What is the Chronic Illness Benefit?
The Chronic Illness Benefit is a benefit that covers medicine for a specified list of chronic conditions according to your plan type. Although a condition may be defined as chronic, we may not be able to cover it from the Chronic Illness Benefit.
What does clinical entry criteria mean?
For a condition to be covered from the Chronic Illness Benefit, there are certain criteria you need to meet.
This ensures that you receive sustainable funding for cost-effective treatment.
We update the 
Chronic Illness Benefit application (CIB) form with the information we need to correctly and efficiently assess the application for chronic cover. Your doctor will need to complete all the relevant sections in the form. We will only accept CIB application forms marked “2012” as the criteria may have changed.
Executive Plan
The Chronic Disease List conditions
What they are and how your Health Plan covers these in 2012
The Council for Medical Schemes has determined that all medical schemes must provide a minimum level of cover for a list of chronic conditions, in any setting according to treatment guidelines. These are called the Prescribed Minimum Benefit Chronic Disease List conditions. Medical schemes are obliged to cover the diagnosis, medical management and medicine for these conditions on all plan types.
The Chronic Disease List conditions
- Addison’s disease
- Asthma
- Bipolar mood disorder
- Bronchiectasis
- Cardiac failure
- Cardiomyopathy
- Chronic obstructive pulmonary disease (COPD)
- Chronic renal disease
- Coronary artery disease
- Crohn’s disease
- Diabetes insipidus
- Diabetes mellitus type 1
- Diabetes mellitus type 2
- Dysrhythmias
- Epilepsy
- Glaucoma
- Haemophilia
- HIV and AIDS (To enrol or request information on our HIVCare programme, please call 0860 99 88 77)
- Hyperlipidaemia
- Hypertension
- Hypothyroidism
- Multiple sclerosis (MS)
- Parkinson’s disease
- Rheumatoid arthritis
- Schizophrenia
- Systemic lupus erythematosus (SLE)
- Ulcerative colitis
The conditions below were previously included in the Additional Disease List (ADL) but are now listed separately as they are covered on all plan types.
- Cushing’s disease
- Hypoparathyroidism
- Organ transplantation
- Paraplegia
- Pemphigus
- Peripheral arteriosclerotic disease
- Pituitary disorders
- Quadriplegia
- Stroke
- Thrombocytopaenia purpura
- Valvular heart disease
How we pay medicines for the Chronic Disease List conditions
We cover approved medicine listed on the formulary , for the Chronic Disease List conditions, in full up to the Discovery Health Medication Rate.
We cover medicines not on the formulary, or a combination of formulary and non-formulary medicines that are in the same medicine category, up to a monthly Chronic Drug Amount, which has been allocated for that particular medicine category.
The Chronic Drug Amount is an amount of money that has been allocated for each medicine category per month for a condition. The medicine category is a grouping of medicines with a similar effect for the management of the condition.
The Prescribed Minimum Benefits and the diagnosis and management of your chronic condition
The Chronic Illness Benefit covers limited diagnostic tests and consultations each year for the Chronic Disease List conditions listed in the Prescribed Minimum Benefits.
Tests to diagnose your condition
We pay diagnostic tests like blood tests and x-rays from the Chronic Illness Benefit only if the claim for the diagnosis is dated no earlier than 120 days prior to registration on the Chronic Illness Benefit. If we receive claims that are dated earlier than this, we pay the claims from the available money in your day-to-day benefit, if available on your plan type.
- We will pay these claims only if we have approved the condition as one of the Chronic Disease List conditions.
- We pay blood tests and x-rays listed, up to a maximum of the Discovery Health Rate.
These are pro-rated based on the date of the approval of your chronic condition.
GP consultations related to your condition
We pay consultations related to your condition from the Chronic Illness Benefit:
- We pay four (4) consultations a year at any GP, up to the agreed rate for each consultation.
Specialist consultations related to your condition
We pay up to a maximum of 300% of the Discovery Health Rate for any specialist.
