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

modifiable risk factors
        

Targeting Shared Risk Pathways to Prevent Stroke, Dementia, and Depression

🧠 What if addressing just a few key lifestyle factors could significantly reduce the risk of stroke, dementia, and depression in older adults?

A recent systematic review has identified 17 **modifiable risk factors**, revealing the interconnected nature of these age-related brain diseases and offering crucial insights for preventive strategies. By focusing on aspects such as blood pressure management, nutrition, and physical activity, we can enhance quality of life for our aging population.

Dive into the article to explore how these findings could shape future healthcare models.

#SyenzaNews #HealthEconomics #HealthcareInnovation #DigitalTransformation

drug price regulation
      

Navigating Drug Price Regulation: Evaluating the Executive Order’s Potential Impacts and Challenges

💊 Curious about the future of drug pricing in the U.S.?

The recent executive order aims to tackle escalating prescription drug costs through measures like international reference pricing and enhanced transparency. However, the implications of these policies could be more complex than anticipated, with potential risks to market access and innovation.

Dive into the article for a detailed analysis of how these regulations could shape the pharmaceutical landscape and what it means for healthcare access in the U.S.

#SyenzaNews #pharmaceuticals #healthcarepolicy

AI Patient Education
       

AI Patient Education: Evaluating ChatGPT and Gemini for Pediatric Condition Materials

🤔 Are AI solutions ready to revolutionize pediatric patient education?

A recent study compared ChatGPT and Gemini in generating educational materials for common pediatric conditions, revealing intriguing insights into content depth, readability, and reliability. While both tools have their merits, there’s significant room for improvement in making AI-generated content accessible and effective for all families.

Curious to learn more about the implications for health literacy and the future of AI in healthcare? Click to read the full article!

#SyenzaNews #AIinHealthcare #HealthTech #DigitalTransformation

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.