Prescribed Minimum Benefit Treatment Baskets for Chronic Disease Baskets of Care 08 Who we are SAB Medical Aid (the Scheme), registration number 09, is the medical scheme. This is a nonprofit organisation, registered with the Council for Medical Schemes and administered by Discovery Health (Pty) Ltd, registration number 997/080/07, an authorised financial services provider. Treatment Baskets for the Prescribed Minimum Benefit (PMB) Chronic Disease (CDL) conditions The Prescribed Minimum Benefit Chronic Disease List is a list of conditions which all medical schemes need to cover on all the Options they offer to their members. This cover includes funding for the diagnosis, treatment and ongoing care of the listed conditions. Read further to understand what procedures, investigations and consultations are covered for both the diagnosis and ongoing management of each condition, over and above any medicine that may be approved. We will only pay Prescribed Minimum Benefit claims if cover for your condition has been approved on the Chronic Medicine Benefit Only claims for procedures and consultations listed in the Prescribed Minimum Benefit (PMB) treatment Baskets will be paid from the Chronic Disease Basket of Care. The benefits are calculated based on the number of months left in the from the date we approve cover for your chronic condition. Where you have approval for more than one PMB CDL condition and you have cover for the same procedures or tests in more than one basket, funding will be limited to the number of procedures or tests in the basket that has the highest quantity.
We will pay for tests and procedures for your condition according to the treatment baskets We pay for certain tests like blood tests and X-rays according to the PMB treatment Baskets. This cover includes tests and procedures for both the diagnosis and ongoing management for each of the PMB Chronic Disease List conditions. We pay for listed blood tests, scans and X-rays up to a maximum of the Scheme Rate. How we pay for GP consultations related to your condition We pay for four consultations a that are related to your registered condition if you use a GP who is a Network Provider. If you choose to use a GP who is not a Network Provider, we will still pay for the consultations. How we pay for specialist consultations related to your condition Depending on your condition, we pay for a specific number of consultations with a specialist, as listed in the treatment Baskets. We will pay the consultation at a specialist who is a Network Provider. We pay up to a maximum of the Scheme Rate for consultations with a specialist who is not a Network Provider. You must pay any difference between what the specialist charges and what we pay. Please make sure your claims have the appropriate ICD-0 code All claims must have the appropriate ICD-0 codes (diagnostic codes) so that we can identify them and pay them from the Chronic Illness Benefit. We will not pay claims from the Chronic Disease Basket of Care in the following instances The claims are submitted without the relevant ICD-0 codes You are not yet registered on the Chronic Disease Programme for the specific PMB condition You have exceeded the frequency limit on consultations or tests in the registered Chronic Disease Basket of Care. To find a doctor who is a Network Provider, please use the MaPS tool on www.sabmas.co.za Contact us You can contact us on 0860 00 or visit our website at www.sabmas.co.za for more information. Page of
