A prescribed minimum benefit is a list of conditions (271 Diagnostic Treatment pairs) and 27 Chronic diseases that appear on the Chronic Disease List. The medical scheme must fund the medical care, treatment, and diagnosis in full. There may be no co-payment, deductible, medical scheme rates applied. Funding may also not come from your personal medical savings account (MSA).

There is only one exception and that is if the medical scheme makes use of a network or designated service provider (DSP) and you voluntary do not make use of the DSP then a co-payment may be levied. However, regulation 8(3) define what is involuntary use of a DSP and then no co-payment may be applied.  These are:

• The services are not available from the DSP or there will be an unreasonable delay
• Immediate medical or surgical treatment was required under circumstances or locations which reasonably precluded the beneficiary from obtaining the services from a DSP
• There is no DSP in reasonable proximity of the beneficiary’s residence or work.

A diagnosis and treatment pair links a specific diagnosis to a treatment based on best practice healthcare and affordability of the treatment and broadly indicates how each of the 270 Prescribed Minimum Benefit (PMB) conditions should be treated at no cost to the beneficiary. The DTPs can be found in annexure A of the Regulations promulgated in terms of the Medical Schemes Act.

A chronic disease list usually refers to a list of conditions that last for or where medication is required for a prolonged period which is usually 1 year or longer. However, in our medical scheme environment it refers to the list of chronic conditions that can also be found in annexure A of the Regulations promulgated in terms of the Medical Schemes Act.

A protocol, also called a medical guideline, is a set of instructions which describe a process to be followed to investigate a particular set of findings in a patient, or the method which should be followed to control, diagnose, or manage a specific disease.

Any person (Provider, broker, beneficiary, member of a medical scheme, provider, or member of the public) must have free access to a protocol at any time. See regulation 15 D (e), and 15 H (b) of the Regulations promulgated in terms of the Medical Schemes Act.

Protocols must be based on evidence-based medicine.

If the protocol is ineffective or cause or would cause harm to a beneficiary appropriate substitution must be made without penalty to that beneficiary.

A formulary is a list of prescription drugs covered by a medical scheme.

Any person (Provider, broker, beneficiary, member of a medical scheme, provider, or member of the public) must have free access to a formulary at any time. See regulation 15 D (e), and 15 H (b) of the Regulations promulgated in terms of the Medical Schemes Act.

Formularies must be based on evidence-based medicine.

If the formulary is ineffective or cause or would cause harm to a beneficiary appropriate substitution must be made without penalty to that beneficiary.