Please make sure all claims must have the appropriate ICD-10 codes (diagnostic codes) so Discovery Health can identify them and pay them from the Chronic Illness Benefit.
We will pay claims from your day-to-day benefits if
- the claims are submitted without the relevant ICD-10 codes
- you are not yet registered on the Chronic Illness Benefit for a Prescribed Minimum Benefit condition.
View more information on Prescribed Minimum Benefit treatment guidelines or contact us on 0860 99 88 77.
How we cover medicine for the Additional Disease List conditions on the Executive Plan
You have access to cover for medicine for additional chronic conditions.
These conditions are listed on the Additional Disease List.
There is no medicine list (formulary) for the Additional Disease List conditions. We pay for approved medicines for these conditions up to the monthly Chronic Drug Amount for that medicine category.
The Additional Disease List conditions
- Ankylosing spondylitis
- Behçet’s disease
- Connective tissue disorder (mixed)
- Cystic fibrosis
- Delusional disorder
- Dermatopolymyositis
- Generalised anxiety disorder
- Huntington’s disease
- Major depression
- Motor neurone disease
- Muscular dystrophy and other inherited myopathies
- Myasthenia gravis
- Obsessive compulsive disorder
- Osteoporosis
- Overlap syndrome (mixed connective tissue disease)
- Paget’s disease
- Panic disorder
- Polyarteritis nodosa
- Post-traumatic stress disorder
- Psoriatic arthritis
- Pulmonary interstitial fibrosis
- Sjögren’s syndrome
- Systemic sclerosis
- Wegener’s granulomatosis
Comprehensive Plans
The Chronic Disease List conditions
What they are and how your Health Plan covers these in 2012
The Council for Medical Schemes has determined that all medical schemes must provide a minimum level of cover for a list of chronic conditions, in any setting according to treatment guidelines. These are called the Prescribed Minimum Benefit Chronic Disease List conditions. Medical schemes are obliged to cover the diagnosis, medical management and medicine for these conditions on all plan types.
The Chronic Disease List conditions
- Addison’s disease
- Asthma
- Bipolar mood disorder
- Bronchiectasis
- Cardiac failure
- Cardiomyopathy
- Chronic obstructive pulmonary disease (COPD)
- Chronic renal disease
- Coronary artery disease
- Crohn’s disease
- Diabetes insipidus
- Diabetes mellitus type 1
- Diabetes mellitus type 2
- Dysrhythmias
- Epilepsy
- Glaucoma
- Haemophilia
- HIV and AIDS (To enrol or request information on our HIVCare programme, please call 0860 99 88 77)
- Hyperlipidaemia
- Hypertension
- Hypothyroidism
- Multiple sclerosis (MS)
- Parkinson’s disease
- Rheumatoid arthritis
- Schizophrenia
- Systemic lupus erythematosus (SLE)
- Ulcerative colitis
The conditions below were previously included in the Additional Disease List (ADL) but are now listed separately as they are covered on all plan types.
- Cushing’s disease
- Hypoparathyroidism
- Organ transplantation
- Paraplegia
- Pemphigus
- Peripheral arteriosclerotic disease
- Pituitary disorders
- Quadriplegia
- Stroke
- Thrombocytopaenia purpura
- Valvular heart disease
How we pay medicines for the Chronic Disease List conditions
We cover approved medicine listed on the formulary, for the Chronic Disease List conditions, in full up to the Discovery Health Medication Rate.
We cover medicines not on the formulary, or a combination of formulary and non-formulary medicines that are in the same medicine category, up to a monthly Chronic Drug Amount, which has been allocated for that particular medicine category.
The Chronic Drug Amount is an amount of money that has been allocated for each medicine category per month for a condition. The medicine category is a grouping of medicines with a similar effect for the management of the condition.
The Prescribed Minimum Benefits and the diagnosis and management of your chronic condition
The Chronic Illness Benefit covers limited diagnostic tests and consultations each year for the Chronic Disease List conditions listed in the Prescribed Minimum Benefits.