Treatment Baskets for Chronic Disease List conditions Condition Diagnostic Ongoing management each Addison s disease U & E only 7 U & E only 7 0 or or Cortisol level 99 ACTH stimulation testing 5 Asthma Flow volume test 88 or 86 Bipolar mood disorder Bronchiectasis 0 or or Flow volume test 88 or 86 Peak flow 9 Peak flow 9 AST Aspartate ALT Alanine 0 AST Aspartate ALT Alanine 0 Thyrotropin (TSH) 507 Thyrotropin (TSH) 507 U & E only 7 U & E only 7 Sputum MC&S sputum analysis for infection Flow volume test 867 & 88 & 885 & 887 & 895 & 9 & 9 88 or 86 Lithium flame ionisation 067 Drug level in biological fluid Sputum MC&S sputum analysis for infection 08 or 70 or 9 0 or or 867 & 88 & 885 & 887 & 895 & 9 & 9 Flow volume test 86 Peak flow 9 Peak flow 9 00 Cardiac failure ECG Electrocardiogram or or or 5 or 6 Echocardiography 6 & 6 & 6 & 60 & 65 ECG Electrocardiogram or or or 5 or 6 Echocardiography 6 & 6 & 6 & 60 & 65 U & E only 7 U & E only 7 Urine analysis (dipstick) 88 Urine analysis (dipstick) 88 cover each Page of
Condition Diagnostic Ongoing management each Cardiac failure B-Type natriuretic peptide 88 B-Type natriuretic peptide 88 0 or or 0 or or 00 Troponin isoforms 6 Drug level in biological Glucose random/fasting 057 fluid C-reactive protein 97 Full blood count 755 Thyrotropin (TSH) 507 Total cholesterol 07 Cardiomyopathy ECG Electrocardiogram or or or 5 or 6 Chronic obstructive pulmonary disease (COPD) Chronic renal disease Echocardiography 6 & 6 & 6 & 60 & 65 00 08 or 70 or 9 cover each ECG Electrocardiogram or or or 5 or 6 Echocardiography 6 & 6 & 6 & 60 & 65 U & E only 7 U & E only 7 Urine analysis (dipstick) 88 Urine analysis (dipstick) 88 B-Type natriuretic peptide 88 B-Type natriuretic peptide 88 0 or or 0 or or 00 00 Glucose random/fasting 057 Prothrombin index (PI) 805 C-reactive protein 97 Therapeutic drug level: Dosage Full blood count 755 Drug level in biological Thyrotropin (TSH) 507 fluid Total cholesterol 07 Flow volume test 88 or 86 806 08 or 70 or 9 Flow volume test 86 00 Peak flow 9 Alpha--antitrypsin 005 Drug level in biological fluid ECG Electrocardiogram or or 6 08 or 70 or 9 ECG Electrocardiogram or or 6 Page of
Condition Diagnostic Ongoing management Chronic renal disease Coronary artery disease each Full blood count 755 Full blood count 755 U & E only 7 U & E only 7 Serum calcium Serum phosphates Serum parathyroid hormone (PTH) 0 or or 06 or 07 or 75 or 76 09 or 0 or or Serum calcium 06 or 07 or 75 or 76 Serum phosphates 09 or 5 Serum parathyroid hormone (PTH) 5 Protein: Quantitative Protein: Quantitative ECG Electrocardiogram Echocardiography or or or 5 or 6 6 & 6 & 6 & 60 & 65 0 or or Platelet count 797 Urine analysis (dipstick) 88 Iron 07 Transferrin Ferritin 58 ECG Electrocardiogram or or or 5 or 6 Echocardiography 6 & 6 & 6 & 60 & 65 0 or or U & E only 7 U & E only 7 Glucose random/fasting 057 Glucose random/fasting 057 Total cholesterol 07 Total cholesterol 07 LDL cholesterol 06 LDL cholesterol 06 HDL cholesterol 08 HDL cholesterol 08 Triglycerides 7 Triglycerides 7 C-reactive protein 97 Urine analysis (dipstick) 88 Full blood count 755 Thyrotropin (TSH) 507 00 Platelet count 797 cover each Page 5 of
