Medical Aid for Chronic Medication

Medical Aid for Chronic Medication in South Africa (2027)

If you take medication for a long-term condition, every open medical scheme in South Africa must cover the 26 Chronic Disease List (CDL) conditions in full on every plan, including the cost of medication on the scheme's formulary. This is required by the Medical Schemes Act as a Prescribed Minimum Benefit. Higher-tier plans extend chronic cover to additional conditions and may give broader medication choice. This guide explains how chronic cover works, where the differences between plans actually sit, and what to compare.

The 26 Chronic Disease List

The CDL is the list of chronic conditions all schemes must cover on every plan as Prescribed Minimum Benefits, including medicine, doctor consultations and tests related to the condition. As listed by the Council for Medical Schemes, the 26 conditions are: Addison disease, asthma, bipolar mood disorder, bronchiectasis, cardiac failure, cardiomyopathy, chronic obstructive pulmonary disorder, chronic renal disease, coronary artery disease, Crohn disease, diabetes insipidus, diabetes mellitus type 1, diabetes mellitus type 2, dysrhythmias, epilepsy, glaucoma, haemophilia, hyperlipidaemia, hypertension, hypothyroidism, multiple sclerosis, Parkinson disease, rheumatoid arthritis, schizophrenia, systemic lupus erythematosus and ulcerative colitis. Depression is not on the CDL; it is covered as a separate PMB condition (see below). The list is set by regulation under the Medical Schemes Act.

How chronic registration works

To access chronic benefits you need to register the condition with your scheme. The process typically involves:

• A diagnosis from a registered doctor with supporting investigations.
• A chronic application form submitted to the scheme.
• Approval against the scheme's protocols (clinical criteria).

Once approved, the scheme funds the chronic medication and related monitoring (such as routine blood tests for diabetes) according to PMB rules.

Formulary, DSP and generics

Three concepts shape what medication is paid:

• Formulary. The list of approved medicines for each chronic condition. PMB cover is provided for medicines on the formulary in full.
• Designated Service Provider (DSP). The pharmacy or pharmacy network the scheme uses for chronic dispensing. Using a non-DSP for chronic medicine can trigger a co-payment.
• Generics. When a generic equivalent exists, schemes typically pay the generic in full. The original brand may require co-payment if not on the formulary.

If your prescribed medicine is not on the formulary you can apply for a chronic medicine exception with clinical motivation from your doctor.

Extended chronic cover

Higher-tier plans add extended chronic conditions beyond the 26 CDL. Examples of conditions sometimes added include attention-deficit disorder, autoimmune conditions, osteoporosis, and specific cancer follow-up therapies. The exact list differs by scheme and tier.

Mental health on chronic

Bipolar mood disorder and schizophrenia are on the CDL, so approved medicine and related care for them are covered as PMBs. Depression is not on the CDL. According to the CMS, major depression is a PMB under the diagnosis and treatment pair for major affective disorders (code 902T), which covers up to 3 weeks of in-hospital treatment a year or up to 15 outpatient psychotherapy sessions a year. Ongoing antidepressant medication outside that is funded according to the plan rules, so check the chronic benefit on the plan you are considering.

Switching schemes while on chronic

Section 29A of the Medical Schemes Act controls what a new scheme may impose. If you apply within 90 days of leaving your old scheme, PMB-level care for CDL conditions must still be covered: with up to 24 months of prior cover the new scheme may apply a condition-specific waiting period of up to 12 months, and with more than 24 months only a general waiting period of up to 3 months, but neither may apply to PMB treatment. Benefits above PMB level, such as extended chronic cover, can be affected. If you had no cover in the 90 days before applying, the waiting periods may exclude PMBs too. The chronic registration needs to be done again with the new scheme, and a broker can manage it. See medical aid waiting periods.

What to compare across plans

1. PMB-level cover is the same on every plan. Compare what is added above PMB.
2. Extended chronic conditions list on the plan you are considering.
3. The scheme's chronic medicine formulary for your specific medication.
4. DSP arrangements (which pharmacy chain you must use).
5. Any non-PMB co-payments on chronic for non-formulary medicines.
6. Day-to-day cover for monitoring (pathology, scripts, specialist visits beyond PMB allocations).

Related guides

See also: Medical aid for pensioners, family medical aid, compare schemes head to head.

How a broker helps you decide

A registered broker conducts a needs analysis (required under the FAIS Act) covering your health needs, chronic conditions, family composition and hospital preferences, then maps those needs to specific plans across the open schemes. The broker handles application paperwork, plan changes and claims support throughout the year. Curemed is FSP 44098 and accredited by CMS as ORG 163. See our credentials.

Chronic medication medical aid FAQs