Chronic Medicine Cover & Benefits (South Africa)

Ever tried picking a medical cover while managing diabetes, asthma, or hypertension? It’s a bit like trying to order lunch with no menu — you know what you need, but not every option has it. Chronic medicine cover isn’t just a bonus; it’s the difference between peace of mind and monthly surprises at the chemist counter.

South African medical schemes must cover Prescribed Minimum Benefits (PMBs)</strong), which include 26 chronic conditions (the PMB Chronic Disease List, or CDL). Beyond the PMBs, many schemes also cover additional chronic conditions and medicines via a formulary and rules such as designated pharmacy networks (DSPs), reference pricing, or co-payments.

PMB Chronic Disease List (CDL)

These conditions are covered as part of the PMBs when clinical entry criteria are met and you follow the scheme’s rules (e.g., DSP/network, formulary alternatives):

  • Addison’s disease
  • Asthma
  • Bipolar mood disorder
  • Bronchiectasis
  • Cardiac failure
  • Cardiomyopathy
  • Chronic obstructive pulmonary disease (COPD)
  • Chronic renal disease
  • Coronary artery disease (e.g., angina / ischaemic heart disease)
  • Crohn’s disease
  • Diabetes insipidus
  • Diabetes mellitus type 1
  • Diabetes mellitus type 2
  • Epilepsy
  • Glaucoma
  • Haemophilia
  • Hyperlipidaemia
  • Hypertension
  • Hypothyroidism
  • Multiple sclerosis
  • Parkinson’s disease
  • Rheumatoid arthritis
  • Schizophrenia
  • Systemic lupus erythematosus (SLE)
  • Ulcerative colitis

Medicine funding follows each scheme’s PMB/CDL formulary and rules. If your prescribed item is non-formulary, you may need to switch to a formulary alternative or pay a co-payment up to a reference price/Chronic Drug Amount.

A–Z of Common Chronic Conditions (Beyond PMBs)

Many schemes also fund additional chronic conditions (outside the CDL) – often within day-to-day/chronic limits or plan-tier benefits. Coverage varies by scheme and plan. Use the expandable lists below to browse common conditions frequently treated as chronic in SA benefit guides.

A–C (Acne, ADHD/ADD, Allergic Rhinitis, Alzheimer’s – early onset, Ankylosing Spondylitis, Anxiety Disorders, Arrhythmias/Atrial Fibrillation, Barrett’s Oesophagus, Benign Prostatic Hyperplasia, Chronic Anaemia, Chronic Migraine, Chronic Pain Syndromes, Chronic Sinusitis, Cystic Fibrosis)
  • Acne – topical retinoids, benzoyl peroxide; oral doxycycline/minocycline; hormonal therapy (females) where indicated; isotretinoin (special rules).
  • ADHD/ADD – methylphenidate, atomoxetine (scheme rules often apply).
  • Allergic Rhinitis – intranasal steroids (fluticasone, budesonide), antihistamines (cetirizine, loratadine), montelukast in select cases.
  • Alzheimer’s (early onset) – donepezil, rivastigmine, memantine (plan-dependent).
  • Ankylosing Spondylitis – NSAIDs, sulfasalazine; biologics in specialist care (strict criteria; pre-auth).
  • Anxiety / Generalised Anxiety Disorder – SSRIs/SNRIs; psychotherapy benefits may apply via allied cover.
  • Arrhythmias / Atrial Fibrillation – beta-blockers, amiodarone, anticoagulants (warfarin/DOACs per rules), rate/rhythm control agents.
  • Barrett’s Oesophagus / GORD – PPIs (omeprazole/esomeprazole), H2 alternatives where appropriate.
  • Benign Prostatic Hyperplasia (BPH) – tamsulosin/alfuzosin, 5-alpha-reductase inhibitors (finasteride/dutasteride).
  • Chronic Anaemia (non-acute) – iron, B12/folate where indicated; ESAs in renal disease (strict criteria).
  • Chronic Migraine – preventives (topiramate, propranolol, amitriptyline), CGRP-targeted agents (plan-dependent).
  • Chronic Pain Syndromes – multimodal therapy; neuropathic agents (gabapentin/pregabalin, duloxetine), TCAs; opioid stewardship rules.
  • Chronic Sinusitis – intranasal corticosteroids, saline irrigation; macrolides in selected chronic cases.
  • Cystic Fibrosis – pancreatic enzymes, inhaled therapies; CFTR modulators (highly specialised; scheme criteria).

