The short version
- PMBs apply to every registered option, including hospital plans and entry-level network options.
- They cover any medical emergency, about 270 listed conditions and the 27 conditions on the Chronic Disease List.
- The scheme must pay PMBs from its risk benefit, not your medical savings account.
- Your scheme can require you to use its designated service providers (DSPs) and its medicine formulary.
- If you couldn't use a DSP, for example in an emergency, the scheme must still pay in full.
- Medical insurance and hospital cash plans aren't medical schemes, so they don't have to cover PMBs.
Chronic cover in our 2026 data
- 27 Chronic Disease List conditions every registered option must cover
- Options in our 2026 data cover between 26 and 75 chronic conditions in total
- Widest list: CompCare SuperCare — Covers 75 chronic conditions (27 PMB plus 48 additional).
PMB cover in 2026, from our data
Every option below covers the PMBs. These are the extremes of the range.
Widest chronic condition list
CompCare SuperCareCovers 75 chronic conditions (27 PMB plus 48 additional).
Computed from published 2026 contributions and brochure figures. Not financial advice.
What counts as an emergency
The sudden and, at the time, unexpected start of a condition that needs immediate treatment, where not treating it would put your life at serious risk or cause serious harm to your body. You don't need pre-authorisation to be treated, but tell the scheme as soon as you can.
Designated service providers and formularies
Schemes can name DSPs — specific hospitals, doctors or pharmacies — for PMB treatment. Use them and the PMB is paid in full. If you choose not to, the scheme can charge a co-payment. If you couldn't use them, because it was an emergency or no DSP was available within a reasonable time or distance, the scheme must pay in full.
For chronic medicine, schemes use a formulary. If your doctor prescribes a medicine outside it without a clinical reason, you may pay a co-payment.
How to make sure a PMB claim is paid
- Ask your doctor whether your diagnosis is a PMB, and to use the correct ICD-10 code on every claim.
- Register chronic conditions with the scheme's chronic programme and get approval before claiming.
- Use the scheme's DSPs and formulary where you can.
- If a PMB claim is short-paid or paid from savings, ask the scheme to reprocess it as a PMB.
- If that fails, follow the appeal steps in our claims guide.
Questions people ask
Do hospital plans cover PMBs?
Yes. Every registered medical scheme option, including hospital plans, must cover PMBs, including chronic medicine for the 27 Chronic Disease List conditions.
Are PMBs covered from day one?
Not always. If you join with no medical scheme cover in the previous 90 days, the scheme may apply waiting periods to PMBs. If you move from another scheme, PMBs must be covered during any waiting period.
Can my medical aid charge a co-payment on a PMB?
Only if you choose to use a provider other than its DSP, or a medicine outside its formulary without clinical reason. Used as the scheme requires, PMBs are paid in full.
Does medical insurance cover PMBs?
No. Medical insurance and hospital cash plans are insurance products, not medical schemes, so the PMB rules don't apply to them.
Related on Medical Aid Online
Sources
This guide is general information, not financial or medical advice. Medical Aid Online is not a medical scheme. Scheme rules and benefits change every year, so check the scheme's own rules and brochure before you decide.
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