Tests to diagnose your condition
We pay diagnostic tests like blood tests and x-rays from the Chronic Illness Benefit only if the claim for the diagnosis is dated no earlier than 120 days prior to registration on the Chronic Illness Benefit If we receive claims that are dated earlier than this, we pay the claims from the available money in your day-to-day benefit, if available on your plan type.
We will pay these claims only if we have approved the condition as one of the Chronic Disease List conditions.
We pay blood tests and x-rays listed, up to a maximum of the Discovery Health Rate.
These are pro-rated based on the date of the approval of your chronic condition.
GP consultations related to your condition
We pay consultations related to your condition from the Chronic Illness Benefit:
On this plan
We pay four (4) consultations a year at a GP participating in the Discovery Health GP network. We’ll pay up to a maximum of 80% of the Discovery Health Rate if you do not use a GP in the Discovery Health GP network.
Specialist consultations related to your condition
We pay for a limited number of specialist consultations as listed in the treatment guidelines in full, if you see a specialist who has agreed to charge the Premier Rate. If you see any other specialist we will pay up to 80% of the Discovery Health Rate.
Please make sure all claims must have the appropriate ICD-10 codes (diagnostic codes) so Discovery Health can identify them and pay them from the Chronic Illness Benefit.
We will pay claims from your day-to-day benefits if:
- the claims are submitted without the relevant ICD-10 codes
- you are not yet registered on the Chronic Illness Benefit for a Prescribed Minimum Benefit condition.
View more information on Prescribed Minimum Benefit treatment guidelines or contact us on 0860 99 88 77.
How we cover medicine for the Additional Disease List conditions
You have access to cover for medicine for additional chronic conditions.
These conditions are listed on the Additional Disease List.
There is no medicine list (formulary) for the Additional Disease List conditions. We pay for approved medicines for these conditions up to the monthly Chronic Drug Amount for that medicine category.
The Additional Disease List conditions
- Ankylosing spondylitis
- Behçet’s disease
- Connective tissue disorder (mixed)
- Cystic fibrosis
- Delusional disorder
- Dermatopolymyositis
- Generalised anxiety disorder
- Huntington’s disease
- Major depression
- Motor neurone disease
- Muscular dystrophy and other inherited myopathies
- Myasthenia gravis
- Obsessive compulsive disorder
- Osteoporosis
- Overlap syndrome (mixed connective tissue disease)
- Paget’s disease
- Panic disorder
- Peripheral arteriosclerotic disease
- Polyarteritis nodosa
- Post-traumatic stress disorder
- Psoriatic arthritis
- Pulmonary interstitial fibrosis
- Sjögren’s syndrome
- Systemic sclerosis
- Wegener’s granulomatosis
Priority Plans
The Chronic Disease List conditions
What they are and how your Health Plan covers these in 2012
The Council for Medical Schemes has determined that all medical schemes must provide a minimum level of cover for a list of chronic conditions, in any setting according to treatment guidelines. These are called the Prescribed Minimum Benefit Chronic Disease List conditions. Medical schemes are obliged to cover the diagnosis, medical management and medicine for these conditions on all plan types.
The Chronic Disease List conditions
- Addison’s disease
- Asthma
- Bipolar mood disorder
- Bronchiectasis
- Cardiac failure
- Cardiomyopathy
- Chronic obstructive pulmonary disease (COPD)
- Chronic renal disease
- Coronary artery disease
- Crohn’s disease
- Diabetes insipidus
- Diabetes mellitus type 1
- Diabetes mellitus type 2
- Dysrhythmias
- Epilepsy
- Glaucoma
- Haemophilia
- HIV and AIDS (To enrol or request information on our HIVCare programme, please call 0860 99 88 77)
- Hyperlipidaemia
- Hypertension
- Hypothyroidism
- Multiple sclerosis (MS)
- Parkinson’s disease
- Rheumatoid arthritis
- Schizophrenia
- Systemic lupus erythematosus (SLE)
- Ulcerative colitis
The conditions below were previously included in the Additional Disease List (ADL) but are now listed separately as they are covered on all plan types.
