Overview

No matter what plan or medical scheme you decide on, there are some common benefits that apply to all members on all plans. In terms of the Medical Schemes Act and its regulations, all medical schemes have to cover the costs related to the diagnosis, treatment and care of any life-threatening emergency medical condition, a defined set of 270 diagnoses as well as 27 chronic conditions. These conditions and their treatments are known as the Prescribed Minimum Benefits (PMB).The PMBs also include HIV or AIDS treatment and cover for certain diagnosis-based procedures.

HIVCare Programme

PMB’s will be paid at the negotiated rate i.e. in full for Designated Service Providers (DSP's) and all other negotiated contracts. Voluntary use of a non-DSP provider will result in 80% of the Scheme Rate being paid. Involuntary use of non-DSP will be covered at negotiated rate or cost in the absence of such a rate.

In most cases, TFG Medical Aid Scheme plans offer benefits which cover far more than the Prescribed Minimum Benefits.

To access Prescribed Minimum Benefits, there are rules that apply:

  • The condition must be part of the list of defined PMB conditions
  • The treatment needed must match the treatments in the defined benefits
  • Members must use the scheme’s designated healthcare service providers.

How to apply for PMB cover

  1. If a member wants to apply for cover, he or she should:
  2. Download and print the applicable PMB application form,
  3. Complete the application form with the assistance of your doctor

Send the completed, signed application form, along with any additional medical information, by email or by fax. The e-mail address and fax number can be found on the application form.