Note: Asthma, COPD, Crohn’s and other CDL items are covered under PMB/CDL when criteria are met.

D–H (Depression, Dermatitis/Eczema, Diabetes (T1/T2)*, Diabetes Insipidus*, Dyslipidaemia*/Hyperlipidaemia*, Epilepsy*, Gout, HIV (PMB), Hypertension*, Hypothyroidism*)
  • Depression – SSRIs/SNRIs, bupropion, mirtazapine, TCAs (with monitoring); psychotherapy benefits where available.
  • Eczema / Atopic Dermatitis – emollients, topical steroids/calcineurin inhibitors; systemic agents/biologics for severe disease (criteria).
  • Diabetes mellitus (T1/T2)* – insulin (various), metformin, DPP-4i, SGLT2i, GLP-1 RA per protocol; strips/needles per plan.
  • Dyslipidaemia*/Hyperlipidaemia* – statins (simvastatin/atorvastatin/rosuvastatin), ezetimibe; PCSK9i (specialist criteria).
  • Epilepsy* – lamotrigine, valproate, levetiracetam, carbamazepine, oxcarbazepine, topiramate (per formulary).
  • Gout – allopurinol/febuxostat (urate-lowering), colchicine; NSAIDs for flares (limits apply).
  • HIV – antiretroviral therapy (PMB programme rules; separate from CDL but PMB-funded).
  • Hypertension* – ACEi (enalapril), ARB (losartan/telmisartan), diuretics (HCTZ), CCB (amlodipine), beta-blockers.
  • Hypothyroidism* – levothyroxine.
I–N (IBD – Crohn’s*/Ulcerative Colitis*, IBS, Lupus*/SLE, Migraine – chronic, Multiple Sclerosis*, Myasthenia Gravis, Narcolepsy, Neuropathic Pain, Osteoarthritis, Osteoporosis, Parkinson’s*, PCOS, Psoriasis / Psoriatic Arthritis)
  • IBD – Crohn’s*/Ulcerative Colitis* – mesalazine, azathioprine, methotrexate; biologics in refractory disease (criteria).
  • IBS – antispasmodics, low-dose TCAs/SSRIs (select cases), gut-acting agents; dietetic care via allied benefits.
  • Lupus*/SLE* – hydroxychloroquine, azathioprine, mycophenolate; biologics under strict rules.
  • Multiple Sclerosis* – interferons, glatiramer, newer DMTs per plan (strict pre-auth).
  • Myasthenia Gravis – pyridostigmine, steroids; immunosuppressants (azathioprine, MMF) as indicated.
  • Narcolepsy – modafinil, sodium oxybate (plan-dependent, specialist rules).
  • Neuropathic Pain – gabapentin/pregabalin, duloxetine, TCAs; adjuncts.
  • Osteoarthritis – chronic NSAID stewardship, duloxetine; intra-articular options (procedural benefits).
  • Osteoporosis – alendronate/risedronate, denosumab, teriparatide (criteria).
  • Parkinson’s disease* – levodopa/carbidopa, dopamine agonists, MAO-B inhibitors.
  • PCOS – metformin (insulin resistance), hormonal therapy; infertility management (plan rules).
  • Psoriasis / Psoriatic Arthritis – topical agents, methotrexate, biologics (criteria).
O–Z (Obstructive Sleep Apnoea, Pernicious Anaemia, Rheumatoid Arthritis*, Schizophrenia*, Systemic Sclerosis, Thyroid Disorders*, Tourette’s, Vasculitis)
  • Obstructive Sleep Apnoea (OSA) – CPAP devices (DME rules), weight-loss and ENT pathways where indicated.
  • Pernicious Anaemia – B12 replacement.
  • Rheumatoid Arthritis* – methotrexate, leflunomide; biologics (criteria, monitoring).
  • Schizophrenia* – antipsychotics (oral/LAI) per formulary; psychosocial support benefits.
  • Thyroid Disorders* – hypo (levothyroxine), hyper (carbimazole/propylthiouracil) per protocol.
  • Vasculitis (selected) – steroids, immunosuppressants; biologics in specialist care.

