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 approved medicine that is not on the formulary will be funded up to the Reference Price for the medicines specific medicine category.

Medicine cover for Additional Disease List conditions

Members on the Executive and Comprehensive Plans (except the Classic Comprehensive Smart 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 CDA.

Full cover for medicine on the Executive plan

For members on the Executive plan, we pay the full cost of the medicine on the exclusive list of medicine. You can find the list of exclusive medicine in Cover for medicine and treatment of chronic conditions document.

Specialised Medicine and Technology benefit

The Specialised Medicine and Technology benefit gives members on the Executive and Comprehensive plans access to specific high cost medicines and new technologies. This benefit is not available on the Classic Smart Comprehensive plan. Read more on this benefit in the Specialised Medicine and Technology document.

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 these DSP's:

• 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

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.

Changes to your approved treatment plan

If you are already approved on the benefit, you do not need to complete a new CIB application form when your treating doctor makes changes to your treatment plan. However, you do need to let us know when your doctor makes these changes so that we can update your authorisation(s). You can do this by emailing a copy of the prescription to us or asking your doctor or pharmacist to do this for you. If your doctor uses HealthID, your doctor can make the treatment plan changes online, provided you have given your consent. If you do not let us know about changes to your treatment plan, we may not pay your claims from the correct benefit.

You need to complete a new CIB application form should you be diagnosed with a new chronic condition.

Treatment baskets for your approved CDL conditions

If you have recently been diagnosed with and approved for cover for a PMB CDL condition, we will pay for the diagnostic tests and procedures from the diagnostic treatment basket in full. Please ask your doctor to provide the date of diagnosis of your condition(s) on the Chronic Illness Benefit application form to assist us to pay your claims from the correct benefit. We will also pay in full for the consultation with the doctor who made the diagnosis. We will only pay for the tests, procedures and consultation provided that you were an active and valid member of the Scheme at the time of the diagnosis and the relevant ICD-10 diagnosis codes are on the claim.

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.

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 benefit guide for more information on cover from the Chronic Illness Benefit.

Request for additional funding for CDL conditions

Your doctor may follow an appeals process to request for additional funding for medicine, tests, procedures and consultations for your approved PMB CDL condition(s). Your doctor needs to complete a Request for additional cover for approved Chronic Disease List conditions form and submit it for review. It is important to note that an appeals process does not guarantee an automatic approval for the additional cover.

Access important documents for your CIB journey

• Chronic Illness Benefit application form (PDF)
• Cover for medicine and treatment of chronic conditions (PDF)
• Chronic Illness Benefit medicine list (formulary) (PDF) (PDF)
• Chronic Illness Benefit medicine (formulary) provisional for 2024 (PDF)
• Request for additional cover for approved Chronic Disease List conditions registered on the Chronic Illness Benefit (CIB) form  (PDF)
• Specialised Medicine and Technology Benefit (PDF)
• Treatment baskets for the Prescribed minimum Benefit Chronic Disease List conditions (PDF)

If your condition is not covered from the Chronic Illness Benefit (CIB), it may be covered from other benefits

• To enroll on the HIV Care Programme download the HIV application form, and ask your nominated GP to help you complete it.
• Click here to find information on the Oncology Programme.
• Download the application for out-of-hospital management for Prescribed Minimum Benefits condition to apply for cover if your condition is a Prescribed Minimum Benefit (PMB).