Chronic Illness Benefit
Chronic medication is life sustaining, prescribed medication (for example medicine without which a person’s life would be endangered) that has to be taken on an ongoing basis for a life threatening medical condition. Although your doctor may define a condition as chronic, it may not meet the rules for cover from this benefit. In that case it will be paid from your acute medicine benefit.
All chronic medicine must meet the following conditions:
- The medicine must qualify for benefits in terms of the registered rules of Remedi. (It would therefore, for example, exclude medicine for cosmetic conditions).
- The medicine must not be addictive or medically unsafe if used for an extended period of time.
- The use of the medicine on a regular basis (usually daily) must be essential for the normal functioning of the body’s physiological processes.
Chronic Disease List
The Chronic Illness Benefit (CIB) covers medicine for a specified list of chronic conditions, including HIV or AIDS, according to the Prescribed Minimum Benefits (PMB) Chronic Disease List (CDL) on all Remedi Options.
Comprehensive and Classic Options
Provided members use medicine that is on Remedi’s defined PMB formulary or medicine list, the PMB CDL benefit is unlimited and pays at 100% of the Remedi Medicine Rate.
Remedi also provides cover for approved medicine that is not on the medicine list – or a combination of medicine on and off the medicine list that is in the same medicine category – up to the monthly Chronic Drug Amount allocated for that particular medicine category.
The Chronic Drug Amount is an amount of money that has been allocated for each medicine category each month for a condition. If the medicine costs are more than the CDA you will have a co-payment.
Approved medicine for certain additional (non-PMB) conditions is funded up to the monthly limit applicable for your Option. There is no formulary or medicine list for these conditions.
As long as you use medicine on the PMB formulary or medicine list and you get your medication from a DSP-contracted network provider, the PMB CDL benefit is unlimited and pays at 100% of the Remedi Medicine Rate.
The following PMB CDL conditions are covered by Remedi on all three options:
- Addison’s Disease
- Bipolar Mood Disorder
- Cardiac Failure
- Chronic Obstructive Pulmonary Disease
- Chronic Renal Disease
- Coronary Artery Disease
- Crohn’s Disease
- Diabetes Insipidus
- Diabetes Mellitus types 1 and 2
- HIV infection or AIDS
- Multiple Sclerosis
- Parkinson’s Disease
- Rheumatoid Arthritis
- Systemic Lupus Erythematosus
- Ulcerative Colitis
Chronic Medicine for non-PMB’s
You also have cover for certain non-PMB chronic conditions, as defined by Remedi, subject to specific monthly limits below. If you are on the Comprehensive Option, claims may be funded from your available Personal Medical Savings Account once the monthly limit has been exhausted.
|Chronic Medicine for non-PMB conditions||Remedi Comprehensive||Remedi Classic|
Subject to clinical protocols and an exclusionary list of conditions
|Limited to R1 295 per beneficiary per month||Limited to R1 075 per beneficiary per month|
Applying for cover on the Comprehensive and Classic Options
If you and/or your dependant(s) require medicine for a chronic condition, or you need to change your medicine that was already approved, your doctor must complete a Chronic Illness application form that can be obtained by phoning the call centre on 0860 116 116. You can also find the Chronic Illness application form on this website under the forms section.
We will confirm whether your application was successful and tell you more about your condition and further benefits that may be available to help manage this condition.
How to get an extended supply of your chronic medicine
Once your chronic condition is registered, your doctor will have to issue a new prescription every six months, as required by law, to allow the pharmacist to dispense your medicine. The pharmacist will process the transaction according to your registered chronic condition and the prescribed medicine.
You can get only one month’s supply of medicine at a time. If you travel outside South Africa and you need an extended supply of medicine (up to three months), you will need to complete an Extended Supply of Medication form for approval. You can find the Extended Supply of Medication form under the forms section or by phoning 0860 116 116.
Applying for cover on the Standard option
You will need to apply to Remedi Medical Scheme for approval through your nominated doctor, who will then complete a form and send it to Remedi Medical Scheme. If approved, you can obtain the medication from Remedi Standard Option’s network pharmacies.
When will your chronic illness cover start?
When doctor completed the form
Less than 3 months ago
Date Dr completed the form
A month or more before the joining date
On the joining date
In the joining month
Date the Dr completed the form
3 months or more since form was filled in
Date on which we got the form
Any requests for extended supply of medication if travelling outside of the borders of South Africa need to be directed to Remedi Medical Scheme at www.yourremedi.co.za or you can phone 0860 116 11.