Tip: If a prescribed medicine isn’t on your plan’s formulary, ask your doctor or pharmacist about a therapeutically equivalent formulary alternative to avoid co-payments.

Expanded Examples — Medicines by Condition

Below are example medicines (generic names) frequently listed on SA chronic formularies. Exact brands/strengths differ per scheme and year.

Condition Common Chronic Medicines (generic) Notes
Asthma / COPD* salbutamol; budesonide; beclomethasone; fluticasone; formoterol; salmeterol; budesonide+formoterol; fluticasone+salmeterol; tiotropium; ipratropium Inhalers often covered in full if on formulary and via network pharmacy.
Hypertension* enalapril; lisinopril; perindopril; losartan; valsartan; telmisartan; amlodipine; hydrochlorothiazide; indapamide; combination ACE/ARB+diuretic First-line agents usually fully funded on formulary.
Hyperlipidaemia* simvastatin; atorvastatin; rosuvastatin; ezetimibe PCSK9 inhibitors in high-risk patients per criteria.
Diabetes (T1/T2)* insulin human/analogue (basal/bolus/mix); metformin; gliclazide; DPP-4i; SGLT2i; GLP-1 RA (plan rules) Devices/strips funded per plan tier and rules.
Epilepsy* lamotrigine; valproate; levetiracetam; carbamazepine; topiramate; oxcarbazepine Choice depends on seizure type and formulary.
Rheumatoid / Psoriatic Arthritis* methotrexate; sulfasalazine; leflunomide; hydroxychloroquine; biologics (criteria) Specialist management; strict pre-authorisation.
IBD – Crohn’s*/UC* mesalazine; azathioprine; methotrexate; steroids; biologics (criteria) Hospital vs. chronic benefit depends on plan and route.
Glaucoma* latanoprost; timolol; dorzolamide; brimonidine; combinations Regular ophthalmology follow-up required.
Hypothyroidism* levothyroxine TSH monitoring as per protocol.
Depression / Anxiety (chronic) SSRIs (sertraline/escitalopram); SNRIs (venlafaxine/duloxetine); bupropion; mirtazapine; TCAs (low-dose) Psych benefits and script limits vary by plan.
Gout (chronic) allopurinol; febuxostat; colchicine Serum urate targets under long-term control.
Parkinson’s* levodopa/carbidopa; pramipexole/ropinirole; selegiline/rasagiline Titration and specialist oversight common.
Osteoporosis alendronate; risedronate; denosumab; teriparatide Criteria (T-scores/fracture risk) usually apply.
Myasthenia Gravis pyridostigmine; steroids; azathioprine; mycophenolate Specialist protocols and authorisations apply.

Legend: “*” also on PMB/CDL list. Always check your plan’s latest formulary and designated pharmacy network to avoid co-payments.

Quick Checks Before You Choose a Plan

  • Does the plan cover non-CDL chronic conditions you need (e.g., gout, psoriasis, osteoporosis)?
  • Which network/DSP pharmacies must you use for full cover?
  • What are the reference prices/Chronic Drug Amounts for your scripts?
  • Are there plan tier limits for chronic/day-to-day benefits that affect your medicines?
  • Can your doctor/pharmacist substitute a formulary alternative to remove co-pays?

FAQs

How do PMB/CDL benefits work for chronic medicines?

Your scheme funds medicines on its PMB/CDL formulary when you meet clinical entry rules and use the designated pharmacy network. Non-formulary items may attract co-payments.

Are insulin and diabetic treatments fully covered?

For registered PMB diabetes, insulin and essential agents are typically funded via the chronic/DSP process. Devices/consumables are plan-dependent.

Can I use my Medical Savings for chronic meds?

Yes, for non-PMB or non-formulary items — but that reduces day-to-day benefits.