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Prescribed Minimum Benefits (PMB)

Minimum Benefits (PMB) are 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 members with continuous care to improve their health and well-being and to make healthcare more affordable.

Your Scheme may make use of Formularies, Designated Service Providers (or Networks) and/or Care Plans to manage these benefits where payment is subject to clinical guidelines, protocols and other Scheme rules.

Ambulatory PMB (aPMB)

Care Plans:

An aPMB Care Plan lists the type and number of services that are likely to be needed by a member to manage a condition, despite benefits being available. It may include out-of-hospital treatment such as doctor’s consultations, radiology and pathology tests, and payment is subject to clinical guidelines, protocols and other Scheme rules.

How will this plan work with my other plans?

Multiple active care plans will be merged. This means you will be authorised for the maximum of the highest number of treatments in the plan for each service. For example: If you are allowed 3 doctor consultations for your Asthma diagnosis and 2 doctor consultations for your diabetes, you will be authorised for the maximum of 3 doctor consultations overall, to be used for both conditions.

Chronic Medicine Management:

Formulary

A formulary is a list of cost effective, evidence-based medicines that your Scheme will cover for the treatment of chronic conditions. These lists are compiled by Medscheme’s Chronic Medicine Management Department (CMM) and are constantly being reviewed, and payment is subject to clinical guidelines, protocols and Scheme Rules.

Your Scheme may apply one or more formulary to your medical aid option.

If you use medication that is outside of the formulary for your medical aid option you may be required to pay a co-payment upfront at the point of dispensing. Formularies include alternative products that will not require a co-payment so if you do not wish to incur any co-payments, please discuss alternative therapies with your treating doctor. If your Scheme applies the Medicine Price List (MPL) this can also affect your co-payment.

Restrictive Formularies

Restrictive Formularies apply to the basic or restrictive medical aid options and provide access to a restrictive range of medicines. For example: Medshield Basic Chronic Formulary, BonCap Chronic Formulary, Blue Door Plus Chronic Formulary and MHRS Restrictive Formulary.

Comprehensive Formulary

The Comprehensive Formulary applies to the more comprehensive medical aid options and provides access to a wider range of medicines, such as the MHRS Comprehensive Formulary.

Designated Service Provider (DSP):

A Designated Service Provider (DSP) is a healthcare professional (doctor, pharmacist, hospital, or network etc.) that is a medical scheme’s first choice when its members need diagnosis, treatment or care for a condition.

If you choose not to visit a required DSP to obtain your medication or other medical services, and may need to pay a co-payment  as determined by your Scheme rules.

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