- Cushing’s disease
- Hypoparathyroidism
- Organ transplantation
- Paraplegia
- Pemphigus
- Peripheral arteriosclerotic disease
- Pituitary disorders
- Quadriplegia
- Stroke
- Thrombocytopaenia purpura
- Valvular heart disease
How we pay medicines for the Chronic Disease List conditions
We cover approved medicine listed on the formulary, for the Chronic Disease List conditions, in full up to the Discovery Health Medication Rate.
We cover medicines not on the formulary, or a combination of formulary and non-formulary medicines that are in the same medicine category, up to a monthly Chronic Drug Amount, which has been allocated for that particular medicine category.
The Chronic Drug Amount is an amount of money that has been allocated per medicine category per month for a condition. The medicine category is a grouping of medicines with a similar effect for the management of the condition.
The Prescribed Minimum Benefits and the diagnosis and management of your chronic condition
The Chronic Illness Benefit covers limited diagnostic tests and consultations each year for the Chronic Disease List conditions listed in the Prescribed Minimum Benefits.
Tests to diagnose your condition
We pay diagnostic tests like blood tests and x-rays from the Chronic Illness Benefit only if the claim for the diagnosis is dated no earlier than 120 days prior to registration on the Chronic Illness Benefit. If we receive claims that are dated earlier than this, we pay the claims from the available money in your day-to-day benefit, if available on your plan type.
We will pay these claims only if we have approved the condition as one of the Chronic Disease List conditions.
We pay blood tests and x-rays listed, up to a maximum of the Discovery Health Rate.
These are pro-rated based on the date of the approval of your chronic condition.
GP consultations related to your condition
We pay consultations related to your condition from the Chronic Illness Benefit:
On this plan
We pay four (4) consultations a year at a GP participating in the Discovery Health GP network. We’ll pay up to a maximum of 80% of the Discovery Health Rate if you do not use a GP in the Discovery Health GP network.
Specialist consultations related to your condition
We pay for a limited number of specialist consultations as listed in the treatment guidelines in full, if you see a specialist who has agreed to charge the Premier Rate. If you see any other specialist we will pay up to 80% of the Discovery Health Rate.
Please make sure all claims must have the appropriate ICD-10 codes (diagnostic codes) so Discovery Health can identify them and pay them from the Chronic Illness Benefit.
We will pay claims from your day-to-day benefits if:
- the claims are submitted without the relevant ICD-10 codes
- you are not yet registered on the Chronic Illness Benefit for a Prescribed Minimum Benefit condition.
View more information on Prescribed Minimum Benefit treatment guidelines or contact us on 0860 99 88 77.
Saver Plans
The Chronic Disease List conditions
What they are and how your Health Plan covers these in 2012
The Council for Medical Schemes has determined that all medical schemes must provide a minimum level of cover for a list of chronic conditions, in any setting according to treatment guidelines. These are called the Prescribed Minimum Benefit Chronic Disease List conditions. Medical schemes are obliged to cover the diagnosis, medical management and medicine for these conditions on all plan types.
The Chronic Disease List conditions
- Addison’s disease
- Asthma
- Bipolar mood disorder
- Bronchiectasis
- Cardiac failure
- Cardiomyopathy
- Chronic obstructive pulmonary disease (COPD)
- Chronic renal disease
- Coronary artery disease
- Crohn’s disease
- Diabetes insipidus
- Diabetes mellitus type 1
- Diabetes mellitus type 2
- Dysrhythmias
- Epilepsy
- Glaucoma
- Haemophilia
- HIV and AIDS (To enrol or request information on our HIVCare programme, please call 0860 99 88 77)
- Hyperlipidaemia
- Hypertension
- Hypothyroidism
- Multiple sclerosis (MS)
- Parkinson’s disease
- Rheumatoid arthritis
- Schizophrenia
- Systemic lupus erythematosus (SLE)
- Ulcerative colitis
The conditions below were previously included in the Additional Disease List (ADL) but are now listed separately as they are covered on all plan types.
