Chronic Illness Benefit

The Chronic Illness Benefit

This is available on all health plans (Executive, Comprehensive, Priority, Saver, Smart, Core, KeyCare plans)

Medicine cover for Chronic Disease List conditions

The Chronic Illness Benefit covers approved medicine for the 27 Prescribed Minimum Benefit (PMB) Chronic Disease List (CDL) conditions on all plans. Approved medicine on the Chronic Illness Benefit medicine list (formulary ) will be funded in full up to the Scheme Rate. Medicines not on the medicine list will be funded up to the Chronic Drug Amount (CDA). The CDA does not apply to the Smart and Keycare plans. On these plans approved medicine that is not on the formulary will be funded up to the Reference Price for the medicines specific medicine category.

Medicine cover for Additional Disease List conditions

Members on the Executive and Comprehensive Plans (except the Classic Comprehensive Smart plan) have further cover for Additional Disease List (ADL) conditions. You can find out more in the benefit guide.

Specialised Medicine and Technology benefit

The Specialised Medicine and Technology benefit gives members on the Executive and Comprehensive plans access to specific high cost medicines and new technologies. This benefit is not available on the Classic Smart Comprehensive plan. Read more on this benefit in the Specialised Medicine and Technology document.

Where to get your chronic medicine

You can get your chronic medicine from any pharmacy or from your dispensing doctor. On certain plans to avoid a 20% co-payment you must obtain their chronic medicine from your designated service provider (DSP). You can find out more information on the benefit guide.

How to access the Chronic Illness Benefit

If you want to access cover from the Chronic Illness Benefit, you must apply for it. You must complete a Chronic Illness Benefit application form with your doctor and submit it for review. If your doctor uses HealthID, your doctor can apply for cover online, provided you have given your consent.

You need to meet the benefit entry criteria for your condition(s) to be registered on the Chronic Illness Benefit. You or your doctor may need to provide certain test results or extra information as indicated on the CIB application form for the condition(s) you are applying for. Please ensure that these documents are submitted with your application to avoid any delays in the process.

Changes to your approved treatment plan

If you are already approved on the benefit, you do not need to complete a new CIB application form when your treating doctor makes changes to your treatment plan. However, you do need to let us know when your doctor makes these changes so that we can update your authorisation(s). You can do this by emailing a copy of the prescription to us or asking your doctor or pharmacist to do this for you. If your doctor uses HealthID, your doctor can make the treatment plan changes online, provided you have given your consent. If you do not let us know about changes to your treatment plan, we may not pay your claims from the correct benefit.

You need to complete a new CIB application form should you be diagnosed with a new chronic condition.

Treatment baskets for your approved CDL conditions

If you have recently been diagnosed with and approved for cover for a PMB CDL condition, we will pay for the diagnostic tests and procedures from the diagnostic treatment basket in full. The Chronic Illness Benefit will also cover a limited number of selected tests, procedures and specialist consultations each year for the ongoing management of your condition(s).

For more detailed information, refer to Cover for medicine and treatment of chronic conditions and Prescribed Minimum Benefit treatment baskets documents.

Request for additional funding for CDL conditions

Your doctor may follow an appeals process to request for additional funding for medicine, tests, procedures and consultations for your approved PMB CDL condition(s). Your doctor needs to complete a Request for additional cover for approved Chronic Disease List conditions form and submit it for review. It is important to note that an appeals process does not guarantee an automatic approval for the additional cover.