Benefits & claims
Prescribed Minimum Benefits (PMBs) explained
By Naledi Mokoena · 7 min read · Updated 24 June 2026
- Conditions covered
- About 270 PMB conditions plus 27 chronic (CDL) conditions
- Emergencies
- Any emergency medical condition is a PMB
- Payment
- Must be paid in full when you follow the rules
- Set by
- Council for Medical Schemes
Prescribed Minimum Benefits (PMBs) are a set of conditions that every registered medical scheme must cover in full, no matter how cheap your plan is. They cover roughly 270 medical conditions, 27 chronic conditions on the Chronic Disease List, and any emergency, so PMBs are the legal safety net under all private cover.
PMBs exist so that no member is left without care for serious illness. The catch is that you usually have to use the scheme's designated service provider and follow the correct process, or you can be left with a co-payment. This guide explains what is covered and how to claim it without surprises.
What counts as a PMB
PMBs fall into three groups:
- A defined list of about 270 conditions, including many cancers, major surgeries and serious illnesses.
- 27 chronic conditions on the Chronic Disease List (CDL), such as asthma, diabetes, hypertension and HIV.
- Any emergency medical condition - care that, without immediate treatment, could lead to serious harm or death.
If your situation fits one of these, the scheme must cover diagnosis, treatment and care.
Paid in full - but with conditions
PMBs must be paid in full, with no limit and no co-payment, but only if you follow the rules. The main rule is that you generally must use the scheme's designated service provider (DSP) for that condition. If you choose a non-DSP without a valid reason, the scheme can apply a co-payment even for a PMB. In a genuine emergency you can use the nearest provider and sort out the DSP afterwards.
PMBs and your chronic medicine
If you have a CDL condition, the scheme must cover approved medicine and treatment as a PMB. You register the condition, the scheme approves a treatment basket and formulary, and your chronic medicine is then funded from the risk pool rather than your savings. Using a non-formulary medicine or non-DSP pharmacy can introduce a co-payment. See chronic disease benefits.
Common PMB myths
- "A hospital plan does not cover chronic conditions." False - PMB chronic conditions must be covered even on a hospital plan.
- "PMBs only apply in hospital." False - they include out-of-hospital care for listed conditions.
- "The scheme can put a rand limit on a PMB." False - PMB care must be funded in full when you follow the DSP and protocol rules.
If your scheme refuses to pay
If you believe a claim is a PMB and the scheme will not pay it in full, first lodge a written dispute with the scheme. If that fails, you can complain to the Council for Medical Schemes at medicalschemes.co.za. The CMS handles PMB disputes and the service is free. Keep your clinical reports and correspondence as evidence.
Frequently asked questions
What are Prescribed Minimum Benefits?
PMBs are a legal minimum set of benefits every medical scheme must cover in full. They include about 270 conditions, 27 chronic Chronic Disease List conditions, and any emergency, regardless of how basic your plan is.
Are PMBs covered on a hospital plan?
Yes. Even the most basic hospital plan must cover PMBs in full, including PMB chronic conditions and emergencies, provided you use the scheme's designated service provider where required.
Why was I charged a co-payment on a PMB?
Usually because you used a non-DSP provider without a valid reason, or did not follow the scheme's protocol. Using the designated service provider for the condition is what guarantees full PMB cover.
Is HIV covered as a PMB?
Yes. HIV is on the Chronic Disease List, so antiretroviral treatment and related care must be covered as a PMB on every registered scheme when you register and follow the protocol.
Can a scheme put a limit on a PMB?
No. PMB care must be paid in full with no rand limit when you follow the DSP and protocol rules. If a scheme imposes a limit on valid PMB care, you can complain to the CMS.
What do I do if my PMB claim is rejected?
Dispute it in writing with your scheme first. If they still refuse, complain to the Council for Medical Schemes at medicalschemes.co.za, which handles PMB disputes free of charge.
