Understanding Juvenile Idiopathic Arthritis and Its Coverage Under Medical Schemes in South Africa

By Staff Writer

September 4, 2023

Juvenile Idiopathic Arthritis (JIA) is an autoimmune disease where the body’s immune system mistakenly attacks its own healthy cells and tissues, leading to inflammation in the joint membrane or the synovial membrane. This condition is the most prevalent type of arthritis in children under the age of 16.

JIA is included in the Chronic Disease List (CDL) of the Prescribed Minimum Benefit (PMB) regulations under Rheumatoid Arthritis in South Africa. This means that medical schemes are obligated to fully fund the diagnosis, treatment, and care costs of this condition, according to the Council for Medical Schemes (CMS). However, the treatment guidelines for JIA reference the algorithm for Rheumatoid Arthritis for adults, which can differ significantly from the needs of children with JIA.

With JIA, an alternative paediatric clinical management protocol must be included within this benefit if it is supported by evidence-based medicine, considering cost-effectiveness and affordability. Sources to use include the American Academy of Orthopaedic Surgeons, Arthritis Kids South Africa, Johns Hopkins Medicine, Mayo Clinic, Medline Plus and National Institutes of Health.

Medical schemes may use medicine formularies – a list of specific medicine for the treatment of the condition. Therefore, it’s crucial to check with the medical scheme which medicines are included in the medicine formularies to avoid a co-payment on the chronic medication. If a member or beneficiary of a medical scheme chooses to use medicines not on the formulary, a co-payment on the treatment may be applied. This update from the CMS does not include specific information regarding the use of biologics in JIA.

Medical schemes are also allowed to put in place baskets of care that allow for a specific number of consultations, blood tests and other tests to monitor the condition. However, when care outside of the normal basket is required, the medical scheme cannot completely refuse to fund it. The treating doctor should send a letter of motivation to the medical scheme indicating the required care and the reasons. If clinically appropriate, the medical scheme must fund it as PMB.

Reference url

Recent Posts

Blinatumomab benefit assessment
            

Blinatumomab Benefit Assessment for ALL and Health Economics

🚀 How does a groundbreaking therapy change the landscape of acute lymphoblastic leukemia treatment?

The recent benefit assessment of Blinatumomab by the German Federal Joint Committee reveals critical insights into its potential as a consolidation therapy for adults with Philadelphia chromosome-negative B-cell precursor ALL. With its orphan drug status promising automatic benefits, the article explores the implications of its high cost and economic impacts, shedding light on the balance needed between innovation and sustainability in healthcare.

Jump into the full analysis to understand how this could impact clinical practice and health economics.

#SyenzaNews #HealthEconomics #MarketAccess

Enhertu reimbursement analysis
                 

Enhertu Reimbursement Analysis: Navigating Cost-Effectiveness Challenges

💡 How do we balance groundbreaking cancer treatments with budget realities?

The recent analysis by the Dutch Healthcare Institute on Enhertu shines a light on the complexities of integrating innovative therapies for HER2-low metastatic breast cancer into national insurance packages. While the clinical efficacy is evident, the substantial cost implications and demand for steep price reductions bring significant challenges to market access.

Explore the nuances of this vital discussion on clinical effectiveness, economic evaluation, and the future of pricing strategies in oncology.

#SyenzaNews #HealthEconomics #MarketAccess

drug price comparison
 

Global Drug Price Gaps Demand Better Drug Pricing Analysis

💊 International drug price comparison reveal stark price gaps—the U.S. pays 4.2 times more for brand-name drugs than OECD peers.

But are these studies fueling a market collapse or opening a strategic opportunity for sustainable pricing in the U.S. and globally?

Discover the shortcomings of international pricing comparisons and how robust drug pricing analysis can help balance access, affordability, and profitability in a complex market.

#SyenzaNews #healthcare #pricing

When you partner with Syenza, it’s like a Nuclear Fusion.

Our expertise are combined with yours, and we contribute clinical expertise and advanced degrees in health policy, health economics, systems analysis, public finance, business, and project management. You’ll also feel our high-impact global and local perspectives with cultural intelligence.

SPEAK WITH US

CORRESPONDENCE ADDRESS

1950 W. Corporate Way, Suite 95478
Anaheim, CA 92801, USA

© 2025 Syenza™. All rights reserved.