Whether your CAD was discovered through a routine investigation or during a cardiac event, the medical aid questions that follow are practical and time-sensitive. This article answers the most important ones.
Does My Medical Aid Have to Cover This?
Yes — twice over. CAD is both a Chronic Disease List (CDL) condition and a Prescribed Minimum Benefit (PMB). This means: - Your scheme must fund your CDL medications indefinitely from a ring-fenced chronic benefit. - Your scheme must fund acute cardiac events (ACS, emergency PCI) under PMB.
Neither the state of your medical savings account nor your plan tier changes this obligation.
Register for the CDL Benefit Now
If you have not yet registered your CAD diagnosis with your scheme's chronic disease benefit, do this immediately. The practical effect:
- Statins, beta-blockers, ACE inhibitors, and antiplatelet agents become funded from your CDL benefit — they no longer deplete your medical savings account.
- CDL benefits are protected; they cannot be depleted like a savings account.
How to register: 1. Call your scheme's chronic benefits department (not the general call centre). 2. Tell them you have been diagnosed with CAD (ICD-10: I25) and need to register for the CDL benefit. 3. Submit the required documentation — typically a cardiologist or physician letter, ECG or stress test report, and the scheme's CDL registration form.
Processing takes 2–4 weeks. During this time, keep your medication receipts — some schemes allow backdated claims once CDL is registered.
I've Been Recommended a PCI or CABG — What Should I Know?
Before any procedure, ask:
-
Is this procedure covered? PCI and CABG are PMB-covered for medically indicated cases. Pre-authorisation is required before any elective procedure. Get this in writing.
-
What will my cardiologist charge? Cardiologists and cardiothoracic surgeons routinely bill above medical aid tariff. Ask your specialist's practice manager: "Do you bill at medical aid tariff, or above tariff? By what percentage?" This lets you estimate your shortfall before you commit.
-
Is the anaesthesiologist in-network? Anaesthesiologists at private hospitals are typically self-employed and bill independently. Ask the hospital or your specialist which anaesthesiologist will be used and whether they bill at tariff.
-
What is my gap cover OPL? Confirm with your gap cover provider what your overall payment limit is (typically ~R220,000/year). This is your total shortfall protection. If your estimated shortfall exceeds the OPL, you will carry the balance.
My Cardiologist Has Recommended Ticagrelor — Why Won't My Scheme Cover It?
Post-PCI dual antiplatelet therapy (DAPT) typically consists of aspirin plus clopidogrel or ticagrelor. Clopidogrel is generally on CDL formularies; ticagrelor may not be, or may be listed as an exception requiring motivation (e.g., for high-platelet-reactivity patients or after STEMI).
If your scheme declines ticagrelor: 1. Ask your cardiologist to submit a clinical motivation explaining why ticagrelor is preferable to clopidogrel in your specific case. 2. If still declined, confirm whether clopidogrel is an acceptable alternative in your clinical situation. 3. If the cardiologist states ticagrelor is medically necessary, escalate through the scheme's appeals process.
PCSK9 Inhibitors: How to Get These Funded
If your cardiologist recommends evolocumab (Repatha) for high-risk CAD or familial hypercholesterolaemia: - This is an injectable biologic; it requires an exceptional-needs application. - Documentation needed: current LDL level, maximum-dose statin evidence (and intolerance documentation if applicable), FH diagnosis if relevant, cardiovascular risk score. - Monthly cost if self-funded: ~R4,500. Getting this approved is worth pursuing.
The Next Three Months: Checklist
| Action | Priority |
|---|---|
| Register for CDL chronic benefit (ICD-10: I25) | Immediate if not done |
| Pre-authorise all planned procedures | Before any PCI/CABG booking |
| Confirm specialist billing rates before procedure | This week |
| Check gap cover status and OPL | This week |
| Ask cardiologist about cardiac rehabilitation | Post-procedure |
| Confirm DAPT medication (clopidogrel/ticagrelor) is on CDL formulary | Before discharge |
Cardiac Rehabilitation: Don't Overlook This
Cardiac rehabilitation is a structured exercise and education programme recommended after ACS, PCI, or CABG. It reduces recurrence risk and improves outcomes. Some plans fund cardiac rehabilitation explicitly; others fund it through a physiotherapy benefit. Ask your scheme what is available before discharge.
Support Resources
Heart and Stroke Foundation South Africa: www.heartfoundation.co.za | 021 422 1586 Cardiac support groups, lifestyle programmes, patient information
Cardiac Devices: What Your Scheme Must Cover
Some patients with advanced CAD develop heart failure or arrhythmia complications requiring implantable devices. If an implantable cardioverter-defibrillator (ICD) or cardiac resynchronisation device (CRT-D) is recommended:
- These are PMB-covered procedures for medically indicated cases.
- Pre-authorisation is required before implantation.
- The device cost (R80,000–R180,000) is separate from the procedure fee and both must be pre-authorised.
- Confirm with your scheme whether the ICD/CRT-D device is funded from the in-hospital benefit or a separate device benefit with its own limit.
Ask your cardiologist to include the device model and indication in the pre-authorisation motivation — incomplete motivations are a common cause of initial declines that are later reversed on appeal.
Should I Change My Scheme After a CAD Diagnosis?
Intra-scheme option changes (moving to a higher benefit tier within the same medical aid) can be made without incurring a new waiting period for an existing condition. If your current plan's cardiac surgical coverage is inadequate, escalating to the highest available option before a planned procedure is worth evaluating.
Moving to a new medical aid after a CAD diagnosis is substantially more complex. New schemes can impose condition-specific waiting periods or exclusions. Never cancel your existing cover in anticipation of joining a new scheme without financial advice.
Talk to Eldon
Get help understanding your plan options →
This page is general information about medical schemes. It is not medical advice: speak to a healthcare professional about your own treatment. Medical aid and gap cover advice is given by Eldon de Waal, a Supervised Representative of Approach Administration (FSP 23579).