside that floor is the difference between a claim being paid in full and a co-payment you did not expect.
Under the Medical Schemes Act, every option must fund the diagnosis, treatment and care costs of 270 defined conditions, any emergency medical condition, and 27 chronic conditions listed on the Chronic Disease List — regardless of how basic the option is or whether benefit limits have run out.
The Chronic Disease List includes conditions such as asthma, diabetes types 1 and 2, hypertension, epilepsy, HIV, hypothyroidism, Crohn's disease and bipolar mood disorder. Registration on the scheme's chronic programme is normally required before medication is funded from risk instead of savings.
A scheme may pay a PMB in full only when you use its designated service provider and stay on its formulary. Choose a different pharmacy, doctor or branded medicine and the scheme may apply a co-payment — legally, provided the designated route was available to you and clinically appropriate.
If a formulary medicine is clinically unsuitable, you can apply for an exception. That process is standard and worth using before paying a recurring monthly shortfall.
Richer options extend chronic funding to additional conditions beyond the 27. If you or a dependant treat a condition that is not on the Chronic Disease List, that extended list is one of the few benefit differences worth paying more for.
Twenty-seven, as listed on the Chronic Disease List, on every registered option — plus 270 diagnosis and treatment pairs and all emergency medical conditions.
Yes, if you choose a provider or medicine outside the scheme's designated network or formulary when a suitable designated option was available. Use the designated route, or apply for a formulary exception, to have the benefit paid in full.
Yes. PMB funding is not subject to annual benefit limits, which is why the statutory floor matters most on entry-level options.