The Medihelp Plus and Dimension Elite benefit options offer benefits for chronic medicine to treat the 25 CDL conditions but also for a number of additional chronic conditions. The Dimension Prime, Necesse and Unify benefit options do not offer benefits for chronic medicine, except for PMB medicine prescribed for the 25 CDL conditions.
Chronic medicine is medicine that is life-sustaining or life-saving. It is used for the treatment of a chronic disease that requires the continual use of medicine for a period of three months or longer. Examples of chronic diseases are allergic rhinitis, osteoporosis, major depression and hypertension (high blood pressure). To qualify for chronic medicine benefits, medicine must comply with the following criteria:
- It must be used to prevent or treat a serious medical condition;
- It must be used for an uninterrupted period of three months or longer;
- It must be used to sustain life, to delay the progress of a disease, and to repair natural physiology;
- It must be registered in South Africa for the treatment of the medical condition for which it is prescribed; and
- It must be the accepted treatment according to local and international treatment protocols and algorithms.
Certain medicine items used exclusively for the treatment of chronic conditions will only be paid from chronic or PMB medicine benefits. Claims to pay these medicine items from the limit for non-chronic medicine will be rejected. In order to qualify for benefits, these medicines must be registered for PMB or as chronic medicine with MEDICHRON. A 60-day claiming period will, however, be granted, during which the medicine items will be paid from the limit for non-chronic medicine to ensure the patient has sufficient medicine available during the registration process. Thereafter, claims for these medicines will be rejected until the medicine items are registered for PMB or as chronic medicine.
Click here for the comprehensive list of medicine items which will not be paid from the limit for non-chronic medicine after the 60-day period.
The ICD-10 coding system is an international diagnostic classification system that is used for statistical purposes. In terms of the Medical Schemes Act, 1998 it is compulsory for a doctor to specify an accurate and complete ICD-10 code next to each item on a prescription to verify the condition (diagnosis) for which the medicine is used. Medihelp reserves the right to reject any prescription item or claim received on which the ICD-10 codes are incomplete, incorrect or omitted. Accurate ICD-10 coding for chronic and PMB conditions are required for quality control purposes.
If you want to know more about pre-authorising your chronic medicines, please click here.