Condition Diagnostic Ongoing management Crohn s disease Colonoscopy 65 or 656 Diabetes insipidus Erythrocyte sedimentation rate or C-reactive protein 7 or 97 Colonoscopy 65 or 656 each C-reactive protein 97 Full blood count 755 Full blood count 755 Histology 567 & 57 or 58 & 58 cover each U & E only 7 U & E only 7 0 or or 0 or or Osmolality: Serum or urine 09 Osmolality: Serum or urine 09 Diabetes type ECG Electrocardiogram or or 6 Microalbuminuria 6 or 6 ECG Electrocardiogram or or 6 Microalbuminuria 6 or 6 Urine analysis (dipstick) 88 Urine analysis (dipstick) 88 Total cholesterol 07 Total cholesterol 07 LDL cholesterol 06 LDL cholesterol 06 HDL cholesterol 08 HDL cholesterol 08 Triglycerides 7 Triglycerides 7 U & E only 7 U & E only 7 Serum creatinine 0 or Serum creatinine 0 or Urine creatinine Urine creatinine Glucose random/fasting 057 HBAc 06 Two-hour glucose-ogtt 09 Tonometry 0 Basic capital equipped in own rooms by ophthalmologists Fundus examination Podiatrist Dietician (Ophthalmologist) 009 00 or 00 or 07 680 or 680 or 680 800 or 80 or 80 or 80 or 80 or 805 (Other Specialist) Page 6 of
Condition Diagnostic Ongoing management Diagnostic test description Diagnostic Diabetes type ECG Electrocardiogram or or 6 Microalbuminuria 6 or 6 ECG Electrocardiogram or or 6 Microalbuminuria 6 or 6 each Urine analysis (dipstick) 88 Urine analysis (dipstick) 88 Total cholesterol 07 Total cholesterol 07 LDL cholesterol 06 LDL cholesterol 06 HDL cholesterol 08 HDL cholesterol 08 Triglycerides 7 Triglycerides 7 U & E only 7 U & E only 7 Serum creatinine 0 or Serum creatinine 0 or Urine creatinine Urine creatinine Glucose random/fasting 057 HBAc 06 Two-hour glucose- OGTT 09 Tonometry 0 Dysrhythmia ECG Electrocardiogram or or or 5 or 6 Echocardiography 6 & 6 & 6 & 60 & 65 Basic capital equipped in own rooms by ophthalmologists Fundus examination Podiatrist Dietician cover each (Ophthalmologist) 009 00 or 00 or 07 680 or 680 or 680 800 or 80 or 80 or 80 or 80 or 805 (Other Specialist) ECG Electrocardiogram or or or 5 or 6 Echocardiography 6 & 6 & 6 & 60 & 65 U & E only 7 U & E only 7 Magnesium: Spectrophotometric 09 Magnesium: Spectrophotometric 0 or or 0 or or 09 C-reactive protein 97 Prothrombin index (PI) 805 Page 7 of
Condition Diagnostic Ongoing management Diagnostic test description Diagnostic Dysrhythmia Thyrotropin (TSH) 507 Therapeutic drug level: Dosage Hour ambulatory ECG monitoring (holter) Serum calcium Epilepsy EEG Electro-encephalography 8 & 9 06 or 07 or 75 or 76 7 & 7 each Drug level in biological fluid EEG Electro-encephalography EEG with special activation 75 Drug level in biological fluid 806 08 or 70 or 9 7 & 7 08 or 70 or 9 cover each Glaucoma Tonometry 0 Tonometry 0 Haemophilia Fundus examination 00 or 00 Fundus examination 00 or 00 Gonioscopy 00 Gonioscopy 00 Basic capital equipped in own rooms by ophthalmologists Visual fields Disc and nerve fibre layer analysis or Disc photography or Optical Coherent Tomography (OCT) of Optic nerve or macula Central corneal thickness measurement Factor VIII or Factor IX antigen or Coagulation factors 009 Basic capital equipped in own rooms by ophthalmologists 06 or 07 06 or 07 or 08 00 ( per eye) 758 or 757 Visual fields 06 or 07 Disc and nerve fibre layer analysis or Disc photography or Optical Coherent Tomography (OCT) of Optic nerve or macula Retinal threshold trend evaluation Factor VIII or Factor IX inhibitors 009 06 or 07 or 08 08 7 Full blood count 755 Full blood count 755 Platelet count 797 Platelet count 797 Fibrinogen titre 85 PTT - Partial thromboplastin time 87 Prothrombin index (PI) 805 Therapeutic drug level: Dosage 806 Bleeding time 7 Thrombin time 8 Hyperlipidaemia Total cholesterol 07 Total cholesterol 07 0 LDL cholesterol 06 LDL cholesterol 06 HDL cholesterol 08 HDL cholesterol 08 Triglycerides 7 Triglycerides 7 Page 8 of