- Cushing’s disease
- Hypoparathyroidism
- Organ transplantation
- Paraplegia
- Pemphigus
- Peripheral arteriosclerotic disease
- Pituitary disorders
- Quadriplegia
- Stroke
- Thrombocytopaenia purpura
- Valvular heart disease
How we pay medicines for the Chronic Disease List conditions
We cover approved medicine listed on the formulary, for the Chronic Disease List conditions, in full up to the Discovery Health Medication Rate.
We cover medicines not on the formulary, or a combination of formulary and non-formulary medicines that are in the same medicine category, up to a monthly Chronic Drug Amount, which has been allocated for that particular medicine category.
The Chronic Drug Amount is an amount of money that has been allocated per medicine category per month for a condition. The medicine category is a grouping of medicines with a similar effect for the management of the condition.
The Prescribed Minimum Benefits and the diagnosis and management of your chronic condition
The Chronic Illness Benefit covers limited diagnostic tests and consultations each year for the Chronic Disease List conditions listed in the Prescribed Minimum Benefits.
Tests to diagnose your condition
We pay diagnostic tests like blood tests and x-rays from the Chronic Illness Benefit only if the claim for the diagnosis is dated no earlier than 120 days prior to registration on the Chronic Illness Benefit. If we receive claims that are dated earlier than this, we pay the claims from the available money in your day-to-day benefit, if available on your plan type.
We will pay these claims only if we have approved the condition as one of the Chronic Disease List conditions.
We pay blood tests and x-rays listed, up to a maximum of the Discovery Health Rate.
These are pro-rated based on the date of the approval of your chronic condition.
GP consultations related to your condition
We pay consultations related to your condition from the Chronic Illness Benefit:
On this plan
We pay four (4) consultations a year at a GP participating in the Discovery Health GP network. We’ll pay up to a maximum of 80% of the Discovery Health Rate if you do not use a GP in the Discovery Health GP network.
Specialist consultations related to your condition
We pay for a limited number of specialist consultations as listed in the treatment guidelines in full, if you see a specialist who has agreed to charge the Premier Rate. If you see any other specialist we will pay up to 80% of the Discovery Health Rate.
Please make sure all claims must have the appropriate ICD-10 codes (diagnostic codes) so Discovery Health can identify them and pay them from the Chronic Illness Benefit.
We will pay claims from your day-to-day benefits if:
- the claims are submitted without the relevant ICD-10 codes
- you are not yet registered on the Chronic Illness Benefit for a Prescribed Minimum Benefit condition.
View more information on Prescribed Minimum Benefit treatment guidelines or contact us on 0860 99 88 77.
Core Plans
KeyCare Plans
The Chronic Disease List conditions
What they are and how your Health Plan covers these in 2012
The Council for Medical Schemes has determined that all medical schemes must provide a minimum level of cover for a list of chronic conditions, in any setting according to treatment guidelines. These are called the Prescribed Minimum Benefit Chronic Disease List conditions. Medical schemes are obliged to cover the diagnosis, medical management and medicine for these conditions on all plan types.
If you are diagnosed with one or more of the Chronic Disease List conditions, you have cover for chronic diseases according to the Discovery Health KeyCare medicine list. On KeyCare Plus, your chosen GP must prescribe the medicine. On the KeyCare Core Plan, any GP can prescribe the medicine.
The Chronic Disease List conditions
- Addison’s disease
- Asthma
- Bipolar mood disorder
- Bronchiectasis
- Cardiac failure
- Cardiomyopathy
- Chronic obstructive pulmonary disease (COPD)
- Chronic renal disease
- Coronary artery disease
- Crohn’s disease
- Diabetes insipidus
- Diabetes mellitus type 1
- Diabetes mellitus type 2
- Dysrhythmias
- Epilepsy
- Glaucoma
- Haemophilia
- HIV and AIDS (To enrol or request information on our HIVCare programme, please call 0860 99 88 77)
- Hyperlipidaemia
- Hypertension
- Hypothyroidism
- Multiple sclerosis (MS)
- Parkinson’s disease
- Rheumatoid arthritis
- Schizophrenia
- Systemic lupus erythematosus (SLE)
- Ulcerative colitis
The conditions below were previously included in the Additional Disease List (ADL) but are now listed separately as they are covered on all plan types.
