Chronic Medication Authorisation: A Guide for SA Doctors

Updated 2026-07-06 · Written for South African healthcare practitioners by Sphygmos.

Chronic medication authorisation is the gateway between a chronic prescription and a medical scheme paying for it month after month. For the conditions on the Chronic Disease List, that cover is a legal entitlement under the Medical Schemes Act 131 of 1998, not a discretionary benefit. This guide sets out what schemes must fund, what they require before they authorise, and what the law says when they refuse.

What chronic medication authorisation is

South African medical schemes do not fund chronic medicine off a prescription alone. The condition must first be registered on the scheme's chronic medicine programme, a step schemes variously call chronic authorisation, chronic benefit registration or a chronic illness benefit application. The Council for Medical Schemes (CMS), the statutory regulator, confirms that registering the condition with the scheme is what opens access to the chronic benefit.

Once the condition is registered, the approved medicine is paid from the scheme's chronic or risk benefit rather than from the member's savings or day-to-day limits. For Chronic Disease List conditions the benefit reaches further than the medicine itself: CMS guidance is that the scheme must also cover the doctors' consultations and tests related to the condition.

The legal position: the Chronic Disease List and PMBs

Prescribed minimum benefits (PMBs) under the Medical Schemes Act 131 of 1998 fall into three groups: the Diagnosis and Treatment Pairs, the Chronic Disease List (CDL) and emergency medical conditions. The CDL covers common chronic conditions such as diabetes (types 1 and 2), hypertension and asthma, and every registered scheme must fund the diagnosis, treatment and ongoing care of a CDL condition on every benefit option it sells.

This is what separates a CDL application from an ordinary benefit request. A member on a hospital plan has the same CDL entitlement as a member on the scheme's richest option. A scheme may manage how the entitlement is delivered, through formularies, treatment protocols and designated service providers, but the underlying obligation to fund care for the condition remains.

Conditions outside the CDL can still attract chronic cover, but as a scheme-rule benefit rather than a statutory one. Whether a non-PMB chronic condition is funded, and to what level, depends on the registered rules of the member's option.

What schemes require before they authorise

Each scheme runs its own application process, but the required content is consistent across the industry. Chronic benefit application forms ask for:

Member and dependant details as registered with the scheme.
The diagnosis with its ICD-10 code.
The prescribing doctor's name and practice details.
The medicine prescribed, with strength and dosage.
Supporting test results where the scheme's form lists them for the condition being applied for.

ICD-10 codes carry the application

Schemes identify Chronic Disease List entitlement at adjudication level from the ICD-10 code, and legislation requires treating providers to include ICD-10 codes on patient accounts. A vague or incorrect code routes the claim away from the chronic benefit before any clinical detail is read.

CMS publishes the PMB condition lists with their associated ICD-10 codes on medicalschemes.co.za. The lists are revised, so the current version is the one that counts.

Formularies, treatment algorithms and designated service providers

The treatment algorithms for the CDL conditions are published in the Government Gazette. CMS describes them as the guidelines for appropriate treatment of each condition, and scheme chronic programmes are built around them.

Around that framework, schemes may apply the cost-control tools the Regulations allow: medicine formularies, managed care protocols and designated service providers (DSPs), commonly a pharmacy network or courier pharmacy for chronic medicine. CMS confirms schemes may use protocols, formularies and DSPs to manage chronic benefits.

These tools change where and with what the condition is treated. They do not remove the funding obligation, and the Regulations set precise limits on when they can leave the patient carrying a cost.

When the scheme must still pay in full: Regulation 8

Regulation 8 to the Medical Schemes Act obliges a scheme to pay for the diagnosis, treatment and care of a PMB condition in full. A co-payment on that care is only permissible where the member voluntarily uses a provider other than the scheme's DSP. Where the DSP is not reasonably accessible, or care began as an emergency, the scheme must pay in full.

Formulary limits have the same shape. The managed health care regulations (Regulations 15H and 15I) require formulary arrangements to provide for appropriate substitution, without penalty to the beneficiary, where a formulary drug has been ineffective or causes, or would cause, an adverse reaction. Whether a patient meets that test is decided on the clinical record.

What a rejected chronic authorisation costs

A rejected or lapsed chronic authorisation does not usually stop the prescription. It moves the cost. The medicine is paid out of pocket or from the member's savings account, co-payments land at the pharmacy, and treatment is interrupted when the patient cannot carry that cost, with the disease control consequences that follow for exactly the conditions the CDL exists to keep stable.

