Medical Aid Schemes that Cover Glaucoma

Glaucoma ribbonGlaucoma is a common eye disease that damages the optic nerve. Often it’s associated with a build-up of pressure within the eye.

What’s known as open-angle glaucoma typically progresses gradually, with the result that patients often don’t notice a problem until significant damage has already occurred.

Closed-angle glaucoma, which is rarer, tends to be more sudden and more painful. It occurs when the angle between the iris and the cornea is too narrow to allow fluid to drain through the channel called the trabecular meshwork.

Although glaucoma is usually curable in its early stages, it can lead to reduced vision and ultimately blindness.

Glaucoma and South African medical aids

Under South Africa’s Medical Schemes Act, glaucoma is one of 270 conditions eligible for Prescribed Minimum Benefits (PMBs). This means that all medical aid schemes are required by law to cover the costs of diagnosing, treating and caring for members with the disease, subject to specific limitations.

The minimum cover depends on the type of glaucoma you’re diagnosed as having:

  • for closed-angle glaucoma, cover must be provided for iridectomy, laser surgery and/or medical and surgical management
  • for glaucoma associated with a disorders of the lens, cover must be provided for surgical management
  • for primary and open-angle glaucoma with failed medical management, cover must be provided for trabeculectomy and/or other surgery. 

In addition, glaucoma is one of 25 Chronic Disease List (CDL) conditions. This means that members automatically qualify for cover for chronic medications, provided they register with a medical aid scheme’s management programme for this purpose.

Medical aid schemes are permitted to limit the medications they’ll cover. These are specified in lists called formularies. On some plans, members may also be required to use network healthcare providers (healthcare providers specified by the scheme) or to make punitive co-payments.

To provide further clarification, we examine the medical aid benefits offered by two leading South African medical aid schemes for members with glaucoma.

Discovery Health cover for glaucoma

Discovery HealthAs one of its key selling points, Discovery Health claims to deliver benefits over and above PMBs.

All members who register with the appropriate chronic disease management programme are covered for:

  • one diagnostic tonometry test and two follow-up tests and specialist consultations per annum
  • basic tests by an ophthalmologist in own rooms, with two annual follow-ups
  • one visual fields diagnostic test, with two annual follow-ups
  • one diagnostic gonioscopy and one retinal threshold trend evaluation per year
  • one diagnostic central corneal thickness test per eye and two visual field tests per annum
  • one diagnostic fundus examination and one annual follow-up.
  • This is the basic information however subject to treatment plan and option.

Discovery Health covers the cost of 11 glaucoma medications on all its options:

  • Trusopt 5 ml owi
  • Lumigan
  • Ocuprost 3 ml
  • Travatan 2.5 ml
  • Alphagan purite 5 ml
  • Glaucosan 5 ml
  • Azaraga 5 ml
  • Combigan 5 ml
  • Cosopt 5 ml
  • Duotrav 2.5 ml
  • Ganfort 3 ml.

In addition, the medical aid covers a portion of costs relating to out-of-formulary medications, know as the Chronic Drug Amount (CDA). The CDA applies to each medicine class and is standard across all options, apart from the entry-level KeyCare Series.

Liberty Medical Scheme cover for glaucoma

Liberty Medical SchemeTo qualify for chronic cover for glaucoma, members of the Liberty Medical Scheme are required to register with the Disease Risk and Chronic Medicine Management programmes. Each member then receives a unique treatment plan, which itemises the services that can be accessed to manage the condition.

All services are paid from major medical benefits and include specialist consultations, diagnostic tests and procedures both in and out of hospital.

Liberty Medical Scheme’s Chronic Medicine Formulary applies to all options and covers the cost of the following glaucoma medications:

  • Alphagan purite 5 ml
  • Isopto carpine 1% 15 ml
  • Isopto carpine 2% 15 ml
  • Isopto carpine 4% 15 ml
  • Azomid
  • Diamox
  • Trusopt 5 ml owi
  • Azoptic 5 ml eye suspension
  • Glaucosan 5 ml
  • Timoptol 5 ml.

For advice on which South African medical plan best meets your healthcare needs, contact one of our consultants.