Chronic Illness Benefit

The Chronic Illness Benefit

This is available on all health plans (Executive, Comprehensive, Priority, Saver, Smart, Core, KeyCare plans)

Medicine cover for Chronic Disease List conditions

The Chronic Illness Benefit covers approved medicine for the 26 Prescribed Minimum Benefit (PMB) Chronic Disease List (CDL) conditions on all plans. Approved medicine on the Chronic Illness Benefit medicine list (formulary) will be funded in full up to the Scheme Rate. Medicines not on the medicine list will be funded up to the Chronic Drug Amount (CDA). The CDA does not apply to the Smart and Keycare plans. On these plans we pay up to the Generic Reference Price (GRP), which is up to the least expensive medicine of the same kind on our medicine list for the condition.

Please refer to page 4 of the Cover for medicine and treatment of chronic conditions, document for the list of PMB CDL conditions.

Medicine cover for Additional Disease List (ADL) conditions

Members on the Executive and Comprehensive Plans (except the Classic Smart Comprehensive plan) have further cover for Additional Disease List (ADL) conditions. There is no medicine list (formulary) for the ADL conditions. Approved medicine for these conditions will be funded up to the Chronic Drug Amount (CDA). Please refer to page 5 of the Cover for medicine and treatment of chronic conditions, document for the list of ADL conditions.

Learn more about the Chronic Illness Benefit

Watch this video for an overview of how to make the most of your health plan when you are diagnosed with a chronic illness.

How to access the Chronic Illness Benefit

If you want to access cover from the Chronic Illness Benefit, you must apply for it. You must complete a Chronic Illness Benefit application form with your doctor and submit it for review. If your doctor uses HealthID, your doctor can apply for cover online, provided you have given your consent.

You need to meet the benefit entry criteria for your condition(s) to be registered on the Chronic Illness Benefit. You or your doctor may need to provide certain test results or extra information as indicated on the CIB application form for the condition(s) you are applying for. Please ensure that these documents are submitted with your application to avoid any delays in the process.

We will send you an email to tell you what we have decided. We will send it within five working days of receipt of your application, to the email address you gave us on the application form. Please wait for the authorisation before you claim your medicine to make sure we pay your approved medicine from the correct benefit.

Where to obtain your chronic medicine

You can obtain your chronic medicine from any pharmacy or from your dispensing doctor. On certain plans to avoid a 20% co-payment members must obtain their chronic medicine from a designated service provider (DSP):

Members on the Priority, Saver, Smart, Core and Delta plans can use MedXpress Network Pharmacies
Members on the KeyCare Plus and KeyCare Core plans can use KeyCare Network Pharmacies
Members on the KeyCare Start plan can use a State facility
Members on the Keycare Start Regional Plan can use their Regional network pharmacy

Order your medicine seamlessly

Discovery MedXpress is a convenient medicine ordering service for prescribed medicines via SMS, the Discovery website and the mobile app. Get your monthly chronic medicine delivered to your door or collect your medicine in-store at a participating pharmacy at no extra cost to you.

LEARN MORE

All our plans offer benefits that are far richer than the Prescribed Minimum Benefits.

To access Prescribed Minimum Benefits, certain rules apply.

Treatment baskets for your approved CDL conditions

The Chronic Illness Benefit will also cover a limited number of selected tests, procedures and specialist consultations each year for the ongoing management of your condition(s).

You also have cover for four (4) GP consultations related to your approved PMB CDL condition(s) per year.

Nominate a primary care doctor

If you are approved for a Prescribed Minimum Benefit (PMB) Chronic Disease List (CDL) condition, you must nominate a general practitioner (GP) in the Discovery Health GP network for your plan to be your primary care doctor for the management of your chronic conditions.

You can nominate your primary care doctor in three simple steps:

Log in to our Discovery app or click here
Navigate to nominate a primary care provider
Follow the prompts in the Care Portal and select a primary care doctor and their associated practice.

You can access your Care portal on the Discovery app or click here to update your nominated GP should you need to do so.

Please refer to the Treatment baskets for the Prescribed Minimum Benefit Chronic Disease List conditions document to view what is covered for your approved PMB CDL condition(s) and how we fund for these.

To make sure that we pay your claims from the correct benefit, we need the claims from your healthcare providers to be submitted with the relevant ICD-10 diagnosis codes. Please ask your doctor to include your ICD-10 diagnosis codes on the claims they submit and on the forms that they complete when they refer you to pathologists and radiologists for tests. This will enable pathologists and radiologists to include the relevant ICD-10 diagnosis codes on the claims they submit ensuring that we pay your claims from the correct benefit.

Please refer to the Cover for medicine and treatment of chronic conditions document for more information on cover from the Chronic Illness Benefit.

Access important documents for your CIB journey

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