Medical Aid Schemes that Cover Ulcerative Colitis

ulcerative colitisUlcerative colitis is a painful condition that occurs when the body’s own immune system attacks the lining of the colon. Environmental factors and a genetic predisposition may contribute to the development of the disease.

Ulcerative requires lifelong treatment and care. In South Africa, it automatically qualifies for Prescribed Minimum Benefits (PMBs). Medical aid schemes in South Africa are required to provide their members with specific state-enforced baseline benefits, as well as chronic cover for medicines published in their scheme formularies or medicine lists after any applicable exclusions.

More costly, premium medical aid plans offer additional day-to-day benefits that may fund follow-up tests, procedures and consultations not defined in the PMBs. They may also provide cover for more expensive branded and generic medicines that don’t appear in the formularies for lower-level plans.

Ulcerative Colitis PMB DTPs

In order to provide cost-effective guidelines based on best practice protocols, all PMB conditions are listed as diagnosis and treatment pairs (DTPs) and identified by a unique code. These codes are critical to the claims process. Without the correct diagnostic indicators, members may lose out on the PMBs.

PMB Treatment Guidelines for Ulcerative Colitis: Discovery Health

South Africa’s largest medical aid scheme, Discovery Health prides itself on providing cover well beyond the stated PMBs on all its medical aid plans. It currently funds the following tests and procedures for ulcerative colitis in full:

  • one colonoscopy as a diagnostic test, two annual follow-ups and three specialist consultations per year
  • one C-reactive protein test on diagnosis, plus two follow-ups per annum
  • one full blood count and two follow-ups per year
  • three diagnostic histology tests and one follow-up per annum.

Momentum Health Medicine Formulary

Momentum Health has an extensive formulary that covers medicines commonly used to treat ulcerative colitis. Members have to register with the appropriate disease management programme or request pre-authorisation to qualify for these benefits.

Why Additional Cover is Useful

Although medication and surgery are the core protocols when treating ulcerative colitis, visiting a dietician or nutritionist and managing stress through relaxation techniques, counselling and psychotherapy are vital in maintaining optimum health and well being.

High-end medical aid plans typically offer more extensive day-to-day cover for therapies and treatments that don’t qualify as PMBs.

At IFC, our consultants are familiar with details of the cover provided by all the top medical aid schemes in South Africa. Speak to one of our consultants today for expert help in finding the best medical aid cover for your needs.