TFG Health Plus
Chronic Benefits
You have access to treatment for a list of 27 medical conditions (including HIV), known as the Chronic Disease List (CDL) and an additional list of diseases called the Additional Disease List (ADL).
The TFG Health Plus benefit plan offers you a richer benefit for chronic conditions than what is required in terms of prescribed minimum benefits (PMB) conditions.
This is what we cover
For Chronic Disease List Conditions, you have full cover for approved chronic medicine on our medicine list up to a maximum of the Scheme's medicine rate. This rate is the price of the medicine and the fee for dispensing it. For medicine not on our list, we cover you up to a set monthly Chronic Drug Amount (CDA). Medicine cover for conditions on the Additional Disease List (ADL) are covered up to the set monthly CDA and no medicine list applies. In addition, non-formulary medicine for CDL conditions and chronic medicine for ADL conditions is subject to a chronic medicine limit of R35,500 per person per year and R97,000 per family per year.
Members registered on the Chronic Illness Benefit (CIB) also have access to one telemetric device per person per year, which will be funded from your hospital benefit and a second device limited to the medical appliances limit. If approved and subject to the Scheme's protocols and clinical entry criteria, blood glucose monitoring devices are limited to one device per person per year, which is limited to the home monitoring device limit of R4,700 per person per year.
Where to obtain your chronic medicine
There is no Designated Service Provider (DSP) applicable on this benefit plan. You can obtain medication from any pharmacy or dispensing GP.
How to get the benefit and to make changes to your approved treatment plan
You must apply for the Chronic Illness Benefit (CIB) and your doctor must complete a Chronic Illness Benefit Application form and send it to us for approval to CIB_APP_FORMS@tfgmedicalaidscheme.co.za to qualify for this medicine funding. If your doctor uses HealthID, your doctor can apply for cover online, provided you have given your consent.
We need to be informed of any changes to your treatment so that we can update your chronic authorisation. You will need to complete a new CIB Application Form should you be diagnosed with a new chronic condition.
Treatment baskets for your approved Chronic Disease List conditions
Please refer to the Prescribed Minimum Benefit treatment baskets document to view what is covered for your approved PMB CDL condition(s) and how we fund for these.
Request for additional funding for Chronic Disease List conditions
Your doctor may follow an appeals process to request for additional funding for medicine, tests, procedures and consultations for your approved PMB CDL condition(s). Your doctor needs to complete a Request for additional cover for approved Chronic Disease List conditions form and submit it for review. It is important to note that an appeals process does not guarantee an automatic approval for the additional cover.
Member Care Programme
If you are diagnosed with one or more chronic conditions, you might qualify for our Care Programme. The programme facilitates high-quality, planned, person-centred care and chronic condition management to achieve improved outcomes. We will contact you to confirm if you qualify. The programme offers organised care to help you manage your conditions and to get the best quality healthcare.
If you are registered and take part in the programme, we will pay in full for your treatment. If you choose not to take part, we will cover the hospital and related accounts up to 80% of the Scheme Rate.
Chronic Dialysis
If you need regular dialysis, we cover these expenses in full if we have approved your treatment plan and you use a provider in our network. If you go elsewhere, we will pay up to 80% of the Scheme Rate.
TFG Health
Chronic Benefits
You have access to treatment for a list of 27 medical conditions (including HIV), known as the Chronic Disease List (CDL). Your chronic benefit cover aligns with the requirements of the Act and you are covered for all Prescribed Minimum Benefit (PMB) related conditions.
This is what we cover
We pay for medicine on the medicine list (formulary) up to a maximum of the Scheme's medicine rate. This rate is the price of the medicine and the fee for dispensing it. For medicine not on our list, we cover you up to the therapeutic reference price of the equivalent medicine or group of medicines, which means you will be covered up to the lowest cost medicine of the same kind on our medicine list (formulary) for the condition.
There may be a co-payment payable depending on the type of medicine and the
How to get the benefit and to make changes to your approved treatment plan
You must nominate a GP in the KeyCare Network to be your primary GP to manage your chronic conditions. To find a doctor and learn more about the nomination process, use the Discovery app and follow the easy to navigate prompts. You can also nominate your GP or manage your existing nomination by calling us at 0860 123 077.
You must apply for the Chronic Illness Benefit (CIB) if you want to access cover. To qualify for this medicine funding, you and your doctor must complete a Chronic Illness Benefit Application Form online, provided you have granted access to your health records to your doctor using HealthID, or send it to us for approval to:
CIB_APP_FORMS@tfgmedicalaidscheme.co.za
We need to be informed of any changes to your treatment so that we can update your chronic authorisation. You will need to complete a new CIB Application Form should you be diagnosed with a new chronic condition. You need to get your approved chronic medicine that is on the Scheme's medicine list from one of our network pharmacies (Clicks or Dischem pharmacies) or from your chosen KeyCare Network GP (if they dispense medicine). If you get your medicine from anywhere else, you will have a 20% co-payment.
Treatment baskets for your approved Chronic Disease List conditions
Please refer to the Prescribed Minimum Benefit treatment baskets document to view what is covered for your approved PMB CDL condition(s) and how we fund for these.
Request for additional funding for Chronic Disease List conditions
Your doctor may follow an appeals process to request for additional funding for medicine, tests, procedures and consultations for your approved PMB CDL condition(s). Your doctor needs to complete a Request for additional cover for approved Chronic Disease List conditions form and submit it for review. It is important to note that an appeals process does not guarantee an automatic approval for the additional cover.
Member Care Programme
If you are diagnosed with one or more chronic conditions, you might qualify for our Care Programme. The programme facilitates high-quality, planned, person-centred care and chronic condition management to achieve improved outcomes. We will contact you to confirm if you qualify. The programme offers organised care to help you manage your conditions and to get the best quality healthcare.
If you are registered and take part in the programme, we will pay in full for your treatment. If you choose not to take part, we will cover the hospital and related accounts up to 80% of the Scheme Rate.
Chronic Dialysis
If you need regular dialysis, we cover these expenses in full if we have approved your treatment plan and you use a provider in our network. If you go elsewhere, we will pay up to 80% of the Scheme Rate.
Documents for your Chronic Illness Benefit (CIB) cover:
Chronic Illness Benefit application form
Chronic Illness Benefit medicine list (formulary)
Prescribed Minimum Benefit treatment baskets
Request for additional cover for approved Chronic Disease List conditions