List of Chronic Conditions: What’s Automatic and What You Need to Register For
You have just been diagnosed; the pharmacist says your medication isn’t covered, and nobody can explain why. The answer often lies in the list of chronic conditions that every South African medical scheme must honour, and a registration step many people never knew existed. That confusion can mean weeks without treatment.
What the List of Chronic Conditions Actually Guarantees
The Chronic Disease List (CDL) is published by the Council for Medical Schemes and covers 26 conditions, including diabetes, hypertension, asthma, epilepsy and chronic kidney disease.
By law, schemes must fund diagnosis, treatment and ongoing care for each condition in the chronic illness list, no matter which plan you choose. KeyHealth covers the full CDL on every plan, while higher-tier options stretch the chronic illness list to include conditions such as migraine, reflux disease, osteoarthritis and osteoporosis. The guarantee does come with two ground rules: use designated providers where required and follow the scheme’s treatment protocols.
Chronic Conditions Cover: Automatic or Registered?
Guaranteed cover is not always automatic.
| Type of Cover | Registration Needed? |
|---|---|
| Emergencies and 271 listed conditions | No, though hospital stays may need pre-authorisation and cancer treatment needs registration on the oncology programme |
| CDL conditions | Yes, to unlock chronic medication |
Without registration, you may be required to pay from your own pocket.
How Registration Works
First, confirm that your diagnosis appears on the list of chronic conditions your plan covers. Your doctor, or your pharmacist after your consultation, then registers the condition with MediKredit on 0800 132 345, giving your diagnosis, ICD-10 code and severity; test results are only needed if requested. Some chronic conditions can be automatically authorised when the correct ICD-10 code is provided.
The request is assessed against the clinical entry criteria for your condition and option, and if it is declined, your doctor or pharmacist is told during the call. Once approved, you can collect your medicine at any dispensing pharmacy, and medicine outside the Condition Medicine List needs a specific authorisation limited to a set period. Schemes also expect fresh prescriptions periodically, so diarise renewal dates.
When Your Medicine Isn’t in the Formulary
A formulary is the scheme’s approved medicine list. If your doctor prescribes outside it, you may face a co-payment, even for CDL conditions. Start by asking your doctor about an equivalent formulary medicine. If those options don’t work or cause harmful side effects, your doctor can advocate for an alternative, and for PMB conditions the scheme must then fund it in full.
Common Mistakes That Delay Approval
Applications for anything on the list of chronic conditions still stall over small errors:
- A missing ICD-10 code or test results
- Incomplete clinical information
- Prescribing non-formulary medicine
- Using a GP other than your nominated GP on Essence
- Collecting medication before approval is confirmed
- Letting an authorisation lapse without a new prescription
Ready to start? Ask your doctor or pharmacist to register your chronic condition with MediKredit, or contact KeyHealth for help before your next repeat prescription falls due.
