An AS diagnosis — often years in the making — finally gives you access to targeted treatment. The path to biologic therapy through your medical aid requires strategic steps and persistence. Here's how to navigate it.
The Honest Starting Point
AS is PMB, not CDL. This distinction matters: CDL gives you a clear chronic medication entitlement; PMB requires that your scheme fund "appropriate management" of AS as a minimum benefit, but leaves room for them to argue about what "appropriate" means. Biologics at R8,000–R15,000/month are where the battles happen.
Start with NSAIDs and build the documented clinical record that supports a biologic pre-authorisation when the time comes.
Step 1: Confirm Diagnosis Is Formally Documented
Ensure your diagnosis is formally documented by a rheumatologist using the Assessment of Spondyloarthritis International Society (ASAS) criteria or equivalent, and coded with the correct ICD-10 code (M45 for AS; M46 for other spondyloarthropathies).
Why this matters: Pre-authorisation requests for biologic therapy will be reviewed by your scheme's clinical team. Ambiguous diagnosis documentation makes the pathway harder.
Ensure your rheumatologist provides: - A diagnosis letter documenting the clinical presentation, HLA-B27 status, and MRI/X-ray findings - Baseline disease activity score (BASDAI — Bath Ankylosing Spondylitis Disease Activity Index) - Documentation of your current medication and response
Step 2: Complete the NSAID Trial — Document It Carefully
Before biologics are approved, most schemes require evidence of adequate NSAID trial (typically 3–6 months of two different NSAIDs at full doses without adequate response).
Document this trial properly: - Prescriptions issued and filled (pharmacy records) - Clinical notes from rheumatologist/GP recording the NSAID dose, duration, and response - BASDAI scores at baseline and after the NSAID trial - Any NSAID side effects that limited use (gastric, cardiovascular, renal) — these may justify earlier biologic access
Without good documentation of NSAID failure, your biologic pre-authorisation will face a higher burden of proof.
Step 3: Contact the Scheme's Managed Care Organisation for the Biologic Pathway
When your rheumatologist believes biologics are indicated:
- Ask your rheumatologist's rooms to submit a biologic pre-authorisation request to your scheme's MCO. Most rheumatology practices are familiar with this process.
- The MCO typically reviews: diagnosis confirmation, NSAID trial documentation, baseline disease activity scores, and proposed biologic.
- Allow 5–10 business days for review.
- If approved, you receive an authorisation number and the approved biologic is funded (at scheme tariff, via DSP pharmacy).
Ask your rheumatologist: "Have you submitted biologic pre-authorisations to [my scheme's MCO] before? Are there specific forms or requirements I should know about?"
Step 4: If the First Biologic Application Is Declined
Declines are common — do not accept them as final.
Standard appeal strategy: 1. Request written reasons for the decline. 2. Your rheumatologist writes a detailed clinical motivation letter addressing the specific reason for decline — referencing NSAID trial documentation, disease severity scores, functional impairment, and the PMB obligation. 3. Submit an internal appeal within 30 days of the decline decision. 4. If internal appeal fails — escalate to the Council for Medical Schemes: 0861 123 267.
The CMS has confirmed in previous rulings that schemes must fund appropriate treatment for PMB conditions, including biologic therapy when clinically indicated. Document your appeal process thoroughly.
Step 5: Consider Biosimilar Options
Biosimilar adalimumab (e.g., Hadlima, Hyrimoz) is clinically equivalent to originator Humira and costs R4,000–R8,000/month vs R10,000–R15,000+ for Humira. Biosimilar etanercept is similarly available.
Ask your rheumatologist: "Is a biosimilar TNF inhibitor appropriate for me, and is it on my scheme's formulary?"
Some schemes preferentially fund biosimilars over originators — this may actually make scheme approval easier.
Step 6: Maintain Physiotherapy Throughout
NSAIDs and biologics suppress inflammation, but physiotherapy and structured exercise are irreplaceable for maintaining spinal mobility, posture, and function. AS causes progressive stiffness — activity counteracts this.
Day-to-day physiotherapy sessions are limited (10–15/year on most plans). Use them strategically: - Priority: core and back strengthening programme with a physiotherapist experienced in AS - Secondary: self-directed home exercise programme to extend the benefit of formal sessions - Group exercise classes (hydrotherapy, yoga) are OOP but cost-effective for ongoing mobility maintenance
Step 7: Monitor and Manage Eye Complications
Anterior uveitis (acute red, painful eye with photophobia) affects ~30–40% of AS patients at some point. It is a distinct condition that requires urgent ophthalmological assessment — untreated uveitis can cause permanent vision damage.
If you develop acute eye redness and pain: See an ophthalmologist same day, not your rheumatologist. Treatment is typically steroid eye drops — day-to-day funded.
Inform your ophthalmologist of your AS diagnosis. Some patients benefit from escalating to a biologic with uveitis-specific efficacy (adalimumab has the strongest evidence for preventing uveitis recurrence).
Support Resources
Arthritis Foundation of South Africa: arthritis.org.za SAPA (SA Physiotherapy Association): physiotherapy.org.za SASOC (SA Society of Rheumatology): sasoc.co.za Council for Medical Schemes: 0861 123 267 | www.medicalschemes.co.za
Talk to Eldon
AS biologic access is one of the most complex medical aid advocacy challenges. AURA helps with pre-authorisation navigation, appeal strategy, and identifying plans with the most accessible biologic formulary.
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