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PMB & CDL

What are PMBs?

PMB (prescribed minimum benefits) are a series of services that medical schemes must cover in terms of the Medical Schemes Act 131 of 1998, including:

  • Medical emergencies (in terms of the legal definition);
  • 270 listed diagnosis and treatment pairs (DTPs); and
  • The 26 diseases on the Chronic Diseases List (CDL).

What are the rules for PMB?

All PMB services must :

  • Be pre-authorised;
  • Follow specialised protocols; and
  • Rendered by designated service providers (DSPs).

Medicine formularies apply for members of the Prime network options and Necesse.
Please always study your benefit option member guide to ensure that you use the DSPs indicated for your option and adhere to all the rules of your option.


How do I access my PMB?

PMB treatment can include:

  • Consultations and services
  • Medicine
  • Hospitalisation
  • Emergencies

Accessing PMB

Consultations & services

  1. Register – phone Medihelp on 086 0100 678. Give the consultant the ICD-10 codes provided by your doctor to register your illness. You will receive an authorisation schedule with approved services.
  2. Only the treatments specified on your authorisation schedule will from part of your treatment protocol and qualify for benefits.
  3. Any new services that your doctor wants to prescribe must be pre-authorised through the same process.

Accessing PMB

Medicine

  1. Visit Medihelp’s secured website for members at www.medihelp.co.za or phone the Call Centre on 086 0100 678 for a PMB/chronic medicine application form.
  2. Complete the form and submit it according to the instructions on the form.
  3. Include all the required supporting documents for your specific condition, such as test results and doctors’ reports.
  4. You will receive an authorisation schedule as soon as your pre-authorisation is complete.
  5. Medicine benefits for members of Necesse and the Prime network options subject to a formulary (a list of medicines for which the Scheme will pay).

Accessing PMB

Hospitalisation

  1. Hospitalisation for a PMB condition must be pre-authorised by phoning Medihelp on 086 0200 678. If you fail to do this, a 20% co-payment will apply.
  2. Emergency admissions must be authorised on the first working day following the admission.
  3. Beneficiaries of the Prime network and Necesse options must be admitted to a network hospital to avoid a 35% co-payment.

Accessing PMB

Emergencies

  1. Only services that meet the legal criteria for medical emergencies will qualify for PMB, provided that the doctor motivates it as such.
  2. Phone Medihelp on 086 0100 678 to authorise the emergency. Emergencies must be authorised as soon as possible after the incident, but no later than the first working day following the emergency admission.

What is the MHRP?

The Medihelp Reference Price (MHRP) applies to all PMB medicine. Medihelp applies an average benefit amount per specific medicine according to a therapeutic class, and that benefit amount will be applied to all medicines that contain the same molecule in the same therapeutic class. You can download the MHRP list from Medihelp’s website at www.medihelp.co.za or phone the Call Centre on 086 0100 678.


What qualifies as an emergency according to the Act?

The Act defines an emergency as “any sudden and unexpected onset of a health condition that requires immediate medical or surgical treatment, where failure to provide such treatment would result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part, or would place the person’s life in serious jeopardy”.

IMPORTANT: A medical emergency must be diagnosed as such by the doctor at the emergency unit.

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