Condition Diagnostic Ongoing management Hyperlipidaemia Thyrotropin (TSH) 507 AST Aspartate Hypertension ECG Electrocardiogram or ALT Alanine ECG Electrocardiogram or each 0 Urine analysis (dipstick) 88 Urine analysis (dipstick) 88 Glucose random/fasting 057 Glucose random/fasting 057 Total cholesterol 07 Total cholesterol 07 Hour ambulatory blood pressure 0 or or U & E only 7 0 or or 7 Potassium cover each Hypothyroidism Thyrotropin (TSH) 507 Thyrotropin (TSH) 507 0 Free thyroxine (FT) 8 Free thyroxine (FT) 8 Total cholesterol 07 Multiple sclerosis MR of the brain pre and post contrast or Parkinson s disease Rheumatoid arthritis MR of the cervical spine and cranio-cervical junction pre and post contrast or MR of the thoracic spine pre and post contrast or MR of the lumbar spine pre and post contrast or Visual evoked potentials (VEP): Unilateral Visual evoked potentials (VEP): Bilateral 00 or 00 50 or 50 or 500 50 or 50 or 500 50 or 50 or 500 MR of the brain pre and post contrast or MR of the cervical spine and cranio-cervical junction pre and post contrast or MR of the thoracic spine pre and post contrast or MR of the lumbar spine pre and post contrast or 68 AST Aspartate 68 ALT Alanine 00 or 00 50 or 50 or 500 50 or 50 or 500 50 or 50 or 500 0 No diagnostic or monitoring tests apply as the diagnosis of this condition remains a clinical one Erythrocyte sedimentation rate or C-reactive protein 7 or 97 Erythrocyte sedimentation rate or C-reactive protein 7 or 97 Full blood count 755 Full blood count 755 Platelet count 797 Platelet count 797 Urine analysis (dipstick) 88 Urine analysis (dipstick) 88 AST Aspartate ALT Alanine 0 AST Aspartate ALT Alanine 0 Anti-CCP 600 Anti-CCP 600 Page 9 of
Condition Diagnostic Ongoing management Rheumatoid arthritis Schizophrenia Systemic lupus erythematosus each X-ray of the right hand 6505 X-ray of the right hand 6505 X-ray of the left hand 6500 X-ray of the left hand 6500 X-ray of the right foot 75 X-ray of the right foot 75 X-ray of the left foot 70 X-ray of the left foot 70 Rheumatoid factor 959 ANF 9 00 AST Aspartate ALT Alanine 00 cover each 0 U & E only 7 Drug level in biological fluid 0 or or 08 or 70 or 9 Full blood count 755 Full blood count 755 Urine analysis (dipstick) 88 Urine analysis (dipstick) 88 U & E only 7 U & E only 7 Platelet count 797 Platelet count 797 Complement fixation test Erythrocyte sedimentation rate or C-reactive protein Skin biopsy 00 96 or 8 7 or 97 0 or or 567 & 0 & 0 & 05 & 07 Complement fixation test 96 or 8 Erythrocyte sedimentation rate or C-reactive protein 00 7 or 97 0 or or Total cholesterol 07 Kidney biopsy 8 kinase 5 or 5 Extractable nuclear antigens 9 or 98 Urine microscopy 867 AST Aspartate ANF 9 ALT Alanine DNA antibodies 59 or 98 Antiglobulin test (Coombs) 709 0 Page 0 of
Condition Diagnostic Ongoing management Systemic lupus erythematosus Histology 567 & 57 or 58 & 58 Ulcerative colitis Colonoscopy 65 or 656 Colonoscopy 65 or 656 each C-reactive protein 97 C-reactive protein 97 Full blood count 755 Full blood count 755 Histology Complaints process 567 & 57 or 58 & 58 Histology 567 & 57 or 58 & 58 Flexible sigmoidoscopy 676 cover each You may lodge a complaint or query with SAB Medical Aid by completing an online Complaints form at www.sabmas.co.za or address a complaint in writing directly to the Principal Officer. If your complaint remains unresolved, you may lodge a formal dispute by following the Scheme s internal dispute process on the SABMAS website. Members who wish to approach the Council for Medical Schemes for assistance may do so in writing to: Council for Medical Schemes Complaints Unit, Block A, Eco Glades Office Park, 0 Witch-Hazel Avenue, Eco Park, Centurion, 057 or email complaints@medicalschemes.com. Customer Care Centre: 086 67 / website www.medicalschemes.com Page of