Medical Aid Chronic Condition Cover

For anyone living with ongoing medical conditions, chronic condition cover is a critical aspect of South African medical schemes. Chronic coverage ensures your condition, treatments, and prescribed medications are funded, reducing financial stress while maintaining health.

What Is Chronic Condition Cover?

Chronic condition cover provides benefits for long-term illnesses that require regular monitoring, treatment, or medication. Common conditions include:

• Diabetes
• Asthma
• Hypertension
• Cardiovascular diseases
• Epilepsy
• Chronic kidney disease

Medical schemes in South Africa manage chronic benefits based on the Chronic Disease List (CDL), which lists conditions that must be funded under all registered medical schemes.

How Chronic Medication Is Covered

Most schemes provide coverage for medication required to manage chronic illnesses. However, you should check:

• Whether your prescribed medicine is on the scheme’s formulary
• Annual limits or sub-limits for chronic medication
• Whether pre-authorisation is required for long-term prescriptions
• Co-payments for medications not fully covered

Some plans also offer digital tools and apps to track chronic medication claims, ensuring you never run out of essential medicine.

Choosing the Right Chronic Condition Plan

When comparing plans for chronic conditions, consider:

• Which conditions are included on the Chronic Disease List (CDL)
• Limits on chronic medication and treatment visits
• Network restrictions for pharmacies or specialists
• Ease of claim submission and management
• Integration with wellness programs for ongoing health support

Higher-tier plans may cover additional chronic illnesses not on the CDL and provide larger day-to-day benefit allocations for specialist consultations or allied health services.

Tips to Maximise Chronic Condition Cover

• Confirm your diagnosis is on the CDL and that your scheme will fund all prescribed treatments.
• Use in-network pharmacies and specialists where applicable.
• Keep track of medication refills and authorisations to avoid interruptions.
• Review plan options annually to ensure coverage matches your evolving health needs.

Frequently Asked Questions

What is the Chronic Disease List (CDL)?

The CDL is a government-mandated list of chronic conditions that all South African medical schemes must provide treatment and medication for.

Does chronic cover include medication?

Yes. Most plans cover the cost of prescribed chronic medications, subject to formulary lists and annual limits.

Are all chronic conditions automatically covered?

No. Only conditions on the CDL are guaranteed. Some schemes offer extended cover for additional chronic illnesses depending on the plan.

Do I need pre-authorisation for chronic treatment?

Many schemes require pre-authorisation for long-term prescriptions or specialist visits to manage costs and ensure treatment compliance.

Can I switch plans if my chronic condition needs change?

Yes. You can usually change options during open enrollment or at renewal to ensure your plan meets your healthcare needs.