Prescribed Minimum Benefits (PMBs)

What are PMBs?

Prescribed Minimum Benefits (PMBs) are defined benefits ensuring all medical scheme members can access minimum health services regardless of benefit option. Schemes must cover diagnosis, treatment, and care for emergencies, ~271 DTP conditions, and 26 CDL chronic diseases.

PMB objectives

Continuous healthcare even when annual benefits are exhausted; correct payer for PMB treatment (including state hospital care); minimum care regardless of age or option; and sustainable scheme finances through better chronic disease management.

Diagnosis Treatment Pairs (DTPs)

Annexure A to the Medical Schemes Act lists diagnosis–treatment pairs linking a diagnosis to appropriate treatment. Care should follow evidence-based public-sector protocols where schemes disagree. Some DTPs include chronic medicine (e.g. HIV, menopause management).

Browse DTP directory →

Chronic Disease List (CDL)

26 chronic conditions with mandated medication, consultations, and tests. Treatment algorithms published in the Government Gazette are minimum standards — scheme cover may not be inferior. Schemes may use protocols, formularies, and Designated Service Providers (DSPs).

Browse all CDL conditions →

Emergency conditions

Sudden, unexpected onset requiring immediate treatment or operation — risk of death, organ damage, or lasting disability without care. Schemes must approve suspected PMB emergencies even before final diagnosis; confirmation may be requested later. Nearest facility is covered in emergencies.

Designated Service Providers

Scheme-first-choice providers for PMB conditions. Non-DSP use may trigger co-payments unless no reasonable DSP exists near home or work. DSPs must deliver without unreasonable delay; if unable, the scheme remains liable at a non-DSP.