- Cushing’s disease
- Hypoparathyroidism
- Organ transplantation
- Paraplegia
- Pemphigus
- Peripheral arteriosclerotic disease
- Pituitary disorders
- Quadriplegia
- Stroke
- Thrombocytopaenia purpura
- Valvular heart disease
How we pay medicines for the Chronic Disease List conditions
We cover approved medicine listed on the formulary, for the Chronic Disease List conditions, in full up to the Discovery Health Medication Rate.
How to apply for the Chronic Illness Benefit
You can only start claiming for chronic medicine once we’ve approved your chronic condition.
To apply for cover:
| Step 1: | Check the chronic conditions list to see if the condition is covered |
| Step 2: | Call us on 0860 99 88 77 to get a Chronic Illness Benefit application form. If you’re on a KeyCare Plus Plan, your chosen GP will have this form. |
| Step 3: | Complete and fax to (011) 539-7000 or post the form to us at: Discovery Health Chronic Illness Benefit Division PO Box 652919 Benmore 2010 |
| Step 4: | Keep a copy of the completed form for your records. |
We’ll review your application and tell you whether we’ve approved it.
What to do if you need a change in medicine
If you need new or additional medicine to treat your chronic conditions, your doctor or pharmacist can call us on 0860 99 88 77 or fax (011) 539-7000.
Remember : KeyCare Core members can visit any doctor. KeyCare Plus members must visit their chosen GP.
You may apply for cover of non-formulary medicine for the Chronic Disease List conditions as an exception
If your doctor can show that you have had an adverse reaction to, or have not responded to medicine on the formulary, we will pay the non-formulary medicine.
We will pay approved medicines up to the maximum of the Discovery Health Medication Rate.
Your doctor will need to complete an appeals form giving us a full medicine history and demonstrable, clinical evidence of the treatment failure or adverse medicine reaction. We may also ask for any relevant supporting documents. You can get an appeals form on www.discovery.co.za or call us on 0860 99 88 77 to send you a form.
Diagnostic tests and consultations for the diagnosis and ongoing management for the Chronic Disease List conditions
The Chronic Illness Benefit covers limited diagnostic tests and consultations for the diagnosis and ongoing management for the Chronic Disease List conditions listed in the Prescribed Minimum Benefits.
These are pro-rated based on the date of the approval of your chronic condition.
How we pay tests done to diagnose your Prescribed Minimum Benefit condition
We pay diagnostic tests listed in the Prescribed Minimum Benefits treatment guidelines.
We pay tests done to diagnose your Prescribed Minimum Benefit condition from the Chronic Illness Benefit only if the claim for the diagnosis is within 120 days of application for chronic medicine cover. If we get claims that are older than 120 days, we will pay the claim from the money available in your day-to-day benefits if available on your chosen plan type.
How we pay consultations and tests for your Prescribed Minimum Benefit condition
This is how we pay consultations listed in the Prescribed Minimum Benefit treatment guidelines:
GP consultations
KeyCare Plus Plan
We pay four (4) consultations a year at your chosen primary or secondary GP in the KeyCare primary care network. If you see any other GP we will pay up to 80% of the Discovery Health Rate
KeyCare Core
We pay four (4) consultations each year at a GP in the KeyCare primary care network. If you choose any other GP we will pay up to 80% of the Discovery Health Rate. Specialist consultations.
We pay specialist consultations in full if you see a specialist who participates in our payment arrangement who has agreed to charge the Discovery Health KeyCare specialist network rate. If you see any other specialist, we will pay up to 80% of the Discovery Health Rate.
Blood tests and x-rays
We pay listed blood tests and x-rays up to the maximum of the Discovery Health Rate.
All claims for tests and consultations must have the appropriate diagnostic ICD-10 code for us to pay these claims. This is in line with legislation.
View more information on Prescribed Minimum Benefit treatment guidelines or contact us on 0860 99 88 77.
