Prescribed Minimum Benefits

According to the Medical Schemes Act, all medical schemes have to pay for a specific minimum level of care for a list of medical conditions. These are called Prescribed Minimum Benefits.

You have cover for Prescribed Minimum Benefit conditions, no matter which Plan you choose. However, there are conditions and limits to this cover

Medical schemes have to pay the costs related to the diagnosis, treatment and care of:

You must meet three requirements to have your treatment paid in full:

Your condition must be on the Prescribed Minimum Benefit lists

You must use medication from our medicine list (formulary), or you may have to pay part of the cost yourself.

You must use the recommended treatment and medication for your condition
You must use our Designated Service Providers

A Designated Service Provider is the same as a network Healthcare Professional. In other words, they are a Healthcare Professional we have an agreement with. You are allowed to use a non-Designated Service Provider, but this may mean you have to pay part of the claim yourself.

If you need to go to the hospital and it is not a medical emergency, we only cover claims if you contacted us and got pre-authorisation before you were hospitalised.

We pay for the cost of the diagnosis, treatment and care of Prescribed Minimum Benefits in South Africa, in full as an Insured Benefit if you meet the three requirements (Conditions for cover) for full coverage. We always pay for emergency medical treatment, even if you use a non-network Healthcare Professional.

If it is not a medical emergency, a network Healthcare Professional is available, and you use a non-network Healthcare Professional, we cover the diagnosis, treatment and care of Prescribed Minimum Benefits at the Scheme Rate.

You have to get pre-authorisation, your treatment has to follow the clinical protocols, and you have to register on our Managed Care Programmes for Prescribed Minimum Benefit cover. This means you must apply for these benefits or we pay for treatment from your day-to-day benefits. After you reach the rand limit for chronic medication, we only provide funding for medication as a Prescribed Minimum Benefit.

Prescribed Minimum Benefits only apply to claims in South Africa. If you claim for a healthcare service that is a Prescribed Minimum Benefit in South Africa, but you received the care or treatment outside the borders of South Africa, we treat them as ordinary claims and pay them according to your Plan’s benefits.

You have to get preauthorisation, use medication on our medicine list (formulary) and get the recommended treatment for the claim to qualify for Prescribed Minimum Benefit cover.

We only pay for the cost of diagnosis as a Prescribed Minimum Benefit if the test confirms that the medical condition is a Prescribed Minimum Benefit condition.

When this schedule sets out insured limits, we pay claims (including Prescribed Minimum Benefits) up to the limit. When you reach the limit, we only pay for treatment as a Prescribed Minimum Benefit if you meet the conditions.

What if I cannot use a network Healthcare Professional?

In a medical emergency, go straight to the nearest hospital. If it is not an emergency, you should use a Healthcare Professional, pharmacy or hospital in our network for Prescribed Minimum Benefit care to make sure we pay for the cost of care in full.

There are other situations in which we pay for Prescribed Minimum Benefits in full even if you do not use a Healthcare Professional in our network, as long as you contact us for permission (pre-authorisation) beforehand. Examples of these situations are:

The healthcare service is not available from someone in the Bankmed Network, or you would have to wait for an unreasonably longtime to receive the treatment or service

You need immediate medical or surgical treatment for a Prescribed Minimum Benefit condition, and the circumstances or location mean you cannot reasonably use a network provider

No network provider is within a reasonable proximity to your home or work address