1. Not all chronic diseases are PMBs – Only diseases on the Chronic Disease List (CDL) as prescribed by the Council for Medical Schemes are PMBs (click here for the list)
  2. You cannot necessarily use any medication you want for a PMB chronic condition - A scheme may draw up what is known as a formulary – a list of safe and effective medicines that can be prescribed to treat certain conditions. The scheme may state in its rules that it will only cover medication in full if the doctor prescribes a drug on that formulary. 
  3. PMBs are life-threatening events and conditions - in some cases specific medical conditions must exist to make a condition a PMB.
  4. A scheme can insist the member make use of a Designated Service Provider (DSP) – if a scheme appoints a DSP and a member voluntarily uses a different provider, the scheme may charge the member the difference between the actual cost and what it would have paid if a DSP was used.
  5. A scheme may request proof of a PMB – this may include test results, x-rays etc, before they will cover the condition as a PMB.