Prescribed Minimum Benefits (PMBs) are guided by a set list of medical conditions that are defined in the Medical Schemes Act of 1998. All medical schemes in South Africa must include the Prescribed Minimum Benefits in the health plans they offer to their members. There are, however, certain requirements that must be met before members can benefit from the Prescribed Minimum Benefits.
The medical condition must be part of the list of defined conditions for Prescribed Minimum Benefits
You may have to send Discovery Health the results of your medical tests and investigations that confirm the diagnosis of your medical condition. This will allow the medical Scheme to identify your condition as one that qualifies for treatment. The treating doctor has to provide the relevant documentation to assist Discovery Health in confirming the diagnosis.
The treatment needed must match the treatments included in the defined benefits.
There are standard treatments, procedures, investigations and consultations for each condition.
You must use the Scheme’s nominated healthcare service provider
You must use a doctor, specialist or other healthcare provider Discovery Health has an agreement with. There are some cases where it is not necessary to meet these requirements, but you will still have cover. An example of this is in a life-threatening emergency.
A Designated Service Provider (DSP) is a hospital or healthcare provider who has an agreement with Discovery Health to provide treatment or services for Prescribed Minimum Benefits at a contracted rate.
- Download the summary of how we cover the Prescribed Minimum Benefits.
- For all Prescribed Minimum Benefit conditions, members must use our Designated Service Provider hospital or healthcare provider to get full cover.
Finding a designated service provider is easy
- To find a designated service provider as a KeyCare member, download a summary of the KeyCare Hospital Network
- To find a designated service provider on the Delta network option plans, download a list of Delta Hospitals Network
- For all other plans, to find a hospital, doctor or a pharmacy in our network use our online MaPS Advisor . The tool shows which of our healthcare professionals we have an agreement with.
Chronic Illness Benefit
All our plans provide comprehensive cover for a list of chronic conditions. For us to cover your medicine from the Chronic Illness Benefit, we need to approve your application.
To apply, complete the Chronic Illness Benefit application form.
Our chronic disease management programmes offer you:
- Access to information on your condition, as well as support and guidance.
- Consultations and diagnostic tests and medicine related to your condition as a Prescribed Minimum Benefit.
- Approved chronic medicine according to the Chronic Illness Benefit formulary, from pharmacies we have an agreement with.
- Access to other healthcare professionals we have an agreement with.
- Additional cover on some health plans.
- Members can appeal for extra cover for an approved chronic condition, provided the member completes a Chronic medicine appeal form together with his or her doctor, and the appeal is approved.