The Autoimmune Association of SA (AASA) urged the Council for Medical Schemes (CMS), to provide clear guidelines regarding the extent to which medical schemes are required to cover expensive specialised treatments that are not commonly available in the public healthcare system. – Business Day (2 September 2024)
These include ustekinumab for Crohn’s disease and adalimumab for rheumatoid arthritis.
“While the CMS has consistently ruled in favour of the patients supported by AASA, some schemes have appealed these decisions, leading to further delays and continued denial of coverage.
“Under Regulations 15H (c) and 151 (c) of the Medical Schemes Act, patients can apply for exceptions if they fail to respond to standard PMB-level treatments
“Discovery Health CEO Ron Whelan said it is unlikely that CMS would issue a blanket decision applicable to the entire industry. He said standardised treatment criteria cannot be set for these cases; each must be evaluated individually.’