The practice carries cost too: repeat consultations to redo applications, correspondence with the scheme's chronic programme, and unbillable hours re-motivating a medicine the doctor has already prescribed. Because scheme reviews and CMS complaints are decided on the paper record, a weak first application follows the claim through every later stage.

Sphygmos drafts chronic authorisation motivations with this framework built in, ready for the doctor to review and sign.

If the scheme still refuses: internal review and the CMS

A refusal is not the end of the road, because CDL cover is statutory. The scheme's internal dispute process comes first: a formal written review of the decision, with the outcome letter kept for the record.

If the outcome still conflicts with the patient's PMB entitlement, the member, or the practitioner assisting them, can lodge a written complaint with the Council for Medical Schemes, which refers the complaint to the scheme for a response and adjudicates against the Act and Regulations. The complaint is decided on the documents: the application, the ICD-10-coded accounts, the clinical records and the rejection correspondence. Details and current forms are on the CMS complaints procedure page at medicalschemes.co.za.

How Sphygmos helps

Sphygmos drafts chronic authorisation motivations with the scheme framework built in: the Medical Schemes Act, the Chronic Disease List entitlement, Regulation 8 and the formulary substitution provisions, applied where the case calls for them and structured around your diagnosis and ICD-10 codes. Every motivation is produced as a draft, ready for your review, amendment and signature. Nothing is ever sent on your behalf.

See Sphygmos, the clinical operating system for South African doctors

Frequently asked questions

What is chronic medication authorisation?

Chronic medication authorisation is the process of registering a patient's chronic condition and prescribed medicine on a medical scheme's chronic programme so the medicine is paid from the chronic benefit rather than from savings or day-to-day limits. Schemes also call it chronic benefit registration or a chronic illness benefit application. The Council for Medical Schemes confirms that registering the condition with the scheme is what opens access to the chronic benefit.

Does a hospital plan have to cover chronic medication?

For Chronic Disease List conditions, yes. The CDL is one of the three prescribed minimum benefit groups under the Medical Schemes Act 131 of 1998, and every registered scheme must fund the diagnosis, treatment and ongoing care of a CDL condition on every benefit option, hospital plans included. Chronic cover for conditions outside the PMB framework depends on the registered rules of the specific option.

What information does a medical scheme need to register a chronic condition?

Scheme application forms consistently ask for the member and dependant details, the diagnosis with its ICD-10 code, the prescribing doctor's practice details, and the medicine with strength and dosage. For several conditions the scheme's form also lists supporting test results. The ICD-10 code is decisive, because schemes identify Chronic Disease List entitlement from the code at adjudication.

Can a scheme refuse a chronic medicine that is not on its formulary?

Not unconditionally for a PMB condition. The managed health care regulations (Regulations 15H and 15I) require formulary arrangements to provide for appropriate substitution, without penalty to the beneficiary, where the formulary drug has been ineffective or causes, or would cause, an adverse reaction. The scheme decides that question on the clinical record, so the outcome turns on what the record shows about the formulary agent and this patient.

Can a scheme charge a co-payment on Chronic Disease List medicine?

Only in limited circumstances. Under Regulation 8, a co-payment on PMB care is permissible only where the member voluntarily uses a provider other than the scheme's designated service provider. Where the DSP is not reasonably accessible, care began as an emergency, or the formulary option is clinically inappropriate for the patient, the scheme must pay in full.

What happens if a chronic authorisation application is rejected?

The scheme's internal dispute process comes first, as a formal written review of the decision. If the rejection still conflicts with the patient's PMB entitlement, a written complaint can be lodged with the Council for Medical Schemes, which adjudicates against the Medical Schemes Act and its Regulations on the documents: the application, the coded accounts, the clinical records and the correspondence. In the meantime the cost of the medicine shifts to the member, which is why rejections carry a real clinical price.

Does the chronic benefit cover consultations and tests as well?

For Chronic Disease List conditions, CMS guidance is that the scheme must cover not only the medication but also the doctors' consultations and tests related to the condition. The treatment algorithms published in the Government Gazette are the guidelines for appropriate treatment of each CDL condition. How the scheme delivers that care, through networks, protocols or designated service providers, is set out in the option's registered rules.

Sources

This guide is general information for healthcare practitioners, not medical, legal, or billing advice. Verify current scheme rules before relying on any detail.